Obstetrics and Gynecology: Maintenance of Knowledge, An Issue of Obstetrics and Gynecology Clinics, 1e

178 Pages·2017·5.74 MB·English

by  Janice L. Bacon

Obstetrics and
Gynecology: Maintenance
of Knowledge
Editors
JANICE L. BACON
PAUL G. TOMICH
OBSTETRICS AND
GYNECOLOGY
CLINICS OF NORTH AMERICA
www.obgyn.theclinics.com
Consulting Editor
WILLIAM F. RAYBURN
June 2017 • Volume 44 • Number 2
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ObstetricsandGynecology:MaintenanceofKnowledge
Contributors
CONSULTING EDITOR
WILLIAMF.RAYBURN,MD,MBA
DistinguishedProfessorandEmeritusChair,DepartmentofObstetricsandGynecology,
AssociateDean,ContinuingMedicalEducationandProfessionalDevelopment,University
ofNewMexicoSchoolofMedicine,Albuquerque,NewMexico
EDITORS
JANICEL.BACON,MD,FACOG
Women’sHealthandDiagnosticCenter,LexingtonMedicalCenter,WestColumbia,
SouthCarolina
PAULG.TOMICH,MD
Professor,DepartmentofObstetricsandGynecology,UniversityofNebraskaMedical
Center,Omaha,Nebraska
AUTHORS
JANICEL.BACON,MD,FACOG
Women’sHealthandDiagnosticCenter,LexingtonMedicalCenter,WestColumbia,
SouthCarolina
ASHABHALWAL,MD
DivisionofMaternal-FetalMedicine,DepartmentofObstetrics,Gynecology,and
ReproductiveSciences,UTHealth-UniversityofTexasMedicalSchoolatHouston,
Houston,Texas
CONSTANCEBOHON,MD,FACOG
AssistantClinicalProfessorofObstetricsandGynecology,GeorgeWashingtonUniversity
SchoolofMedicineandHealthSciences,Washington,DC
ELIZABETHR.BURTON,MD
AssistantClinicalProfessor,DivisionofGynecologicOncology,DepartmentofObstetrics
andGynecology,HanjaniInstituteofGynecologicOncology,AbingtonHospital,Jefferson
Health,TheSidneyKimmelMedicalCollege,ThomasJeffersonUniversity,Abington,
Pennsylvania
LAURAM.CARLSON,MD
ClinicalFellow,DivisionofMaternalFetalMedicine,DepartmentofObstetricsand
Gynecology,UniversityofNorthCarolinaSchoolofMedicine,ChapelHill,NorthCarolina
SUNEETP.CHAUHAN,MD
DivisionofMaternal-FetalMedicine,DepartmentofObstetrics,Gynecology,and
ReproductiveSciences,UTHealth-UniversityofTexasMedicalSchoolatHouston,
Houston,Texas
iv Contributors
JOSHUAD.DAHLKE,MD
DivisionofMaternal-FetalMedicine,DepartmentofObstetricsandGynecology,
NebraskaMethodistWomen’sHospitalandPerinatalCenter,Omaha,Nebraska
DENISEM.ELSER,MD
Director,Urogynecology,Women’sHealthInstituteofIllinois,OakLawn,Illinois
ANTHONYR.GREGG,MD,MBA,FACOG,FACMG
BLStalnakerProfessor,Director,MaternalFetalMedicine,DepartmentofObstetricsand
Gynecology,DirectorofObstetrics,UniversityofFloridaHealthSystem,Universityof
FloridaCollegeofMedicine,Gainesville,Florida
JESSICAR.JACKSON,MD,MSBS
AdjunctClinicalPostdoctoralFellow,MaternalFetalMedicine,DepartmentofObstetrics
andGynecology,UniversityofFloridaCollegeofMedicine,Gainesville,Florida
LYNNR.MACK,MD
AssociateProfessor,DivisionofDiabetes,Endocrinology&Metabolism,Departmentof
InternalMedicine,TheNebraskaMedicalCenter,Omaha,Nebraska
BENJIEBROWNMILLS,MD
AdjunctProfessorofPediatrics,AssociateProfessor,DepartmentofObstetrics&
Gynecology,GreenvilleHealthSystem,UniversityofSouthCarolinaSchoolof
Medicine–Greenville,Greenville,SouthCarolina
ROGERP.SMITH,MD
AssistantDeanforGraduateMedicalEducation,ProfessorofClinicalBiologicSciences,
CharlesE.SchmidtCollegeofMedicine,FloridaAtlanticUniversity,BocaRaton,Florida
JOELI.SOROSKY,MD
Chair,DepartmentofObstetricsandGynecology,HanjaniInstituteofGynecologic
Oncology,AbingtonHospital,JeffersonHealth,TheSidneyKimmelMedicalCollege,
ThomasJeffersonUniversity,Abington,Pennsylvania
PAULG.TOMICH,MD
Professor,DepartmentofObstetricsandGynecology,UniversityofNebraskaMedical
Center,Omaha,Nebraska
ERINE.TRACY,MD,MPH
AssociateProfessor,VincentObstetricsandGynecology,Obstetrics,Gynecology,and
ReproductiveBiology,MassachusettsGeneralHospital,HarvardMedicalSchool,
Boston,Massachusetts
NEETAL.VORA,MD
AssistantProfessor,DivisionofMaternalFetalMedicine,DepartmentofObstetricsand
Gynecology,UniversityofNorthCarolinaSchoolofMedicine,ChapelHill,NorthCarolina
ObstetricsandGynecology:MaintenanceofKnowledge
Contents
Foreword:LifelongLearningRequiresMaintenanceofKnowledge xi
WilliamF.Rayburn
Preface:MaintenanceofKnowledge xiii
JaniceL.BaconandPaulG.Tomich
Contraception:MenarchetoMenopause 143
ErinE.Tracy
Contraceptionservicesshouldbepartofroutinehealthcaremaintenancein
reproductive-agedwomen,especiallyinlightofthefactthatapproximately
50%ofpregnanciesintheUnitedStatesremainunplanned.Barriermethods,
especiallycondoms,mayplayaroleinsexuallytransmitteddiseasepreven-
tionbutarelessefficaciousforpregnancyavoidance.Thereareseveralavail-
ablehormonalcontraceptiveoptions,includingthecombinationhormonal
pill,progestin-onlypill,combinationhormonalpatchesandrings,injectable
progestins,implantableprogestins,intrauterinedevices(copperorproges-
tin),andpermanentsterilization.Thesemethodshavevaryingefficacy,often
relatedtopatientcomplianceortoleranceofsideeffects.
