(BQ) Part 2 book “Blueprints obstetrics & gynecology” has contents: Benign disorders of the upper genital tract, endometriosis and adenomyosis, pelvic organ prolapse, urinary incontinence, puberty, the menstrual cycle, and menopause, abnor malities of the menstrual cycle,… and other contents.
Part II Gynecology Chapter 13 Benign Disorders of the Lower Genital Tract BENIGN LESIONS OF THE VULVA, VAGINA, AND CERVIX This chapter encompasses an overview of the many congenital anomalies, epithelial disorders, and benign cysts and tumors of the vulva, vagina, and cervix Infections of these structures are covered in Chapter 16, and premalignant and malignant lesions are covered in Chapter 27 (vulva and vagina) and Chapter 28 (cervix) CONGENITAL ANOMALIES OF THE VULVA AND VAGINA A variety of congenital defects occur in the external genitalia, vagina, and cervix including but not limited to labial fusion, imperforate hymen, transverse vaginal septum, longitudinal vaginal septum, vaginal atresia, and vaginal agenesis Congenital anomalies of the female genital tract are associated with concomitant anomalies in the upper reproductive tract as well as anomalies in the genital urinary (GU) tract such as unilateral renal agenesis, pelvic or horseshoe kidneys, or irregularities in the collecting system LABIAL FUSION Labial fusion is associated with excess androgens Most commonly, the etiology is the result of exogenous androgen exposure but may also be due to an enzymatic error leading to increased androgen production The most common form of enzymatic deficiency is 21-hydroxylase deficiency (Chapter 23) leading to congenital adrenal hyperplasia This may be phenotypically demonstrated in the neonate with ambiguous genitalia, hyperandrogenism with salt wasting, hypotension, hyperkalemia, and hypoglycemia The neonates often present in adrenal crisis with salt wasting seen approximately 75% of the time This autosomal recessive trait occurs in roughly in 40,000 to 50,000 pregnancies The diagnosis is made by elevated 17α-hydroxyprogesterone or urine 17-ketosteroid with decreased serum cortisol Because cortisol is not being made in the adrenal cortex, the treatment for this disorder is exogenous cortisol The exogenous cortisol then negatively feeds back on the pituitary to 174 decrease the release of adrenocorticotropic hormone (ACTH), thus inhibiting the stimulation of the adrenal gland that is shunting all steroid precursors into androgens If salt wasting is documented, a mineralocorticoid (usually fludrocortisone acetate) is also given Labial fusion and other forms of ambiguous genitalia often require reconstructive surgery IMPERFORATE HYMEN The hymen is at the junction between the urogenital sinus and the sinovaginal bulbs (Fig 13-1) Before birth, the epithelial cells in the central portion of the hymenal membrane degenerate, leaving a thin rim of mucous membrane at the vaginal introitus This is known as the hymenal ring When this degeneration fails to occur, the hymen remains intact This is known as an imperforate hymen It occurs in in 1,000 female births Other congenital abnormalities of the hymen are shown in Figure 13-2 These can result from incomplete degeneration of the central portion of hymen An imperforate hymen results in an obstruction to the outflow tract of the reproductive system This can lead to a buildup of secretions in the vagina behind the hymen (hydrocolpos or mucocolpos) similar to that seen with a transverse vaginal septum (Fig 13-3) If not identified at birth, an imperforate hymen is often diagnosed at puberty in adolescents who present with primary amenorrhea and cyclic pelvic pain These symptoms are due to the accumulation of menstrual flow behind the hymen in the vagina (hematocolpos) and uterus (hematometra) In these patients, the physical examination may be notable for the absence of an identifiable vaginal lumen, a tense bulging hymen, and possibly increasing lower abdominal girth Treatment of imperforate hymen and other hymenal abnormalities is with surgery to excise the extra tissue, evacuate any obstructed material, and create a normalsized vaginal opening (Color Plate 7) TRANSVERSE VAGINAL SEPTUM The upper vagina is formed as the paramesonephric (Müllerian) ducts elongate and meet in the midline The internal portion of each duct is canalized and the remaining septum between them dissolves (Fig 13-1A) The caudal portion of the Müllerian ducts develops into the uterus and Chapter 13 / Benign Disorders of the Lower Genital Tract • 175 Figure 13-1 • Embryonic formation of the vagina and uterus (From Sadler T Langman’s Medical Embryology, 9th ed Baltimore, MD: Lippincott Williams & Wilkins; 2003.) upper vagina (Fig. 13-1B and C) The lower vagina is formed as the urogenital sinus evaginates to form the sinovaginal bulbs (Fig. 13-1B) These then proliferate to form the vaginal plate The lumen of the lower vagina is then formed as the central portion of this solid vaginal plate degenerates (Fig. 13-1C) This process is known as canalization or vacuolization The vagina is formed as the Müllerian system from above joins the sinovaginal bulb–derived system from below This takes place at the Müllerian tubercle (Fig. 13-1B) The Müllerian tubercle must be canalized for a normal vagina to form If this does not occur, the tissue may be left as a transverse vaginal septum These septa often lie near the junction between the lower two-thirds and upper one-third of the vagina (Fig. 13-3) but can be found at various levels in the vagina This occurs in approximately in 30,000 to 1 in 80,000 women Similar to the imperforate hymen, diagnosis is usually made at the time of puberty in adolescents who present with primary amenorrhea and cyclic pelvic pain accompanied by menstrual symptoms On physical examination, patients typically have normal external female genitalia and a short vagina that appears to end in a blind pouch The transverse vaginal septa are usually less than cm thick and may have a central perforation Ultrasound and MRI can be used to characterize the thickness and location of the septum and to confirm the presence of other parts of the reproductive tract Surgical correction is the only form of treatment A Figure 13-2 • Congenital abnormalities of the hymen (A) Normal (B) Imperforate (C) Microperforate (D) Septate VAGINAL ATRESIA Vaginal atresia (also known as agenesis of the lower vagina) is often confused with imperforate hymen or transverse vaginal septum It occurs when the lower vagina fails to develop and is replaced by fibrous tissue The ovaries, uterus, cervix, and upper vagina are all normal Developmentally, vaginal atresia results when the urogenital sinus fails to contribute the lower portion of the vagina (Fig. 13-1) It presents during adolescence with primary amenorrhea and cyclic pelvic pain Physical examination reveals the absence of an introitus and the presence of a vaginal dimple Pelvic imaging with ultrasound and/or MRI may show a large hematocolpos and confirm the presence of a normal upper reproductive tract Surgical correction can be achieved by incising the fibrous tissue and dissecting it until the normal upper vagina is identified Any accumulated blood or materials can be evacuated and the normal upper vaginal mucosa is then brought down to the introitus and sutured to the hymenal ring This is known as a vaginal pull-through procedure VAGINAL AGENESIS Vaginal agenesis, also known as Mayer-Rokitansky-KusterHauser syndrome (MRKH), occurs in to 2.5 per 10,000 female births It is characterized by the congenital absence of the vagina (Color Plate 8) and the absence or hypoplasia of B C D 176 • Blueprints Obstetrics & Gynecology the level of the peritoneum The mold and graft are inserted into the neovagina Once the mold is removed, dilators must still be used for several months to maintain vaginal patency While normal sexual intercourse is possible after these surgical and nonsurgical procedures, the patient will be unable to carry a pregnancy She can, however, have her eggs harvested for use with a gestational surrogate Vaginal septum Figure 13-3 • Transverse vaginal septum all or part of the cervix, uterus, and fallopian tubes These patients typically have normal external genitalia, normal secondary sexual characteristics (breast development, axillary, and pubic hair), and normal ovarian function These patients are phenotypically and genotypically female with normal 46,XX karyotypes These patients typically present in adolescence with primary amenorrhea Pelvic imaging with ultrasound and MRI can be used to assess the vagina, uterus, ovaries, and