PANCE Blueprint Reproductive System (7%)

Lessons

1. 2020 PANCE Reproductive System Content Blueprint

2. 2019 PANRE and Pilot Alternative to PANRE Reproductive System Content Blueprint

3. Reproductive System With Joe Gilboy PA-C (Video Lecture)

   40 mins

   Joe Gilboy PA-C
4. Reproductive System Comprehensive Exam
5. Reproductive System Flashcards
6. Breast Disorders (PEARLS)
   1. Breast abscess

      Often is a complication of mastitis - symptoms are the same with the addition of localized mass and systemic signs of infection

      • Staphylococcus aureus is the most common cause. Incision and drainage + antibiotics (nafcillin/oxacillin IV or cefazolin PLUS metronidazole)
   2. Fibroadenoma

      Young adult female with painless, firm solitary (rubbery feeling) well defined mobile breast mass. No changes with menstrual cycle
   3. Fibrocystic disease

      Multiple bilateral breast masses that increase in size and pain before menses, usually resolves with the start of the menstrual cycle. Aspiration of cysts- straw colored fluid with no blood
   4. Galactorrhea

      Bilateral milky breast secretions that occur in a non-lactating patient

      • Rule out prolactin-secreting pituitary adenoma, TSH, CT or  MRI. Treat with dopamine agonist - bromocriptine
   5. Gynecomastia

      Physiologic gynecomastia: affects pubescent boys. Watch and wait, typically resolved in 1 year

      • Drugs: particularly spironolactone, anabolic steroids, and antiandrogens
      • Klinefelter’s syndrome- XXY karyotype, tall, thin, long limbs. Hypogonadism. Treatment: Danazol

   6. Mastitis (Lecture)

      Occurs in breastfeeding mothers. Organism: S. aureus, treat with Dicloxacillin, warm compresses. Continue to breastfeed

      • Infectious (unilateral) - Unilateral, fever, chills and color change
      • Congestive (bilateral) - Bilateral breast engorgement that usually occurs in primigravidas
      • Inflammatory breast cancer presents with breast tenderness and color change, but fever and chills are not usually present
7. Cervical Disorders (PEARLS)

   1. Brian Wallace PA-C Podcast: S2 Review of Cervical and Vaginal Disorders

      Brian Wallace PA-C
   2. Cervicitis (Lecture)

      Usually occurs due to sexually-transmitted diseases, such as chlamydia or gonorrhea, herpes, HPV, trichomonas

      • Cervical motion tenderness. Ceftriaxone for gonorrhea + Azithromycin for Chlamydia
   3. Cervical Dysplasia

      HPV especially types 16, 18. Associated with cigarette smoking

      • Transformational zone most commonly affected, Gardasil vaccine at age 11-12 it can be administered starting at 9 years of age
      • Pap smear every 3 years starting at age 21 (regardless of sexual activity). Every 5 years if pap smear and HPV are negative starting at age 30
      • ASC-US or LSIL, CIN-1: Reflex HPV, if positive and at least 25 years old – colposcopy, if negative or under 25 years old – retest in 1 year
      • HSIL, CIN-2, CIN-3, CIS: Colposcopy. Outside cervix – LEEP or cryotherapy
8. Complicated Pregnancy (PEARLS)

   1. Brian Wallace PA-C Podcast: S2 Complicated Pregnancy Parts 1-5

      Brian Wallace PA-C

   2. Abortion

      • Threatened – vaginal bleeding, closed cervical os
      • Inevitable – vaginal bleeding, open cervical os, no passage of tissue
      • Incomplete – vaginal bleeding and tissue passage from open cervical os
      • Complete – complete passage of fetal tissue
   3. Abruptio placentae

      When you see painful vaginal bleeding in the third trimester think abruptio placenta

      • Delivery of the fetus and placenta is definitive treatment, blood type, cross-match and coag studies as well as placement of large bore IV line, Cesarean section most often is the preferred route for delivery
   4. Breech presentation

      A breech birth happens when a baby is born bottom first instead of head first

      • Around 3-5% of pregnant women at term (37-40 weeks pregnant) will have a breech baby
      • Prevalence decreases with increasing gestational age. Twenty to 25 percent of fetuses under 28 weeks are breech, but only 7 to 16 percent are breech at 32 weeks, and only 3 to 4 percent are breech at term
      • Breech presentation may be frank, complete, or incomplete
      • The diagnosis of breech presentation is based on physical examination, with ultrasound confirmation, if the diagnosis is uncertain
      • External cephalic version at or near term, followed by a trial of vaginal delivery if the version is successful and planned cesarean delivery if breech presentation persists
   5. Cesarean delivery

      C-sections constitute about 32% of deliveries in the United States

      • most common reasons for cesarean are a previous cesarean, dystocia or failure to progress, breech presentation and fetal distress
   6. Cord prolapse

      Umbilical cord prolapse occurs when the umbilical cord comes out of the uterus with or before the presenting part of the fetus

