perimenopausally, with diffuse exudative vaginitis, massive vaginal-cell exfoliation, purulent vaginal discharge, and occasional vaginal and cervical spotted rash. Laboratory findings included an elevated pH, increased numbers of parabasal cells, the absence of gram-positive bacilli and their replacement by gram-positive cocci on Gram staining. Clindamycin 2% cream is usually effective.

C.Noninfectious vaginitis and vulvitis

1.Noninfectious causes of vaginitis include irritants (eg, minipads, spermicides, povidone-iodine, topical antimycotic drugs, soaps and perfumes) and contact dermatitis (eg, latex condoms and antimycotic creams).

2.Typical symptoms, including pruritus, irritation, burning, soreness, and variable discharge, are most commonly confused with acute candida vaginitis. The diagnosis should be suspected in symptomatic women who do not have an otherwise apparent infectious cause.

3.Management of noninfectious vaginitis includes identifying and eliminating the offending agent. Sodium bicarbonate sitz baths and topical vegetable oils may provide

some local relief. Topical corticosteroids are not recommended.

References: See page 155.

Obstetrics

Prenatal Care

I.Prenatal history and physical examination

A.Diagnosis of pregnancy

1.Amenorrhea is usually the first sign of conception. Other symptoms include breast fullness and tenderness, skin changes, nausea, vomiting, urinary frequency, and fatigue.

2.Pregnancy tests. Urine pregnancy tests may be positive within days of the first missed menstrual period. Serum beta human chorionic gonadotropin (HCG) is accurate up to a few days after implantation.

3.Fetal heart tones can be detected as early as 11-12 weeks from the last menstrual period (LMP) by Doppler. The normal fetal heart rate is 120-160 beats per minute.

4.Fetal movements ("quickening") are first felt by the patient at 17-19 weeks.

5.Ultrasound will visualize a gestational sac at 5-6 weeks and a fetal pole with movement and cardiac activity by 7- 8 weeks. Ultrasound can estimate fetal age accurately if completed before 24 weeks.

6.Estimated date of confinement. The mean duration of pregnancy is 40 weeks from the LMP. Estimated date of confinement (EDC) can be calculated by Nägele's rule: Add 7 days to the first day of the LMP, then subtract 3 months.

B.Contraceptive history. Recent oral contraceptive usage often causes postpill amenorrhea, and may cause erroneous pregnancy dating.

C.Gynecologic and obstetric history

1.Gravidity is the total number of pregnancies. Parity is expressed as the number of term pregnancies, preterm pregnancies, abortions, and live births.

2.The character and length of previous labors, type of delivery, complications, infant status, and birth weight are recorded.

3.Assess prior cesarean sections and determine type of C- section (low transverse or classical), and determine reason it was performed.

D.Medical and surgical history and prior hospitalizations are documented.

E.Medications and allergies are recorded.

F.Family history of medical illnesses, hereditary illness, or multiple gestation is sought.

G.Social history. Cigarettes, alcohol, or illicit drug use.

H.Review of systems. Abdominal pain, constipation, headaches, vaginal bleeding, dysuria or urinary frequency, or hemorrhoids.

Basic Prenatal Medical History

Current Pregnancy History

Initial Prenatal Assessment of past Obstetrical History

I.Physical examination

1.Weight, funduscopic examination, thyroid, breast, lungs, and heart are examined.

2.An extremity and neurologic exam are completed, and the presence of a cesarean section scar is sought.

3.Pelvic examination

a.Pap smear and culture for gonorrhea are completed routinely. Chlamydia culture is completed in high-risk patients.

b.Estimation of gestational age by uterine size

(1)The nongravid uterus is 3 x 4 x 7 cm. The uterus begins to change in size at 5-6 weeks.

(2)Gestational age is estimated by uterine size: 8 weeks = 2 x normal size; 10 weeks = 3 x normal; 12 weeks = 4 x normal.

(3)At 12 weeks the fundus becomes palpable at the symphysis pubis.

