Notes

Emergency contraceptive pills are not an abortifacient, and they have not been shown to cause any teratogenic effect if inadvertently administered during pregnancy. They are more effective the sooner they are taken after unprotected intercourse, and it is recommended that they be started within 72 hours, and no later than 120 hours. - start with that then continue normal contraceptives
Ideal candidates for progestin-only pills include women who have contraindications to using combined oral contraceptives (estrogen and progestin containing). Contraindications to estrogen include a history of thromboembolic disease, women who are lactating, women over age 35 who smoke or women who develop severe nausea with combined oral contraceptive pills.
Oral contraceptives will decrease a woman’s risk of developing ovarian and endometrial cancer. The first developed higher dose oral contraceptive pills have been linked to a slight increase in breast cancer, but not the most recent (current) lower dose pills. Women who use oral contraceptive pills have a slightly higher risk of developing cervical intraepithelial neoplasia, but their risk of developing PID, endometriosis, benign breast changes and ectopic pregnancy are reduced.
Hysteroscopic tubal occlusion (Essure®) can be performed in the office and places coils into the fallopian tubes that cause scarring that blocks the tubes.
The levonorgestrel intrauterine device is protective against endometrial cancer due to release of progestin in the endometrial cavity. She is not a candidate for oral contraceptive pills because of her poorly controlled chronic hypertension. The progestin-only pills have a much higher failure rate than the progesterone intrauterine device. She is not a candidate for the copper-containing intrauterine device because of her history of Wilson’s disease.
Ortho evra patch - It has a significantly higher failure rate when used in women who weigh more than 198 pounds.
While Depo-Provera is an effective form of contraception, it may not be the best choice in this woman with a high BMI.
*************The patient has a septic abortion. She has fever and bleeding with a dilated cervix which are findings seen with septic abortion. Threatened abortions clinically have vaginal bleeding, a positive pregnancy test and a cervical os closed or uneffaced. Missed abortions have retention of a nonviable intrauterine pregnancy for an extended period of time (i.e. dead embryo or blighted ovum). A normal pregnancy would have a closed cervix. Ectopic pregnancy would likely present with bleeding, abdominal pain, possibly have an adnexal mass, and the cervix would typically be closed.****************
The management of septic abortion includes broad-spectrum antibiotics and uterine evacuation.
Antiphosphospholipid antibodies are associated with recurrent pregnancy loss. The workup for antiphospholipid syndrome includes assessment of anticardiolipin and beta-2 glycoprotein antibody status, PTT, and Russell viper venom time. Recurrent pregnancy loss is defined as > two consecutive or > three spontaneous losses before 20 weeks gestation. The treatment is aspirin plus heparin.
Medical abortion is associated with higher blood loss than surgical abortion. Early in pregnancy (less than 49 days) both medical and surgical procedures can be offered. Mifepristone (an antiprogestin) can be administered, followed by misoprostol (a prostaglandin) to induce uterine contractions to expel the products of conception.
Manual vacuum aspiration is more than 99% effective in early pregnancy (less than eight weeks).
Mifepristone, a progesterone receptor blocker, is used for pregnancy termination. It is recommended for use within 49 days of the last menstrual period, but there is data to show that it can be effective up to nine weeks.
Missed abortion - Misoprostol can be administered orally or vaginally and will induce uterine cramping with expulsion of products of conception.
This patient is having heavy bleeding as a complication of medical termination of pregnancy. The most likely etiology for her bleeding is retained products of conception. This is managed best by performing a dilation and curettage.
Ninety-seven percent of pregnancies found to have an endometrial stripe thickness < or = 8 mm were abnormal (EP or spontaneous abortion).
This patient has postoperative endometritis that could be due to introduction of bacteria into the uterine cavity at the time of dilation and curettage. It is important to begin antibiotics immediately. After starting antibiotics, an ultrasound should be obtained to look for products of conception. If found, the patient would then require a repeat dilation and curettage.
Bacterial vaginosis - The majority of women are asymptomatic; however, patients may experience a thin, gray discharge with a characteristic fishy odor that is often worse following menses and intercourse. Modified Amsel criteria for diagnosis include three out of four of the following: 1) thin, gray homogenous vaginal discharge; 2) positive whiff test (addition of potassium hydroxide releases characteristic amine odor); 3) presence of clue cells on saline microscopy; and 4) elevated vaginal pH >4.5. Treatment consists of Metronidazole 500 mg orally BID for seven days, or vaginal Metronidazole 0.75% gel QHS for five days.
Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects Caucasian premenarchal girls and postmenopausal women. Patients typically present with extreme vulvar pruritus and may also present with vulvar burning, pain and introital dyspareunia. Vagina not involved. Treatment involves use of high-potency topical steroids.
Lichen planus is a chronic dermatologic disorder involving the hair-bearing skin and scalp, nails, oral mucous membranes and vulva. This disease manifests as inflammatory mucocutaneous eruptions characterized by remissions and flares. The exact etiology is unknown, but is thought to be multifactorial. Vulvar symptoms include irritation, burning, pruritus, contact bleeding, pain and dyspareunia. Clinical findings vary with a lacy, reticulated pattern of the labia and perineum, with or without scarring and erosions as well. With progressive adhesion formation and loss of normal architecture, the vagina can become obliterated. Patients may also experience oral lesions, alopecia and extragenital rashes. Treatment is challenging, since no single agent is universally effective and consists of multiple supportive therapies and topical high potency corticosteroids.