kidneys because these patients will often have associated urologic and skeletal anomalies Treatment for patients with vaginal agenesis involves a combination of psychosocial support, counseling, and nonsurgical and surgical correction individualized to the patient In motivated patients, a vagina can be created using serial vaginal dilators pressed into the perineal body (Frank and Ingram procedures) This can take months to several years depending on the patient If this nonsurgical approach fails, a variety of vaginal, laparoscopic, and abdominal procedures are available to create a neovagina The most commonly used is the McIndoe procedure In this procedure a split-thickness skin graft is taken from the buttocks and is placed over a silicone mold to create a tube with one closed end (Fig 13-4) A transverse incision is then made at the vaginal dimple and the fibrous tissue in the location of the normal vagina The tissue is then dissected to BENIGN EPITHELIAL DISORDERS OF THE VULVA AND VAGINA Benign lesions of the mucosa of the vulva and vagina come under this broad category The nonneoplastic epithelial disorders of the vulva, including lichen sclerosis, lichen planus, lichen simplex chronicus, and vulvar psoriasis, were formerly known as the vulvar dystrophies “Dystrophy” is no longer an acceptable term; the 2006 International Society for the Study of Vulvar Disease classification system now lists the specific dermatologic disorders (Table 13-1) These lesions often require histologic examination (Table 13-2) to identify and treat the disorder and to differentiate the lesion from vulvar and vaginal intraepithelial neoplasia and cancer (Chapter 27) Lichen sclerosis is an inflammatory dermatosis that can be found on the vulva of women of all age groups, but has major significance in postmenopausal women, where it is associated with a 3% to 4% risk of vulvar skin cancer The etiology is unknown, but several mechanisms have been proposed including immunologic, genetic, hormonal, and infectious mechanisms The resulting atrophy can cause resorption of the labia minora, labial fusion, occlusion of the clitoris, contracture of the vaginal introitus, thinning of the vulvar skin, and skin fragility (Fig 13-5) Lichen planus is an uncommon inflammatory skin condition that can affect the nails, scalp and skin mucosa Vulvar lichen planus is characterzed by papular or erosive lesions of the vulva that may also involve the vagina The etiology is unknown, but several mechanisms have been proposed including immunologic, genetic, hormonal, and infectious mechanisms This inflammatory dermatosis results in chronic eruption of shiny purple papules with white striae on the vulva Similar lesions are often found on the flexor surfaces, and mucous membrane of the oral cavity Lichen planus can be associated with vaginal adhesions and with erosive vaginitis It generally occurs in women in their 50s or 60s and it is associated with a 3% to 4% risk of vulvar skin cancer Figure 13-4 • McIndoe procedure to make a neovagina The skin graft is sewn around a mold (Image from Emans J Pediatric & Adolescent Gynecology, 5th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2004.) Chapter 13 / Benign Disorders of the Lower Genital Tract • 177 j TABLE 13-1 Pathological Subsets and Their Clinical Correlates Lichenoid pattern (and dermal homogenization/ sclerosis pattern) Lichen sclerosus Lichen planus Acanthotic pattern (formerly squamous cell hyperplasia) Psoriasis Lichen simplex chronicus Primary (idiopathic) acanthosis Secondary (superimposed on lichen sclerosus, lichen planus, or other vulvar disease) Spongiotic pattern Atopic dermatitis Allergic contact dermatitis Irritant contact dermatitis Vesiculobullous pattern Pemphigoid, cicatricial type Linear IgA disease Vasculopathic pattern Aphthous ulcers Figure 13-5 • A late case of lichen sclerosis Note the thin, white, atrophic epithelium and the labial fusion (From Rubin E, Farber JL Pathology, 3rd ed Philadelphia, PA: Lippincott Williams & Wilkins; 1999.) Behcet disease Plasma cell vulvitis Acantholytic pattern Hailey-Hailey disease Darier disease Papular genitocrural acantholysis Granulomatous pattern Crohn disease Melkersson-Rosenthal syndrome Intraepithelial neoplasia VIN, usual type a VIN, warty type b VIN, basaloid type c VIN, mixed (warty/basaloid) type VIN, differentiated type Lynch PJ, Moyal-Barrocco M, Bogliatto F, Micheletti L, Scurry J 2006 ISSVD classification of vulvar dermatoses: pathologic subsets and their clinical correlates J Reprod Med; 2007:52(1):3–9 Lichen simplex chronicus is characterized by thickened skin with accentuated skin markings and excoriations due to chronic itching and scratching The intense pruritis may be due to atopic dermatitis, psoriasism, neuropathic pain, or psychologic disorders This skin disorder leads to a scratch–itch cycle; it may begin with something that rubs, irritates, or scratches the skin, such as clothing This may cause the person to rub or scratch the affected area Constant scratching causes the skin to thicken The thickened skin itches, causing more scratching, which causes more thickening Clinical Manifestations History Patients with benign lesions of the vulva and vagina present with a variety of complaints including vulvar itching, irritation, and burning They may also report dysuria, dyspareunia, and vulvar pain and feel that the skin of their vulva is tender, bumpy, irritated, or thickened Physical Examination These disorders range in appearance from erythematous plaques to hyperkeratotic white plaques to erosions and ulcers (Table 13-2) Occasionally, petechiae and/or ecchymoses are present as a result of trauma from scratching Diagnostic Evaluation Vulvar psoriasis may be a feature of psoriasis—a very common skin rash that affects up to 2% of the population There are several different types but the usual form appears as silvery-red scaly patches over the elbows and knees Other areas of the skin can be affected including the scalp and nails Psoriasis can occur on the genital skin as part of more general disease but in some people, it affects only this area The etiology is unknown Diagnosis of these disorders may be made clinically Often histologic confirmation is sought, and biopsy of vulvar lesions is appropriate (Fig. 13-6) for identification purposes and to rule or premalignant and malignant disease Indications for definite biopsy include ulceration, unifocal lesions, uncertain suspicion of lichen sclerosus, unidentifiable lesions, and lesions or symptoms that recur or persist after conventional therapy Vulvar and vaginal lesions can be evaluated with a colposcope and this will aid directed biopsy 178 • Blueprints Obstetrics & Gynecology or Dove, and take morning and evening tub baths without additives High-potency topical steroids such as clobetasol can be used to treat lichen sclerosus or lichen planus and severe lichen simplex chronicus, and low- to medium-potency steroids should be used for mild cases of dermatoses (Table 13-2) The frequency of use ranges from once per week to one to two times a day Treatment of lichen simplex chronicus and atopic dermatitis is often limited However, lichen sclerosus and lichen planus are chronic conditions and require longterm maintenance with topical steroid application, one to three times per week In general, there is no role for topical estrogens or testosterone in the treatment of these disorders; however, low-dose vaginal estrogen is an effective treatment for concomitant postmenopausal vulvovaginal atrophy Similarly, surgical management is generally not indicated in treatment of these disorders An exception is cases of lichen planus, where postinflammatory sequelae can include vaginal adhesions and introital stenosis Likewise, surgical procedures to enlarge the introitus and open adhesions in lichen sclerosus may be necessary if attempts at intercourse have been unsuccessful following conservative measures Figure 13-6 • Vulvar biopsy (From Beckman CRB, Ling FW, Laube DW, et al Obstetrics and Gynecology, 4th ed Baltimore, MD: Lippincott Williams & Wilkins; 2002.) Differential Diagnosis The differential diagnosis of benign lesions of the vulva and vagina includes disorders such as aphthous ulcers, Behỗet syndrome, Crohn disease, erythema multiforme, bullous pemphigoid, and plasma cell vulvitis The differential diagnosis also includes carcinomas such as squamous cell, basal cell, melanoma, sarcoma, and Paget disease of the vulva Biopsies should therefore be performed whenever there is uncertainty Treatment For all of these lesions, healthy