Vooique g ectag equ ot Stud def pois E! +Pav tbere PRACTICE AND APPROACH GYNECO : TO THE PATIENT GP ceramh 4 tig ‘woman's first visit with a physician is often for contraception POUR 4 & young woman's frst visit with a physicion ie often for contraception Pp gnancy This first visit is of major importance, as it may affect her tude and actions toward Juture care needs ; as wife-mother, she will aly select! for her family, =40tond qu Zpoud af mere 2 A patient's personal expectations, interpretations, and response to Aeckelhy ta pada STtP 2S aNd therapy, 28 viell a8 disease patterns, aro influenced by het vt Pucureutture and socioeconomic status. Modssty may make the physical, particularly the pelvic, examination an ordegt, The patient may be ignorant ordeal =, “f generative and somal functions, RefiowS Mand cultural backgrounds "er 4 ¢ altitudes about pregnancy, contrace! ion, and abortion. Visual Nkerun = any portign of the genital tract may be proscribed For some, luo tem BCA oe of highiyMdesitable requirement may be virgimty at marriage, arn puliory quently equated with the size of the hymenal ¢ ; thus, an modafory § — seemnation may be limited or impossible On the orther hand, premarital obotegataty semual acty with muitiple partners is commen in young people and tion, cervieal neopla: fanned pregnanc nd attata ward menstruation vary markedly . eg, mens tionally associated with soiling, shame, and “sickness” ; menstrual flow was thought of as “cleansing” sv thot a heavy flow might Qlonsng joommed au femuune and a light flow or longer mterval interpreted as = PM cok Seuilflure account fr: amount th - ender Pregnancy detection and subsgquegt care. or sexual or they postpone examinations until Seieont problem arises 3 might nisidered too rumor or embartassing te annoying discharge, dyspareunia, urmany incontinence, oF a fohly by Shaina thorough exammation, Patients may or may not be aware of psychologic stress that peould Ligmenting or causing their symptoms. Some patients use minor Thordug! “ymmptoms 22 3 pretense when they actually wish to explore other aotonal feelings about future medical care q é . Confidentiality must be observed and affirmed to adult Ss 2 3 patients. The rights of minors whe do not want parents Ss = E_ medical probiems, especially those associated with sexual activi 2 ye be respevied. h states have laws “emancipating” mino: 2 2s = a ° 2 concerning pregnancy, contraception, abortion, sexually € % diseases, or marriage, Women now expect to be involved in i re. Therefore, patients must receive support an ticlent information to understand their prob and available alternatives pre of therap The gynecologic history goed manners (courhisi’) Decor a Rapport begins with the physcian's courtesy, attention, and friendly, Smdin = unavrried manter while compiling the medical history 4 nonjudgmental Ta lakinghty 2REToH in questions, geabires and attindes avolds moratizing or Pehanansip dogmatic opimuen and encourages an sccurate lustory. Sines the Piysician’s attitude toward women may differ from that of the patient, st be exercised to avoid making the patient feel embarrassed, dependent, An appropriate response recognizes her worth and uurages realization of her independence cut PEaMary Complaint shovid te identitied and explored in Backgroun data reveal the patient as an individual Menstruat) ‘Ristory inctudes tie age of tmenarche of the patient (and other family wnembers) : irequency, regularity, duration poses of fig. and pain ot a ‘Sigua aateeg : i ‘ther symptoms with or before menses ,abnorMial Bleeding and dates of 2 menses. Semial activity, orientation, and pss to lems can nce forth ning A history of venereal disease! inciting pes and condyiome, should be noted The possibility of pregnancy hould be explored, along with attitudes. knowledge, an rience with vontacepiives HESEOFy Of pregnancy! includes the umber ot pregnancies, their dates and outcomes, and problems i brogtant Pain, i poe teARG ede ce “nee OU, 3 y to radiate, what exacerbates it or gives relief, and how it relates to GI cr urinary function: Fever should be noted 3 Alkeview of past itinésses! fotlews, mciuding hospitalization and surgery, with details of abdominal or pele surgery. Any History of benign disease - ex, mastitis, enlarged thymus, quest ihenorthagia, or skin disorders - should be eticited, as well ay reports of Possible exposure t diethylstilbestrol (DES) by mothers who were | pregnant or by daughters born during the years of its use (1947 to 1971).3 The patient's general health should be reviewed, including ber ‘Psychologic status, with particular attention to depression, anziety, or drug abuse. Any history of weight change, bulimia, or anorexia nervosa should be investigated. Drug intake should be noted, with reference to allergies and especially to drugs affecting the present condition, since they may conflict with proposed treatment or be contraindicated in pregnancy. Reference to use or abuse of tobacco, alcohol, or other drugs must be explored. 