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OB/GYN

Case 22 Vaginal Infections

- Trichomonas vaginalis: foul-smelling vaginal discharge that is greenish & frothy. Strawberry
cervix is usually noted on exam. On microscopic exam there is motile, flagellated trichomonads, &
many white blood cells.
- Fungal infections tend to have thick discharge & cause significant pruritis.
- The discharge of bacterial vaginosis is often thinner & patients complain of a fishy odor.
- Bacterial vaginosis: condition of excessive anaerobic bacteria in the vagina, leading to a discharge
that is alkaline.
- Candida vulvovaginitis: vaginal &/or vulvar infection caused by Candida species, usually w/
heterogenous discharge & inflammation.
- Trichomonas vaginitis: infection of the vagina caused by the protozoa Trichomonas vaginalis,
usually associated w/ a frothy green discharge & intense inflammatory response.
- More than 75% of women have at least one episode of vulvovaginal candidiasis during their
lifetime.
o The presenting symptom is a thick, whitish discharge that has no odor & the patient complains of
significant pruritis of the external & internal genitalia.
o The discharge has a pH b/w 4.0 & 5.0.
o The diagnosis is confirmed by wet mount or KOH preparation showing budding yeast or
pseudohyphae.
o Fungal cultures are not needed to confirm the diagnosis, but they are useful if the
infection recurs or is unresponsive to treatment.
- Treatment of complicated or recurrent infection should begin w/ an intensive regimen for 10 14
days followed by 6 months of maintenance therapy to reduce the likelihood of recurrence.
- Trichimoniasis is classified as a sexually transmitted disease. The incubation period is 3-21 days
after exposure.
o Certain factors predispose to infection, such as multiple sexual partners, pregnancy, &
menopause.
o The presenting complain is copious amounts of thin, frothy, green-yellow or gray malodorous
vaginal discharge.
o Vaginal exam may reveal that the cervix has a strawberry appearance or that
redness of the vagina & perineum is present.
o Wet mount prep can demonstrate motile trichomonads, although cultures may be necessary.
o The recommended treatment for trichomonas is oral metronidazole, given in a single, 2-g oral dose
or 1-week regimen of 500 mg twice a day to both the patient & her sexual partner.
o It is important to screen for other sexually transmitted diseases (STDs) & to
remember to treat the partner to ensure better cure rates.
- Bacterial vaginosis (BV) arises when normal vaginal bacteria are replaced w/ an overgrowth of
anaerobic bacteria & G. vaginalis. It is not an STD, but is associated w/ multiple sexual partners.
o Diagnosis is based on the presence of 3 out of the 4 criteria: (1) a thin, homogenous
vaginal discharge; (2) a vaginal pH more than 4.5; (3) a positive KOH whiff test (a fishy
odor present after the addition of 10% KOH
to a smaple of the discharge); & (4) the presence of clue cells in a wet
mount preparation. o Txment options include both metronidazole or
clindamycin.
o Treatment of BV in a symptomatic pregnant women may reduce the incidence of preterm
delivery.
- Mucopurulent cervicitis is characterized by purulent or mucopurulent discharge from the
endocervix, which may be associated w/ vaginal discharge &/or cervical bleeding.
o Approx. 50% of gonococcal infections & 70% of chlamydial infections are asymptomatic in
women.

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o The gold standard for establishing the diagnosis of a culture is cervical discharge. Emperic
treatment should be considered in areas of high prevalence of infection or if follow-up is
unlikely.
o Txment of gonorrhea is ceftriaxone 125 mg intramuscularly & for chlamydia is doxycycline
100 mg orally BID for 7 days or azithromycin in a single 1-g dose.
- Pelvic inflammatory disease (PID) is defined as inflammation of the upper genital tract, including
pelvic peritonitis, endometritis, salpingitis, & tuboovarian abscess caused by infection w/
gonorrhea, Chlamydia, or vaginal & bowel flora.
o Lower abdominal tenderness w/ both adnexal & cervical motion tenderness without other
explanation of illness is enough to diagnose PID.
o Other criteria that enhance the specificity of the diagnosis include temperature more than 101 degree
F, abnormal cervical or vaginal discharge, elevated sedimentation rate, elevated C-reactive protein, &
cervical
infection w/ gonorrhea or Chlamydia.
o B/c of the clinical similarity b/w PID & ectopic pregnancy, a serum pregnancy test should be
performed on all patients suspected of having PID.
o Less-severe disease can generally be treated on an outpatient basis. Women who are pregnant,
have HIV, or have severe disease generally require inpatient therapy & treatment w/ parenteral
antibiotics.
o Pts w/ PID need to be aware of potential complications, including the potential for recurrence of
disease, the development of tuboovarian abscess, chronic abdominal pain, infertility, & the
increased risk of ectopic
pregnancy.