      • It is an obstetric emergency and depending on the duration and intensity of compression, may lead to fetal hypoxia, brain damage, and death 
      • Malpresentation and rupture of membranes with the presenting part not applied firmly to the cervix are the most common risk factors for a prolapsed umbilical cord during labor
      • The first sign of umbilical cord prolapse is usually a sudden and severe decrease in fetal heart rate that does not immediately resolve
      • On a fetal heart tracing, this would usually look like moderate to severe variable decelerations
      • Immediate cesarean section is the management of choice for a prolapsed umbilical cord
      • Other interventions include manual elevation of the presenting fetal part and repositioning of the mother to knee-chest position
   7. Dystocia

      Dystocia is defined as an abnormal labor progression  - macrosomia ( big baby),  small pelvis, poor contractions.

      • Shoulder Dystocia: failure of the shoulders to deliver spontaneously after delivery of the fetal head - Turtle Sign – retraction of the delivered head against the maternal perineum McRoberts maneuver and Woods “Corkscrew”
   8. Ectopic pregnancy (Lecture)

      Most often in ampulla. Serial quantitative Beta HCG and transvaginal ultrasound

      • Ring of fire sign (hypervascular lesion with peripheral vascularity on Doppler). HCG is > 1,500, but no fetus in utero. Normal pregnancy HCG increases by 66% every 48 hours 

       
   9. Fetal distress

      Non-stress testing

      • GOOD- Reactive NST - > 2 accelerations in 20 minutes, with increased fetal heart rate 15 bpm lasting > 15 seconds, indicates fetal well being
      • BAD - Nonreactive NST - No fetal heart rate accelerations or < 15 bpm lasting < 15 seconds, get contraction stress test

      Contraction stress test - measures fetal response to stress at times of uterus contraction

      • GOOD - Negative CST - No late decelerations in the presence of 2 contractions in 10 minutes, indicates fetal well being, repeat CST as needed
      • BAD - Positive CST - Repetitive late decelerations in the presence of 2 contractions in 10 minutes, worrisome especially if nonreactive NST, prompt delivery

      APGAR - Appearance, Pulse, Grimace, Activity, Respiration (view scoring system)

      • Score from 1-10 with > 7 normal, 4-6 fairly low, 3 and under critically low
      • Test is done at 1 and 5 minutes after birth
   10. Gestational diabetes

       13 mins

       Most common complication: macrosomia. Glucose tolerance test between 24 and 28 weeks of gestation - 50 g (1 hour) glucose challenge test (non-fasting). Positive if blood glucose is > 130 mg/dL

       • If ≥ 130 mg/dl after 1 hour then get a 3 hour 100 g glucose tolerance test (GOLD STANDARD)
       • Results are positive if - One hour > 180, Two hour > 155, Three hour > 140
       • Insulin is considered first line therapy, glyburide, dietary management
   11. Gestational trophoblastic disease (Lecture)

       Beta HCG higher than expected, size-date discrepancy, hyperemesis

       • Mole Types: Complete mole - no fetal parts “Grape-like” mass or “snowstorm” on transvaginal ultrasound.
       • Incomplete mole - fetal parts
       • Choriocarcinoma - cancer of gestational contents
   12. Hypertension disorders in pregnancy

       Treatment goal: < 140/90. Treat with Methyldopa, Hydralazine, metoprolol

       • Contraindicated: ACE inhibitors, ARBs, diuretics, calcium channel blockers
       • Preeclampsia - Classic triad: HTN, + Proteinuria and edema after 20 weeks GA
       • Eclampsia - HTN, +Proteinuria + seizures or coma. TX magnesium  and delivery
       • HELLP syndrome is a manifestation of preeclampsia with hemolysis, elevated liver enzymes, and low platelets.
   13. Incompetent Cervix

       History of cone biopsy, DES exposure. Causes 2^nd trimester abortion

       • Cervical cerclage. Placed at 14-16 weeks and removed at 36 weeks to allow for delivery
   14. Multiple gestation

       One in 80 births, 3% chance of twins, monitor for complications

       • Elevated beta-HCG. Two or more fetuses observed on ultrasound
       • Monozygotic: identical, Dizygotic: fraternal
   15. Placenta previa (Lecture)

       Painless vaginal bleeding *bright red in 3rd trimester (versus painful, dark red vaginal bleeding in placenta abruptio) usually no abdominal pain

       • No pelvic/cervical digital exam, no intercourse, no vigorous exercise
   16. Postpartum hemorrhage (Lecture)

       Blood loss: > 500 mL of blood within the first 24 hours after vaginal delivery or 1,000 ml with cesarean

       • Uterine atony - defined as a boggy and enlarged uterus - 90% of postpartum hemorrhages.
         • Treatment: Uterotonic agents (contracts the uterus down): Oxytocin IV, Misoprostol, bimanual uterine massage, last resort hysterectomy.
       • Genital Track Trauma - precipitous labor, operative vaginal delivery (forceps, vacuum extraction).
         • Treatment: Laceration greater than 2 cm are repaired surgically.
       • Retained Placental Tissue - Occurs when separation of the placenta from uterine wall or expulsion of the placenta is incomplete.
         • Treatment: Surgery.
       • Coagulation Disorders -DIC associated with severe preeclampsia, amniotic fluid embolism, placental abruption.
   17. Premature rupture of membranes

       Clinical definition: rupture of membranes at ≥ 37 weeks gestation prior to the start of uterine contractions.

