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https://t.me/MedicalBooksStore HP Stamp Hacker & Moore’s E S S E N T I A L S O F OBSTETRICS & GYNECOLOGY https://t.me/MedicalBooksStore Hacker & Moore’s E S S E N T I A L S O F OBSTETRICS & GYNECOLOGY Sixth Edition Neville F. Hacker, MD Professor of Gynaecologic Oncology Conjoint, University of New South Wales Director, Gynaecological Cancer Centre Royal Hospital for Women Sydney, Australia Joseph C. Gambone, DO, MPH, Executive Editor Professor Emeritus of Obstetrics and Gynecology David Geffen School of Medicine at UCLA Attending Physician, Ronald Reagan UCLA Medical Center Clinical Professor of Obstetrics and Gynecology Western University of Health Sciences College of Osteopathic Medicine of the Pacific Private Infertility and Reproductive Endocrinology Practice, Durango, Colorado Calvin J. Hobel, MD Miriam Jacobs Chair in Maternal-Fetal Medicine Cedars-Sinai Medical Center Professor of Obstetrics and Gynecology Professor of Pediatrics David Geffen School of Medicine at UCLA Los Angeles, California 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 HACKER & MOORE’S ESSENTIALS OF OBSTETRICS & GYNECOLOGY, SIXTH EDITION ISBN: 978-1-4557-7558-3 INTERNATIONAL EDITION ISBN: 978-0-323-34053-3 Copyright © 2016 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and know ...

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https://t.me/MedicalBooksStore HP Stamp Hacker & Moore’s E S S E N T I A L S O F OBSTETRICS & GYNECOLOGY https://t.me/MedicalBooksStore Hacker & Moore’s E S S E N T I A L S O F OBSTETRICS & GYNECOLOGY Sixth Edition Neville F. Hacker, MD Professor of Gynaecologic Oncology Conjoint, University of New South Wales Director, Gynaecological Cancer Centre
Royal Hospital for Women Sydney, Australia Joseph C. Gambone, DO, MPH, Executive Editor Professor Emeritus of Obstetrics and Gynecology David Geffen School of Medicine at UCLA Attending Physician, Ronald Reagan UCLA Medical Center Clinical Professor of Obstetrics and Gynecology Western University of Health Sciences College of Osteopathic Medicine of the Pacific Private Infertility and Reproductive Endocrinology Practice, Durango, Colorado Calvin J. Hobel, MD Miriam Jacobs Chair in Maternal-Fetal Medicine Cedars-Sinai Medical Center Professor of Obstetrics and Gynecology Professor of Pediatrics David Geffen School of Medicine at UCLA Los Angeles, California 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 HACKER & MOORE’S ESSENTIALS OF OBSTETRICS & GYNECOLOGY,
SIXTH EDITION ISBN: 978-1-4557-7558-3 INTERNATIONAL EDITION ISBN: 978-0-323-34053-3 Copyright © 2016 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the
safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2010, 2004, 1998, 1992, and 1986. Library of Congress Cataloging-in-Publication Data Hacker & Moore’s essentials of obstetrics & gynecology / [edited by] Neville F. Hacker, Joseph C. Gambone, Calvin J. Hobel.—6th edition. p. ; cm. Hacker and Moore’s essentials of obstetrics and gynecology Essentials of obstetrics and gynecology Preceded by Hacker and Moore’s essentials of obstetrics and
gynecology / [edited by] Neville F. Hacker, Joseph C. Gambone, Calvin J. Hobel. Includes bibliographical references and index. ISBN 978-1-4557-7558-3 (pbk. : alk. paper)–ISBN 978-0-323- 34053-3 (international edition) I. Hacker, Neville F., editor. II. Gambone, Joseph C., editor. III. Hobel, Calvin J., editor. IV. Title: Hacker and Moore’s essentials of obstetrics and gynecology. V. Title: Essentials of obstetrics and gynecology. [DNLM: 1. Obstetrics–methods. 2. Genital Diseases, Female. 3. Pregnancy Complications. WQ 100] RG101 618—dc23 2015035364 Acquisitions Editor: James Merritt Developmental Editor: Julia Rose Roberts Publishing Services Manager: Catherine Jackson Project Manager: Rhoda Howell Design Manager: Renee Duenow Illustrations Manager: Nichole Beard Marketing Manager: Melissa Darling Printed in Canada Last digit is the print number: 9 8 7 6 5 4 3 2 1 http://www.elsevier.com/permissions This edition is dedicated to our wives, Estelle Hacker, Marge (Morris) Gambone, and Marsha Lynn
Hobel. Their understanding and support for the time and effort required to complete this project was essential. https://t.me/MedicalBooksStore vii Contributors Carolyn J. Alexander, MD Southern California Reproductive Center Beverly Hills, California; Clinical Associate Professor David Geffen School of Medicine at UCLA University of California, Los Angeles Los Angeles, California Jonathan S. Berek, MD, MMS Laurie Kraus Lacob Professor Chair, Department of Obstetrics and Gynecology Stanford University School of Medicine Director, Stanford Women’s Cancer Center Director, Stanford Health Care Communication Program Stanford, California Lony C. Castro, MD, FACOG Specialist, Maternal-Fetal Medicine Professor and Chair, Department of Obstetrics and
Gynecology COMP/Western University of Health Sciences Pomona, California Sara Churchill, MD Resident Physician Department of Obstetrics and Gynecolo gy Cedars Sinai Medical Center Los Angeles, California Daniel A. Dumesic, MD Professor, Department of Obstetrics and Gynecology Division Chief, Reproductive Endocrinology and Infertility David Geffen School of Medicine at UCLA University of California, Los Angeles Los Angeles, California Michael L. Friedlander, PhD, FRACP Conjoint Professor of Medicine Prince of Wales Clinical School University of New South Wales Sydney, Australia Brian J. Koos, MD, DPhil Professor, Department of Obstetrics and Gynecology David Geffen School of Medicine at UCLA University of California, Los Angeles Los Angeles, California Amy R. Lamb, PhD, CNM Nurse-Midwife and Researcher Obstetrics and Gynecology Cedars-Sinai Medical Center Los Angeles, California
Anita L. Nelson, MD Professor, Department of Obstetrics and Gynecology David Geffen School of Medicine at UCLA University of California, Los Angeles Los Angeles, California; Medical Director, Research Division California Family Health Council Los Angeles, California William H. Parker, MD Health Sciences Clinical Professor Department of Obstetrics and Gynecology UCLA School of Medicine Santa Monica, California Andrea J. Rapkin, MD Professor of Obstetrics and Gynecology David Geffen School of Medicine at UCLA University of California, Los Angeles Los Angeles, California Bassam H. Rimawi, MD, FACOG Department of Gynecology and Obstetrics Division of Reproductive Infectious Diseases and Maternal Fetal Medicine Emory University School of Medicine Atlanta, Georgia viiiviii C O N T R I B U T O R S Ingrid A. Rodi, MD Health Sciences Clinical Professor