4 Since the urinary tract is frequently involved in gynecologic disease, the patient should be questioned about urinary frequency, nocturia, dysuria, involuntary loss of urine) and vaginal protrusion. Similarly, GI symptoms should be reviewed : change of bowel habit, stool color, anoremia, nausea, vomiting, abdominal pain, food intolerance, and possible symptoms (past or present) of liver disorder § Breast problems, inctuding pain or growth, should be noted. A review of general endocrine status includes abnormal growth or lactation and symptoms of other endocrine dysfunction. A history of , anemias, phlebitis, or other abnormal clotting may give clues to the cause of abnormal menses or preclude hormone medication. The cardiac status ; history of cardiac disease, hypertension, or smoking, or cholesterol or triglyceride abnormality may also influence therapy. A history of migraine headache or seizures may affect treatment , drugs used to control migraine or seizures may be detrimental in Pregnancy. A family history may disclose hereditary disease - especially pertinent are ovarian, uterine, and breast cancer ; diabetes ; bowel polyps or cancer ; and genetic abnormalities. P any Penvlvoury . aa The gynecologic examination = Evamen cuniimogaqut 1 The bladder must be emptied before pefvie cxamfnation ; the urine specimen should be examined for sugar, albumin, and bacteria Measurements of Hb or HCT should be done as indicated (ez, by heavy menses, tiredness, pallor, or previous anemia). Laboratory assessments oxamyn\ may include CEC, Urinalysis, and cholestere! and lipid levels Conypiiit 2The physcial examination includes height, weight, BP, and a check of_heart, lungs, and lymph nodes. Abnormal body hair texture or distribution should be noted The thyroid gland may be enlarged, nodular, or tender 2 4 thorough breast examination in both seated and supine positions notes maturation, tenderness, syminetry, retraction of skin or nipples, and masses. Gentieness and warm hands are appreciated. During this Procedure, the physician may instruct the patient in breast self-examination Qutebal porn ‘ t 4 Abdominal examination always begins away (rom an area of pain. Using a flat hand, the physician should systematically probe (not poke) _ each quadrant of the abdomen for masses and tenderness. t up ausetr crt tine The following findings should be n location, tnobility, nd: preset nce of a mass and its size, nd tenderness ; scars or distention | and ascites or suggestion of other abdominal fluids, Liver size and peslbie tenderness and polpability of the kidneys, liver, and spleen should aise ‘be noted. If the patient has an abdominal complaint, bowel sounds should be checked. mn, and any accompanying rigidity of the abdominal wall should be noted. Refertat of tenderness If tenderness is present, its severity, locatio Referral of ace cieewhere in the abdomen of rebound tenderness indicates peritoneal irritation 3 The pelvic examination is usually deferred until last. The physcian’s unhurried explanations and sensitive and gentle Put matter-of-fact atsitude help the patient to relax, ensuring a more thorough examination. Having emptied her bladder, the patient sho uid assume the position (in which the hips and knees are flexed with the buttocks at the Inspection of the genital area shows hair distr (edge of the table and the legs supported by heel or knee stirrups) Spution, clitoral size, vulvar jesions, discoloration, discharge, inflammation, and hymenai_orifice patency. A gentle touch on the inner thi genitalia reduces the startle st betore touching the ex. The labia aati be spread with the fingers of one hand. To expose the cervix @5d avoid pressure on the urethra, a warmed, water-lubricated speculum should be inserted into the upper vagina and then opened. (Lubricating jelly should act ‘pe used, since it may interfere with the Papanicolaou test) 6 The Papanicolagn (Pap) test examines preinvasive lesions (| exfoliated cells to detect ayspalasia, carcinoma in situ) as well 28 Invasivé jesions. The Pap test should detect 80 to 85 Rol cervical malignancies and premalignant states. The patient ould have refrained from douching or vsing vaginal medication for 24h An inadequate sample OF Ot infected malignant lesion may produce false-negative results. Only 50 & of tests are positive in patients who have endometrial malignancies Virat and other ifections may be diagnosed, and the estrogen may be obtained ? An endocervical sample should be taken bua Aolt with a Saline-moistened, cotton-tipped applicator or a brush ‘that is rotated or rolled thinly on a slide! The visible cervix should then be firmly s919, with an Ayre spatula ; a sample from the pos ved circumflemally ‘err fornix (vaginal pool) may be included. These specimens may be placed on the sone slide as the endocervical smear of on a separate slide, at the discretion of the cytologist. DES-exposed women should also have vaginal wail scrapings prelat! cxamined. The semple should be fixed immediately with ab alcohol dc2a pum Solution or spray. With the