Vaginitis:BeyondtheBasics 159
BenjieBrownMills
Vaginal complaints are one of the most common reasons women seek
the advice of a health care provider. Uncomplicated infections such as
vulvovaginal candidiasis, bacterial vaginosis, or trichomoniasis are easy
to diagnose and treat. However, about 8% of patients will have a more
complicatedcoursewithfailuretorespondtotreatmentorrapidrecurrence
of symptoms. Understanding the need for a methodical, diagnostic
approachtohelpthesewomenwithrecurrentorrefractorycasesofvaginal
symptomswillaidtheclinicianachievesuccessfulpatientoutcomes.
AbnormalUterineBleeding:CurrentClassificationandClinicalManagement 179
JaniceL.Bacon
Abnormaluterinebleedingisnowclassifiedandcategorizedaccordingto
the International Federation of Gynecology and Obstetrics classification
system: PALM-COEIN. This applies to nongravid women during their
reproductiveyearsandallowsmorecleardesignationofcauses,thusaid-
ingclinicalcareandfutureresearch.
RecognitionandTherapeuticOptionsforMalignancyoftheCervixandUterus 195
ElizabethR.BurtonandJoelI.Sorosky
An update on the current epidemiology and a review of the risk factors
of cervical and endometrial cancers are discussed. Cervical cancer
vi Contents
preventionwithafocusonhumanpapillomavirusvaccinationandcervical
cancerscreeningisreviewed,emphasizingthenewfocusoflessfrequent
interventioninanefforttomaintainhighratesofearlydetectionofdisease
while decreasing unnecessary and anxiety-provoking colposcopies, bi-
opsies, and excisional procedures. The replacement of traditional endo-
metrial hyperplasia terminology with more relevant clinical categories,
with an emphasis on the introduction of endometrial intraepithelial
neoplasia, is presented. Fertility-sparing options in the management of
earlycervicalandendometrialcancersarereviewed.
GestationalDiabetes:Diagnosis,Classification,andClinicalCare 207
LynnR.MackandPaulG.Tomich
Gestationaldiabetesmellitus(GDM)affectsapproximately6%ofpregnant
women,andprevalenceisincreasinginparallelwiththeobesityepidemic.
Protocols for screening/diagnosing GDM are controversial with several
guidelinesavailable.TreatmentofGDMresultsinareductionintheinci-
dence of preeclampsia, shoulder dystocia, and macrosomia. If diet and
lifestyle changes do not result in target glucose levels, then treatment
with metformin, glyburide, or insulin should begin. It is generally recom-
mendedthatpregnanciescomplicatedbyGDMdonotgobeyondterm.
Forwomenidentifiedtohaveprediabetes,intensivelifestyleintervention
andmetforminhavebeenshowntopreventordelayprogressiontotype
2diabetes.
UpdatesontheRecognition,PreventionandManagementofHypertensionin
Pregnancy 219
JessicaR.JacksonandAnthonyR.Gregg
Systematic reviews with meta-analysis represent the highest level of
evidenceusedtoguideclinicalpractice.Thedefiningcriteriausedtodiag-
nosepreeclampsia haveevolved,andwilllikelycontinue toevolve. Pro-
teinuria is sufficient but not necessary when defining preeclampsia.
Hypertension without proteinuria but with severe features is diagnostic.
The methods used to measure urinary protein have changed. The gold
standardremainsthe24-hoururinetest.Theefficacyoflow-doseaspirin
in preventing preeclampsia is a function of baseline risk. Data suggest
thattreatingmildtomoderatebloodpressurehasclearmaternalbenefits
withlittlefetalorneonatalrisk.
