Obstetrics & Gynecology Morning Report: Beyond the Pearls

Front Cover
IFC
OBSTETRICS & GYNECOLOGY MORNING REPORT: Beyond the Pearls
Copyright
Dedication
LIST OF CONTRIBUTORS
PREFACE
FOREWORD
CONTENTS
1 - A 34-Year-Old Woman With Cervical Dysplasia in Pregnancy
What is the etiology of cervical cancer?
What are the vaccination options for cervical cancer?
What are screening recommendations for cervical cancer?
What are the recommendations for management of HSIL in the nonpregnant woman?
How is a colposcopy performed?
What additional considerations are made in pregnancy?
How do you counsel this patient about her biopsy results?
How should her cervical dysplasia affect her mode of delivery?
Does the patient’s cervical dysplasia limit her options for postpartum contraception?
What are your options for management?
What is the follow-up plan for this patient?
Case Summary
References
2 - A 23-Year-Old Woman with Hyperemesis Gravidarum
What questions should be asked when interviewing this patient?
What should the physical exam include?
What is the differential diagnosis?
What is the working diagnosis?
What laboratory evaluation and radiologic testing should be performed on this patient?
What is the etiology of NVP?
What are the risk factors for NVP?
How is NVP treated?
What is the more severe form of NVP?
Case Summary
References
3 - A 31-Year-Old Woman With Rash in Pregnancy
When a pregnant woman develops blisters, what is important to know in her history?
What clues in the history point away from a diagnosis of allergic contact dermatitis?
What clues in the patient’s history could point toward a diagnosis of an arthropod assault?
What clues in this patient’s history might point toward gestational pemphigoid?
What treatment options can begin before the patient sees the dermatologist?
She is curious if this condition will recur in future pregnancies; what advice can you give her?
Case Summary
References
4 - A 38-Year-Old Woman with GDM
What is GDM?
What are some relevant questions in your history that might suggest GDM?
What risk factors does this patient have for GDM?
Who should be screened for GDM?
How is GDM diagnosed?
What are the risks of untreated GDM?
Is antenatal testing indicated with GDM?
How should labor and delivery be managed in patients with GDM?
How should the patient be managed postpartum?
Case Summary
Resources
References
5 - A 27-Year-Old Woman With Human Immunodeficiency Virus in Pregnancy
Describe the pertinent history and physical examination for the patient with HIV
What laboratory evaluation provides the diagnosis for HIV?
What provides the diagnosis for acquired immune deficiency syndrome (AIDS)?
What laboratory, imaging studies, and management should be pursued?
What is the treatment for HIV during pregnancy?
For decreasing CD4 counts, what is the appropriate prophylaxis?
How do you counsel the patient postpartum?
Case Summary
References
6 - A 30-Year-Old Woman With Gestational Trophoblastic Disease
What is the initial differential diagnosis for the patient?
What laboratory, imaging studies, and management should be pursued?
What is your diagnosis?
Case Summary
References
7 - A 28-Year-Old Woman Presenting With Symptoms of Depression in the Postpartum Period
Why is it important to ask about and discuss emotional health in postpartum women?
Is it baby blues, depression, or psychosis?
What are additional questions you need answered at this point?
What immediate interaction and treatment should you undertake?
What referral and long-term treatment is appropriate?
Case Summary
References
8 - A 25-Year-Old Woman With Pica in Pregnancy
How does this information help you form a differential diagnosis?
What are the concerns that arise with the consumption of soils or “magnesia”?
Is consuming so much ice of concern?
How do you approach treating the underlying iron deficiency?
How do you approach addressing the actual pica substances?
How do you approach her long-term care?
Case Summary
References
9 - A 27-Year-Old Woman With Opiate Dependence in Pregnancy
Why is it important to screen for opioid abuse in pregnancy?
What is a validated method to screen for substance abuse in pregnancy?
Based on the history and physical exam for this patient, what is her COWS score?
What are the goals of treatment for opioid dependence in pregnancy?
What is NAS?
What additional testing should you perform prior to initiation of methadone therapy?
How should methadone opioid replacement therapy be initiated?