(4)At 16 weeks, the uterus is midway between the symphysis pubis and the umbilicus.

(5)At 20 weeks, the uterus is at the umbilicus. After 20 weeks, there is a correlation between the number of weeks of gestation and the number of centimeters from the pubic symphysis to the top of the fundus.

(6)Uterine size that exceeds the gestational dating by 3 or more weeks suggests multiple gestation, molar pregnancy, or (most commonly) an inaccurate date for LMP. Ultrasonography will confirm inaccurate dating or intrauterine growth failure.

c.Adnexa are palpated for masses.

II. Initial visit laboratory testing

A.Routine. A standard panel of laboratory tests should be obtained on every pregnant woman at the first prenatal visit. Chlamydia screening is recommended for all pregnant women.

Initial Prenatal Laboratory Examination

B.Human immunodeficiency virus

1.HIV testing is recommended for all pregnant women.

2.Retesting in the third trimester (around 36 weeks of gestation) is recommended for women at high risk for acquiring HIV infection.

C.At-risk women should receive additional tests:

1.Gonorrhea, tuberculosis and red cell indices to screen for thalassemia (eg, MCV <80), hemoglobin electrophoresis to detect hemoglobinopathies (eg, sickle cell, thalassemias)

2.Hexosaminidase A for Tay Sachs screening (serum test in nonpregnant and leukocyte assay in pregnant individuals), DNA analysis for Canavan's disease, cystic fibrosis carrier testing, serum phenylalanine level, toxoplasmosis screen, and Hepatitis C antibodies.

3.Testing for sexually transmitted diseases (eg, HIV, syphilis, hepatitis B surface antigen, chlamydia, gonorrhea) should be repeated in the third trimester in any woman at high risk for acquiring these infections; all women under age 25 years should be retested for Chlamydia trachomatis late in pregnancy.

D.CBC, AB blood typing and Rh factor, antibody screen, rubella, VDRL/RPR, hepatitis B surface Ag.

E.Pap smear, urine pregnancy test, urinalysis and urine culture. Cervical culture for gonorrhea and chlamydia.

F.Tuberculosis skin testing, HIV counseling/testing.

G.Hemoglobin electrophoresis is indicated in risks groups, such as sickle hemoglobin in African patients, B- thalassemia in Mediterranean patients, and alphathalassemia in Asian patients. Tay-Sachs carrier testing is indicated in Jewish patients.

III.Initial patient education

A.Frequency of prenatal visits, recommendations for nutrition, weight gain, exercise, rest, and sexual activity, routine

pregnancy monitoring (eg, weight, urine dipstick, blood pressure, uterine growth, fetal activity and heart rate), listeria precautions, toxoplasmosis precautions (eg, hand washing, eating habits, cat care) should be discussed.

B.Abstinence from alcohol, cigarettes, illicit drugs should be assessed. Information on the safety of commonly used nonprescription drugs, signs and symptoms to be reported should be discussed, as appropriate for gestational age (eg, vaginal bleeding, ruptured membranes, contractions, decreased fetal activity).

C.Headache and backache. Acetaminophen (Tylenol) 325650 mg every 3-4 hours is effective. Aspirin is contraindicated.

D.Nausea and vomiting. First-trimester morning sickness may be relieved by eating frequent, small meals, getting out of bed slowly after eating a few crackers, and by avoiding spicy or greasy foods. Promethazine (Phenergan) 12.5- 50 mg PO q4-6h prn or diphenhydramine (Benadryl) 25-50 mg tid-qid is useful.

E.Constipation. A high-fiber diet with psyllium (Metamucil),

increased fluid intake, and regular exercise should be advised. Docusate (Colace) 100 mg bid may provide relief.

IV.Nutrition, vitamins, and weight gain

A.All pregnant women should be encouraged to eat a wellbalanced diet. Folic acid is recommended in the preconceptional and early prenatal period to prevent neural tube defects (NTDs). A standard prenatal multivitamin satisfies the requirements of most pregnant women.