vulvar and vaginal hygiene practices are of recommended Patients should avoid tightfitting clothes; pantyhose; panty liners; scented soaps and detergents; bubble baths; washcloths; and feminine sprays, douches, and powders Patients should wear loose-fitting cotton underwear and loose-fitting clothing They should use unscented detergents and soaps such as Neutrogena j BENIGN CYSTS AND TUMORS OF THE VULVA AND VAGINA A variety of cysts and tumors can arise on the vulva and vagina Cysts can originate from occlusion of pilosebaceous ducts, sebaceous ducts, and apocrine sweat glands Treatment of benign cystic and solid tumors is needed only if the lesions become symptomatic or infected EPIDERMAL INCLUSION CYSTS Epidermal inclusion cysts are the most common tumor found on the vulva These cysts usually result from occlusion of a pilosebaceous duct or a blocked hair follicle They are lined with squamous epithelium and contain tissue that would normally be exfoliated These solitary lesions are normally small and asymptomatic; however, if these become superinfected and develop into abscesses, incision and drainage or complete excision is the treatment TABLE 13-2 Benign Epithelial Disorders of the Vulva and Vagina Physical Findings Symptoms Treatment Options Lichen sclerosis Symmetric white, thinned skin on labia, perineum, and perianal region; shrinkage and agglutination of labia minora Usually pruritus or dyspareunia, often asymptomatic High-potency topical steroids (clobetasol or halobetasol 0.05%) 1–2ϫ/d for 6–12 wk, then a maintenance schedule of topical steroid Lichen planus Multiple shiny, flat, red-purple papules, usually on the inner aspects of the labia minora and vestibule with lacy white changes; often erosive Pruritus with mild inflammation to severe erosions High-potency topical steroids (clobetasol or halobetasol 0.05%) 1–2ϫ/d for 6–12 wk, then a maintenance schedule of topical steroid Lichen simplex chronicus Localized thickening of the vulvar skin, slight scaling Chronic pruritus Medium- to high-potency topical steroid 2ϫ/d for or more weeks Vulvar psoriasis Red moist lesions, sometimes scaly Asymptomatic or sometimes pruritus Topical steroids, UV light Chapter 13 / Benign Disorders of the Lower Genital Tract • 179 SEBACEOUS CYSTS When the duct of a sebaceous gland becomes blocked, a sebaceous cyst forms The normally secreted sebum accumulates in this cyst Cysts are often multiple and asymptomatic As with any cyst, these can become superinfected with local flora and require treatment with incision and drainage APOCRINE SWEAT GLAND CYSTS Sweat glands are found throughout the mons pubis and labia majora They can become occluded and form cysts FoxFordyce disease is an infrequently occurring chronic pruritic papular eruption that localizes to areas where apocrine glands are found The etiology of Fox-Fordyce disease currently is unknown Hidradenitis suppurativa is a skin disease that most commonly affects areas bearing apocrine sweat glands or sebaceous glands, such as the underarms, breasts, inner thighs, groin, and buttocks As in the axillary region, if these cysts become infected and form multiple abscesses, excision or incision and drainage are the treatments of choice If an overlying cellulitis is present, antibiotics are often used as well SKENE’S GLAND CYSTS Skene’s glands, or paraurethral glands, are located next to the urethra meatus (Fig. 13-7) Chronic inflammation of the Skene’s glands can cause obstruction of the ducts and result in cystic dilation of the glands BATHOLIN’S DUCT CYST AND ABSCESS The Bartholin’s glands are located bilaterally at approximately 4-o’clock and 8-o’clock positions on the posteriorlateral aspect of the vaginal orifice (Fig. 13-7) They are mucus-secreting glands with ducts that open just external to the hymenal ring Obstruction of these ducts leads to cystic dilation of the Bartholin’s duct while the gland itself is unchanged (Fig. 13-8) If the cyst remains small (1 to cm) and is asymptomatic, it can be left untreated and will often resolve on its own or with sitz baths When a Bartholin’s duct cyst first presents in a woman older than 40 years, a biopsy should be performed to rule out the rare possibility of B artholin’s gland carcinoma While many Bartholin’s cysts will resolve with minimal treatment, some cysts can become quite large and cause pressure symptoms such as local pain, dyspareunia, and difficulty walking If these cysts not resolve, they can become infected and lead to a Bartholin’s gland abscess These abscesses are the result of polymicrobial infections, but they are also occasionally associated with sexually transmitted diseases These abscesses can become quite large, causing exquisite pain and tenderness and associated cellulitis Bartholin’s abscesses or symptomatic cysts should be treated like any other abscess: by incision and drainage However, simple incision and drainage can often lead to recurrence; therefore, one of the two methods can be used Word catheter placement is commonly performed in the emergent setting or in the office This method involves making a small incision (5 mm) to drain and irrigate the abscess Then a Word catheter with a balloon tip is placed inside the remaining cyst and inflated to fill the space The balloon is left in place for to weeks, being serially reduced in size, while epithelialization of the cyst and tract occurs (Fig. 13-9) Marsupialization is usually done for recurrent Bartholin’s duct cysts or abscesses The entire abscess or cyst is incised and the cyst wall is sutured to the vaginal mucosa to prevent reformation of the abscess (Fig. 13-10) Clitoral hood Clitoris Urethra Skene’s gland Labium minora Vestibule Labium majora Hymenal ring Bartholin’s duct opening Posterior fourchette Perineum Figure 13-7 • Vulvar and perineal anatomy (From Beckman CRB, Ling FW, Laube DW, et al Obstetrics and Gynecology, 4th ed Baltimore, MD: Lippincott Williams & Wilkins; 2002.) Figure 13-8 • Gross appearance of a Bartholin’s cyst of the vulva (From LifeART image copyright © 2006 Lippincott Williams & Wilkins All rights reserved.) 180 • Blueprints Obstetrics & Gynecology Vaginal adenosis A Columnar epithelium B Cervical collar Figure 13-9 • Word catheter (A) before inflation and (B) after inflation The balloontipped end is placed into the incision site on the Bartholin’s cyst A small-gauge needle is inserted into the opposite end and to mL of water is injected The inflated balloon remains inside the cyst for to weeks until an epithelialized tract is formed to prevent blockage of the duct to recur With either treatment, warm sitz baths several times per day are recommended both for pain relief and to decrease healing time Adjunct antibiotic therapy is only recommended when the drainage is cultured for Neisseria gonorrhoeae, which occurs approximately 10% of the time Concomitant cellulitis or an abscess that seems refractory to simple surgical treatment should also be treated with antibiotics that cover skin flora, primarily Staphylococcus aureus GARTNER’S DUCT CYSTS Gartner’s duct cysts are remnants of the mesonephric ducts of the Wolffian system They are found most commonly in the anterior lateral aspects of the upper part of the vagina Figure 13-11 • Congenital cervical abnormalities due to in utero DES exposure Other characteristic DES-associated cervical anomalies include cervical ectropion, cervical ridges, and hypoplastic cervix (From Bickley LS, Szilagyi P Bates’ Guide to Physical Examination and History Taking, 8th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2003.) Most are asymptomatic However, patients may present in adolescence with dyspareunia or difficulty inserting a tampon These cysts are typically treated by excision When removal is necessary, an IVP and cystoscopy should be performed preoperatively to locate the position of the bladder and ureters relative to the cyst Urethral diverticula, ectopic ureters, and vaginal and cervical cancer should be ruled out Because of the potential for significant bleeding during excision, vasopressin may be used to maintain hemostasis during the procedure BENIGN SOLID TUMORS OF THE VULVA AND VAGINA There are many benign solid tumors of the vulva and the vagina Some of the most common include lipomas, hemangiomas, and urethral caruncles Lipomas are soft pedunculated or sessile tumors composed of mature fat cells and fibrous strands These tumors not require removal unless they become large and symptomatic Cherry hemangiomas are elevated soft red papules, also known as Campbell De Morgan spots or senile angiomas; they contain