       • Preterm premature rupture of membranes (PPROM) describes PROM < 37 weeks gestation.
       • Diagnosis: Need to confirm that this is truly amniotic fluid
         • Speculum - fluid pulling in posterior fornix
         • Nitrazine test - blue (due to elevated pH) determine if this is amniotic fluid - PH > 7.1 means it is positive
         • Microscope examination - ferning - take a specimen of the fluid put it on a slide and let it air dry will see "fern pattern" crystallization of the amniotic fluid (crystallization of estrogen and amniotic fluid)
       • Treatment depends on gestational age:
         • > 34 weeks – induce labor
         • 32-34 weeks collect fluid and check for lung maturity – then induce
         • < 32 weeks stop contractions and start 2 doses of steroid injection then deliver the baby – give antibiotics
   18. RH incompatibility (Lecture)

       Rh negative mother, Rh positive fetus - 1'st pregnancy is always unaffected Give Rhogam at 28 weeks, within 72 hours of delivery and during any uterine bleeding throughout pregnancy

       • Given if Rh negative mother and father Rh positive or unknown. Risk of hydrops fetalis
9. Contraceptive Methods

   • Barrier methods: 
     • Failure rates are as high as 40%, offer STI protection, safe for patients with contraindications to hormones
     • Male condoms: 20% failure rate, offers STI protection
     • Female condoms: 21% failure rate, offers STI protection
     • Diaphragm: 15% failure rate, must remain in place 6-24 hours after intercourse, requires pelvic exam and fitting
   • Spermicides Nonoxynol-9
     • Destroys sperm - often used with other forms of BCP such as condoms
     • 27% failure rate
     • Slight increased risk for HIV
   • OCP's
     • 9% failure rate, 0.3% failure rate when used correctly
     • Improves dysmenorrhea and controls menstrual cycle
     • Combined estrogen and progesterone - not used in women > 35 years of age that are smokers, patients with history of blood clots, breast cancer or migraines with aura
     • 35 and younger who smoke OK
   • Progestin-only mini pill
     • 9% failure rate, 0.3% failure rate when used correctly
     • Safe in lactation - can be used in breastfeeding woman
     • No estrogenic side effects (headache, nausea, HTN)
   • Transdermal patch
     • The contraceptive efficacy of the transdermal patch is comparable to that of combined OCP's
     • The failure rate is 0.3 percent with perfect use and 9 % with typical use
   • NuvaRing
     • Flexible plastic vaginal ring
     • 7% failure rate
     • Applied every week for 3 weeks then 1 week off
   • IUD
     • Most effective form of birth control. Reversible.
     • Copper IUD (Paragard) -  0.8% failure rate, women who cannot have hormones that want children later in life (replaced every 10 years)
     • Progestin-only IUD (Mirena)- 0.2% failure rate, replaced every 3-5 years
   • Depo-Provera
     • Long-acting progesterone injection
     • 5% failure rate
     • lasts 3 months
   • Implanon
     • Long-acting progesterone implanted in the upper arm
     • 0.05% failure rate
     • lasts 3 years
   • Emergency contraception
     • Up to 25% failure rate
     • Levonorgestrel emergency contraceptive (Plan B One-Step, etc) within 3 days of unprotected sex or prescribe Ella (ulipristal) within 5 days
     • Consider a copper IUD within 5 days if the woman also wants long-lasting contraception. It's the most effective emergency contraceptive
     • Recommend backup for 7 days after levonorgestrel...and for 14 days or until the next period after Ella, whichever comes first.
   • Sterilization
     • Tubal ligation - 0.5% failure rate, permanent
     • Essure - chemicals or coils to scar fallopian tubes - 0.5% failure rate, can be done in office
     • Vasectomy - 0.15% failure rate - vas deferens from each testicle is clamped, cut, or otherwise sealed. This prevents sperm from mixing with the semen that is ejaculated from the penis.
10. Human Sexuality