Case 16 Labor & Delivery:

- Signs that could confirm the rupture of membranes:
o Visualization of amniotic fluid leaking from the cervix, the presence of pooling of amniotic
fluid in the posterior vaginal fornix, demonstration of a pH above 6.5 in fluid collected
from the vagina using Nitrazine paper, or visualization of ferning on a sample of fluid on
an air-dried microscope slide.
- Recommended antibiotic prophylaxis for GBS colonization during labor: Penicillin 5 million units IV
loading dose followed by 2.5 million units IV every 4 hrs; IV ampicillin, cephalothin, erythromycin,
clindamycin, & vancomycin.
- Fetal lie: the relationship of the long axis of the fetus to the long axis of the mother; either
longitudinal or transverse.
- Fetal presentation: the part of the fetus that is either foremost in the birth canal or in closest
proximity to the birth canal.
- Labor: regular uterine contractions that lead to the effacement & dilation of the cervix.
- Premature rupture of membranes: rupture of the fetal membranes prior to the onset of labor.
- The first stage of labor is from the onset of labor until the cervix is completely dilated.
o During the latent phase of labor, the contractions become stronger, longer lasting, & more
coordinated.
o The active phase of labor, which usually starts at 3-4 cm of cervical dilation, is when
the rate of cervical dilation is at its maximum. Contractions are usually strong &
regular.
- The second stage of labor is from complete cervical dilation (10 cm) thru the delivery of the fetus.
- The third stage of labor begins after the delivery of the baby & ends w/ the delivery of the placenta
& membranes.
- The progress of labor usually depends upon the three Ps.
o The power is the strength of the uterine contractions during the active phase of labor
& of the maternal pushing efforts during the 2nd phase of labor.
o The passenger is the fetus. Its size, lie, presentation, & position w/in the birth canal all play a
role in the progression of labor & rate of fetal descent.
o The shape & size of the pelvis can result in delay or failure of descent of the fetus b/c of
the relative disproportion b/w the fetal & pelvic sizes.
- When the pregnant patient is admitted to the labor & delivery unit, fetal well-being is assessed by
either continuous or intermittent fetal heart rate monitoring. Important considerations in
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interpreting fetal heart rate data are the baseline heart rate, variability, & periodic heart rate
changes.
- The presence of accelerations, whether occurring spontaneously or in response to contractions,
fetal movement, or stimulation of the fetus virtually ensures that the fetal arterial pH is greater
than 7.2.
- Decelerations are generally defined as early, late, or variable based ont eh timing of the
deceleration in relation to a contraction.
o An early deceleration coincides w/ a contraction in onset of the fetal heart rate decline &
return ot the
baseline.
o A late deceleration is a gradual reduction in the fetal heart rate that starts at or after the peak of a
contraction & has a gradual return to the baseline.
o A variable deceleration is an abrupt decrease in fetal heart rate, usually followed by
an abrupt return to baseline that occurs variability in its timing, relative to a
contraction.
- During labor, the fetal head descends thru the birth canal & undergoes 4 cardinal movements.
o During initial descent, the head undergoes flexion, bringing the fetal chin to the chest.
o As descent progresses internal rotation occurs, causing the fetal occiput to move anteriorly
toward the maternal symphysis pubis.
o As the head approaches the vulva it undergoes extension, to allow the head to pass below the
symphysis pubis & through the upward-directed vaginal outlet.
o Further extension leads to the delivery of the head, which then restitutes via external
rotation to face either to the maternal right or left side.
- The anterior shoulder can get stuck below the maternal pubic symphysis, this is called shoulder
dystocia & is an obstetrical emergency. Maneuvers, including hyperflexion of the hips (McRoberts
maneuver), suprapubic pressure, cutting an episiotomy, or rotation of the fetal body in the
vaginal canal are attempted.

Case 26 Postpartum Care:

- Endometritis: a polymicrobial infection of the endometrium of the uterus, usually caused by
ascending infection from the vagina.
- Lochia: yellow-whit discharge, consisting of blood cells, decidual cells, & fibrinous products,
that occurs following delivery.
- In women who are not breast-feeding, menstruation usually restarts by the 3 rd postpartum month.
- The 4 Ts of postpartum hemorrhage:
o Tone: uterine atony
o Trauma: cervical, vaginal, or perineal lacerations; uterine
inversion o Tissue: retained placenta or membranes.
o Throbin: coagulopathies.
- Uterine atony is the most common cause of postpartum hemorrhage.
o Initial management of uterine atony includes the IV administration of oxytocin &
initiation of bimanual uterine massage.
o Methylergonovine is contraindicated in patients w/ hypertension, as it may cause an abrupt
increase in blood pressure.
- Postpartum fever, especially if associated w/ uterine tenderness & foul-smelling lochia, is often a
sign of endometritis.