Director, Fertility Services UCLA Medical Center Santa Monica, California Amy E. Rosenman, MD, FACOG, FPMRS Health Sciences Clinical Professor of Obstetrics and Gynecology David Geffen School of Medicine at UCLA University of California, Los Angeles Los Angeles, California David E. Soper, MD J. Marion Sims Professor Department of Obstetrics and Gynecology Medical University of South Carolina Charleston, South Carolina John Williams III, MD Clinical Professor Department of Obstetrics and Gynecology David Geffen School of Medicine at UCLA University of California, Los Angeles Director of Reproductive Genetics Department of Obstetrics and Gynecology Cedars-Sinai Medical Center Los Angeles, California Mark Zakowski, MD Associate Professor of Anesthesiology Adjunct, Charles Drew University of Medicine and Science Chief, Obstetric Anesthesiology, Cedars-Sinai Medical Center
Los Angeles, California ix Preface It has been thirty years since the first edition of Essen- tials of Obstetrics and Gynecology was published. As stated in the Preface to the First Edition, there was then, and continues to be today, a need for a textbook that covers the essential aspects of the specialty of Obstetrics and Gynecology, which is written primarily for the student and resident physician training in the field. The text has become known as ”Hacker and Moore” over the years, as a tribute to the pioneering work of the original editors. The late J. George “Jerry” Moore was the Professor and Chairman of Obstetrics and Gynecology at the University of California at Los Angeles (UCLA), and the concept for the book was his. Neville Hacker was then an Assistant Professor in the Department and was in charge of the Student Clerk- ship. He was co-opted by Jerry to co-edit the book, after the entire UCLA faculty had agreed to participate in its writing. The first edition of any textbook contains the vision and forms the foundation of the intent of the work, as outlined in the original preface. The editors have always felt that a new edition should be published only when there was significant new clinical information to report. Based on that standard, we believe it is now time for the sixth and latest edition of “Hacker and Moore” to be published.
Medical education is continuously evolving, and has changed significantly since the first edition of this text- book was published in 1986. The internet with its world-wide web and other technologies have made information instantly available to students and resi- dents on a mobile phone or tablet during a clinical meeting. They are being taught to be life-long learners and information seekers. The classroom dynamics have been flipped in the past decade, in the sense that information transfer and gathering occurs before a seminar, with classroom time now increasingly devoted to discussions and problem solving by teams of stu- dents supported by diverse faculty mentors. This is appropriate, because health care is increasingly being delivered by multidisciplinary teams of professionals rather than by individual practitioners. With the ever- increasing complexity of medical and surgical care, this trend is expected to continue. Textbooks have the recognized disadvantage of not always containing the latest information on a topic and of having a limited “shelf life.” But just as newspapers and periodicals (printed or electronic) provide a “first and early draft” of human history and require frequent correction over time, medical texts should contain and document the time-tested facts of a discipline, along with newer information viewed through the prism of evidence-based and safe practice. It is our belief that textbooks will continue to provide the reliable essen- tials of all clinical practice, including the practice of obstetrics and gynecology. All of the 42 chapters in this edition have been updated. Some chapters have been completely rewrit- ten. Others have been modified due to changes in clini-
cal practice. As was the case in previous editions of this text, we have worked to include only the “essentials” of obstetrics and gynecology, making difficult choices about the breadth and depth of the material presented. Every attempt has been made to include material con- sistent with the learning objectives and goals proposed by the Association of Professors in Gynecology and Obstetrics (APGO), available on their website at www. apgo.org. In addition to the authors and editors of this current edition, we wish to acknowledge and thank those who have contributed to all previous editions.* Their knowl - edge and wisdom contained in their words, some of *Contributors from all previous editions: Juan J. Arce, Carol L. Archie, Ricardo Azziz, Martha J. Baird, Richard A. Bashore, A. David Barnes, Michael J. Bennett, Narender N. Bhatia, Jennifer Blake, Clifford Bochner, J. Robert Bragonier, Charles R. Brinkman III, Michael S. Broder, Philip G. Brooks, John E. Buster, Maria Bustillo, Richard P. Buyalos, Mary E. Carsten (deceased), Anita Bachus Chang, R. Jeffrey Chang, George Chapman, Ramen H. Chmait, Gautam Chaudhuri, Kenneth A. Conklin, Irvin M. Cushner (deceased), Alan H. DeCherney, Cath- erine Marin DeUgarte, William J. Dignam (deceased), John A. Eden, Bruce B. Ettinger, Ozlem Equils, Robin Farias-Eisner, Larry C. Ford (deceased), Michelle Fox, Janice I. French, Ann Garber, Anne D.M. Graham, Paul A. Gluck, William A. Growdon, John Gunning (deceased), Lewis A. Hamilton, Hunter A. Hammill, George S. Harris, Robert H. Hayashi, James M. Heaps, Howard L. Judd (deceased),
Continued http://www.apgo.org http://www.apgo.org xx P R E FA C E which remain in this edition, form the foundation of this work and will continue to enlighten future stu- dents of obstetrics and gynecology. We greatly appreciate, and wish to acknowledge, the support and professionalism of James Merritt and his excellent production staff, particularly Rhoda Howell, Rachel McMullen, Amy Meros, and Julia Roberts at Elsevier. We hope that the knowledge acquired from this book will encourage many to pursue a more in depth study of the specialty. Joseph C. Gambone (Executive Editor) Neville F. Hacker Calvin J. Hobel Daniel A. Kahn, Samir Khalife, Ali Khraibi, Matthew Kim, Oscar A. Kletzky (deceased), Grace Elizabeth Kong, Larry R. Laufer, Thomas B. Lebherz (deceased), Joel B. Lench, Ronald S. Leuchter, John K.H. Lu, Michael C. Lu, Donald E. Marsden, John Marshall, Ruchi Mathur, James A. McGregor, Arnold L. Medearis deceased) David R. Meldrum, Robert Monoson, J. George Moore (deceased), Thomas R. Moore,