    • Gender - Societal perception of maleness or femaleness
    • Affirmed gender - When one's gender identity is validated by others as authentic
    • Agender - Person who identifies as genderless or outside the gender continuum
    • Cisgender - Not transgender; a person whose gender identity and/or expression aligns with their sex assigned at birth
    • Crossdressing - Wearing of clothes typically associated with another gender; the term transvestite can be considered pejorative and should not be used
    • Cultural humility - Concept of not projecting one's own personal experiences and preconceptions of identity onto the experiences and identities of others
    • Differences of sex development - Congenital conditions characterized by nuanced chromosomal, gonadal, or anatomic sex development (e.g., congenital adrenal hyperplasia, androgen insensitivity syndrome, Turner syndrome); not a universally accepted term; also called disorders of sex development or intersex
    • Genderqueer - Umbrella term for a broad range of identities along or outside the gender continuum; also called gender nonbinary
    • Gender diverse - General term describing gender behaviors, expressions, or identities that are not congruent with those culturally assigned at birth; may include transgender, nonbinary, genderqueer, gender fluid, or non-cisgender identities and may be more dynamic and less stigmatizing than prior terminology (e.g., gender nonconforming); this term is not used as a clinical diagnosis
    • Gender dysphoria - Distress or impairment resulting from incongruence between one's experienced or expressed gender and sex assigned at birth; DSM-5 criteria for adults include at least six months of distress or problems functioning due to at least two of the following:

    • • A marked incongruence between one's experienced or expressed gender and primary and/or secondary sex characteristics
      • Strong desire to be rid of one's primary and/or secondary sex characteristics
      • Strong desire for the primary and/or secondary sex characteristics of the other gender
      • Strong desire to be of the other gender
      • Strong desire to be treated as the other gender
      • A strong conviction that one has the typical feelings and reactions of the other gender

    • Gender expression - External display of gender identity through appearance (e.g., clothing, hairstyle), behavior, voice, or interests
    • Gender identity - An Internalized sense of self as being male, female, or elsewhere along or outside the gender continuum; some persons have complex identities and may identify as agender, gender nonbinary, genderqueer, or gender-fluid
    • Gender identity disorder – Diagnosis related to gender dysphoria or gender incongruence in earlier versions of the DSM and ICD
    • Gender incongruence - General term describing a difference between gender identity and/or expression and designated sex; an ICD-11 diagnosis that does not require a mental health diagnosis
    • Sex - Maleness or femaleness as it relates to sex chromosomes, gonads, genitalia, secondary sex characteristics, and relative levels of sex hormones; these biologic determinants may not necessarily be consistent; sex assigned at birth is typically based on genital anatomy
    • Sexual orientation - Term describing an enduring physical and emotional attraction to another group; sexual orientation is distinct from gender identity and is defined by the individual
    • They/them - Neutral pronouns preferred by some transgender persons
    • Transgender - General term used to describe persons whose gender identity or expression differs from their sex assigned at birth
    • Transgender female - A transgender person designated as male at birth
    • Transgender male - A transgender person designated as female at birth
    • Transfeminine - Nonbinary term used to describe a feminine spectrum of gender identity
    • Transmasculine - Nonbinary term used to describe a masculine spectrum of gender identity
    • Transphobia - Prejudicial attitudes about persons who are not cisgender
    • Transsexual - Historical term for transgender persons seeking medical or surgical therapy to affirm their gender
11. Infertility

    Failure to conceive after 1 year of unprotected intercourse

    • First step: Test male sperm, anovulation is the most common cause - amenorrhea and abnormal periods - 65% female, 20-40% male, 15% unknown. Treatment for anovulatory women: Clomiphene citrate

12. Menopause

    Menopause is a clincal diagnosis and is defined by cessation of menses for at least 12 months

    • Average age is 51.5. Definitive diagnosis: FSH > 30 mIU/mL
    • Women who have a uterus should be given a progestin in addition to estrogen because unopposed estrogen increases risk of endometrial cancer.
    • Know the contraindications for HRT: ↑ triglycerides, Undiagnosed vaginal bleeding, Endometrial cancer, history of breast CA or estrogen sensitive cancers, CVD History, DVT or PE history
13. Menstrual Disorders (PEARLS)
    1. Amenorrhea (ReelDx + Lecture)

       Primary: no menses by age 16

       • Turner’s syndrome – XO karyotype, webbed neck, broad chest. Androgen insensitivity – breast development only. Imperforate hymen – observed on speculum exam. Mullerian agenesis – secondary sex characteristics, no uterus

       Secondary: previously had menses, amenorrhea for 6 months

       • Most often pregnancy. Also caused by weight changes, hypothyroid, prolactinoma
    2. Dysmenorrhea

       Pain with menses or precede menses by 1 to 3 days. Pain tends to peak 24 h after onset of menses and subsides after 2 to 3 days

       • Primary: Begins early after menarche, not associated with pelvic pathology, associated with prostaglandins, treatment with NSAIDs and oral contraceptive pills
       • Secondary: New onset in an older women, associated with a secondary pathologic (structural) cause - adenomyosis, endometriosis, fibroid, PID, IUD, treat underlying cause
    3. Premenstrual syndrome (PMS)

       Caused by an imbalance of estrogen and progesterone along with excess prostaglandin production

       • Symptoms during luteal phase (1-2 weeks before menses) - Bloating, irritability. PMDD - causes marked disruption in functioning.
       • Symptoms resolve at the onset of menses.
    4. Dysfunctional uterine bleeding (Lecture)