an abnormal proliferation of blood vessels Retention cyst Figure 13-10 • Incision, drainage, and marsupilization of a Bartholin’s abscess (From LifeART image copyright © 2006 Lippincott Williams & Wilkins All rights reserved.) Figure 13-12 • Nabothian cysts of the cervix (From Bickley LS, Szilagyi P Bates’ Guide to Physical Examination and History Taking, 8th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2003.) Chapter 13 / Benign Disorders of the Lower Genital Tract • 181 Finally, in rare instances, endometriosis can implant on or near the cervix These cysts tend to be red or purple in color and the patient will often have associated symptoms of endometriosis such as cyclic pelvic pain and dyspareunia CERVICAL POLYPS Figure 13-13 • Cervical polyp (From Bickley LS, Szilagyi P Bates’ Guide to Physical Examination and History Taking, 8th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2003.) Urethral caruncles and urethral prolapse present as small, red, fleshy tumors found at the distal urethral meatus These occur almost exclusively in postmenopausal women as a result of vulvovaginal atrophy This results in formation of an ectropion at the posterior urethral wall These lesions are usually asymptomatic and no treatment is required When bloody spotting results, a short course of topical estrogen is appropriate Rarely, surgical excision may be needed BENIGN CERVICAL LESIONS CONGENITAL ANOMALIES Isolated congenital anomalies of the cervix are rare In case of a uterine didelphys with a double vagina, a double cervix (bicollis) may be found, but this does not arise in isolation However, 25% of women who were exposed in utero to diethylstilbestrol (DES) have an associated abnormality of the cervix These benign abnormalities include cervical hypoplasia, cervical collars (Fig. 13-11), cervical hoods, cock’s comb cervix, and pseudopolyps These women are also at increased risk of cervical insufficiency in pregnancy Women who have been exposed to DES in utero are also at increased risk of a very rare clear cell adenocarcinoma of the cervix and vagina This cancer is seen in young women under the age of 20 but only occurs in 0.1% of D ES-exposed patients CERVICAL CYSTS Most cervical cysts are dilated retention cysts called nabothian cysts (Fig. 13-12) These are caused by intermittent blockage of an endocervical gland and usually expand to no more than cm in diameter Nabothian cysts are more commonly found in menstruating women and are usually asymptomatic Most often, nabothian cysts are discovered on routine gynecologic examination and require no treatment Cervical cysts can also be mesonephric cysts These are remnants of the mesonephric (wolffian) ducts that can become cystic These cysts differ from nabothian cysts in that they tend to lie deeper in the cervical stroma and on the external surface of the cervix True cervical polyps are benign growths that may be pedunculated or broad-based (Fig. 13-13); these can arise anywhere on the cervix and are often asymptomatic When symptomatic, cervical polyps usually cause intermenstrual or postcoital spotting rather than pain Although cervical polyps are not usually considered a premalignant condition, they are generally removed to decrease the likelihood of masking irregular bleeding from another source such as cervical cancer, fibroids, adenomyosis, endometrial polyps, endometrial h yperplasia, and endometrial cancer Removal of pedunculated cervical polyps is typically quick and easily performed in the office However, sessile (broad-based) polyps or larger polyps may require removal with electrocautery in the office or the operating room Hysteroscopy may also be helpful in distinguishing cervical polyps from endometrial polyps CERVICAL FIBROIDS Leiomyomas (myomas or fibroids) are common benign tumors of the uterine corpus but may also arise in the cervix or prolapse into the cervical canal from the endometrial cavity Leiomyomas can cause symptoms of intermenstrual bleeding similar to both uterine fibroids and cervical polyps Depending on their location and size, these can also cause dyspareunia and bladder or rectal pressure Fibroids of the cervix can cause problems in pregnancy and may lead to hemorrhage, poor dilation of the cervix, malpresentation, or obstruction of the birth canal When evaluating an asymptomatic cervical fibroid, the possibility of cervical cancer should be ruled out, and then the fibroid can be followed with routine gynecologic care Symptomatic fibroids can be surgically removed but, depending on their location, hysterectomy rather than myomectomy may be required CERVICAL STENOSIS Cervical stenosis can be congenital, a product of infection, atrophy, or scarring (cervical surgical manipulation or radiotherapy) Less frequently, cervical stenosis can result from obstruction with a neoplasm, polyp, or fibroid Cervical stenosis is typically asymptomatic and does not affect menstruation or fertility In these settings, no treatment is indicated However, if egress from the uterus is completely or partially blocked, oligomenorrhea, amenorrhea, dysmenorrhea, or an enlarged uterus may result Cervical stenosis can also impede access to the endocervical and endometrial canals for diagnostic and therapeutic procedures And, it can result in cervical dystocia during labor When symptoms are present or access to the endocervical or endometrial canals are needed, cervical stenosis can be treated by gently dilating the cervix Prolonged patency can be improved by leaving a catheter in the cervical canal for a few days after the stenosis is relieved Any obstructive lesions should be removed 182 • Blueprints Obstetrics & Gynecology KEY POINTS • Labial fusion may be the result of excess androgen exposure or an enzymatic deficiency, most commonly 21-hydroxylase deficiency leading to congenital adrenal hyperplasia and ambiguous external genitalia • Treatment of benign cystic and solid skin tumors is only needed if the lesions become symptomatic or infected This can generally be achieved with incision and drainage or excision • Patients with imperforate hymen and transverse vaginal septa commonly present with primary amenorrhea at puberty and cyclic abdominal pain Both can be repaired surgically • Bartholin’s cysts and abscesses are located at 4-o’clock and 8-o’clock positions on the labia majora Cysts are usually asymptomatic and resolve on their own • Vaginal agenesis is seen in patients with MRKH who have an absent vagina and partial uterus and tubes Patients are genetically female with normal ovarian function and normal secondary sexual characteristics • When a Bartholin’s cyst first appears in a woman older than 40 years, the cyst wall should be biopsied to rule out the rare possibility of Bartholin’s gland carcinoma • • Vulvar itching and lesions can be secondary to a variety of atopic and atrophic skin changes, irritants, and allergens Lesions can become hypertrophic secondary to chronic irritation and pruritus Large symptomatic Bartholin’s cysts and Bartholin’s abscesses should be appropriately drained along with placement of a Word catheter or marsupialization Antibiotics are generally not indicated • Diagnosis of vulvar lesions is made by palpation, visualization, magnified vulvoscopy, and biopsy Cancer should always be excluded by biopsy • Congenital anomalies of the cervix are rare and may be associated with abnormalities of the upper genital tract and/or in utero exposure to DES • Treatment involves hygiene practices, avoidance of irritants, and use of medium- to high-potency topical steroids There is a limited role for vaginal estrogens and surgery in the treatment of these disorders • Cervical polyps and fibroids are typically benign and can be removed if symptomatic • Cervical stenosis may be congenital or idiopathic and may result from scarring from infection or surgical manipulation When symptomatic, the stenosis can be treated with gentle dilation of the cervical canal • A variety of cysts can arise on the vulva and vagina from occlusion of pilosebaceous ducts, sebaceous ducts, and apocrine sweat glands Clinical Vignettes Vignette A 26-year-old G0 patient comes in with a problem visit for a complaint of an intermittent painless mass on her vulva near the introitus It seems to be aggravated by intercourse, but usually goes away on its own She’s had two lifetime sexual partners and has been with her last partner for 5 years She has always had normal periods and Pap smears and has never had an STI You examine her and find a cm nontender mass in the area described What type of abnormality is this most likely