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- Urinary tract infections are another common cause of fever after both vaginal &
cesarean deliveries.
- Approx. 30% to 70% of women develop a temporary state known st
as the
maternity blues or baby blues. This condition develops w/in the 1 wk after
delivery & typically resolves by the 10th postpartum day.
o Symptoms include tearfulness, sadness, & emotional lability.
- The symptoms of postpartum depression are the same as in major depression.
There is a high recurrence rate in subsequent pregnancies & an increased risk in
women w/ a history of depression unrelated to pregnancy.
o Treatment is similar to the treatment of nonpregnancy-related depression.
- Postpartum psychosis is a rare, but potentially devastating, complication following
pregnancy.
- Neonatal benefits of breast-feeding include ideal nutrition, increased resistance to
infection, & a reduced risk of GI difficulties. Maternal benefits include improved
mother-child bonding, more rapid uterine involution, quicker return to pre-pregnant
body weight, convenience, decreased costs, & long-term reduced risks of ovarian &
breast cancer.
- There are few contraindications to breast-feeding.
o HIV infection, acute, active hepatitis B infection and women who have
had breast-reduction surgery w/ nipple transplantation will be unable to
breast feed.
- In breast-feeding women, the progestin-only pills are preferred b/c the combination of
OCPs might reduce lactation.
- Non-breast-feeding women should wait 3 weeks after delivery to start combined
OCPs, as the risk of thromboembolic disease is higher in those who start at earlier
times.
- Diaphragms & cervical caps can be used, but should be refitted at the 6-week visit to
ensure an appropriate fit.
- Lactation-induced amenorrhea provides a high level of natural contraception in the
1st 6 months postpartum.

Case 28 Family Planning Contraceptives:

- Intrauterine contraceptive device: Small T-shaped device, usually plastic w/ or w/out
copper or a progestin, placed in the endometrial cavity as a method of long-term
contraception.
- Typical use effectiveness: overall efficacy in actual use, when forgetfulness &
improper use occur.
- Perfect use effectiveness: efficacy of a method when always used correctly,
consistent & reliable use occur.
- Barrier contraceptive: prevents sperm from entering upper female reproductive tract.
- Steroid hormone contraception: synthetic estrogen &/or progestin to provide
contraception in various methods, including oral contraceptive pills, contraceptive
patch, contraceptive ring, contraceptive injection, & implants.
- There are 2 types of oral contraceptive pills (OCPs): combination pills, which contain
both estrogen & a progestin, &
mini pills which contain only progestin.
o The combination pill suppresses ovulation through inhibition of the
hypothalamic-pituitary-ovarian axis, alters the cervical mucus, retards
sperm entry, & discourages implantation into an unfavorable
endometriums.
o Combination oral contraceptives offer significant protection against ovarian
cancer, endometrial cancer, iron-deficiency anemia, pelvic inflammatory
disease (PID), & fibrocystic breast disease.
o Women who take combination pills have a lower risk of functional ovarian
cysts.
o The minipill reduces cervical mucus & causes it to thicken. The mucus
thickening prevents the sperm from reaching the egg & keeps the uterine
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lining from thickening, which prevents the fertilized egg from implanting in
the uterus.
- If a pill is missed it should be taken as soon as possible & the next dose should be
taken as usual.
- Depo-provera is an injectable form of progestin. Each injection provides
contraception protection for 14 weeks.
o Side effects include irregular menses, weight gain, & facial/body hair growth.
- The patchs efficacy & side effects are comparable to that of combined OCPs,
although there may be an increased risk of vascular thrombosis w/ use of the patch.
- A woman inserts the NuvaRing herself, wears it for 3 weeks, then removes &
discards the device. The main adverse effect being disrupted bleeding.
- Spermicides should be inserted into the vagina w/in an hour before intercourse. If
intercourse is repeated, more spermicide should be inserted. The active
ingredient in most spermicides is the chemical nonoxynol-9.
o When spermicides are used w/ a condom, the failure rate is comparable to
that of oral contraceptives.
- There are 5 barrier methods of contraceptions: male condoms, female condoms,
diaphragm, sponge, & cervical cap.
- Condoms on the market are made either of latex rubber or natural skin. Of these
2 types, only latex condoms are highly effective in preventing STDs.
- The diaphragm must be fitted by a health professional & the correct size
prescribed to ensure a snug seal w/ the vaginal wall. The diaphragm should be
left in place for at least 6 hrs after intercourse.
- An IUD alters the uterine & tubal fluids, particularly in the case of copper-bearing
IUDs, inhibiting the transport of sperm through the cervical mucus & uterus.
Progesterone-containing IUDs also thin the uterine lining.
o The risk of PID w/ IUD use is highest in those women w/ multiple sex
partners or who have a history of previous PID.
o IUD is recommended primarily in women in mutually monogamous
relationships.
o Absolute contraindications for IUD include current, recent (w/in 3 months) &
recurrent endometritis, PID, or STD; pregnancy; anatomically distorted uterine cavity;
& known or suspected HIV infection.