       DUB is defined as excessive uterine bleeding with no demonstrable organic cause: Polymenorrhea (cycles with intervals of 21 days or fewer), menorrhagia (abnormally heavy or prolonged bleeding) and/or metrorrhagia (uterine bleeding at irregular intervals)

       • Diagnosis of exclusion; treat with oral contraceptives and NSAIDs

14. Neoplasms of the breast and reproductive tract (PEARLS)
    1. Breast Cancer (Lecture)

       Most common malignancy in women. Risk factors (increased exposure to estrogen): Menarche before age 12, old age of first full term pregnancy, no pregnancies, menopause after age 52

       • Mammogram every 2 years from age 50-74. Every 2 years beginning at age 40 if increased risk factors – 10 years prior to the age the 1'st degree relative was diagnosed. Clinical breast exam: every 3 years in women age 20-39 y/o then annually after age 40. Breast self exam – monthly beginning at age 20 – immediately after menstruation or on days 5-7 of the menstrual cycle.
    2. Cervical Cancer (Lecture)

       Friable, bleeding cervical lesion on exam. Squamous cell carcinoma. Most caused by HPV (High risk types, 16 and 18)
    3. Ovarian Cancer (Lecture)

       Patient in mid-50's with abdominal fullness, bloating, fatigue, weight loss and ascites

       • Tumor marker: CA 125, second most common gynecological cancer (first is endometrial)
       • Asymptomatic premenopausal patients with simple ovarian cysts < 10 cm in diameter can be observed or placed on suppressive therapy with oral contraceptives.
       • Postmenopausal women with simple cysts < 3 cm in diameter may also be followed, provided the serum CA 125 level is not elevated and the patient has no signs or symptoms suggestive of malignancy. If the cyst is > 3 cm or the CA 125 is elevated, further evaluation is necessary.
    4. Endometrial cancer (Lecture)

       Postmenopausal vaginal bleeding, most common GYN malignancy, usually adenocarcinoma

       • Endometrial biopsy -  vaginal bleeding in a post menopausal women is CA until proven otherwise
       • Treatment: Hysterectomy bilateral salpingo-oophorectomy +/- radiation
    5. Vaginal and Vulvar Cancer

       • Vaginal cancer  - abnormal vaginal bleeding. Squamous cell carcinoma caused by HPV
       • Vulvar Cancer - vaginal pruritis is most common presentation. Squamous cell and melanoma – pruritic black lesions. Paget’s – pruritic red lesions
15. Ovarian Disorders (PEARLS)

    1. Brian Wallace PA-C Podcast: S2 Ovaries and PID

       24 mins

       Brian Wallace PA-C
    2. Ovarian Cysts (Lecture)

       Pain, menstrual delay, hemorrhagic shock from cyst rupture - Follicular cysts are most common, diagnose with ultrasound. Observe - Most resolve within 6-8 weeks (2 menstrual cycles). Persistent cysts, large cysts (>6 cm) or complex cysts can be removed

       • PCOS: Obesity, hirsutism, acne, amenorrhea or oligomenorrhea, menarche occurs at expected age. Strongly associated with obesity, acanthosis nigricans, insulin resistance and hyperinsulinemia. Ultrasound: String of pearls. Labs: LH:FSH > 2.0, increased androgens, increased testosterone. Treat with oral contraceptives, metformin
    3. Polycystic ovarian syndrome

       PCOS is a syndrome involving irregular or absent menses, clinical or biochemical evidence of hyperandrogenemia (hirsutism or acne, elevated blood testosterone), infertility (anovulation), insulin resistance, and obesity

       • Labs: LH:FSH > 2.0, increased androgens, increased testosterone
       • Ultrasound demonstrates string of pearls
       • Treatments include weight loss, birth control pills to regularize periods, metformin to help with insulin resistance and improve menstrual cycles,statins to control high cholesterol, clomiphene to help with ovulation and procedures to remove excess hair
    4. Ovarian torsion

       Ovarian torsion refers to the rotation of the ovary at its pedicle to such a degree as to occlude the ovarian artery and/or vein

       • Patients with ovarian torsion often present with sudden onset of sharp and usually unilateral lower abdominal pain, in 70% of cases accompanied by nausea and vomiting
       • Abdominal ultrasound with Doppler flow is the diagnostic test of choice
       • Doppler flow is not always absent in torsion – the gold standard for the diagnosis of ovarian torsion is laparoscopy
       • The mainstay of the treatment of ovarian torsion includes laparoscopic surgery to uncoil the ovary
16. Pelvic inflammatory Disease (Lecture)

    PIDis an infection that ascends from the cervix or vagina to involve the endometrium and/or fallopian tubes

    • Causative agents include Gonorrhea and Chlamydia
    • Chandelier sign (cervical motion tenderness)
    • Common symptoms include pelvic pain and fever. There may be vaginal discharge (cervicitis)
    • Complications: infertility, ectopic pregnancy, tubo-ovarian abscess (adnexal mass)