to be? a Skene’s gland cyst b Gartner’s duct cyst c Bartholin’s duct cyst d Cystocele e Epidermal inclusion cyst medication The patient says these helped minimally but her intense pruritus has been persistent for more than a year She was married for 35 years but is now widowed and has not been sexually active in 3 years You examine her and find a thin white atrophic epithelium and a contracted, small introitus There is loss of the normal architecture of the labia minora An area of hypopigmentation surrounds the labia and the anus in a figure-of-eight pattern Wet prep shows a pH of 5.5, rare pseudohyphae, no lactobacilli, no WBC or RBC, and rare clue cells What would you next? a Collect fungal cultures b Screen for gonorrhea and chlamydia c Prescribe a longer course of oral fluconazole (Diflucan) d Check a fasting glucose level e Perform a vulvar biopsy What treatment would you recommend for this patient? a Expectant management b Word catheterization c I&D d Marsupialization e Excision Most likely the diagnosis is: a atrophic change b lichen simplex c lichen sclerosis d lichen planus e vulvar psoriasis Two years later she comes in with a recurrent cyst This time it is tender, red, and growing She is having difficulty sitting at work, and has not been able to exercise for days due to pain She denies fever or chills What treatment you recommend? a Expectant management b Word catheterization c I&D d Marsupialization e Excision How would you counsel this patient regarding her treatment options? a Expectant management b Topical estrogen c Topical high-potency steroids d Oral steroids e Surgical excision If this patient had been 46 years old at the first onset of her cyst, what would be required? a Biopsy of the cyst wall b Word catheterization c I&D d Marsupialization e Excision of the cyst Vignette While on call you are paged to the emergency department to see a 16-year-old G0 adolescent girl with cyclic pelvic pain She has never had a menstrual cycle She denies any history of intercourse She is afebrile and her vital signs are stable Her pregnancy test is negative On physical examination, she has age-appropriate breast and pubic hair development and normal external genitalia However, when attempting the pelvic examination, you are unable to locate a vaginal introitus You obtain a transabdominal ultrasound, which reveals a hematocolpos and hematometra Your next patient is a 65-year-old G2P2 new patient who has been referred from her primary care provider for recurrent yeast vaginitis Review of her outside medical records reveals five episodes of vulvar pruritus that were treated with oral and vaginal antifungal What is the most likely diagnosis? a Transverse vaginal septum b Vertical vaginal septum c Imperforate hymen Vignette 183 Clinical Vignettes C Index • 477 Ovarian tumors, 308, 392–396, 393t, 394f, 395–396t Ovaries, streak, 186 Over-the-counter (OTC) pregnancy tests, 9, 11 Overdistended bladder, 260, 260f Overflow (urinary) incontinence, 250, 251t, 259–260, 260f, 260t Ovulation, 269, 271–272f, 323, 358 induction of, 286–287, 353t, 355–357, 356f Ovulation-enhancing drugs, 101 Ovulatory disorders, 346–347, 347–349f, 348–349t, 349, 350–380f Oxacillin, 233 Oxcarbazepine, 149 Oxybutynin, 259t, 263, 2f65 Oxytocin, 16, 19, 43, 51, 53, 57, 60, 61, 69, 69t, 73, 75, 81, 87, 100, 114, 164, 341, 406, 411, 416 Oxytocin antagonists, 80 Paclitaxel, 396, 399 Paget disease of nipple, 425 of vulva, 361 Pain evaluation, of breast, 418 Palliative care, of cervical cancer, 378 PALM-COEIN, 295 Pap smear See Papanicolaou smear Pap test, 366, 368, 379, 380, 381 Papanicolaou (Pap) smear, 296, 299, 352, 364, 369, 369–371f, 370–371, 376, 385 abnormal, 371–372, 371–372t Paracervical block, 340 ParaGard IUD, 334, 336 Paramesonephric ducts See also Müllerian ducts formation of organs, 199, 201 Parasitic fibroids, 201 Parasitic leiomyoma, 190 Paraurethral gland cysts See Skene’s gland cysts Parity, Paroxetine, 171, 274, 295 Partial molar pregnancies, 402t, 407–408, 408f Partial previa, 62 Parvovirus B19, 136, 144, 146 Patau syndrome See Trisomy 13 Patch See Ortho Evra patch Paternal gametogenesis, 22, 24 Paxil, 304 PCOS See Polycystic ovary syndrome PE See Pulmonary embolus Peak growth velocity, 267 Pediatric AIDS Clinical Trials Group (PACTG) protocol 076, 138, 146 Pediculosis, 220–221 Pelvic adhesions, 294, 349 Pelvic examination, 11 Pelvic exenteration, 363 Pelvic inflammatory disease (PID), 225, 228, 230–231, 231–232f, 235, 237, 322, 347 barrier contraceptives, 238 with infertility, 238 Pelvic nerve, 251 Pelvic organ prolapse, 239–245, 239f, 240t, 241–244f, 243t, 251 Pelvic Organ Prolapse Quantitative scale (POP-Q), 241–242, 246, 248 Pelvic pain, 174–175, 197, 204, 230–231 Pelvic radiation, 261, 363, 386 Pelvic rest, 72, 74 Pelvic ultrasound, 20–21, 23, 170, 172, 199, 201, 236, 238, 288, 290, 385–386, 393, 395t, 406, 407, 409, 412, 414 Pelvic X-ray, 201 Pelvis, maternal, 81, 81f Penicillin, 7, 140–141, 216t, 218, 224 Penicillin G, 133, 218 Percreta, 62 Percutaneous umbilical blood sampling (PUBS), 8, 33 Perimenopause, 269, 273, 298 Perinatal transmission, 138 Perineal lacerations, 52, 55f treatment of, 169 Perineal support, 59, 60 Periodic abstinence, 316, 318f Peripartum cardiomyopathy (PPCM), 150 Permethrin, 220–221 Persistent occiput transverse and posterior position, 84–85 Persistent/invasive moles, 408–410, 409f, 410t Pessaries, 243, 243f, 248, 256, 257f Peutz–Jeghers syndrome (PJS), 390 PGE1M (Misoprostol), 60 PGE2 pessary (Cervidil), 60 pH, of fetal scalp, 47–48, 48f Phenazopyridine, 132 Phenergan, 147 Phenobarbital, 88t, 114, 148, 148t Phenothiazine, 284, 324t, 418t Phenoxybenzamine, 260 Phenytoin, 88t, 114, 148, 148t, 149, 309, 324t Phthirus pubis, 220–221 Physical examination, 343, 345 Pica, PID See Pelvic inflammatory disease Piperonyl butoxide, 220 Pitocin, 171 Pituitary disorders, 282 Placenta delivery of, 45f, 51 development of, 269 retained, 52, 54f Placenta accrete, 62, 64, 64t, 164, 288, 290–291 diagnosis of, 72, 74 management plan, 72, 74 precautions of, 72, 74 risk of, 72, 74 Placenta increta, 62, 64t Placenta percreta, 62, 64, 64t Placenta previa, 62–66, 63f, 64–65t, 65f, 72, 74 labor with, 76 Placental abruption, 67–69, 67f, 67–68t, 73, 76, 120 Placental separation, 59, 61 Placental site trophoblastic tumors (PSTTs), 408, 409f, 411, 413, 415 Plan B, 328, 332 Plasma ACTH testing, 314 Plasma cell mastitis See Mammary duct ectasia Platypelloid pelvis, 81, 81f PMDD See Premenstrual dysphoric disorder PMOF See Premature ovarian failure PMS See Premenstrual syndrome Pneumoniae, 215 POC See Products of conception Podofilox, 220 Podophyllin, 220 Polycystic ovary syndrome (PCOS), 284, 295, 308, 310, 313, 347, 349, 351f test for, 311, 314 Polyhydramnios, 98 Polyhydramnios-oligohydramnios (polyoli) sequence See Twin-to-twin transfusion syndrome Polymenorrhea, 296, 296t Polymicrobial infections, 143, 146 Polyps cervical, 181, 181f endometrial, 194 Pomeroy method, 335 Pool test, 40 POP-Q See Pelvic Organ Prolapse Quantitative scale Position, of fetus, 41–42, 44f, 81–85, 81–82f, 83–84f Postcoital bleeding, 376 Postcoital pill, 328 Posterior tibial nerve stimulation, 259 Postmenopausal bleeding, 298–299, 298t, 385, 385t diagnosis of, 301, 303 Postmenopause, 273–275, 273f, 274t 478 • Index Postoperative chemotherapy, 400 Postpartum bleeding, 410 Postpartum blues, 171 Postpartum care, 161–167 Postpartum contraception, 162 Postpartum depression, 168, 171 Postpartum endomyometritis, 235, 237 Postpartum hematocrit, 169, 172 Postpartum hemorrhage, 163–165, 164–165t, 165f cause of, 168, 171–172 risk factors for, 168, 171 Postpartum tubal ligation (PPTL), 162, 329–330 Postterm pregnancy, 1, 97, 101 associations, 107, 110 diagnosis of, 106, 110 Posttubal ligation syndrome, 330 Postvoid residual, 254 Potassium chloride, 341 Potter syndrome, 30–31 PPCM See Peripartum cardiomyopathy PPROM See Preterm premature rupture of membranes PPTL See Postpartum tubal ligation Prazosin, 260 Precocious puberty, 267–268 Prednisone, 151, 309 Preeclampsia, 111–114, 112–113t, 116, 118, 153–154, 153t, 404 diagnosis of, 157, 159–160 Pregestational diabetes, 121, 123–126, 123–125t Pregnancy, 1–4, 2f, 2t, 4t, 284, 285, 296 antiretroviral therapy in, 146 bilateral luteomas of, 310, 313 after breast cancer, 428 during chronic renal disease, 157, 159 dating of, 1–2, 101 diabetes during, 121–126, 122t, 123–125t early complications of, 13–19 ectopic pregnancy, 13–14, 14f, 14t, 323 incompetent cervix, 16–17, 16t recurrent pregnancy loss, 17–18 spontaneous abortion, 15f, 15–16, 15t elective termination of, 337–341, 