John Morris (deceased), Suha H.N. Murad, Sathima Natarajan, Lauren Nathan, John Newnham, Tuan Nguyen, Bahij S. Nuwayhid, Gary Oakes, Dotun Ogunyemi, Aldo Palmieri, Groesbeck P. Parham, Ketan S. Patel, Margareta D. Pisarska, Gladys A. Ramos, Anthony E. Reading, Robert C. Reiter, Jean M. Ricci (Goodman), Michael G. Ross, Edward W. Savage, William D. Schlaff, Mousa Shamonki, James R. Shields, Klaus J. Staisch (deceased), Eric Surrey, Khalil Tabsh, Christopher M. Tarnay, Maryam Tarsa, Nancy Theroux, Paul J. Toot, Maclyn E. Wade (deceased), Nathan Wasserstrum, Barry G. Wren, and Linda Yielding. 2 1 CHAPTE R CALVIN J. HOBEL • JOSEPH C. GAMBONE A Life-Course Perspective for Women’s Health Care Safe, Ethical, Value-Based Practice with a Focus on Prevention ■ Clinical practice in obstetrics and gynecology, based upon the principles of safe, ethical and value-based care, is facilitated by viewing wellness and sickness in the
context of a life-course perspective. Effective clinical care of mother and child must begin early, even before conception, and continue throughout life. ■ Adaptive developmental plasticity and epigenetic modi- fication of genes during and after pregnancy can have a significant impact on chronic diseases later in life. ■ Clinicians should incorporate the major ethical princi- ples of nonmaleficence, beneficence, autonomy, and justice into their practices, along with the duties and ideals of confidentiality and multidisciplinary collaboration. ■ Regulatory, economic, and public pressure make assess- ment and improvement of safety and value essential in the delivery of women’s health care. Optimal health outcomes can only be achieved when principles from continuous quality assessment and high reliability orga- nizations are combined with the systematic approach of safety science and evidence-based medicine. ■ The promising area of clinical preventive services in
obstetrics and gynecology, as in all heath care, is trans- forming the practice of medicine in a very positive way. CLINICAL KEYS FOR THIS CHAPTER This chapter of Essentials of Obstetrics and Gynecology is being revised at a time when the health and wellness of the population of the United States and some other developed countries of the world are being evaluated and questioned. A recent study by the Harvard Busi- ness School conducted by Professor Michael Porter and his team ranked the United States only 70th in the world in terms of overall health and wellness. Despite the fact that the United States spends far more on health care (nearly 18% of gross domestic product or GDP) than any other nation, it continues to be ranked only about 37th out of 191 nations for health status and health system performance. Further, the United States is ranked only 46th for average life- expectancy and 42nd for infant mortality by the World Health Organization (WHO). Clearly, the United States must strive to improve its standing on these and other mea-
sures of performance. This is especially important at a time when the health care delivery system enters the era of the Affordable Care Act (ACA), and efforts to provide care to all citizens at a reasonable cost are underway. Obstetrics and gynecology is one of the most exciting and challenging areas of health care, with a number of significant opportunities for improvement such as infant and maternal mortality. The specialty provides students and young physicians in training with the knowledge and skills necessary to improve the health of women and their children very early in their lives. In this first chapter of the book, some basic principles and guidelines for improving health care are provided, and several important factors that are influ- encing the health of women and their children are suggested. Principles of Practice There are four basic principles for practicing and improving health care. First, the safety of our patients must always be paramount. In recent years we have
made major improvements in patient safety, in large part by emphasizing teamwork and implementing practices proven to be effective in the airline industry. Second, we must be true to our personal pledge made when taking the Hippocratic Oath—to adhere to ethical practices. Third, we must transform to a value- based system of health care delivery. Because medi- cine has become very complex, we must be open to a C H A P T E R 1 A Life-Course Perspective for Women’s Health Care 3 structure include altered DNA methylation by both histone acetylation and methylation. Since the last edition of this text, investigators have determined that alterations in the in utero environ- ment during pregnancy may result in modifications to the chromatin structure. These modifications may lead to persistent changes in postnatal gene expression which may render the child more susceptible to early onset adult disease. The conditions during preg- nancy that account for these epigenetic changes are preeclampsia, preterm birth, intrauterine growth restriction (IUGR), obesity, diabetes, poor nutrition, smoking, and some cancers. Even the mothers with these pregnancy conditions are themselves at greater
risk for cardiovascular disease, hypertension, and dia- betes later in life. The onset for these conditions occurs earlier in life compared to those women who have normal pregnancies. Thus having a normal pregnancy may be protective of disease later in life. It is now thought that the effect of harmful behav- iors and our environment on the expression of our genes may account for up to 40% of all premature deaths in the United States. Two of the top behavioral factors related to this premature death rate are obesity (and its usual physical inactivity) and smoking. Envi- ronmental exposures to metals, solvents, pesticides, endocrine disruptors, and other reproductive toxicants are also major concerns. Second, in human biology, a phenomenon called adaptive developmental plasticity plays a very impor- tant role in helping to adjust behavior to meet any environmental challenge. In order to understand human development over time (a life-course perspec- tive), one must first understand what is normal and what adverse circumstances may challenge and then change normal development of the fetus. These pro- tective modifications of growth and development which are programmed in utero to prevent fetal death, may become permanent. The price the fetus may pay for short-term survival is later vulnerability to
