Notes

Pap test screening is not indicated in patients who have had a hysterectomy, unless it was done for cervical cancer or a high-grade cervical dyspalsia. Patients with a uterus can discontinue cervical cancer screening between the ages of 65–70 if they have had three consecutive negative smears or two negative consecutive cotesting in the last 10 years and no history of high-grade cervical intraepithelial neoplasia or cancer. Patients still need yearly bimanual and rectovaginal exam.
Women ages 30 to 65 years should be screened with cytology and HPV testing (‘‘co-testing’’) every five years (preferred) or cytology alone every three years (acceptable).
The American Society for Colposcopy and Cervical Pathology guidelines recommend immediate LEEP or colposcopy for women with HSIL cytology test results. A diagnostic excisional procedure is recommended for women with HSIL cytology test results when the colposcopic examination is inadequate.
This patient has findings suggestive of acute salpingitis (pelvic inflammatory disease) including lower abdominal pain, adnexal tenderness, fever, cervical motion tenderness, and vaginal discharge. Mucopurulent cervicitis with exacerbation in the symptoms during and after menstruation is classically gonorrhea. Chlamydia is frequently associated with gonorrhea and also causes cervicitis and pelvic inflammatory disease.
This patient most likely has trichomoniasis. The erythematous patches on the cervix are characteristic of “strawberry cervicitis.” Trichomonads are unicellular protozoans, which are easily seen moving across the slide with flagella. The slide must be examined immediately. The discharge is mixed with saline and placed on the slide with a cover slip. Women with trichomonas vaginal infections may have a frothy, yellow-green vaginal discharge. Clue cells are seen on a saline wet mount in women who have bacterial vaginosis. Clue cells are characterized by adherent coccobacillary bacteria that obscure the edges of the cells. A drop of KOH releases amines from the cells and a fishy odor is noted if bacterial vaginosis is present. Yeast vaginitis is characterized by a thick white clumpy discharge which results in erythema, swelling and intense pruritus. Multinucleate giant cells and inflammation may be herpes.
The American Congress of Obstetricians and Gynecologists’ (ACOG) recommendation from 2012 is for patients to have cervical cancer screening starting at 21 years of age regardless of history of sexual activity
Women should be offered colorectal cancer screening starting at age 50. Options include yearly hemoccult testing, flexible sigmoidoscopy every five years, or colonoscopy every 10 years.
ACOG recommends that women aged 40 years and older be offered screening mammography annually.
Bone density screening is recommended for women beginning at age 65 unless they have pre-existing risk factors which warrant earlier screening. Risk factors for osteoporosis are early menopause, glucocorticoid therapy, sedentary lifestyle, alcohol consumption, hyperthyroidism, hyperparathyroidism, anticonvulsant therapy, vitamin D deficiency, family history of early or severe osteoporosis, or chronic liver or renal disease.
This patient has pulmonary edema. Plasma osmolality is decreased during pregnancy which increases the susceptibility to pulmonary edema. Common causes of acute pulmonary edema in pregnancy include tocolytic use (drugs used to reduce preterm labor), cardiac disease, fluid overload and preeclampsia.
Pregnancy - TBG increases so total t4 and t3 increase, but free t4 stays same.
This patient’s presentation is classic for a molar pregnancy. Beta-hCG levels in normal pregnancy do not reach one million. A chest x-ray would be the most appropriate step, as the lungs are the most common site of metastatic disease in patients with gestational trophoblastic disease. Though a repeat quantitative Beta-hCG will be required on a weekly basis, an immediate post-operative value will be of little clinical utility.
The recommendations for pregnancy weight gaint are: underweight (BMI < 18.5 kg/m2) total weight gain 28 – 40 pounds; normal weight (BMI 18.5 – 24.9 kg/m2) total weight gain 25 – 35 pounds; overweight (BMI 25 – 29.9 kg/m2) total weight gain 15 - 25 pounds; and obese (BMI > 30 kg/m2) total weight gain 11 - 20 pounds.
Folic acid non-risk patients at least 0.6 mg/day. Prior neural tube defect 4 mg folic acid.
Braxton Hicks contractions are characterized as short in duration, less intense than true labor, and the discomfort as being in the lower abdomen and groin areas. True labor is defined by strong, regular uterine contractions that result in progressive cervical dilation and effacement
Cultures for group B streptococcus are not required in women who have group B streptococcal bacteriuria during the current pregnancy or who have previously given birth to a neonate with early-onset group B streptococcal disease because these women should receive intrapartum antibiotic prophylaxis. Universal screening with a recto-vaginal culture at 35–37 weeks of gestation is recommended for all women who do not have an indication for intrapartum antibiotic prophylaxis. All women with positive cultures for group B streptococci should receive intrapartum antibiotic in labor unless a cesarean delivery is performed before onset of labor in a woman with intact amniotic membranes.