338f, 338t fetal complications of, 94–103 hypercoagulability of, 158 hypertension during, 111–115, 112t chronic hypertension, 115 eclampsia, 111, 112t, 114–115, 114t preeclampsia, 111–114, 112–113t, 153–154, 153t infection during, 131–142, 132t management during, 156, 159 maternal complication during, 156– 157, 158 medical complications of, 147–155 coagulation disorders, 151–152, 152f hyperemesis gravidarum, 147 maternal cardiac disease, 149–150 maternal renal disease, 150–151 maternal thyroid disease, 153 seizures, 88, 88t, 114, 114t, 147–149, 148–149t substance abuse, 154–155 systemic lupus erythematosus, 153–154, 153t routine problems of, rubella infection, 143, 145 White classification of diabetes in, 129 Pregnancy-induced hypertension See Gestational hypertension Preimplantation genetic diagnosis, 357 Preinvasive cervical carcinoma, 376, 377t Preinvasive neoplastic disease of vagina, 363–364 of vulva, 360–365, 361–362f, 363f, 363t Premature ovarian failure (PMOF), 269, 284, 289, 291–292, 315 See also Primary ovarian insufficiency Premature rupture of membranes (PROM), 40, 41f, 80–81 Prematurity, 112t Premenstrual dysphoric disorder (PMDD), 294–295 Premenstrual syndrome (PMS), 294–295, 302, 304 etiology of, 304 with vitamin supplementation, 302, 304 Prenatal care, 4–7, 5t, Prenatal diagnosis, 25, 33–34, 34f Prenatal screening, 25–34, 31–32t, 31–33f, 36, 38 for chromosomal abnormalities, 27–28, 27f, 31–33 for fetal congenital abnormalities, 28–31, 28–30f for genetic diseases, 25–27 prenatal diagnosis, 25, 33–34, 34f for sex chromosomal abnormalities, 28 Prenatal treatment See Prenatal screening Prenatal vitamins, 4, 4t Prepregnancy BP, 119 Presentation, of fetus, 40, 41–42, 44f, 81–85, 81–82f, 83–84f, 103 Pressors, 232 Preterm delivery, 1, 78 Preterm labor (PTL), 16, 78, 291 Preterm premature rupture of membranes (PPROM), 80–81 Preterm rupture of membranes, 80–81 Previable infant, Primary amenorrhea, 174–175, 281–284, 282–283t, 283f, 296t Primary dysmenorrhea, 293, 301, 303 Primary ovarian insufficiency, 346 diagnosis of, 359 Primary syphilis, 228 Primidone, 147, 148t Prior classical hysterotomy, 59, 61 Probenecid, 218, 231 Procaine penicillin, 218 Prodromal labor, 42 Products of conception (POC), 15, 164 Progesterone, 11, 249, 278, 279, 280, 358, 359 measurement of, 313 Progesterone challenge test, 285, 286t Progesterone-eluting IUD, 162, 169, 172, 196, 295 Progesterone hormone, 188, 194, 196t, 269, 271f, 275, 384, 416 Progesterone OCPs, 162 Progesterone-only contraception, 162, 167, 190, 196, 317t, 326–327, 327t, 332 Progesterone receptor antagonist, 339 Progesterone receptor positive tumor, 428 Progesterone therapy, 18, 150, 196, 286, 298–299, 309, 321, 328, 332, 351, 356, 383–385, 387 Progestin, administration of, 249 Progestin implant, 327 Progestin-only oral pill, 334, 336 Progestin therapy, 196, 207, 208t, 210, 274, 284, 297, 297t, 299, 309, 323–326, 328, 332, 383, 387, 420, 429 Progression, of labor, 48–54, 49–54f, 53t, 56t Prolactin, 3, 279, 416 Prolactinomas, 292 Prolapse See Pelvic organ prolapse Prolapsed uterus, 240 Proliferative and secretory phases, in endometrium, 279 Proliferative phase, of menstrual cycle, 269 Prolonged rupture of membranes, 80 PROM See Premature rupture of membranes Prophylaxis, 11 Index • 479 Propranolol, 256, 406 Propylthiouracil (PTU), 153 Prostaglandin analogs, 339 Prostaglandin E2 (PGE2) gel, 58, 60 Prostaglandin inhibitors, 80 Prostaglandins, 16, 19, 42, 43, 57, 87, 100, 114, 134, 164, 293, 341 Prostin, 164 Protease inhibitors, 233, 234 Proteinuria, 113, 159–160 Proteus mirabilis, 215 Proton pump inhibitors, Prozac, 300, 304 Pruritus vaginal, 365 vulvar, 360–362 Pseudoephedrine, 256 Psoriasis, vulvar, 176–178, 181t PSTTs See Placental site trophoblastic tumors Psychotropic drugs, 419 PTL See Preterm labor PTU See Propylthiouracil Pubarche, 267, 270f, 279 Pubertal sequence, normal, 277, 279 Puberty, 267–269, 268f, 269t breast bud development, 277, 279 PUBS See Percutaneous umbilical blood sampling Pudendal block, 55, 56t Pudendal nerve, 251 Puerperium care See Postpartum care Pulmonary angiography, 152, 152f Pulmonary embolus (PE), 151–152, 152f, 324 diagnosis of, 156, 158 Pulmonary hypertension, 150 Pulmonary physiology, of pregnancy, 2, 2f Pulse oximetry, of fetus during labor, 47–48, 48f Pyelonephritis, 131–133, 215, 237 complication of, 143, 145 Pyrethrins, 220 Pyrimethamine, 141 Quad screen, 11, 32, 118 Quadravalent vaccine (Gardasil), 220 Quantitative serum ß-hCG, 414 Radial hysterectomy, 380, 382 Radiation, 380, 382 Radiation therapy, 365, 377, 386, 397, 425 See also Pelvic radiation Radical hysterectomy, 307–377 Radical vulvectomy, 362–363, 363f, 366, 368 Raloxifene, 274, 274t Rash allergy, 133 RDS See Respiratory distress syndrome Recommended daily dietary allowances, for pregnant women, 4t Rectocele, 239, 239f, 240, 241f, 242, 243t, 244f Rectovaginal fistula, 265 Recurrence of breast cancer, 427 of cervical cancer, 377–378 of endometrial cancer, 387 of ovarian tumors, 396 Recurrent pregnancy loss, 17–18 Reglan, 147, 284 Relaxation, pelvic See Pelvic organ prolapse Renal agenesis, 30 Renal disease, maternal, 150–151 Renal physiology, of pregnancy, Reproductive tract See Lower reproductive tract; Upper reproductive tract Reserpine, 418t Respiratory distress syndrome (RDS), Retained placenta, 52, 54f Retained products of conception, 164 Revealed hemorrhage, 67 Reversal, of tubal sterilization, 331, 331t Rh IgG See Anti-D immunoglobulin Rh incompatibility, 98–100, 99–100f, 99t Rh status, 342, 344 RhoGAM, 6, 16, 19, 66, 69, 90, 92, 99, 100, 103, 338, 406 Rifampin, 324t Right-sided ectopic pregnancy, 21, 23 Right upper-quadrant (RUQ) pain, question about, 119 Risedronate, 275 Ritodrine, 79 Ritonavir, 233 ROM See Rupture of membranes Rotterdam criteria, 313 Round ligament pain, Routine evaluation, of breast, 417–418, 418f Routine postpartum care, 161–162 Routine prenatal laboratory test screening, 143 Routine prenatal visits, 5–7 Routine sonographic, evaluation of, 391 Rubella, 94, 137–138 infection, 143, 145 Rubin maneuver, 86, 87f, 90, 92 Rupture of fetal vessels, 70–71 of uterus, 54, 56t, 69–70, 69t, 87, 165 Rupture of membranes (ROM), 40, 41f, 42, 71 See also Premature rupture of membranes; Preterm rupture of membranes diagnosis of, 58, 60 Sacral neuromodulation, 259, 265 Salt wasting, 311, 314 Saprophyticus, 215 Saquinavir, 233 Sarcoptes scabiei, 220–221 Savage syndrome, 281–282 Scabies, 220–221 Scalp electrode, 46 SCC See Squamous cell carcinoma Screening See also Prenatal screening for cervical cancer, 370–371, 371f mammography, 416, 417f during pregnancy, 6, 6t, 121–122, 122t Seasonale, 324 Seasonique, 324 Sebaceous cysts, 179 Second-degree laceration, 58, 60 Second stage of labor, 48–49 Second trimester, Second-trimester abortion, 16, 337, 338t, 340–341, 340f, 341t Second-trimester screening, 32–33, 32t, 32–33f Second-trimester visits, Secondary amenorrhea, 284–287, 285t, 286f, 286t, 287f, 296t Secondary dysmenorrhea, 191, 209, 294, 294f Secretory phase, of menstrual cycle, 269 Sedatives, 54 Seizure, 117, 120 maternal, 88, 88t, 114, 114t, 147– 149, 148–149t Selective estrogen receptor modulators (SERMs), 275, 327t, 424 Selective serotonin reuptake inhibitors (SSRIs), 167, 171, 274, 274t, 295, 300, 384 Self-catheterization, 260 Semen analysis, 354, 354t Senile angiomas See Cherry hemangiomas Sensitized Rh negative patient, 99–100, 100f Sentinel lymph node biopsy (SLNB), 362, 426 Septate uterus, 187, 188f, 190f, 199, 201 Septic pelvic thrombophlebitis, 237 Septum, transverse vaginal, 174–175, 175–176f, 281 Serial deep tendon reflex (SDTR) examination, 89, 91 480 • Index SERMs See Selective estrogen receptor modulators Serotonergic/adrenergic reuptake inhibitors, 256 Serotonin and norepinephrine reuptake inhibitors (SNRIs), 274, 295 Serous cystadenocarcinomas, 395 Serous discharge, 419 Serous tumors, 395 Sertoli cells, 314 Sertoli-Leydig cell tumors, 310, 313, 398 Sertraline, 171, 295 Serum testosterone, 310, 313 Serum tumor markers, 397, 397t Serum ß-hCG, 289, 291, 412, 414 Severe preeclampsia, 112t, 114 Sex chromosomal abnormalities, 28 Sex chromosomal aneuploidy, 36, 38 Sex cord-stromal tumors, 398 of ovary, 313 Sex steroids, 267, 306, 307f Sexual dysfunction, 240 Sexual intercourse, 176 Sexual partners, Trichomonas infections in, 227 Sexually transmitted infections (STIs), 318, 320 screening of, 301, 303 SGA See Small for gestational age Sheehan’s syndrome, 290 Shingles See Varicella zoster virus Shoulder dystocia, 85–87, 87f, 171 fetal complication of, 90, 92 maneuver used to, 90, 92 risk for, 89, 