speculum m place, grass lesions. may Pe noted; mginale continuous infusion in the epidural space. Caudal injection is rarely used today. Spinal anesthesia may be used for cosdiean Section but nas a risk of spinal headache afterwards, so it is used less often. © nstant attendance and frequent, {a 5 min) vital sign checks are neowesary ‘detect and treat possible hypotension. Qs “taux % General anesthesia with potent inhalation agents such as isoflurane can be very depressing to both mother and fetus and therefore is not ‘ed for routine delivery. Analgesia by 49.8 nitrous oxide ay be used as ong as verbal contact with ie patient Pub \eer oes interest in prepared childbirth has lessened the use of such agents except weeech or twin delivery or cesarean section. Considerable experience 1¢ ired to use them safely UF pour Ce 5. A vaginal examination is performed to determine the position and Gation of the head. The patient is instructed te bear down and strain. with each contraction to move the head down through the pelvis and progressively dilate the vaginal introftus so that more and more of the head will appear. When about 3 or 4 om of the head is visible in @ primipara during a contraction (somewhat earlier in a multipara), the following maneuvers can facilitate delivery and reduce the possibility of acesy tie | te leo | kare | -to nor ds moftre ys1 », perineal laceration : the physician Gf right-handed) places the left palm over the baby’s head during a contraction to control and, if necessary slightly retard its progress, while placing the curved fingers of the right hand against the dilating perineum through which the baby’s brow\or chin .., is felt. Applying pressure against the brow or chin with the curved fingers ~ helps to advance the head The physician controls advancement or retardation of the head to effect slow and controlled detivery. 6. Use of forceps for delivery is often an arbitrary decision. I an epidural anesthetic that. precludes vigorous straining is used, forceps may be tequired and are safe! However, if a local anesthetic that allows bearing down efforts is used, forceps usually are not needed unless complications interfer. If the 2nd stage of labor is likely to be prolonged ecause the patient is having difficulty straining, forceps should be used. 7 An episiotomy, surgical incision of the perineum, should pe performed for patients in whom the perineuin does not. gaa Feadityy and is obstructing delivery. This procedure substitates 4 st gicat tadision Tor oacessive stretching and possible tearing of the perineal tissues. The incision is easier to repair properly than a tear and may decrease anterio® tears, The most common episiotomy is a midiine incision made with scissors from the midpoint’ of the posterior fourchetl> aivedlly backward toward the rectum. This type risks extension into the rectal sphincter or jocum itself, but if recognized promptly, the extension can be repaired guccessfully and vill heal well, Episioproctotomy (intentionally cutting inte the rectum) is not recommended because the incidence of recto-vaginal fistula is unacceptably high, Tears or extensions inte the rectum ap usually be prevented by Keeping the baby's head well flexed until the (Getipital prominence passes beyond the subpubic arch. Another type of episiotomy is a mediolateral incision made with scissors from the midpoint of the posterior fourchette at a 45° angle laterally on either side. Although this type usually dees not extend into the sphincter oF rectum, postoperative pain and healing time, are increased, Thus, unless problems are expected, the midling Spisi Stoiny is recommended @. Following delivery of the head, the baby's body rotates so that the shoulders are in an anteroposterior position . gentle downward pressure of the nead delivers the anterior shoulder under the symphysis. The head i& gently lifted, the posterior shoulder slides over the perineum, and the rest Of the baby's body follows without difficulty. The baby’s nose, mouth, and pharpn are aspirated with a buib ¢yringe to remove obstructions (mucus tnd fluids) and help establish’ respirations. The cord should be Gouble-clamped and cut between the clamps, and a plastic lp should be applied. The baby is then placed in a ‘warmed resuscitation bassinet or ob the mother's abdomen. 