What additional care will your patient need throughout her pregnancy?
Case Summary
References
10 - A 29-Year-Old G1P0 Woman With Hypothyroidism in Pregnancy
What important questions should be asked to rule out other diagnoses?
What is your differential diagnosis at this point?
Does the thyroid exam have to be abnormal for thyroid disease?
What if a palpable nodule was noted on her thyroid exam?
What changes in the thyroid occur in pregnancy?
How important is treatment for overt hypothyroidism in pregnancy?
What can happen if overt hypothyroidism is not treated in pregnancy?
How would you approach treatment?
How do you adjust medication during pregnancy?
What do you do if she experiencing symptoms of overtreatment?
What nutritional requirements are there in pregnancy related to the thyroid?
What is the patient’s prognosis?
Case Summary
References
11 - A 30-Year-Old Woman Undergoes Carrier Screening
When is the optimal time to discuss the reported family history?
What genetic testing is typically available in the preconception period?
What is CF?
What is this patient’s risk to be a carrier and have a child with CF?
What testing should be offered to this patient?
Should you offer carrier screening for additional conditions?
Based on these results, what is this patient’s risk of having an affected child with CF?
What CF carrier screening, genotyping, or sequencing would you offer to the partner?
What is fragile X syndrome?
Should you offer to test the patient’s partner to see if he is a carrier for fragile X syndrome?
What does it mean to be an intermediate carrier for fragile X?
Is testing for fragile X syndrome recommended at delivery?
What is the most appropriate next step?
Should you recommend that they do not attempt a pregnancy?
Case Summary
References
12 - A 36-Year-Old Woman With
Why is it important to ask about headache in pregnancy?
In addition to her headache, what other information should be gathered from this patient?
Are there any fetal considerations that need to be evaluated?
What is your diagnosis at this time, and how would you manage her?
Are there any special considerations for her postpartum care?
What does the patient need to do at home, and can this happen again in a future pregnancy?
Case Summary
References
13 - A 20-Year-Old Woman With Preterm Premature Rupture of Membranes
What is the differential diagnosis during pregnancy for suspected vaginal loss of fluid?
What is the next step in evaluating this patient?
What is the appropriate laboratory and imaging evaluation?
What is your diagnosis?
What are the etiology and risk factors for PPROM?
How do you counsel the patient regarding this diagnosis?
What is the next step in management?
Describe the management of labor, delivery, and postpartum care for patients with PPROM
How do you counsel the patient regarding future pregnancy?
Case Summary
Acts of Grace Foundation
References
14 - A 36-Year-Old Woman at 33 Weeks’ Gestation With Bleeding
How does this information help you narrow your differential diagnosis?
How do you assess a patient like this in triage?
What laboratory values or imaging should you obtain?
What other complications can arise from a placenta previa?
What are the classifications of placenta previa?
What other life-threatening causes must be considered?
Case Summary
References
15 - A 36-Year-Old Woman With Placental Abruption
What lab evaluation is necessary?
What imaging would you like to perform for this patient?
What is your next step in management?
How do you diagnose disseminated intravascular coagulation?
What measures do you need to take to treat her DIC?
Case Summary
References
16 - A 35-Year-Old Woman With Lower Extremity Swelling
What are important questions to ask women in the puerperium period with leg swelling?
What clues in the history and exam will help you to narrow your differential diagnosis?
What further studies will you order?
What are the treatment options?
What further workup would you order?
What would be your next step of management?
Case Summary
References
17 - A 31-Year-Old Woman Admitted for Induction of Labor
What is induction of labor?
What are the reasons for inducing labor in a pregnant woman?
What are the contraindications to induction of labor?
How can the likelihood of a successful induction be determined?
What is cervical ripening, and how can it be performed?
What are the risks associated with cervical ripening and induction of labor?
What are some important criteria to consider (and document) before labor is induced?
How should this patient’s tachysystole and abnormal fetal heart rate be managed?
How is a failed induction diagnosed?
Case Summary
References
18 - A 35-Year-Old Pregnant Woman With Abdominal Pain
What are the imperative questions to ask in the patient who presents with abdominal pain?