conditions such as obesity, hypertension, insulin resis- tance, atherosclerosis, and even diabetes. In relation to individual X and individual Y with the same genomic makeup but different in utero environ- mental influences, metabolic changes that may be ini- tiated in utero in response to inadequate nutritional supplies (Figure 1-1) can lead to insulin resistance and eventually the development of type 2 diabetes. These adaptive changes can even result in a reduced number of nephrons in the kidneys as a stressed fetus conserves limited nutritional resources for more important organ systems in utero. This can then lead to a greater risk of hypertension later in life. This series of initially protective but eventually harmful developmental changes was first described in humans by David Barker, a British epidemiologist, who carefully assessed birth records of individuals more cost-effective multidisciplinary approach to both diagnostic and therapeutic practice. Performance improvement efforts, practice management skills, and effective communication are all necessary to efficiently optimize clinical outcomes and value. Fourth, and perhaps most importantly, we must focus on the pre- vention and early mitigation of disease, in addition to
our continued focus on its treatment. This should occur in a patient-centered manner, meeting their needs and expectations. For this reason, we emphasize an approach called a life-course perspective for clinical practice, beginning with preconception health, continuing throughout pregnancy, the postpartum period (interconception health), and then giving children and their mothers a health perspective for adopting and maintaining healthy living. Before delving more deeply into these principles of practice (safety, ethics, value, and prevention), some newer concepts about the origins of disease are impor- tant to mention. LIFE-COURSE PERSPECTIVE When does disease begin and lead to pathology and illness during the course of life? First, although genetics is beginning to provide a much better understanding of the etiology of poor health, it probably accounts for only about one-third of the direct causes. Imprinted genes from both the mother and the father play an important role in passing on characteristics to the offspring. This imprinting process maintains the phenotype of the family in sub- sequent generations. However, some imprinted and nonimprinted genes can be upregulated or downregu-
lated by subsequent epigenetic modifications, due to environmental influences. For example, person X with gene A has a disease but person Y with the same gene does not. Clearly there is more to human development and disease risk than genetic makeup. Currently it is thought that factors such as poverty or abnormal health behaviors (poor nutrition and smoking) and/or envi- ronmental conditions can influence the expression of gene A without actually changing its genomic makeup. This may occur directly or these factors may activate another gene, A-2 downstream, which may then affect gene A. This process whereby human cells can have the same genomic makeup but different characteristics is referred to as epigenetics (literally meaning “on top of genetics”), an exciting new frontier. The developmental origins of adult disease hypoth- esis (Barker hypothesis) postulates that perturba- tions in the gestational environment may influence the development of adult diseases such as cardiovas- cular disease, obesity, diabetes, and stroke. Current evidence suggests that this occurs through the repro- gramming of gene expression via epigenetic changes
in chromatin structure. Epigenetic changes in chromatin 4 PA R T 1 Introduction Normally, as soon as the fight or flight is over, the stress response is turned off. The body’s sympathetic response is counteracted by a parasympathetic response, which fires a signal via the vagal nerve to slow down the heart, and the HPA axis is shut off by cortisol via negative feedback mechanisms. Negative feedback mechanisms are common to many biological systems and work very much like a thermostat. When the room temperature falls below a preset point, the thermostat turns on the heat. Once the preset tempera- ture is reached, the heat turns off the thermostat. Stress turns on the HPA axis to produce cortisol. Cortisol, in turn, turns off the HPA axis to keep the stress response in check. This stress response works well for acute stress but it tends to break down under chronic stress. In the face of chronic and repeated stress, the body’s stress response is always turned on, and over time will wear out. The body goes from being “stressed” to
being “stressed out”—from a state of allostasis to allostatic overload. This describes the cumulative wear and tear on the body’s adaptive systems from chronic stress. Helpful physiologic mechanisms that initially protect may eventually be harmful. The life-course perspective synthesizes both the developmental programming mechanisms of early life events and allostatic overload mechanisms of chronic life stress into a longitudinal model of health development. It is a way of looking at life not as discon- nected stages, but as an integrated continuum. Thus to promote a healthy first pregnancy, preconception health should be a priority. To promote preconception health, adolescent health must be provided to young girls so that as women having children, they are free of diseases such as diabetes, hypertension, and obesity and have been encouraged to eat a healthy diet and to abstain from using tobacco products. Rather than episodic care that many women now receive, as a specialty we must strive toward disease prevention and health promotion over the continuum of a woman’s life.