9. The 3rd stage of labor begins after delivery of the infant and ends with delivery of the placenta. After delivery, the physcian places & nand gently on tie niggas, fundus to detect contractions placental separation usually occurs during the 15t or 2nd contraction, often with a gush of12 flood froma behind the separating placenta The mother can usually push out the placenta. If not, and if significant bleeding occurs, the placenta can usually be expressed by firm, downward pressure on the uterus. If this 18 not effective, the, umbilical cord is held taut iil the uterus is pushed upward, away frdm the placenta: (Manta! reitiova ‘py inserting the entire hand inte he uterine cavity, separating the placenta from its attachement, then extracting the placenta may be necessary). The placenta should be examined for completeness, as fragments left in the uterus can’ cause -delayed hemorrhage If the placenta is incomplete, the uterine cavity shovld be explored manually. Some obstetricians routinely explore the uterus after each delivery. Immediately alter delivery of the placenta, an oxytocic drug should be given (oxytocin 10 TU IM or, if the IV infusion is ‘running, in the IV fluid) to aid in firm contraction of the uterus. Oxytocin should not be given as a single large IV dose, since cardiac arrhythinia may occur 10. After inspection to rule out or repair lacerations in the cervix or yagina and to make sure the uterus is contracting, and after repair of the episiotomy, the patient may be taken to the (recovery room. If all is well, the infant can be. presented to the mother so that they con be taken there together. Many mothers wish to begin breast-feeding soon after delivery, and this should be encouraged. Mother, infant, and father should remain together in a warm, private area for an hour of more, as this may increase parent-infant emotional attachment (bonding). The baby may then be taken to the nursery. The mother should be observed for about 1 h for bleeding, BP problems, and general well-being, The time from delivery of the placenta to 4 h postpartum is frequently called the 4th stage of labor , most complications, especially hemorrhage, cecur at this:time, and frequent observation is mandatory.13 ABNORMALITIES AND COMPLICATIONS OF PREGNANCY Jveclement SPONTANEOUS ABORTION ¢ Abortion generally is defined as dalivery or foss of the products of conception before the 20th wh of pregnancy, but. definitions vary. For this discussion, 20 wk of gestation, which corresponds to a fetal weight of about 500 gm, is used as the limit for abortion. Dativery between 20 and 36 wk Js wonsideres moturee Incidence and Etiology cortrackions About 20 to 30 % of women bleed or have cramping sometime during the first 20 wk of pregnancy ; 10 to 15 % actually spontaneously abort. Since in 60 % of spontaneous abortions the fetus is either absent or grossly maiformed, and in 25 to 60 % it has chromosomal abnormalities incompatible with tife, spontaneous abortion may be a natural rejection of 4 maldeveloping rétus. About 65 % of spontaneous abortions occur in the first trimester and tend to be related to fetal causes ; those occurring in the 2 nd trimester usually have maternal causes. Maternal factors that have been suggested as calises of spontaneous abortion include an incompetent, amputated, or lacerated cervix ; congenital or acquired anomalies of the uterine cavity ; hypothyroidism ; digh: ellitus ; chronic nephritis ; acute infection ; use of cocaine, especially “aid severe emotional shock. Many viruses, most notably cytomegalo-herpes- and rubella viruses, have been implicated as s. The importance of uterine tt ids or retroversion and ifipaired juteum function appears to nave been overestimated, A relationship to physcial trauma has not been substantiated, Classification An abortion is termed either @atly (before 12 wk of pregnancy) or ‘até (between 12 and 20 wk). This distinction is made because more difficulties are encountered in treating late abortions. After 12 wk of Pregnancy, the uterine cavity is obliterated and instrumentation is more likely to cause perforation. Since a definitive placenta has begun to form with a more organized and larger blood supply, bleeding is more tikely Fetal bones have also begun to form, and the long bones of the linibs may Perforate the uterus during evacuation. Further, the size of a fetus at > 12 wk of pregnancy makes it difficult to dilate the cervix enough to pass the fetus.Dac :Diloher ewrefinge Avorlenwnt 14 Abortions may be spontaneous or induced. Spontaneous abortions occur without any instrumentation. Induced abortions, are those done for \\ medical or elective reasons. Abortions performed to save the pregnant woman's fife or health are referred to as therapeutic cous abortions may be threatened, inevitable, incomplete, or complete. Threatened abortion is any bleeding or cramping of the uterus in ‘the first’ 20 We of pregnancy. Jeoritae le abortio: intolerable pain or bleeding that threatens the wortlan's Well-being ‘It part of the products of conception is passed or if the membranes are ruptured, the abortion is incomplete. If ali ot the products of conception are passed, the uterus has contracted toward normal size, and the cervix fas closed, the abortion is complete. The occurrence of 3 or more consecutive spontaneous abortions is termed habitual | abortion and requires extensive diagnostic investigation. Genetic “and Chtdmosomal studies should be performed Among the endocrinopathies and metabolic diseases to be ruled out are hypo-and hyperthyroidism, diabetes mellitus, and chronic renal disease. Immunologic causes such as the lupus anticoagulant should be investigated. Defective corpus Iuteum function is always suspected Anatomic abnormalities of the