How does the clinical picture develop in a patient with appendicitis?
What should be considered in your differential diagnosis?
What laboratory changes are associated with appendicitis?
What imaging studies are useful in diagnosing appendicitis?
Diagnosing acute appendicitis in a pregnant patient
What is the treatment of choice for a pregnant female with appendicitis?
Case Summary
References
19 - A 32-Year-Old Woman With Severe Postpartum Headache
What is the first step in evaluating the patient with a postpartum headache?
What are the diagnostic criteria by the International Headache Society?
Why is it important to elicit a history of headache?
How does this information help you form a differential diagnosis?
What is the anatomy of the spinal tract?
What other types of headaches have to be considered?
What is the pathophysiology of PDPH?
How do you treat this patient who complains of severe headache?
What is an EBP, and how is it performed?
How does EBP work?
What are the risks and benefits of an EBP?
What is your differential diagnosis at this point?
What would you do if she returned in a few days with a recurrence of the headache?
Case Summary
References
20 - A 25-Year-Old Woman With Obesity in Pregnancy
On presentation to prenatal care, what is the first assessment?
What are the goals during her first prenatal visit?
What are complications of obesity during pregnancy?
What are the recommendations for weight gain during pregnancy in obese women?
For patients with obesity, what type of skin incision is preferred during a cesarean delivery?
Are there any long-term implications of obesity on the women’s health?
What has been the impact of bariatric surgery on the health of a woman of reproductive age?
What is bariatric surgery? What are the types and their risk and benefit profiles?
Case Summary
References
21 - A 33-year-Old Woman With Postpartum Vaginal Edema
What is your differential diagnosis?
What is the initial management?
How would you manage the patient now?
Case Summary
References
22 - A 16-Year-Old Girl With Diabetic Ketoacidosis in Pregnancy
What is most likely causing this patient’s lethargy?
What other important questions or findings will help in our differential?
With the information provided, what is the likely diagnosis?
What is the clinical presentation of DKA?
What are the precipitating factors for the development of DKA?
What is the mechanism for the development of DKA?
What is the mechanism for the development of DKA?
What are the implications of acidosis (DKA) on the fetus?
Is DKA a mandatory indication for delivery?
What is the prognosis for the mother and the fetus?
What is the treatment for DKA?
How do we know if the patient is getting better?
Case Summary
References
23 - A 38-Year-Old Woman With Abnormal Quad Screen
What is prenatal genetic screening? What are its objectives?
Compare the various genetic screening methods during pregnancy
What are integrated, sequential, and contingent screenings?
What is the management plan for the patient?
What are the risk factors for Down syndrome in the fetus?
What is the significance of an increased NT finding in the first trimester?
What is a cystic hygroma?
With its high sensitivity and specificity, why can’t NIPT replace invasive diagnostic tests?
How does multifetal gestation affect the screening test’s performance?
Case Summary
References
24 - A 17-Year-Old Woman With a History of Sickle-Cell Disease Presenting With Bone Pain
What clues in the history and physical point to the diagnosis of SCD crisis?
How would you treat this patient?
How should you counsel the patient’s family?
Will the patient get a blood transfusion?
How do we manage SCD pain?
Will the patient require a cesarean delivery?
What are the postpartum recommendations for patients with SCD?
What type of contraception can be utilized in patients with SCD?
Case Summary
References
25 - A 28-Year-Old Woman With Valvular Heart Disease in Pregnancy
What is the differential diagnosis of a systolic murmur?
What cardiac exam findings will be altered during pregnancy?
Do heart murmurs during pregnancy require a workup?
What workup should be performed to evaluate a concerning heart murmur in pregnancy?
How common is aortic stenosis in pregnancy, and what are the common causes?
Should you be concerned about aortic stenosis in pregnancy?
How can pregnancy outcomes with aortic stenosis be predicted?
What workup should be performed for a pregnant patient with aortic stenosis?
What cardiac testing will be altered in pregnancy?
What is the familial inheritance risk of a bicuspid aortic valve?
How should a pregnant patient with aortic stenosis be managed during pregnancy?