Vestibulodynia (formally vulvar vestibulitis) syndrome consists of a constellation of symptoms and findings limited to the vulvar vestibule, which include severe pain on vestibular touch or attempted vaginal entry, tenderness to pressure and erythema of various degrees. Symptoms often have an abrupt onset and are described as a sharp, burning and rawness sensation. Women may experience pain with tampon insertion, biking or wearing tight pants, and avoid intercourse because of marked introital dyspareunia. Treatment includes use of tricyclic antidepressants to block sympathetic afferent pain loops, pelvic floor rehabilitation, biofeedback, and topical anesthetics.
Lichen simplex chronicus, a common vulvar non-neoplastic disorder, results from chronic scratching and rubbing, which damages the skin and leads to loss of its protective barrier. Over time, a perpetual itch-scratch-itch cycle develops, and the result is susceptibility to infection, ease of irritation and more itching. Symptoms consist of severe vulvar pruritus, which can be worse at night. Clinical findings include thick, lichenified, enlarged and rugose labia, with or without edema. The skin changes can be localized or generalized. Diagnosis is based on clinical history and findings, as well as vulvar biopsy. Treatment involves a short-course of high-potency topical corticosteroids and antihistamines to control pruritus.
Mucopurulent cervicitis (MPC) is characterized by a mucopurulent exudate visible in the endocervical canal or in an endocervical swab specimen. MPC is typically asymptomatic, but some women have an abnormal discharge or abnormal vaginal bleeding. MPC can be caused by Chlamydia trachomatis or Neisseria gonorrhoeae; however, in most cases neither organism can be isolated. Patients with MPC should be tested for both of these organisms. The results of sensitive tests for C. trachomatis or N. gonorrhoeae (e.g. culture or nucleic acid amplification tests) should determine the need for treatment, unless the likelihood of infection with either organism is high or the patient is unlikely to return for treatment. Antimicrobial therapy should include coverage for both organisms, such as azithromycin or doxycycline for chlamydia and a cephalosporin or quinolone for gonorrhea. Uncomplicated cervicitis, as in this patient, would require only 125 mg of Ceftriaxone in a single dose. Ceftriaxone 250 mg is necessary for the treatment of upper genital tract infection or pelvic inflammatory disease (PID).
Most cases of recurrent genital herpes are caused by HSV-2. Up to 30% of first-episode cases of genital herpes are caused by HSV-1, but recurrences are much less frequent for genital HSV-1 infection than genital HSV-2 infection. Genital HSV infections are classified as initial primary, initial nonprimary, recurrent and asymptomatic. Initial, or first-episode primary genital herpes is a true primary infection (i.e. no history of previous genital herpetic lesions, and seronegative for HSV antibodies). Systemic symptoms of a primary infection include fever, headache, malaise and myalgias, and usually precede the onset of genital lesions. Vulvar lesions begin as tender grouped vesicles that progress into exquisitely tender, superficial, small ulcerations on an erythematous base. Initial, nonprimary genital herpes is the first recognized episode of genital herpes in individuals who are seropositive for HSV antibodies. Prior HSV-1 infection confers partial immunity to HSV-2 infection and thereby lessens the severity of type 2 infection. The severity and duration of symptoms are intermediate between primary and recurrent disease, with individuals experiencing less pain, fewer lesions, more rapid resolution of clinical lesions and shorter duration of viral shedding. Systemic symptoms are rare. Recurrent episodes involve reactivation of latent genital infection, most commonly with HSV-2, and are marked by episodic prodromal symptoms and outbreaks of lesions at varying intervals and of variable severity. Clinical diagnosis of genital herpes should be confirmed by viral culture, antigen detection or serologic tests. Treatment consists of antiviral therapy with acyclovir, famciclovir or valacyclovir.
. This patient has a vulvar lesion causing her pain. The next step is to perform a biopsy to evaluate for vulvar cancer. Estrogen cream and clobetasol (a high potency steroid) are treatments for vulvadynia. To diagnosis vulvadynia, all other causes of pain must first be excluded, including infectious etiologies as well as other vulvar conditions.
The patient has the diagnosis of detrusor instability. The parasympathetic system is involved in bladder emptying and acetylcholine is the transmitter that stimulates the bladder to contract through muscarinic receptors. Thus, anticholinergics are the mainstay of pharmacologic treatment. Oxybutynin is one example. Although the tricyclic antidepressant, amitriptyline, has anticholinergic properties, its side effects do not make it an ideal choice. Vaginal estrogen has been shown to help with urgency, but not urge incontinence. Pseudoephedrine has been shown to have alpha-adrenergic properties and may improve urethral tone in the treatment of stress incontinence. Kegel exercises or pelvic muscle training are used to strengthen the pelvic floor and decrease urethral hypermobility for the treatment of stress urinary incontinence.