uterus (eg, polyps, fibroids, congenital " defects) should be evaluated by hysterography, D&C, or hysteroscopy Specific treatment, such as unification of a double uterts excision of septum, or myomectomy, may be needed = Missed abortion occurs when the fetus has died but has been MONO. retained in utero 4 wk or longer. After 6 wk, the dead fetus syndrome may develop, with 2 tablets/day are given, Also, if » 2 tablets are taken daily, one dose blocks absorption of the succeeding doses, thereby reducing total intake. Megalo-blastic anemia dus to folic acid deficiency is treated with folic acid 1 mg bid True megaioblastic anemia may require hospitalization for bone marrow examination and further treatment. These anemia can be profound enough (Hb < © gm/dL) to necessitate transfusion. Resistant iron-deficiency anemia or magelobiastic anemia warranty consultation for definitive treatment, “Shotgun” vitamin therapy (tr se ‘with multiple vitamins) or administration of iron by injection is occasionally warranted. There is conflicting evidence that routine supplemental iron therapy is necessary in pregnancy. However, most pregnant patients should be given supplemental iron (ferrous sulfate 300 to $00 mg/day), even though the Hb level is normal at the beginning of the pregnancy This prophylactic measure prevents depletion of reserves and the anemia that may ensue with any abnormal bleeding or with a subsequent pregnancy. , Treatment of sickde celt anemia is more controversial, Exchange transfusion for the mother is recommended by some but disputed by others. No evidence confirms any treatment other than supportive care a HYPEREMESIS GRAYIDARUM eek raid = ani benign + Aelignsnt nauses and vomiting fo the extent that the pregnant weanen becomes dalparated and acidotts Pathology Persistent hyperemesis gravidarum may be associated with serious river damage. Autopsies in such cases usually show severe necrosis in the central portion of the lobules or widespread fatty degeneration similar to hat seen in starvation Hemorrhagic retinjtis is a serious complication and indicates a grave prognosis : the mortality rate in such patients is 50 % ERC steww de morfalile™ Symptoms, Signs, and Diagnosis eat by. Patients do not gain weight , they udually los? weight’ Weight. loss, dehydration, and ketosis confirm that the vomiting Is extensive. Many lo Morve: aueir Ares soupregnant women with morning sickness feel as though they are yomiting everything they ingest, but u they contmue to gan weight and are net dehydrated, the condition is not hypermesis gravidarum. psychologic factors are prominent in this syndrome but do not tessen the danger Patients should be evaluated for unsuspected liver disease, kidney infection, pancreatitis, intestinal obstruction, G1 tract lesions, and intracranial lesions, since these condtions can cause vomiting, Treatment The acidosis and dehydration are corrected with IV infusion of water, glucose, and electrolytes. The patzent should be kept in bed in hospital and given nothing by mouth for 24h, Antiemetics and sedatives should be used as necessary. Occasionally, 1V vitamin therapy is required After the dehydration and acute vomiting are corrected, bland oral feedings sn small amounts at frequent intarvais may be started and increased as tolerated ‘sually vomiting ceases within a few days, but sometimes the regimen of fasting, IV fiuids, and small nieals has to be repeated once or twice Repeatet ophtalmoscopic examinations are imperative, and it rrhagic retinitis appears, the pregnancy should be terminated at once on in the abserice of 4 developing retinitis, termination of the pregnancy should be considered in the rare cases that do not respond to therapy (as evidenced by continiied weight loss, jaundice, and increasing pulse rate) té éclampiic ot elampiie PREECLAMPSIA AND ECLAMPSIA nes B Preeclampsia : Develgpssen! of nypertension itis aibumisuris 2 seins Patmeen the 20th wk of pregnancy and the end of the lust week postpertira Ectampsta + Cotié andor convuisire selzures if the Sr tine pariod, wathout other etiokygy The cology of pre-eclampela anc eclampeia is unknwon. Preeclampsia develops in 5 % of pregnant worreh, suaily in primigravidas and women with preexisting hypertension oF vascular disease. If untreated, preeclampsia characteristically smotders a variable length of time and suddenly progresses to eclampsia. Eclampet® Gevelops in 1/200 preeciamptic patients and is usually fatal if untreated. 4 major complication of preeclampsia is abruptio placente (Gee belly tinder THIRD TRIMESTER BLEEDING), apparently caused by the vascular disease, Low-dose aspirin therapy has been tried as a preventive measure in high-risk patients ; however, the data on results are mixed, and th therapy should probably be considered experimental symptoms, Signs and Diagnosis Any pregnant woman wh jevelops, a BR ait 40/90 mm Hg, ders of the face or hands, or albuminusia of > [lor whose BP rises bY 30 mm Hg systolic or 15 mu Hg diastolic (even though it does not reach levels above