Is surgical repair of aortic stenosis recommended during pregnancy?
How should women with aortic stenosis be delivered?
What is the role of a preconceptional counseling visit in women with valvular heart disease?
How should mechanical valves be monitored during pregnancy?
What anticoagulant should be used in pregnant women with prosthetic valves?
How should other valvular diseases in pregnancy be managed?
Case Summary
References
26 - A 25-Year-Old Woman Undergoes Noninvasive Aneuploidy Screening
What is noninvasive aneuploidy screening?
What facts and questions do you include in your counseling session?
What is the significance of these results?
What additional testing can be offered to diagnose or rule out Down syndrome?
Case Summary
References
27 - A 27-Year-Old Woman With Vaginal Bleeding in Pregnancy
Why is it important to ask about vaginal bleeding in pregnant women?
What are the risk factors for this finding? What are the conditions associated with it?
What is your differential diagnosis?
Case Summary
References
28 - A 27-Year-Old Woman With History of Asthma
What is asthma and its clinical presentation?
How is asthma diagnosed?
How is asthma treated?
What is the significance of asthma classification and approach to management?
What is the normal physiology of the respiratory system during pregnancy?
What is the effect of pregnancy on asthma?
What is the effect of asthma on pregnancy?
How does management differ for the pregnant patient with asthma?
What is status asthmaticus?
What is the optimal ventilator strategy for an acute asthma exacerbation?
Case Summary
References
29 - A 34-Year-Old Woman With Sleep Disturbance During Pregnancy
Are there physiologic reasons that OSA would be worse during pregnancy?
What are the testing options to diagnose sleep apnea?
What are the health risks associated with untreated OSA?
Are there any additional potential risks of untreated OSA to the mother that should be consideredin a patient who is pregnant?
Are there any potential risks of untreated OSA to the fetus?
What are the treatment options for OSA? Are there any specific recommendations for treatmentduring pregnancy?
Are there specific instructions you would give to this woman regarding her delivery and postpartum recovery with regard to her OSA?
Will OSA that was diagnosed during pregnancy “resolve” after pregnancy is over?
Case Summary
References
30 - A 25-Year-Old Woman in Her Third Trimester of Pregnancy
How does a prior history of SLE nephritis impact pregnancy?
What does the specific history of class IV nephritis mean for her pregnancy?
When is it safe for patients with SLE to become pregnant?
When should referral to a maternal–fetal medicine (MFM) specialist be considered?
How do you interpret her autoantibody profile as it relates to her pregnancy?
What is neonatal lupus?
What causes congenital heart block to occur?
What is the risk of her child developing cardiac neonatal lupus?
How does her historical treatment course impact her current pregnancy?
Are her current medications safe?
In a patient with a history of lupus nephritis, what specific physical exam findings should you look for?
What is your differential diagnosis based on the laboratory testing?
On inpatient admission, the primary team asks whether additional labs are warranted. What labs should be recommended and why?
What other antibodies would be useful to evaluate this patient?
How do you interpret this new information and additional labs from Table 30.8 and Figs. 30.5 and 30.6?
When would a repeat renal biopsy be indicated?
What are some other management considerations in patients with lupus nephritis in pregnancy?
Case Summary
References
31 - A 29-Year-Old Woman With Systemic Lupus Erythematosus Planning Pregnancy
How does SLE affect fertility and pregnancy?
Does this patient have active lupus? If so, how can you tell?
What immunosuppressive medications are safe to be given during pregnancy?
What immunosuppressive medications are safe to be given during pregnancy?
How should her mild arthritic flare be treated now that she is pregnant?
What medications should be avoided at this time for treatment of her arthritis?
Is it advisable for this patient to breastfeed?
Case Summary
References
32 - A 29-Year-Old Woman With Shortness of Breath
What is the differential diagnosis of SOB in pregnancy?
How does heart failure present on physical exam?
What is pulmonary hypertension?
What is the best screening test for pulmonary hypertension?
What is the most specific test for pulmonary hypertension?
What is the pathogenesis of PAH?
What are targeted therapies for PAH?