92 Shoulder presentation, 84 Sickle cell disease, 26 Sinusoidal pattern, on fetal monitoring strip, 72, 75 Sister Mary Joseph nodule, 393 Skene’s gland cysts, 179, 179f Skin dimpling, 424 Skin separation, 170, 172 SLE See Systemic lupus erythematosus SLNB See Sentinel lymph node biopsy Small for gestational age (SGA), 78, 94–96, 95–96f, 95t Smoking, 154, 324, 360, 370, 381 SNRIs See Serotonin and norepinephrine reuptake inhibitors Spectinomycin, 139 Speculum examination, 76 Spermicide, 317–320, 318–320f, 326, 331–332 Spina bifida, 25f, 29 Spinal anesthesia, 57, 60, 260t Spiral chest CT, 156, 158 Spiramycin, 141 Spironolactone, 309, 314 Splinting, 240 Spontaneous abortion, 15f, 15–16, 15t, 322 Squamous cell carcinoma (SCC) of cervix, 375–378, 375f, 376–378t, 377f of vagina, 364, 364t of vulva, 362–363, 362f, 363f, 363t Squamous intraepithelial lesions, 381 SSRIs See Selective serotonin reuptake inhibitors St John’s wort, 274t, 324t Stadol, 54 Staging, 368 of cervical cancer, 376, 376f, 376t, 377f of endometrial cancer, 383t, 384, 386, 386t of fallopian tube carcinoma, 399 of gestational trophoblastic disease, 408 of labor, 48–54, 50–54f, 53t, 56t of ovarian tumors, 395, 396t of vaginal cancer, 364, 364t of vulvar cancer, 362, 363t Staphylococcus aureus, 172, 180, 232, 319 Staphylococcus saprophyticus, 215 Station, 41, 43f Status epilepticus, 88t Stavudine, 233 Stein-Leventhal syndrome See Polycystic ovary syndrome (PCOS) Stenosis, cervical, 181, 284, 294, 348–349, 353 Sterile vaginal examination, 76 Sterilization, 329–331, 330f, 331f, 331t Steroids, 7, 78, 178, 181t, 182, 276, 309, 354t, 365, 370 topical high-potency, 183, 185 Stillbirth, prevention of, 128, 130 STIs See Sexually transmitted infections Stool softeners, 7, 161 Streak ovaries, removal of, 184, 186 Streptococci, 231 Streptococcus See Group B Streptococcus Stress (urinary) incontinence, 250, 251t, 253, 255–258, 256f, 257–258f, 263, 265 Striated muscle relaxants, 260 Stromal hyperplasia/hyperthecosis, 308 Subacute bacterial endocarditis (SBE) prophylaxis, 149 Subserosal fibroids, 201 Substance abuse, during pregnancy, 154–155 Succenturiate lobe, 72, 75 Succenturiate placenta, 64t, 70 Suction curettage, 414 See also Dilation and curettage Sulfadiazine, 141 Sulfasalazine, 354t Superficial vein thrombosis (SVT), 151 Superimposed preeclampsia, 115 Suprapubic pressure, 86–87, 86f Surgical evacuation, 337, 338f Surgical resection, 364 Surgical sterilization, 329–331, 330f, 331f, 331t Survival rate of breast cancer, 427–428t, 428 of cervical cancer, 377, 378t of endometrial cancer, 386, 387t of fallopian tube carcinoma, 399 of germ cell tumors, 398 of ovarian tumors, 396 of vaginal carcinoma, 365 of vulvar carcinoma, 363 SVT See Superficial vein thrombosis Swyer syndrome, 282 Symmetric growth, 94 Syndrome X, 402 See also Metabolic syndrome Synthroid, 155 dose of, 157, 159 Syphilis, 140–141, 216–218, 216t, 217f, 227, 228 Systemic adjuvant chemotherapy, 426–427 Systemic adjuvant hormone therapy, 427 Systemic lupus erythematosus (SLE), 153–154, 153t Systemic pharmacologic intervention, 54–55 Systemic vascular resistance, during pregnancy, Tachysystole, 50 Tacrolimus, 151 TAHBSO See Total abdominal hysterectomy and bilateral salpingooophorectomy Tamoxifen, 194, 196t, 274, 348–349, 384, 389, 391, 420, 424, 427, 429, 433 Tampon tests, 60, 80 Taxol, 400, 403 Tay-Sachs disease, 26 Tenofovir disoproxil fumarate plus emtricitabine (TDF/FTC), 233 TENS See Transcutaneous electrical nerve stimulation Tension-free transvaginal sling (TVT), 265 Teratogens, 28, 94, 95t, 148 Terazosin, 260 Terbutaline, 50, 79, 85 Terconazole, 222 Term delivery, Index • 481 Testicular feminization, 281 Testicular regression, 314–315 Testosterone therapy, 178 Tetracycline, 139, 218, 231 Thalassemia, 26–27 Theca lutein cysts, 196–197, 202, 308, 404, 406f, 412, 414 Thelarche, 267, 269t, 270f, 277, 279 Theophylline, 324t Third stage of labor, 51–52, 54f Third trimester, Third-trimester labs, 6–7 Third-trimester visits, Thoracodorsal nerve, 416, 417f Threatened abortion, 15, 24 Ps, 91 3TC See Lamivudine Thyroid disease, maternal, 153, 351 Thyroid hormone replacement, 18, 286, 297t Thyroid-stimulating hormone (TSH), levels of, 157, 159 Thyroid storm, 406 Tigan, 147 Tinidazole, 222, 227 TOA See Tubo-ovarian abscess Tobacco abuse, 105, 108 Tocolysis, 78–80, 80f Tocolytics, 17, 66, 78–80, 85, 88, 134 TOLAC See Trial of labor after cesarean Tolterodine, 259t Topical high-potency, steroids, 183, 185 Topiramate, 149, 324t TORCH titers, 108 Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO), 386, 386t, 395, 396 Toxic shock syndrome, 232–233, 319 Toxoplasmosis, 141 TPAL designation, 9, 11 Tranexamic acid (Lysteda), 297, 304 Transcutaneous electrical nerve stimulation (TENS), 293 Transdermal estrogen and progestin contraception, 293, 298, 317t, 325–326, 325f Transformation zone (TZ), of cervix, 370, 371f Transient tachypnea, of newborn, 110 Transobturator approach midurethral sling (TOT), 265 Transvaginal aspiration, 355–356, 356f Transvaginal ultrasound, 11, 200, 202, 303, 343, 345 Transverse presentation, 41 Transverse vaginal septum, 174–175, 175–176f, 281 Trastuzumab, 427, 433 Treponema pallidum, 227, 228 See also Syphilis Treponema pallidum particle agglutination assay (TPPA), 228 Trial of labor after cesarean (TOLAC), 54, 56t contraindication to, 59, 61 setting of, 73, 75–76 Trichloroacetic acid, 220 Trichomonas infections, 227 Trichomonas vaginalis, 222, 222f, 227, 228 Trichomoniasis, 227 Tricyclic antidepressants, 256, 284, 324t Trimethadione, 148, 148t Trimethoprim/sulfamethoxazole, 131, 215 Triple screen, 6, 32 Triplets, 103 Triploid karyotpyes, 414 Trisomy 13, 28, 32t Trisomy 18, 27–28, 32, 32t, 37, 39 Trisomy 21 See Down syndrome Trophoblast, 269 Trophoblastic embolization, 406 TTTS See Twin-to-twin transfusion syndrome Tubal occlusion, 333, 335 Tubal patency, 202 Tubal pregnancy, implantation in, 23 Tubal sterilization, 329–331, 330f, 331t Tubo-ovarian abscess (TOA), 202, 225, 228, 231–232, 232f, 236, 238 Tubo-ovarian complexes (TOCs), 238 Tuboplasty, 353 Tumor receptor status, 426 Tumors See also Malignant breast disease epithelial, 395–396, 396t germ cell, 396–398, 397f, 397t of ovaries, 308, 392–396, 393t, 394f, 395–396t placental site trophoblastic, 408, 409f, 411 serous, 395 of sex cord-stroma, 398 of vulva and vagina, 178–180, 179–180f Turner syndrome, 28, 38, 282, 291, 349 See also Gonadal dysgenesis 24-hour urine protein collection, 116, 118, 314 Twin-to-twin transfusion syndrome (TTTS), 101, 103, 106, 110 Twins See Multiple gestations 2-hour glucose tolerance test, performing, 106, 109 Tylenol, 10, 11 Type diabetes (T1DM), 124–125, 125t congenital anomalies, risk of, 127, 129 risk, during pregnancy, 127, 129 Type diabetes (T2DM), 125–126 congenital anomalies, risk of, 127, 130 glucose challenge test, 127, 129 TZ See Transformation zone Tzanck smear, 218 Ulcerated lesions, of lower reproductive tract, 215–219, 216t, 217f, 218f Ulipristal (Ella, EllaOne), 329 Ultrasound, 138 See also Pelvic ultrasound of ectopic pregnancy, 13, 14f of endometrioma, 206f of incompetent cervix, 17f of neural tube defects, 29f placenta, location of, 76 of placenta previa, 65f for pregnancy dating, for prenatal fetus assessment, in prenatal screening, 33–34, 33–34f of trisomy, 27–28, 27f umbilical artery Doppler, 95, 95–96f Underactive detrusor muscle See Overflow (urinary) incontinence Unilateral salpingo-oophorectomy, 397, 400, 402 Unsensitized Rh negative patient, 99 Upper genital tract, benign disorders of, 187–198 Upper reproductive tract, infection of, 230–234 Ureterovaginal fistulas, 261, 263, 265 Urethra anatomy, 250–251, 251–252f Urethral caruncles, 181 Urethral prolapse, 181 Urethrocele, 239, 242 Urethrovaginal fistula, 265 Urethrovesical junction (UVJ), 250 Urge incontinence, 254f, 259t Urgency (urinary) incontinence, 250, 251t, 257–260 Urinalysis with culture and sensitivity, 264, 266 Urinary dysfunction, 240 Urinary fistula, 261, 261f Urinary frequency, Urinary incontinence, 250–262, 251–252f, 251t, 255f bladder outlet obstruction with overflow, 263, 265 continuous incontinence secondary to urinary fistula, 263, 265 482 • Index Urinary ovulation predictor kits, 310, 313 Urinary tract infections (UTIs), 131–133, 215 Urine drug screen, 77 Urine pregnancy test, 333, 335, 342, 344 Urodynamics, 254 Uroflowmetry, 254 Urogenital atrophy, 301, 303 Urogenital diaphragm, 201 Uterine anomalies, 199, 201 Uterine artery embolization, 172, 193, 193f Uterine atony, 164 treatment of, 169, 171 Uterine bleeding, 295–298, 296t, 297t, 340, 385, 410 Uterine