B.Nutritional recommendations for pregnant women are based upon the prepregnancy body mass index (BMI). A weight gain of 12.5 to 18 kg (28 to 40 lb) for underweight women (BMI<19.8), 7 to 11.5 kg (15 to 25 lb) for overweight women (BMI $26), and 11.5 to 16 kg (25 to 35 lb) for women of average weight (BMI 19.8 to 26.0) is recommended.

V.Clinical assessment at first trimester prenatal visits

A.Routine examination at each subsequent visit consists of measurement of blood pressure and weight, measurement of the uterine fundus to assess fetal growth, auscultation of fetal heart tones, and determination of fetal presentation and activity. The urine is typically screened for protein and glucose at each visit.

B.At 9 to 12 weeks the fetal heart usually can be heard by of gestation using a Doppler instrument. Transvaginal ultrasound can determine fetal viability as early as 5.5 to 6.5 weeks.

Frequency of Prenatal Care Visits in Low-Risk Pregnancies

VI.Clinical assessment at second trimester visits

A.Questions for each follow-up visit

1.First detection of fetal movement (quickening) should occur at around 17 weeks in a multigravida and at 19 weeks in a primigravida. Fetal movement should be documented at each visit after 17 weeks.

2.Vaginal bleeding or symptoms of preterm labor should be sought.

B.Fetal heart rate is documented at each visit.

VII. Second-trimester laboratory

A.Maternal serum testing at 15-16 weeks

1.Triple screen (α-fetoprotein, human chorionic gonadotropin [hCG], estriol). In women under age 35 years, screening for fetal Down syndrome is accomplished with a triple screen. Maternal serum alpha-fetoprotein is elevated in 20-25% of all cases of Down syndrome, and it is elevated in fetal neural tube deficits. Levels of hCG are higher in Down syndrome and levels of unconjugated estriol are lower in Down syndrome.

2.If levels are abnormal, an ultrasound examination is performed and genetic amniocentesis is offered. The triple screen identifies 60% of Down syndrome cases. Low levels of all three serum analytes identifies 60-75% of all cases of fetal trisomy 18.

B.At 15-18 weeks, genetic amniocentesis should be offered to patients >35 years old, and it should be offered if a birth defect has occurred in the mother, father, or in previous offspring.

C.Screening ultrasound. Ultrasound measurement of crown-rump length at 7 to 14 weeks is the most accurate technique for estimation of gestational age; it is accurate within three to five days.

D.At 24-28 weeks, a one-hour Glucola (blood glucose measurement 1 hour after 50-gm oral glucose) is obtained to screen for gestational diabetes. Those with a particular risk (eg, previous gestational diabetes or fetal macrosomia), require earlier testing. If the 1 hour test result is greater than 140 mg/dL, a 3-hour glucose tolerance test is necessary.

E.Second trimester education. Discomforts include backache, round ligament pain, constipation, and indigestion.

VIII. Clinical assessment at third trimester visits

A.Fetal movement is documented. Vaginal bleeding or symptoms of preterm labor should be sought. Preeclampsia symptoms (blurred vision, headache, rapid weight gain, edema) are sought.

B.Fetal heart rate is documented at each visit.

C.At 26-30 weeks, repeat hemoglobin and hematocrit are obtained to determine the need for iron supplementation.

D.At 28-30 weeks, an antibody screen is obtained in Rhnegative women, and D immune globulin (RhoGAM) is administered if negative.

E.At 36 weeks, repeat serologic testing for syphilis is recommended for high risk groups.

F.Sexually transmitted disease. Testing for sexually transmitted diseases (eg, HIV, syphilis, hepatitis B surface antigen, chlamydia, gonorrhea) should be repeated in the third trimester in any woman at high risk for acquiring these infections; all women under age 25 years should be retested for Chlamydia trachomatis late in pregnancy.