How does pregnancy impact PAH?
Case Summary
References
33 - A 42-Year-Old With Heavy Vaginal Bleeding
What are the next steps in evaluating this patient?
What is the definition of abnormal menstrual bleeding, and what are the causes?
What is the best imaging test to evaluate this patient’s abnormal physical exam?
What is the diagnosis? How do you counsel the patient about the ultrasound?
What are fibroids, and how are they related to bleeding and symptoms?
How are fibroids related to hormones?
What are the next steps in managing this patient’s bleeding and acute anemia?
Case Summary
References
34 - A 38-Year-Old Woman With Acute Pelvic Pain
What is your initial differential diagnosis?
Why is it important to consider the age of the patient?
What other risk factors should you ask about in the history?
What negative physical exam findings are important in this case?
Which laboratory test should be ordered for this patient?
What type of imaging test should be ordered for this patient’s evaluation?
Based upon this information, what is the most likely diagnosis in this patient?
How are adnexal masses categorized?
Case Summary
References
35 - A 17-Year-Old Girl With Recent Onset of Pelvic Pain
What are common causes of pelvic pain in a young female?
What should be done to evaluate this patient?
What is pelvic inflammatory disease?
How does PID present? What are the risks of not recognizing PID?
What history is needed when PID is suspected, and what are risk factors for PID?
What makes a patient a candidate for empiric treatment of PID?
How can the patient reduce her risk for recurrent PID? How does this affect her future fertility?
What contraception is safe for a woman with PID?
Case Summary
References
36 - A 28-Year-Old Woman With Abdominal Pain and Vaginal Bleeding
What are your differential diagnoses for this patient?
What is your next step in the evaluation of this patient?
Based on these findings, what diagnoses are possible or likely?
What physical exam findings would be concerning for an ectopic pregnancy?
What would be your concerns about observing this patient further?
Is medical management an option for this patient?
What is the patient’s diagnosis?
How would you counsel a patient with one former ectopic pregnancy and unilateral salpingectomy about future pregnancy?
Case Summary
References
37 - A 19-Year-Old With Postoperative Fever and Lower Abdominal Pain
What is the differential diagnosis for this patient?
What are the next steps in the patient’s evaluation?
What is the most likely cause of this patient’s symptoms?
What factors lead to increased risk for postabortal endometritis?
Could this postabortal endometritis have been prevented?
How is postabortal endometritis treated?
When should she follow up with her provider?
Why is it important to treat postabortal endometritis?
Could this patient have had postabortal placement of an intrauterine device (IUD)?
Case Summary
References
38 - A 34-Year-Old Woman With Postoperative Flank Pain
What is your differential diagnosis for this patient?
How do you classify the different types of urinary incontinence?
What is the most likely cause of the patient’s urinary incontinence?
What test can you do in the office to specifically evaluate this patient for a fistula?
What was the sequence of events that led to the formation of this patient’s fistula?
What patient and surgical factors lead to an increased risk of fistula formation?
What other imaging would be merited on suspicion of a vesico-vaginal or uretero-vaginal fistula?
How do you approach treatment of uretero-vaginal fistula?
How do you follow this patient after discharge?
Case Summary
References
39 - A 35-Year-Old Woman With an Abnormal Pap Smear
What are the risk factors for an abnormal Pap smear?
How do providers manage abnormal Pap smears?
How would you describe a colposcopy experience to a patient?
How would you prepare yourself, the examiner, to perform a colposcopy?
What is the transformation zone (TZ), and what is its role in colposcopy?
How do solutions applied to the cervix highlight lesions or dysplasia on colposcopy?
What if no lesions are seen on the colposcopic view of the cervix?
What descriptors are used to describe colposcopic lesions, and what is most concerning?
How is a cervical biopsy performed?
What different results might be seen on cervical biopsy?
What types of treatment are available?
Which types of dysplasia should be treated?
Case Summary
References
40 - A 28-Year-Old Woman With a History of Pulmonary Embolism Who Desires Contraception
What are the risk factors for venous thromboembolism (VTE)?
What tests should be ordered to evaluate for familial thrombophilic syndrome?