IMPACT ON PUBLIC HEALTH The public health implications of the Barker hypoth- esis and other life-course events are significant. This is the beginning of an exciting era in medicine where young physicians and other health care professionals can begin to take charge of these events and change our health care delivery system in a very positive way. Patients should be encouraged to take responsibility for improving their own health, particularly by prac- ticing healthy behaviors early in life. They should also be encouraged to improve and maintain a healthy “green” environment. Currently there are only a few environmental and behavioral factors that have been clearly identified as part of the Barker hypothesis. Many others are yet to be discovered. and linked low birth weight (<2500 grams) to the development of hypertension, diabetes, atheroscle- rosis, and stroke later in life. The association between poor fetal growth during intrauterine life, insulin resis- tance, and cardiovascular disease is known as the Barker hypothesis. The process whereby a stimulus or insult, at a sensitive or critical period of fetal develop- ment, induces permanent alterations in the structure
and functions of the baby’s vital organs is now com- monly referred to as developmental programming. Third, another important concept in the life- course perspective is allostasis, which describes the body’s ability to maintain stability during physiologic change. A good example of allostasis is found in the body’s stress response. When the body is under stress (biological or psychological), it activates a stress response. The sympathetic system kicks in and adren- alin flows to make the heart pump faster and harder (with the end result of delivering more blood and oxygen to vital organs including the brain). The hypothalamic-pituitary-adrenal (HPA) axis is also activated to produce more cortisol, which has many actions to prepare the body for fight or flight. FIGURE 1-1 The potential effects of intrauterine nutrition on sub- sequent adult health. There are genetic, nutritional, and environ- mental causes of poor fetal growth leading to a small phenotype. Having a large phenotype at birth has advantages. These data form the basis of the “developmental origins of adult disease” hypoth- esis (Barker hypothesis). Having a low birth weight increases the risk for diseases and conditions such as hypertension, atheroscle- rosis, stroke, and diabetes later in life. For example, a nutritionally
deprived fetus in utero may develop insulin resistance as an adap- tation to preserve glucose supply to the brain rather than releasing it from the circulation to other less important tissues. Later in life, the insulin resistance that was protective in utero could increase the risk of diabetes as an adult. (From Bateson P, Barker D, Clutton- Brock T, et al: Developmental plasticity and human health. Nature 430:419-421, 2004. Adapted by permission from Macmillan Pub- lishers Ltd.) HighLow Good Poor A d u lt h e a lth Nutritional level Large
phenotype (Body size) Small phenotype (Body size) C H A P T E R 1 A Life-Course Perspective for Women’s Health Care 5 to an adverse drug reaction (ADR). The latter may account for 1 out of 5 injuries or deaths for hospitalized patients. ADRs commonly occur from an overdose, a side effect, or an interaction among several concomi- tantly administered drugs. In order to minimize ADRs, health care providers should avoid the following actions: 1. Prescribing unnecessary medications 2. Treating mild side effects of one drug with a second, more toxic drug 3. Misinterpreting a drug’s side effect for a new medical problem and prescribing another medication 4. Prescribing a medication when there is any uncer- tainty about dosing In the absence of automated systems, providers
should strive to write legibly and use only approved abbrevia- tions and dose expressions. Most health care facilities publish and circulate an acceptable list of appropriate abbreviations, as a means of reducing medication errors. MEDICAL ERROR REPORTING According to the U.S. Agency for Healthcare Research & Quality (AHRQ), “Reporting is an important compo- nent of systems to improve patient safety.” Incident reporting is an important and inexpensive method to detect medical error and prevent future adverse events. Unfortunately, this method may fail to impact clinical outcomes effectively, because most hospital reporting systems do not capture the majority of errors. Report- ing should be considered a quality improvement process (focused on system failures) rather than a performance evaluation method (blaming individual providers). As a founding member of the National Patient Safety Foundation and the National Patient Safety Partnership, the Joint Commission on the Accredita-
tion of Healthcare Organizations ( JCAHO), now more commonly known as The Joint Commission (TJC), has formed a coalition with the U.S. Pharmacopoeia (USP), the American Medical Association (AMA), and the American Hospital Association (AHA) to create patient safety reporting principles. Recognizing that fear of liability discourages error reporting, TJC has advised the U.S. Congress that federal statutory pro- tection must be afforded to those who report medical error. An anonymous nonpunitive environment will encourage reporting. Many states have implemented mandatory reporting systems for selected medical errors to improve patient safety and reduce errors. Others consider incident reporting and analysis as peer review activities immune from liability. The IOM report recommends that health care providers be required to report errors that result in serious harm. Information collected should be made available to the public. AHRQ publishes case summaries of Adaptive developmental plasticity will take place secondary to changes in genes as a result of environ- mental and behavioral practices. Even the controversial concept of climate change may play a role in this phe-