    Clinical findings suggested by direct abdominal tenderness, cervical motion tenderness, and adnexal tenderness plus 1 or more of the following:

    • Temperature > 38°C
    • WBC count > 10,000/mm3
    • Pelvic abscess found by manual examination or ultrasonography

    Tx:

    • Outpatient: ceftriaxone IM 250 mg once + PO doxycycline 100 mg BID × 14 d ± PO Flagyl 500 mg BID × 14 d
    • Inpatient: Severely ill or nausea and vomiting precludes outpatient management
      • Doxycycline + IV cefotetan or cefoxitin × 48 h until the condition improves, then PO doxycycline 100 mg BID × 14 d
      • Clindamycin + gentamicin daily, if normal renal function, ×48 h until the condition improves, then PO doxycycline 100 mg BID × 14 d
17. Sexually transmitted infections

    Primary syphilis - Caused by Treponema pallidum (spirochetes)

    • Appears in 2-10 weeks
    • Painless genital ulceration (chancre)
    • Darkfield microscopy, VDRL/RPR (a rapid but nonspecific screening test), and/or an FTA-ABS (specific and diagnostic, the gold standard)
    • Treat with IM benzathine penicillin for primary and secondary disease

    Secondary syphilis

    • Appears 1-3 months after primary infection
    • Maculopapular rash on palms and soles, fever, headache, and generalized lymphadenopathy
    • Condylomata lata(moist lesions on the genitals which are highly infectious)

    Tertiary syphilis

    • Aortic aneurysm and aortic regurgitation
    • Granulomatous gummas of the CNS, heart and great vessels
    • IV penicillin G (for Gummas) for congenital and late disease

    Gonorrhea - Caused by Neisseriae gonorrheae

    • Dysuria, urinary frequency, and purulent yellow-green discharge
    • May progress to PID, high rate of coinfection with chlamydia
    • Nucleic acid amplification test (NAAT)
    • Evaluation may include cervical and urethral cultures for chlamydia and gonorrhea
    • Clean-catch urine culture to rule out UTI
    • Saline/KOH/Gram stain of vaginal discharge
    • Ceftriaxone 250 mg IM x 1, also treat for presumed chlamydia infection
    • If urethritis is refractory to azithromycin, consider Trichomonas and treat with metronidazole

    Chlamydia - Caused by Chlamydia trachomatis serotypes D-K

    • Often asymptomatic, but may cause dysuria, cervicitis, PID, lymphogranuloma venereum, or infertility
    • Nucleic acid amplification test (NAAT) is the gold standard
    • Azithromycin 1g PO x 1 or Doxycycline BID x 7 days
    • In pregnancy azithromycin 1 gm x 1 dose or amoxicillin TID x 7 days
    • Do not need to routinely treat for presumed gonorrhea infection, but should in patients with confirmed gonorrhea or high-risk patients

    Trichomonas is a flagellated protozoan

    • Pruritus and a malodorous, frothy, yellow-green discharge
    • Diffuse vaginal erythema and red macular lesions may be visible on the cervix
    • Wet mount reveals motile flagellates
    • Metronidazole 2 g (four 500 mg tablets) PO x 1 dose is the first-line agent for pregnant and nonpregnant women with trichomoniasis
    • An alternative multi-dose regimen is metronidazole 500 mg orally twice a day for seven days
    • All partners should be treated

    Venereal warts (condylomata acuminata)

    • External lesions associated with HPV 6,11, endocervical warts caused by HPV 16, 18, 31, 33. Transmitted sexually and have an incubation period of 1 to 6 months
    • Painless, soft, fleshy, "cauliflower-like lesion"
    • Lesions can be on the vulva, vaginal wall, the cervix, and the perineum Biopsy lesion with 5% acetic acid to detect condylomata acuminata
    • No treatment is satisfactory. Relapse is frequent and requires retreatment
    • Treatment modalities include podofilox (an antimiotic), cryotherapy, laser surgery, or electrocauterizations, and biopsy, imiquimod (interferon inducer) are widely used but require multiple applications and frequently fail
    • Presence during pregnancy does not require a cesarean section

    Herpes - Caused by HSV-2

    • Paresthesia and burning followed by painful vesicles and ulcerations
    • In primary infections, patients may present with fever, malaise, and adenopathy
    • A Tzanck smear for lesions suspicious of HSV
    • Topical acyclovir ointment during a flare-up, oral acyclovir to decrease the rate and severity of recurrence
18. Trauma (Pearls)
    1. Physical assault

       Domestic violence screening at first prenatal visit, again at least once per trimester, again at postpartum visit

       • Domestic violence often begins or, if already present, increases during pregnancy and the postpartum period
       • Leave abusive situation ensuring a safe place to go, counseling to assess the risk of danger, create a plan for safety