factor infertility, 348–349, 348t Uterine fibroids risk factors for, 199, 201 test for, 199, 201 Uterine hypertonus, 50 Uterine inversion, 165, 165f Uterine leiomyoma, 188–194, 191–193t, 193f, 208t, 209–210 Uterine perforation, 343, 345 Uterine prolapse, 239, 242, 243t Uterine rupture, 54, 56t, 69–70, 69t, 87, 165, 172 explanation for, 75 risk of, 75, 170, 173 Uterine septa, 187, 188f, 190f, 199, 201 Uterosacral nodularity, on rectovaginal examination, 211, 213 Uterotonic agents, 165 Uterotonics, 415 Uterus congenital müllerian anomalies of, 187, 188–190f, 188t formation of, 174–175, 175f UTIs See Urinary tract infections UVJ See Urethrovesical junction Vacuum extraction, 51 complication of, 59, 61 Vacuum extractors, 59, 60 Vagina benign cysts and tumors of, 178–180, 179–180f benign epithelial disorders of, 176–180, 177–180f, 177t, 180t benign lesions of, 174 cancer of, 364, 364t congenital anomalies of, 174–176, 175–176f formation of, 174–175, 175f infection of, 221–222, 221–222f lacerations of, 163–165 neoplastic disease of, 360–365, 361t preinvasive disease of, 363–364 Vaginal adenosis, 180f Vaginal agenesis, 175–176, 176f, 281 Vaginal atresia, 175, 175f, 184, 185, 281 Vaginal atrophy, 274, 299 Vaginal birth after cesarean (VBAC), 54, 56t Vaginal bleeding, 23, 70, 294f, 364, 385, 385t, 405, 407, 410, 415 pelvic ultrasound for, 20 with placenta previa, 64–65 with placental abruption, 68 with spontaneous abortion, 15t, 16 Vaginal delivery, 50, 51–52f, 161 Vaginal dilators, 176, 186 Vaginal estrogen, 185, 186, 264, 266 Vaginal hematoma, 163–164 Vaginal intraepithelial neoplasia (VAIN) primary treatment for, 368 of vagina, 363–364 Vaginal ring, 317t, 326, 326f Vaginal septum, 174–175, 175–176f, 281 Vaginal vault prolapse, 240, 243, 243t, 245 Vaginoplasty, 186 Vaginosis See Bacterial vaginosis VAIN See Vaginal intraepithelial neoplasia Valacyclovir, 219 Valproate, 148, 148t Valproic acid, 36, 38, 148–149 Valvular disease, 150 Vancomycin, 233 Variable deceleration, of fetal heart rate, 45, 46f Varicella vaccine (Varivax), 135 Varicella zoster immune globulin (VZIG), 136 Varicella zoster virus (VZV), 135–136 Varicose veins, Vasa previa, 62, 64t, 70, 72, 75 Vasectomy, 331, 331f Vasodilators, 150 Vasomotor symptoms, 275 Vasopressin, 180 Vasopressors, 13 VBAC See Vaginal birth after cesarean Velamentous cord insertion, 70 Velamentous placenta, 64t Venlafaxine (Effexor), 274, 275, 295 Venography, 158 Venous stasis, principal causes for, 158 Venous thromboembolism risk factors of, 156, 158, 172 Ventilation/perfusion scanning, 152, 152f Vertex position, 60 Vertex presentation, 41, 83–84, 83–84f Vertical incision, 172 Vesicouterine fistula, 265 Vesicovaginal fistula, 265 VIN See Vulvar intraepithelial neoplasia Vincristine, 427 Viral shedding, 226, 228 Virilism, 306–309 Virilization, of fetus, 310, 313 Vitamin B12 supplementation, 147 Vitamin B6 supplementation, 295, 300, 420 Vitamin D supplementation, 275, 295, 300, 327, 327t Vitamin E supplementation, 420 Vitamin K supplementation, 149, 149t Vitamin supplementation for PMS and PMDD, 295 for pregnant women, 4, 4t Voiding cystourethrogram, 261 Voiding diary, 254 Vomiting, 3, 147 V/Q scanning See Ventilation/perfusion scanning Vulva benign cysts and tumors of, 178–180, 179–180f benign epithelial disorders of, 176–180, 177–180f, 177t, 180t benign lesions of, 174 cancer of, 362–363, 362f, 363f, 363t congenital anomalies of, 174–176, 175–176f melanoma of, 363 neoplastic disease of, 360–365, 361t Paget disease of, 361 Vulvar architecture, distortion of, 185 Vulvar biopsy, 177, 178f, 183, 185 Vulvar carcinoma, 368 Vulvar intraepithelial neoplasia (VIN), 185, 360–361, 361f Vulvar pruritus, 360–362 Vulvar psoriasis, 176, 177–178, 181t Vulvectomy, 363, 363f Vulvitis, 215 Vulvodynia, 361 VZIG See Varicella zoster immune globulin VZV See Varicella zoster virus Warfarin, 151–152, 158 Weight loss, 302, 305 Index • 483 White blood cell (WBC) test, 117, 119 White classification of gestational diabetes, 122, 124 Wide local excision, 360–361, 422 Wide radical local excision, 362 Wood’s cork maneuver, 92 Word catheter, 179, 180f Word catheterization, 183, 185 Wound infections, 165–166 Wound separations, 166 X-linked disorders, 25 X-linked dominant syndromes, 25 46,XY chromosomes, 282 Yeast infections, of vaginitis, 185 Zavanelli maneuver, 87, 92 ZDV See Zidovudine Zidovudine (ZDV, AZT), 138, 139, 146, 233 Zidovudine IV use, during labor and delivery, 236, 238 Zidovudine–lamivudine, 139 Zofran, 147 Zoloft, 300, 304 Color Plate • Fetal hydrops caused by the accumulation of fluid in fetal tissues (From Sadler TW Langman’s Medical Embryology, 10th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2006.) Color Plate • Newborn with disseminated herpes simplex virus (HSV) infection Note the healing ulcerations on the abdomen of the infant (From Sweet R, Gibbs R Atlas of Infectious Diseases of the Female Genital Tract Philadelphia, PA: Lippincott Williams & Wilkins; 2005.) Color Plate • Congenital varicella syndrome characterized by longbone defects, chorioretinitis, and cerebral cortical atrophy (From Sweet R, Gibbs R Atlas of Infectious Diseases of the Female Genital Tract Philadelphia, PA: Lippincott Williams & Wilkins; 2005.) Color Plate • Congenital CMV “blueberry muffin” baby with jaundice and thrombocytopenia purpura (From Sweet R, Gibbs R Atlas of Infectious Diseases of the Female Genital Tract Philadelphia, PA: Lippincott Williams & Wilkins; 2005.) Color Plate • Congenital syphilis—mulberry molar (From Sweet R, Gibbs R Atlas of Infectious Diseases of the Female Genital Tract Philadelphia, PA: Lippincott Williams & Wilkins; 2005.) Color Plate • Congenital toxoplasmosis with hepatosplenomegaly, jaundice, and thrombocytopenia purpura (From Sweet R, Gibbs R Atlas of Infectious Diseases of the Female Genital Tract Philadelphia, PA: Lippincott Williams & Wilkins; 2005.) A B Color Plate • Imperforate hymen Note bulging hymen (A) and subsequent drainage of obstructed material once the hymenal tissue is excised (B) (From Rock J, Johns H TeLinde’s Operative Gynecology, 9th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2003.) Color Plate • Vaginal agenesis also known as Mayer-Rokinsky-KusterHauser syndrome Notable for congnital absence of the vagina with variable uterine development (From Emans J, Laufer M, Goldstein DP Pediatric and Adolescent Gynecology, 5th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2005.) Color Plate • Laparoscopic view of a large ovarian cyst C = ovary with cyst U = uterus O = normal ovary (From Emans J, Laufer M, Goldstein DP Pediatric and Adolescent Gynecology, 5th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2005.) Color Plate 10 • Fitzhugh-Curtis syndrome (From Sweet R, Gibbs R Atlas of Infectious Diseases of the Female Genital Tract Philadelphia, PA: Lippincott Williams & Wilkins; 2005.) Color Plate 11 • Complete procidentia (prolapse) of the uterus and vagina (From Berek, JS Berek & Novak’s Gynecology, 14th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2006.) Color Plate 12 • Laparoscopic view of adult pelvic inflammatory disease (From Sweet R, Gibbs R Atlas of Infectious Diseases of the Female Genital Tract Philadelphia, PA: Lippincott Williams & Wilkins; 2005.) Color Plate 13 • Acanthosis nigricans associated with insulin resistance (From Berek JS Berek & Novak’s Gynecology, 14th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2006.) Color Plate 14 • Colposcopic view of cervix with CIN III showing mosaicism and punctations (From Berek JS Berek & Novak’s Gynecology, 14th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2006.) Color Plate 15 • Laparoscopic view of large ovarian mass (M) and normal uterus (U) and ovary (O) (From Berek JS Berek & Novak’s Gynecology, 14th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2006.) Color Plate 16 • Mature cystic teratoma (dermoid cyst) (From Berek JS Berek & Novak’s Gynecology, 14th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2006.) ... al Obstetrics and Gynecology, 4th ed Baltimore, MD: Lippincott Williams & Wilkins; 20 02. ) Figure 13-8 • Gross appearance of a Bartholin’s cyst of the vulva (From LifeART image copyright © 20 06... should be removed 1 82 • Blueprints Obstetrics & Gynecology KEY POINTS • Labial fusion may be the result of excess androgen exposure or an enzymatic deficiency, most commonly 21 -hydroxylase deficiency... Endocrinology and Infertility, 7th ed Philadelphia, PA: Lippincott Williams & Wilkins; 20 05.) 190 • Blueprints Obstetrics & Gynecology Figure 14-4 • (A) A hysterosalpingogram of a double uterus (B)