nomenon. Biological processes are very powerful and frequently unpredictable. Physicians must increasingly strive for a safe, ethical, and value-based practice. In order to facilitate the improvement of the health and wellness of women and children, four basic prin- ciples of practice should guide our strategy: patient safety, ethical practice, value, and the need for a patient-centered focus on prevention, as follows. Patient Safety—The First Principle of Practice Safety in health care is not a new concept. Facilities have had safety programs in place since the early 1900s, but these programs have traditionally focused on emergency preparedness, environmental safety, secu- rity, and infection control. The term patient safety, meaning avoidance of medical error, was first coined by the American Society of Anesthesiologists in 1984, when they inaugurated the Anesthesia Patient Safety Foundation to give assurance that the effects of anes- thesia would not harm patients. Medical errors now rank as the fifth leading cause of death in the United States. The Institute of Medicine (IOM) published an alarming report in 1999
called To Err Is Human: Building a Safer Health System. This report estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors. Error is defined as failure of a planned action to be completed as intended (e.g., failing to operate when obvious signs of appendicitis are present) or the use of a wrong plan to achieve an aim (e.g., wrong diag- nosis, wrong medication administered). Medication errors alone, occurring either in or out of the hospital, are estimated to account for over 7,000 deaths annu- ally. According to the National Council on Patient Information and Education, “more than 2/3 of all phy- sician visits end with a prescription.” An estimated 39-49% of all medication errors occur at the stage of drug ordering. Patient noncompliance also contrib- utes to medical errors. The U.S. Pharmacopoeia (USP) MedMARx error tracking service estimates that as many as 100,000 medication errors occur annually. Because reporting is voluntary and does not include all medical facilities in the United States, the scope of the problem is likely to be much larger. A preventable adverse drug event (ADE) is one type of medication error. Administering
the incorrect drug, an incorrect dose, wrong frequency, or incorrect route may cause an ADE. A drug that cures one patient’s condition may be the one that causes another patient’s injury or death due 6 PA R T 1 Introduction ideals and the concepts derived from them are com- monly accepted and taken into account. Four such principles or ideals are nonmaleficence, beneficence, autonomy, and justice; these are generally accepted as the major ethical concepts that apply to health care. NONMALEFICENCE The principle of primum non nocere or “first, do no harm” originates from the Hippocratic school, and although few would dispute the basic concept, in day- to-day medical practice, physicians and their patients may need to accept some harm from treatment (such as necessary surgical trauma) in order to achieve a desired outcome. However, there is an ethical obliga- tion to be certain that recommended medical treat- ment, surgery, or diagnostic testing is not likely to cause more harm than benefit.
BENEFICENCE The duty of beneficence, or the promotion of the welfare of patients, is an important part of the Hippo- cratic Oath. Most would see its strict application as an ideal rather than a duty, however. One could save many suffering people in a Third World country by practicing there or by giving a large portion of one’s income in aid, but few would consider it a moral duty to do so. On the other hand, when the concept of beneficence involves a specific patient encounter, the duty applies. A physi- cian prevented by conscience from participating in the performance of an abortion, for example, would gener- ally be expected to provide lifesaving care for a woman suffering complications after such a procedure— putting her welfare first. AUTONOMY The right of self-determination is a basic concept of biomedical ethics. To exercise autonomy, an individ- ual must be capable of effective deliberation and be neither coerced into a particular course of action nor limited in her or his choices by external constraints. Being capable of effective deliberation implies a level
of intellectual capacity and the ability to exercise that capacity. There are a number of situations in which it may be reasonable to limit autonomy: (1) to prevent harm to others, (2) to prevent self-harm, (3) to prevent immoral acts, or (4) to benefit many others. The concept of informed consent is derived directly from the principle of autonomy, and from a desire to protect patients and research subjects from harm. There is general agreement that consent must be gen- uinely voluntary and made after adequate disclosure of information. As a minimum, when a patient con- sents to a procedure in health care, the patient should be informed about the expectation of benefit as well as the other reasonable alternatives and possible risks that are known. Table 1-1 provides a useful checklist reported medical errors and near misses on their website. DISCLOSURE OF MEDICAL ERROR The National Patient Safety Foundation (NPSF) was one of the first organizations to address the issue of disclosure. Their position, finalized in November
2000, states, “When a health care injury occurs, the patient and the family or representatives are entitled to a prompt explanation of how the injury occurred and its short- and long-term effects. When an error con- tributed to the injury, the patient and the family or representatives should receive a truthful and compas- sionate explanation about the error and the remedies available to the patient. They should be informed that the factors involved in the injury will be investigated so that steps can be taken to reduce the likelihood of similar injury to other patients.” The Joint Commission now requires hospitals to dis- close any serious harm caused by medical errors to the harmed parties. Disclosing an error can be very diffi- cult for physicians because they may struggle with intense feelings of incompetence, betrayal of the patient, and fear of litigation. Studies suggest that phy- sicians with good relationship skills are less likely to get sued. Furthermore, suits are settled more rapidly and for less money if errors are disclosed early. Simple rules for disclosing errors include: admit the mistake, acknowledge the listener’s anger, speak slowly, and stop frequently to allow the listener to talk. Usually, the attending physician is the one who should make the disclosure and offer an apology.