    2. Sexual assault

       Sexual assault is any involuntary sexual act in which a person is coerced or physically forced to engage against their will or any non-consensual sexual touching of a person

       • Cultures from the vagina, the anus, and usually, the pharynx for gonorrhea and Chlamydia, RPR for syphilis, hepatitis antigens, HIV, urinalysis, pregnancy test for menstrual-aged women (regardless of contraceptive status)

       Prophylactic antibiotic therapy should be initiated

       • Rocephin 250 mg followed by oral doxycycline twice daily x 7 days
       • Tetanus toxoid if indicated
       • The patient should be given the option of emergency contraception
       • Counseling: As soon as possible after the event, and preferably before leaving the emergency department, the patient should talk to a mental health professional and follow-up counseling should be scheduled

       Close follow up at one week, six weeks, and again at 12-18 weeks (may need to repeat HIV titers)
    3. Trauma in pregnancy

       Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise

       • A pregnant woman may lose 35% blood volume without typical signs of shock
       • Fetal pulse changes are an early warning of maternal circulatory compromise
       • If thoracostomy necessary, the tube should be inserted 1 or 2 intercostal spaces higher than usual
       • Consider RhoGAM and O-negative blood until crossmatched blood becomes available
       • If the patient enters cardiac arrest, C-section should be performed for viable pregnancies (>23 weeks) as soon as possible to facilitate maternal resuscitation and fetal salvage
       • Radiographic studies needed for maternal evaluation including CT scan should NOT be deferred or delayed due to fetal exposure concerns
       • If the fetus is viable (> 23 weeks) and mother is stabilized, start fetal monitoring 
       • If vaginal bleeding is present, do NOT perform speculum or digital vaginal exam. Obtain an ultrasound to evaluate for placenta previa
19. Uncomplicated Pregnancy (Pearls)

    1. Brian Wallace PA-C Podcast: S2 OB Prenatal Care & Active vs Passive Studying

       26 mins

       Brian Wallace PA-C
    2. Normal labor/delivery

       Cervical examination:

       • Dilation – up to 10 cm.
       • Effacement (softening) – up to 100%.
       • Station (position of the baby the head) – 0 is at ischial spine.

       Stages of labor:

       • Stage 1: Onset contractions to full dilation (primi- 6-20 hours ) (multi- 2-14 hours).
       • Stage 2: Full dilation to baby delivery (primi- 30 mins-3 hours) (multi- 5-6 minutes).
       • Stage 3: After baby delivery to expulsion of placenta (0-30 mins).
         • Placenta should have 2 arteries and 1 vein.

       APGAR score:

       • Activity (2=active movement), Pulse (2= >100 BPM), Grimace (2= pulls away, sneeze), Appearance (2=pink), Respiration (2=crying).
       • Score > 6 is good.
       • A score of 4 necessitates resuscitation.
    3. Prenatal diagnosis and care (Lecture)

       G_ P_ or G_ P _ _ _ _

       • G is the number of pregnancies.
       • P is the number of deliveries.
       • Or P is full-term deliveries, premature deliveries, abortions, living children.

       Nagel’s rule for due date: LMP + 7 days - 3 months.

       • Chadwick’s sign: blue cervix.
       • Hegar's sign - cervical softening.
       • Advanced maternal age is 35 - offer testing for genetic abnormalities.
       • Total weight gain range should be 25–35 lb, except in obese women, for whom weight gain should be <15 lb.
       • Folic acid supplementation (0.4–0.8 mg) prior to conception; 4 mg for secondary prevention.
       • Monthly visits to a healthcare professional for weeks 4–28 of pregnancy
       • Visits twice monthly from 28 to 36 weeks
       • Weekly after week 36 (delivery at week 38–40)

       First trimester (weeks 1-12)

       • Fetal heart tones: 10-12 weeks
       • Screening:
         • PAPP-A
         • Free beta HCG
         • Nuchal translucency- ultrasound (10-13 weeks) - >3.5 mm – trisomy or neural tube defect
         • CVS (10-13 weeks)

       Second trimester (weeks 13-27)

       • Fetal movement:
         • Nullipara: 18-20 weeks
         • Multipara: 14-16 weeks
       • Uterine growth
         • At umbilicus – 20 weeks
         • Weeks gestation should equal fundal height in cm.
       • Screening
         • Maternal AFP.
           • Increased- neural tube defects.
           • Decreased- trisomy.
         • Inhibin A.
         • Unconjugated estriol.
         • Ultrasound (18-20 weeks) - anatomy scan, gender reveal.
         • Amniocentesis (15-18 weeks).