How should this patient be counseled regarding contraception recommendations?
What are the recommendations for a family history of VTE?
What should you tell the patient about hormone-containing methods?
What other reliable, progestin-only options are available for this patient?
What recommendations should be given to patients with thrombophilias and contraceptive management in the perioperative period?
Case Summary
References
41 - A 56-Year-Old Woman With Menopausal Symptoms
What history is necessary in a patient with these symptoms?
How is menopause defined, and what are the associated symptoms?
What are the physical exam findings in a postmenopausal patient?
What laboratory evaluation is indicated in a patient with menopausal symptoms?
What is the treatment of menopause, and when should it initiated?
When is hormone replacement therapy contraindicated?
What are alternatives to HRT for postmenopausal symptoms?
Are there advantages to HRT other than symptom control?
When should the patient consider stopping her estrogen?
Case Summary
References
42 - A 22-Year-Old Woman With Painful Menses
What is your differential diagnosis for this patient?
What factors of the history can differentiate these three diagnoses on the differential?
What types of laboratory testing or imaging studies would be useful for this patient?
How do you next counsel your patient?
What is the next step in management?
What surgical options should you discuss with her?
What is long-term follow-up for this patient?
Case Summary
For Further Reading
43 - A 26-Year-Old Woman With Irregular Menses
What additional information would you want to know from the patient?
What is the differential diagnosis for irregular menstrual bleeding?
What should you look for in the physical exam?
What is the pathophysiology of hirsutism, and what are some common causes?
How would you make a diagnosis of PCOS?
What comorbidities are associated with PCOS, and how can you screen for them?
What PCOS therapies are available to patients who do not currently desire pregnancy?
How would you manage hirsutism in a woman with PCOS?
What therapies are available for PCOS patients who currently desire pregnancy?
What are some important recommendations that you want to review with her?
Case Summary
References
44 - A 25-Year-Old With Recurrent Pregnancy Loss
What additional information do you want from this patient?
What would be your working diagnosis based on the information that you have on hand?
What are common causes of RPL?
What testing would you recommend for this patient for her RPL?
What do you recommend next?
How would you advise her on trying to get pregnant again?
Case Summary
References
45 - A 17-Year-Old Girl With Absent Menses
What other questions do you want to ask this patient?
How should one approach the diagnosis in primary amenorrhea?
What would be the most likely cause of amenorrhea in our patient?
What are the physical exam findings to look for when evaluating primary amenorrhea?
What labs should be part of her initial workup?
What additional workup would you like to order for this patient?
What physical exam findings are commonly seen in Turner syndrome?
What treatment options are available for her?
How would you counsel this patient about attempting pregnancy in the future?
Case Summary
References
46 - A 33-Year-Old Woman With Infertility and Endometriosis
What additional questions would you want to ask this patient?
What would be your working diagnosis based on this information?
What are common causes of infertility?
What testing would you recommend to this patient?
What would you recommend for this patient?
What would you discuss next with this patient?
What do you recommend next for this patient?
Case Summary
References
47 - A 22-Year-Old Woman With Amenorrhea
What is the difference between primary and secondary amenorrhea?
How is galactorrhea related to hyperprolactinemia?
What medications can cause amenorrhea?
What are the next steps in evaluation?
What are causes of hyperprolactinemia?
What if the patient is taking a medication that may elevate her prolactin?
What are secretory or pituitary tumor causes of hyperprolactinemia?
What is the next step in management?
How long should the patient continue her dopamine agonist?
What are contraindications to dopamine agonist therapy?
How should women be counseled about prepregnancy planning?
How are prolactinomas monitored during pregnancy?
How are growing, symptomatic prolactinomas treated during pregnancy?
Case Summary
References
48 - A 3-Year-Old Girl With Vaginal Discharge
How is the prepubertal genital tract different from older pubertal females?
What is the differential diagnosis of vulvovaginal symptoms in a prepubertal child?
Following a thorough history, how will you perform a physical exam?
What tests should you obtain?
How should the foreign body found on physical exam be removed?