Ethical Practice— The Second Principle Obstetrics and gynecology encompasses many high- profile areas of ethical concern such as in vitro fertiliza- tion (IVF) and other assisted reproductive technologies (ART), abortion, the use of aborted tissue for research or treatment, surrogacy, contraception for minors, and sterilization of persons with a mental illness. Neverthe- less, most ethical problems in the practice of medicine arise in cases in which the medical condition or desired procedure itself presents no moral problem. In the past, the main areas of ethical concern have related to the competence and beneficence of the physician. Current areas of ethical concern should include the goals, values, individual and appropriate cultural preferences of the patient, as well as those of the com- munity at large. Consideration of such issues enriches the study of obstetrics and gynecology by emphasizing that scientific knowledge and technical skills are most meaningful in a social and moral context. During the day-to-day consideration of ethical dilemmas in health care, a number of principles or
C H A P T E R 1 A Life-Course Perspective for Women’s Health Care 7 considerations of autonomy but also helps promote beneficence, as is the case with honesty. In obstetrics and gynecology, conflicts can arise as in the case of a woman with a sexually transmitted infection who refuses to have a sexual partner informed, or a school- aged child seeking contraceptive advice or an abortion. There are many other situations in which conflicting responsibilities make confidentiality a difficult issue. The U.S. Health Insurance Portability and Accountabil- ity Act (HIPAA) mandates strict rules that physician practices and health care facilities must adhere to regarding the confidentiality and security of patient health care records. Some are concerned that these regulations could restrict the flow of information about patient care and may hinder efforts to improve overall performance. Caring for a pregnant woman creates a unique maternal-fetal relationship because the management
of the mother inevitably affects her baby. Until recently, the only way by which an obstetrician could produce a healthy baby was by maintaining optimal maternal health, but as the fetus becomes more accessible to diagnostic and therapeutic interventions, new prob- lems emerge. Procedures performed on behalf of the fetus may violate the personal integrity and auton- omy of the mother. The obstetrician with a dual responsibility to mother and fetus faces a potential conflict of interest. Most conflicts will be resolved due to the willingness of most women to undergo consid- erable self-sacrifice to benefit their fetus. When a woman refuses consent for a procedure that presents her with significant risk, her autonomy will generally be respected. However, there may be cases in which an intervention that is likely to be efficacious carries little risk to the mother and can reasonably be expected to prevent substantial harm to the fetus. These have occa- sionally ended in a court-ordered intervention. Health care is a multidisciplinary activity and respectful and collegial relationships with other health professionals are very important. Although the physician has traditionally been the only decision maker, this situation has often caused concern among
other health care professionals. There is increasing (PREPARED) that expands on the minimum informa- tion required. The exercise of autonomy may put considerable stress and conflict on those providing health care, as in the case of a woman with a ruptured ectopic pregnancy who refuses a lifesaving blood transfusion for religious reasons and dies despite the best efforts of the medical team. More complex questions may be raised by court- ordered cesarean deliveries for the benefit of the fetus. JUSTICE Justice relates to the way in which the benefits and burdens of society are distributed. The general princi- ple that equals should be treated equally was espoused by Aristotle and is widely accepted today, but it does require that one be able to define the relevant differ- ences between individuals and groups. Some believe all rational persons to have equal rights; others empha- size need, effort, contribution, and merit; still
others seek criteria that maximize both individual and social utility. In most Western societies, race, sex, and reli- gion are not considered morally legitimate criteria for the distribution of benefits, although they too may be taken into account in order to right what are per- ceived to be historic wrongs, in programs of affirma- tive action. When resources are scarce, issues of justice become even more problematic. There are often com- peting claims from parties who appear equal by all rel- evant criteria, and the selection criteria themselves become a moral issue. Most modern societies find the rational rationing of health care resources to be appro- priate and acceptable (Figure 1-2). OTHER DUTIES OF ETHICAL PRACTICE Confidentiality is a cornerstone of the relationship between physician and patient. This duty arises from TABLE 1-1 THE PREPARED SYSTEM: A CHECKLIST TO GUIDE PATIENT AND PROVIDER IN THE PROCESS OF INFORMED CONSENT P lan The course of action being considered R eason The indication or rationale E xpectation The chances of benefit and failure
P references Patient-centered priorities (utilities) and cultural preferences affecting choice A lternatives All other reasonable options R isks The potential for harm from treatment E xpenses All direct and indirect costs D ecision Fully informed collaborative choice and consent Modified from Reiter RC, Lench JB, Gambone JC: Consumer advocacy, elec- tive surgery, and the “golden era of medicine.” Obstet Gynecol 74:815–817, 1989. FIGURE 1-2 Representation of arbitrary rationing commonly based on access or ability to pay versus planned clinical resource management based on measured value. Explicit rationing is objec- tionable to many despite the fact that implicit rationing still occurs. Based on measured value Explicit (planned) Based on access or ability to pay
Implicit (arbitrary) RationalIrrational RATIONING 8 PA R T 1 Introduction Value—The Third Principle of Practice The mandate from payers (government and employ- ers) and the public to measure and improve the effec- tiveness and efficiency (value) of health care services is clear. Unfortunately, change based on adoption of national standards derived from evidence-based prac- tice and randomized controlled trials (RCTs) alone may be too expensive and slow to meet this mandate. Furthermore, the results from RCTs may not always establish how diagnostic and therapeutic procedures actually work in clinical practice. For these reasons, health care organizations, including schools of public health and physician groups, must develop the tools to identify and adopt best practices and improve clin- ical outcomes locally. Value in health care is defined as “clinical outcomes considering the resources used,” or results divided
by the costs of care. Figure 1-3 illustrates a collaborative process that may be used to involve the patient in the determination of value when decisions about treat- ments are being made. The past 40 years that have been devoted to the measurement and pursuit of quality improvement have not been successful in terms recognition that other clinicians involved in health care have a right to participate in any decision making. Physicians have not been as aware of the sen- sitivities of the nursing profession and other allied health professionals as they should have been. For example, the decision to either operate or not on a newborn with severe spina bifida inevitably leaves nurses with responsibilities to the infant, the parents, and the doctor that may be in direct conflict with their personal values. They may rightly request to be party to the decision-making process, and although the exact models whereby such a goal may be achieved are debatable, physicians must be aware of the legitimate moral concerns of nurses and others involved.
