254. Obstetrics And Gynecology: Maintenance Of Knowledge

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254. Obstetrics And Gynecology: Maintenance Of Knowledge

254. Obstetrics And Gynecology: Maintenance Of Knowledge



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Foreword: Lifelong Learning Requires Maintenance of Knowledge xi
William F. Rayburn
Preface: Maintenance of Knowledge xiii
Janice L. Bacon and Paul G. Tomich
Contraception: Menarche to Menopause 143
Erin E. Tracy
Contraception services should be part of routine health care maintenance in
reproductive-aged women, especially in light of the fact that approximately
50% of pregnancies in the United States remain unplanned. Barrier methods,

especially condoms, may play a role in sexually transmitted disease preven-
tion but are less efficacious for pregnancy avoidance. There are several avail-
able hormonal contraceptive options, including the combination hormonal

pill, progestin-only pill, combination hormonal patches and rings, injectable

progestins, implantable progestins, intrauterine devices (copper or proges-
tin), and permanent sterilization. These methods have varying efficacy, often

related to patient compliance or tolerance of side effects.
Vaginitis: Beyond the Basics 159
Benjie Brown Mills
Vaginal complaints are one of the most common reasons women seek
the advice of a health care provider. Uncomplicated infections such as
vulvovaginal candidiasis, bacterial vaginosis, or trichomoniasis are easy
to diagnose and treat. However, about 8% of patients will have a more
complicated course with failure to respond to treatment or rapid recurrence
of symptoms. Understanding the need for a methodical, diagnostic
approach to help these women with recurrent or refractory cases of vaginal
symptoms will aid the clinician achieve successful patient outcomes.
Abnormal Uterine Bleeding: Current Classification and Clinical Management 179
Janice L. Bacon
Abnormal uterine bleeding is now classified and categorized according to
the International Federation of Gynecology and Obstetrics classification
system: PALM-COEIN. This applies to nongravid women during their

reproductive years and allows more clear designation of causes, thus aid-
ing clinical care and future research.

Recognition and Therapeutic Options for Malignancy of the Cervix and Uterus 195
Elizabeth R. Burton and Joel I. Sorosky
An update on the current epidemiology and a review of the risk factors
of cervical and endometrial cancers are discussed. Cervical cancer
Obstetrics and Gynecology: Maintenance of Knowledge

prevention with a focus on human papillomavirus vaccination and cervical
cancer screening is reviewed, emphasizing the new focus of less frequent
intervention in an effort to maintain high rates of early detection of disease

while decreasing unnecessary and anxiety-provoking colposcopies, bi-
opsies, and excisional procedures. The replacement of traditional endo-
metrial hyperplasia terminology with more relevant clinical categories,

with an emphasis on the introduction of endometrial intraepithelial
neoplasia, is presented. Fertility-sparing options in the management of
early cervical and endometrial cancers are reviewed.
Gestational Diabetes: Diagnosis, Classification, and Clinical Care 207
Lynn R. Mack and Paul G. Tomich
Gestational diabetes mellitus (GDM) affects approximately 6% of pregnant
women, and prevalence is increasing in parallel with the obesity epidemic.
Protocols for screening/diagnosing GDM are controversial with several

guidelines available. Treatment of GDM results in a reduction in the inci-
dence of preeclampsia, shoulder dystocia, and macrosomia. If diet and

lifestyle changes do not result in target glucose levels, then treatment

with metformin, glyburide, or insulin should begin. It is generally recom-
mended that pregnancies complicated by GDM do not go beyond term.

For women identified to have prediabetes, intensive lifestyle intervention
and metformin have been shown to prevent or delay progression to type
2 diabetes.
Updates on the Recognition, Prevention and Management of Hypertension in
Pregnancy 219
Jessica R. Jackson and Anthony R. Gregg
Systematic reviews with meta-analysis represent the highest level of

evidence used to guide clinical practice. The defining criteria used to diag-
nose preeclampsia have evolved, and will likely continue to evolve. Pro-
teinuria is sufficient but not necessary when defining preeclampsia.