How would the evaluation change if the parents reported continued vaginal bleeding and no foreign object was found in the vagina?
What after-care information should be provided to the patient’s parents?
Case Summary
References
49 - A 15-Year-Old Concerned About Not Having Her Period
When should delayed menarche be evaluated?
What is the most common cause of primary amenorrhea?
What is the differential diagnosis in this case?
What is the next step in evaluation?
What is this patient’s diagnosis, and what is the etiology?
What is the recommended treatment for this patient?
What are this patient’s fertility options?
What if the patient had no pubic hair but a short (2 cm) vagina? What is the most likely diagnosis in this scenario?
What is the pathophysiology of CAIS and the associated karyotype?
How do you counsel an adolescent with MRKH about sexuality?
Case Summary
References
50 - A 14-Year-Old Girl With Heavy Menstrual Bleeding Since Menarche
What additional history would be helpful to assess this patient?
What is in the differential diagnosis of abnormal uterine bleeding in an adolescent?
Should this patient be evaluated for a bleeding disorder?
How is iron deficiency anemia treated?
What is the pathophysiology of von Willebrand disease?
How should the patient’s heavy menses be treated?
What are the risks and benefits of combined OCPs?
How can acute, heavy vaginal bleeding be managed in an adolescent patient?
Case Summary
References
51 - An 11-Year-Old With Gender Identity Concerns
What is gender dysphoria?
What are the initial steps in caring for this patient?
How does the onset of puberty affect the management of this patient?
Is any additional history needed for this patient?
What medical treatment options are available to transgender patients?
Does hormonal treatment have an effect on future fertility? What are this patient’s options?
What surgical options are available to transgender patients?
What long-term health considerations need to be discussed specific to transgender patients?
Case Summary
References
52 - A 65-Year-Old Postmenopausal Woman With Abdominal Distension
What are the next steps in the evaluation of this patient?
How is epithelial ovarian cancer staged?
What are the goals of surgery for ovarian cancer?
What does the patient do next?
Case Summary
References
53 - A 52-Year-Old Perimenopausal Woman With Irregular Bleeding
What are your next steps?
What is the likely diagnosis?
What is the incidence of cervical cancer?
What are some risk factors for the development of cervical cancer?
What are the main histologic subtypes of cervical cancer?
What is the pathogenesis for cervical cancer?
How is cervical cancer staged?
How is cervical cancer treated?
What is the recommended treatment of early-stage cervical cancer?
What is chemoradiation for cervical cancer?
What is a radical hysterectomy?
Case Summary
References
54 - A 58-Year-Old Woman With Postmenopausal Bleeding
What can cause postmenopausal bleeding?
With what symptoms does a patient with endometrial cancer usually present?
What are risk factors for endometrial cancer?
How do you classify endometrial cancer?
What is the initial evaluation of endometrial cancer?
What tests should be ordered for evaluation of endometrial cancer and presurgical planning?
What is the treatment for endometrial cancer?
Does the patient need additional treatment?
How common is recurrence, and what could be done if the cancer returns?
What does the patient do next?
Case Summary
References
55 - A 35-Year-Old Woman With a Family History of Ovarian Cancer
Which inherited genetic disorders carry an increased risk of ovarian cancer?
Who should be offered hereditary cancer risk assessment for hereditary breast and ovarian cancers?
What genetic testing should be offered to women with or at increased risk of ovarian/fallopiantube/primary peritoneal cancer?
What is the BRCA gene, and how common are mutations?
What is the lifetime risk of ovarian and breast cancer in a patient with BRCA mutation?
How should a risk-reducing BSO be performed?
Case Summary
References
56 - A 29-Year-Old Woman With Vaginal Bleeding
What is the differential diagnosis of vaginal bleeding?
What is the most likely diagnosis?
Who is at risk for developing GTN?
What are the next steps for diagnosis in our patient?
Where is GTN most likely to metastasize?
What laboratory or imaging studies should be ordered?
How is GTN staged?
How is GTN treated?
How should this patient be monitored?
Case Summary
References
57 - A 63-Year-Old With Known Ovarian Cancer and New-Onset Abdominal Symptoms
What are the next steps in this patient’s care?