       Third trimester (weeks 28- birth)

       • Full term is 37 weeks. Plan for induction after 40 weeks.
       • Vaccines:
         • Tdap (28 weeks).
         • Rhogam (28 weeks) – for Rh-negative mothers only.
       • Screening:
         • Gestational diabetes (24-28 weeks): 50g non fasting 1-hour test followed by 3-hour GTT if > 130 mg/dl on 1-hour
         • Rh antibodies for Rh-negative mothers (28 weeks).
         • Vaginal-rectal culture for Group B strep (35 weeks) - If positive, treat with IV penicillin during delivery.
         • Nonstress test: 20-minute monitoring -  should see two accelerations (15 BPM above baseline, for 15 seconds), and no decelerations.
         • Biophysical profile: NST, amniotic fluid level, fetal movements, fetal tone, fetal breathing.
    4. Postnatal/postpartum care

       The postpartum period can be divided into three distinct stages

       • Initial or acute phase, 6–12 hours after childbirth
       • The subacute postpartum period, which lasts 2–6 weeks
       • The delayed postpartum period, which can last up to 6 months

       A woman giving birth in a hospital may leave as soon as she is medically stable, which can be as early as a few hours postpartum

       • Average for a vaginal birth is one to two days
       • The average cesarean section postnatal stay is three to four days
20. Uterine disorders (PEARLS)

    1. Brian Wallace PA-C Podcast: Disorders of the Uterus

       Brian Wallace PA-C
    2. Endometriosis (Lecture)

       19 mins

       Endometriosis is a benign disease related to the menstrual cycle, usually cyclical associated with the 3 D's: Dyspareunia (painful intercourse), dyschezia (difficulty in defecating), dysmenorrhea

       • Uterus is fixed and retroflexed. Tender nodularity of cul de sac and uterine ligaments.
       • Laparoscopy: Chocolate cysts observed. Definitive study
       • Treatment: Resect endometriosis, oral contraceptive therapy
    3. Leiomyoma (Lecture)

       Abnormal uterine bleeding; polymenorrhea, menorrhagia, intermenstrual bleeding and/or metrorrhagia along with urinary symptoms (eg, urinary frequency or urgency). Uterine mass.

       • Black women, family history, diagnose with Ultrasound
       • Intramural fibroids are most common, definitive treatment: myomectomy or hysterectomy
    4. Prolapse

       Caucasian women, after labor/delivery, chronic cough. Vaginal fullness, abdominal pain worse late in day, after prolonged standing. Relieved by lying down.

       • Prolapse of the uterus into the vaginal canal - graded by uterine descent: 0°- No descent. 1° - descent between normal and ischial spine. 2°- between ischial spines and hymen. 3°- within hymen. 4° - through hymen.
       • Prolapse of the bladder into the front wall of the vagina (cystocele) -  leads to a “reservoir effect” where the bladder is not completely emptied when the urine is passed
       • Prolapse of the rectum into the back wall of the vagina (rectocele) - complain of a sensation of bulging in the vagina when they strain to open their bowels.
21. Vaginal/vulvar disorders (PEARLS)
    1. Cystocele (bladder hernia)

       Bladder prolapse (cystocele) is a bulge of the bladder into the vagina

       • A cystocele can result from childbirth, constipation, violent coughing, heavy lifting, or other pelvic muscle strain
       • Symptoms include feeling pressure in the pelvis and vagina, discomfort when straining, and feeling that the bladder hasn't fully emptied after urinating

       Treatment includes a flexible ring pessary to support the bladder or surgical repair with mesh augmentation. In rare cases, estrogen may also be used
    2. Vaginal Prolapse

       Feeling of vaginal or pelvic pressure, heaviness, bulging, bowel or bladder symptoms. Common after hysterectomy.

       • Baden-Walker grades of female genital prolapse – uses the hymen as crossing point
         • Grade 1 – descent above the hymen, Grade 2 – descent to the hymen, Grade 3 – descent beyond the hymen, Grade 4 – total prolapse
    3. Rectocele

       Herniation of rectum into the posterior wall of the vagina

       • Childbirth and other processes that put pressure on the tissue wall can lead to a rectocele
       • Results in pelvic pressure + bowel symptoms
         • Symptoms include a soft bulge of tissue in the vagina that may or may not protrude through the vaginal opening
         • Defecatory dysfunction (constipation, straining, incomplete emptying)
         • Perceived or discovered bulge into the vagina, low back pain
       • POP-Q (pelvic organ prolapse quantification): quantifies the extent and location of defects
         • Get a colonoscopy to rule out cancer and rectal studies if indicated

       TX: Kegel exercises, pelvic floor retraining, behavioral changes, bowel regimen, pessary, surgical repair or repair with mesh augmentation
    4. Vaginitis

       • Trichomonas: Frothy yellow, green, gray vaginal discharge and strawberry cervix. Wet mount: Flagellated protozoa. pH: Basic. Treatment: Metronidazole
       • Bacterial vaginosis: Organism: Haemophilus aka Gardnerella. Signs: Fishy odor, thin gray discharge. Wet mount: Clue cells. pH: Basic > 4.5. Treatment: Metronidazole
       • Candida: Thick white vaginal discharge. Associated with recent antibiotic use, diabetes mellitus, steroid use. KOH prep: Pseudohyphae. pH: Normal 4. Treatment: Fluconazole