Hypertension without proteinuria but with severe features is diagnostic.
The methods used to measure urinary protein have changed. The gold
standard remains the 24-hour urine test. The efficacy of low-dose aspirin
in preventing preeclampsia is a function of baseline risk. Data suggest
that treating mild to moderate blood pressure has clear maternal benefits
with little fetal or neonatal risk.
Obstetric Emergencies: Shoulder Dystocia and Postpartum Hemorrhage 231
Joshua D. Dahlke, Asha Bhalwal, and Suneet P. Chauhan
Shoulder dystocia and postpartum hemorrhage represent two of the most
common emergencies faced in obstetric clinical practice, both requiring
prompt recognition and management to avoid significant morbidity or

mortality. Shoulder dystocia is an uncommon, unpredictable, and unpre-
ventable obstetric emergency and can be managed with appropriate inter-
vention. Postpartum hemorrhage occurs more commonly and carries

significant risk of maternal morbidity. Institutional protocols and algorithms
for the prevention and management of shoulder dystocia and postpartum
hemorrhage have become mainstays for clinicians. The goal of this review

is to summarize the diagnosis, incidence, risk factors, and management of
shoulder dystocia and postpartum hemorrhage.
Prenatal Diagnosis: Screening and Diagnostic Tools 245
Laura M. Carlson and Neeta L. Vora
The American Congress of Obstetricians and Gynecologists recommends
that all pregnant women be offered aneuploidy screening or diagnostic
testing. A myriad of screening and testing options are available to patients
based on their risk profile and gestational age. Screening options include
traditional serum analyte screening, such as first-trimester screening or
quadruple screening, and more recently, cell-free DNA. Diagnostic testing
choices include chorionic villus sampling and amniocentesis. The number
of screening and diagnostic modalities complicates prenatal counseling

for physicians and can be difficult for patients to grasp. Appropriate pre-
test and posttest counseling is important to ensure adequate understand-
ing of results and ensure testing strategy is concordant with patient goals.

Cancer Recognition and Screening for Common Breast Disorders and Malignancy 257
Constance Bohon

Breast cancer is predicted to be the most common newly diagnosed can-
cer in women in 2016. Screening mammography is the most commonly

used method for the detection of breast cancer in women of average
risk. A genetic risk assessment is recommended for women with a greater
than 20% to 25% chance of having a predisposition to breast and ovarian

cancer. Evaluation of a breast mass begins with a detailed history, assess-
ment for cancer risk, and physical examination.

Recognizing and Managing Common Urogynecologic Disorders 271
Denise M. Elser

Many women experience urogynecologic or pelvic floor disorders, espe-
cially urinary incontinence and pelvic organ prolapse. The obstetrician/gy-
necologist is often the first health care professional to evaluate and treat

these disorders. Treatments include pelvic floor muscle training, behav-
ioral therapies, oral medications, neuromodulation, intradetrusor medica-
tions, and surgery. When approaching the woman with symptomatic

prolapse, familiarity with pessaries and various surgical procedures aid

in counseling. Referral to a pelvic floor physical therapist or to a female pel-
vic medicine and reconstructive surgeon should be considered. Increasing

attention to data on cost-effectiveness is a necessity.
The Menopausal Transition 285
Janice L. Bacon
A clear understanding of the physiology of the menopausal transition,
clinical symptoms, and physical changes is essential for individualized
patient management, maximizing benefits and minimizing risks for the

present and the future. Menopause, defined by amenorrhea for 12 consec-
utive months, is determined retrospectively and represents a permanent

end to menses. Many physical changes occur during the menopausal

Contents vii

transition and beyond. Knowledge of symptoms and findings experienced
by women undergoing the menopausal transition allow individualized
care- improving quality of life and enhancing wellbeing for years to come.
Special Article
Burnout in Obstetricians and Gynecologists 297
Roger P. Smith
It is estimated that 40% to 75% of obstetricians and gynecologists
currently suffer from professional burnout, making the lifetime risk a virtual

certainty. Although these statistics make for a dismal view of the profes-
sion, if the causes and symptoms can be identified simple steps can be

implemented to reverse the threat. With a little care, the enjoyment of prac-
tice can be restored and the sense of reward and the value of service can

be returned.
Index 311



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