What are options for treatment for recurrent epithelial ovarian cancer?
What chemotherapy is given at the time of recurrent ovarian cancer?
What options does the patient have now?
What is palliative care?
What is the patient’s diagnosis at this time?
What is the management of SBO in this patient?
What is hospice?
Case Summary
References
58 - A 57-Year-Old Woman With Pain on Sexual Intercourse
Why is it important to ask about and address sexual concerns among women?
When a woman has pain with intercourse, what do you need to know about her history?
What clues in the history might point toward vaginal atrophy?
What clues in the history might point toward a musculoskeletal origin of the pain?
In addition to evaluating the vaginal mucosa for atrophy and the pelvic muscles for pain, what other information should be gathered from this patient on pelvic exam?
What is the foreign body in this woman’s vagina, and how does that relate to her pain?
What treatment options exist for this woman’s vaginal mesh erosion?
What does the patient need to know prior to having the mesh removed?
What treatments can you offer the patient at this point?
Case Summary
References
59 - A 62-Year-Old Woman With Urinary Urgency and Incontinence
What are some causes of urinary frequency and urgency?
What initial workup should be performed at her first visit?
What is the patient’s likely diagnosis?
What are some first-line therapies to treat OAB?
What medical treatment can you offer the patient, and what is the mechanism of action?
What third-line treatments exist for the treatment of OAB?
Case Summary
References
60 - A 51-Year-Old With Frequent Urinary Tract Infections and Vaginal Dryness and Burning
What type of history is important to discuss with this patient and why?
What are physical signs of GSM? What physical exam is indicated to evaluate this patient?
How do you establish a diagnosis of recurrent UTI in this patient?
What are the common organisms isolated in recurrent UTIs?
What are the risk factors for recurrent UTIs in postmenopausal women?
How would you manage recurrent UTIs in the postmenopausal woman?
What measures can be taken to prevent recurrent UTIs?
What treatments can you offer the patient for her GSM?
Case Summary
References
61 - A 32-Year-Old Woman With Urinary Leakage on Exercise
What are risks factors for stress incontinence?
Why does SUI occur?
Is there any additional workup needed to make the diagnosis of SUI?
What treatment options are available to her?
Do you need to perform urodynamic testing prior to antiincontinence surgery?
What surgical options are available to treat stress incontinence?
What are the potential risks to mid-urethral slings?
What is the success rate of the operations to treat stress incontinence?
Case Summary
References
62 - A 43-Year-Old Woman With Pelvic Pain, Symptoms of Bladder Infections Despite Negative Urine Cultures
Why is it important to differentiate urinary frequency with pain from urinary urgency?
What is the relationship between IC/BPS and other pain disorders?
What are important elements of the physical exam if IC/BPS is suspected?
Are there any diagnostic tests to solidify the IC/BPS diagnosis?
What is important for the patient to know about IC/BPS?
Which treatments are most effective for IC/BPS?
What other therapies can be offered to this patient?
Case Summary
References
63 - A 65-Year-Old With Vaginal Bulge and Pelvic Pressure
What questions should you ask when obtaining the patient’s history?
What are some risks factors for POP?
What are key physical findings that you should look for?
What additional workup should be performed for this patient?
What are the risks of not intervening?
What nonsurgical options can you offer to the patient?
What surgical modalities are available for her?
How do you counsel her about the long-term durability of a POP surgery?
Case Summary
References
64 - A 63-Year-Old Woman With Fecal Incontinence
Why is it important to ask about fecal incontinence in women?
When a woman presents with FI, what should you ask about her history?
What is the role of an obstetric history when evaluating a woman with FI?
In addition to obstetrical injuries, what are other risk factors associated with FI?
What is the physiology of normal defecation?
What anatomic components are responsible for continence?
What physical exam findings are important for the evaluation of FI?
What studies are necessary for the workup of FI?
What are other initial treatment options that should be offered to the patient?
What other nonsurgical interventions are available to patients for FI?
When should surgical options for FI be offered to patients, and what common surgical options are available?
Case Summary
References
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