G.Screening for group B streptococcus colonization at 35-37 weeks. All pregnant women should be screened for group B beta-hemolytic streptococcus (GBS) colonization with swabs of both the lower vagina and rectum at 35 to 37 weeks of gestation. The only patients who are excluded from screening are those with GBS bacteriuria earlier in the current pregnancy or those who gave birth to a previous infant with invasive GBS disease. These latter patients are not included in the screening recommendation because they should receive intrapartum antibiotic prophylaxis regardless of the colonization status.

H.Influenza immunization is recommended for women in the second and third trimesters and for high-risk women prior to influenza season regardless of stage of pregnancy.

I.Third trimester education

1.Signs of labor. The patient should call physician when rupture of membranes or contractions have occurred every 5 minutes for one hour.

2.Danger signs. Preterm labor, rupture of membranes, bleeding, edema, signs of preeclampsia.

3.Common discomforts. Cramps, edema, frequent urination.

J.At 36 weeks, a cervical exam may be completed. Fetal

position should be assessed by palpation (Leopold’s Maneuvers).

References: See page 155.

Normal Labor

Labor consists of the process by which uterine contractions expel the fetus. A term pregnancy is 37 to 42 weeks from the last menstrual period (LMP).

I.Obstetrical History and Physical Examination

A.History of the present labor

1.Contractions. The frequency, duration, onset, and intensity of uterine contractions should be determined. Contractions may be accompanied by a '’bloody show" (passage of blood-tinged mucus from the dilating cervical os). Braxton Hicks contractions are often felt by patients during the last weeks of pregnancy. They are usually irregular, mild, and do not cause cervical change.

2.Rupture of membranes. Leakage of fluid may occur alone or in conjunction with uterine contractions. The patient may report a large gush of fluid or increased moisture. The color of the liquid should be determine, including the presence of blood or meconium.

3.Vaginal bleeding should be assessed. Spotting or bloodtinged mucus is common in normal labor. Heavy vaginal bleeding may be a sign of placental abruption.

4.Fetal movement. A progressive decrease in fetal movement from baseline, should prompt an assessment of fetal well-being with a nonstress test or biophysical profile.

B.History of present pregnancy

1.Estimated date of confinement (EDC) is calculated as 40 weeks from the first day of the LMP.

2.Fetal heart tones are first heard with a Doppler instrument 10-12 weeks from the LMP.

3.Quickening (maternal perception of fetal movement) occurs at about 17 weeks.

4.Uterine size before 16 weeks is an accurate measure of dates.

5.Ultrasound measurement of fetal size before 24 weeks of gestation is an accurate measure of dates.

6.Prenatal history. Medical problems during this pregnancy should be reviewed, including urinary tract infections, diabetes, or hypertension.

7.Antepartum testing. Nonstress tests, contraction stress tests, biophysical profiles.

8.Review of systems. Severe headaches, scotomas, hand and facial edema, or epigastric pain (preeclampsia) should be sought. Dysuria, urinary frequency or flank pain may indicate cystitis or pyelonephritis.

C.Obstetrical history. Past pregnancies, durations and outcomes, preterm deliveries, operative deliveries, prolonged labors, pregnancy-induced hypertension should be assessed.

D.Past medical history of asthma, hypertension, or renal

disease should be sought.

II.Physical examination

A.Vital signs are assessed.

B.Head. Funduscopy should seek hemorrhages or exudates, which may suggest diabetes or hypertension. Facial, hand and ankle edema suggest preeclampsia.

C.Chest. Auscultation of the lungs for wheezes and crackles may indicate asthma or heart failure.

D.Uterine Size. Until the middle of the third trimester, the distance in centimeters from the pubic symphysis to the uterine fundus should correlate with the gestational age in weeks. Toward term, the measurement becomes progressively less reliable because of engagement of the presenting part.

E.Estimation of fetal weight is completed by palpation of the gravid uterus.

F.Leopold's maneuvers are used to determine the position of the fetus.

1.The first maneuver determines which fetal pole occupies the uterine fundus. The breech moves with the fetal body. The vertex is rounder and harder, feels more globular than the breech, and can be moved separately from the fetal body.