ObstetricEmergencies:ShoulderDystociaandPostpartumHemorrhage 231
JoshuaD.Dahlke,AshaBhalwal,andSuneetP.Chauhan
Shoulderdystociaandpostpartumhemorrhagerepresenttwoofthemost
common emergencies faced in obstetric clinical practice, both requiring
prompt recognition and management to avoid significant morbidity or
mortality.Shoulderdystociaisanuncommon,unpredictable,andunpre-
ventableobstetricemergencyandcanbemanagedwithappropriateinter-
vention. Postpartum hemorrhage occurs more commonly and carries
significantriskofmaternalmorbidity.Institutionalprotocolsandalgorithms
forthepreventionandmanagementofshoulderdystociaandpostpartum
hemorrhagehavebecomemainstaysforclinicians.Thegoalofthisreview
Contents vii
istosummarizethediagnosis,incidence,riskfactors,andmanagementof
shoulderdystociaandpostpartumhemorrhage.
PrenatalDiagnosis:ScreeningandDiagnosticTools 245
LauraM.CarlsonandNeetaL.Vora
TheAmericanCongressofObstetriciansandGynecologistsrecommends
that all pregnant women be offered aneuploidy screening or diagnostic
testing.Amyriadofscreeningandtestingoptionsareavailabletopatients
basedontheirriskprofileandgestationalage.Screeningoptionsinclude
traditional serum analyte screening, such as first-trimester screening or
quadruplescreening,andmorerecently,cell-freeDNA.Diagnostictesting
choicesincludechorionicvillussamplingandamniocentesis.Thenumber
of screening and diagnostic modalities complicates prenatal counseling
forphysiciansandcanbedifficultforpatientstograsp.Appropriatepre-
testandposttestcounselingisimportanttoensureadequateunderstand-
ingofresultsandensuretestingstrategyisconcordantwithpatientgoals.
CancerRecognitionandScreeningforCommonBreastDisordersandMalignancy 257
ConstanceBohon
Breastcancerispredictedtobethemostcommonnewlydiagnosedcan-
cer in women in 2016. Screening mammography is the most commonly
used method for the detection of breast cancer in women of average
risk.Ageneticriskassessmentisrecommendedforwomenwithagreater
than20%to25%chanceofhavingapredispositiontobreastandovarian
cancer.Evaluationofabreastmassbeginswithadetailedhistory,assess-
mentforcancerrisk,andphysicalexamination.
RecognizingandManagingCommonUrogynecologicDisorders 271
DeniseM.Elser
Manywomenexperienceurogynecologicorpelvicfloordisorders,espe-
ciallyurinaryincontinenceandpelvicorganprolapse.Theobstetrician/gy-
necologistisoftenthefirsthealthcareprofessionaltoevaluateandtreat
these disorders. Treatments include pelvic floor muscle training, behav-
ioraltherapies,oralmedications,neuromodulation,intradetrusormedica-
tions, and surgery. When approaching the woman with symptomatic
prolapse, familiarity with pessaries and various surgical procedures aid
incounseling.Referraltoapelvicfloorphysicaltherapistortoafemalepel-
vicmedicineandreconstructivesurgeonshouldbeconsidered.Increasing
attentiontodataoncost-effectivenessisanecessity.
TheMenopausalTransition 285
JaniceL.Bacon
A clear understanding of the physiology of the menopausal transition,
clinical symptoms, and physical changes is essential for individualized
patient management, maximizing benefits and minimizing risks for the
presentandthefuture.Menopause,definedbyamenorrheafor12consec-
utivemonths,isdetermined retrospectivelyandrepresents apermanent
end to menses. Many physical changes occur during the menopausal
viii Contents
transitionandbeyond.Knowledgeofsymptomsandfindingsexperienced
by women undergoing the menopausal transition allow individualized
care-improvingqualityoflifeandenhancingwellbeingforyearstocome.
Special Article
BurnoutinObstetriciansandGynecologists 297
RogerP.Smith
It is estimated that 40% to 75% of obstetricians and gynecologists
currentlysufferfromprofessionalburnout,makingthelifetimeriskavirtual
certainty.Althoughthesestatisticsmakeforadismalviewoftheprofes-
sion,ifthecausesandsymptomscanbeidentified simplestepscanbe
implementedtoreversethethreat.Withalittlecare,theenjoymentofprac-
ticecanberestoredandthesenseofrewardandthevalueofservicecan
bereturned.
Index 311
ObstetricsandGynecology:MaintenanceofKnowledge ix
OBSTETRICS AND GYNECOLOGY CLINICS
FORTHCOMINGISSUES RECENTISSUES
September2017 March2017
EvaluationandManagementofVulvar HealthCareforUnderservedWomen
Disease WandaKayNicholson,Editor
ArunaVenkatesan,Editor
December2016
December2017 CriticalCareObstetrics for theObstetrician
ManagementofLaborandDelivery andGynecologist
AaronB.Caughey,Editor CarolynM.ZelopandStephanieR.Martin,
Editors
March2018
ReproductiveGenetics September2016
LorraineDugoff,Editor HysterectomyandtheAlternatives
JohnA.OcchinoandEmanuelC.Trabuco,
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