Health care delivery takes place in a very complex environment and relationships with other interested parties is becoming increasingly important. Hospi- tals, health insurance companies, and governments all claim an interest in what services are made avail - able or paid for, and this may prevent individual patients from receiving what their physician may con- sider optimal care. This poses moral problems not only for physicians on a case-by-case basis but also for insurance companies and society as a whole. An atmo- sphere of mutual trust should be sought, earned, and practiced in these relationships. Finally, and very importantly, all physicians and other health care providers should be mindful of a potential conflict of interest that may occur during practice or during performance of committee work at the local or national level. Even the appearance of a conflict between a personal interest and the duty to put patient care interest first can undermine the confi- dence that patients and the public have in them. MALPRACTICE AND MALOCCURRENCE Medical malpractice refers to care that is negligent and
below the accepted standard. When an undesired outcome occurs irrespective of the care that is given, it is referred to properly as medical maloccurrence. The system of tort law that currently applies to medical malpractice in the United States distorts the difference between these two events in many cases. Clearly there is preventable medical error resulting from negligent care, but many of these events are not properly addressed in our system. Too often medical maloccur- rence is judged to be malpractice. The interface of medicine and the law raises major ethical issues because legality and morality are not always synonymous. Professional liability insurance premiums for obstetricians are testimony to the rele- vance of legal issues to obstetric practice. Professional liability is affecting every major decision that is made by the practicing obstetrician and gynecologist, and under these conditions, the “tunnel vision” that ensues may obscure the ability to see clear answers to ethical questions. FIGURE 1-3 Involving the patient in the determination of value in decision making. Defining the Plan or Procedure along with its
Reason or indication, its evidence-based Expectations, and the patient-centered Preferences for it helps to determine its effective- ness. Further defining of all other Alternatives, the associated Risks and complications along with all Expenses (Costs) determines its efficiency. Making a collaborative Decision based on this process helps to determine the Value of the treatment. (Modified from Gambone JC, Reiter RC, Hagey S: Clinical outcomes in gynecology: hysterectomy. Curr Probl Obstet Gynecol Fertil 16(4), 1993.) P lan R eason E xpectations P references A lternatives R isks E xpenses D ecision VALUE EFFICIENCY EFFECTIVENESS C H A P T E R 1 A Life-Course Perspective for Women’s Health Care 9
making is replacing the older solo “captain of the ship” principle for high-risk, high-consequence health care activities. One checklist developed for health care for use in the operating room (Figure 1-4) was tested worldwide by the WHO and resulted in a 47% reduction in surgical mortality and a 36% reduction in inpatient complications. The use of medical teams in health care has resulted in similar reductions in both mor- tality and morbidity. Both of these interventions are relatively inexpensive when compared to the gains and both are highly effective. Patient-Centered Prevention— The Fourth Principle of Practice The prevention and mitigation of existing disease has become an extremely important and sometimes of reducing the high cost of care, particularly in the United States. Transforming health care organizations into high reliability organizations (HROs) that deliver patient-centered value has become the main focus of performance improvement today. HIGH RELIABILITY IN HEALTH CARE Recent progress in health care outcomes has been
attained by introducing the concepts and tools of HROs into health care delivery facilities. The two industries that have led as HROs have been commercial aviation and nuclear power plants. In aviation, the adoption of checklists and crew resource management (CRM) has improved commercial aviation safety significantly. The concepts of CRM (called medical team manage- ment in health care) are now being adopted for high- risk procedures in trauma centers and operating rooms. The development of high reliability teams for decision- FIGURE 1-4 Surgical safety checklist. (Based on the WHO Surgical Safety Checklist: Available at http://whqlibdoc.who.int/publications/ 2009/9789241598590_eng_Checklist.pdf, © World Health Organization 2009. All rights reserved.) SURGICAL SAFETY CHECKLIST Before induction of anaesthesia Before skin incision Before patient leaves operating room (with nurse, anaesthetist, and surgeon)(with nurse, anaesthetist, and surgeon)(with at least nurse and anaesthetist) Has the patient confirmed his/her identity, site, procedure, and consent? Is the site marked?
Is the anaesthesia machine and medication check complete? Is the pulse oximeter on the patient and functioning? Does the patient have a: Known allergy? Difficult airway or aspiration risk? Risk of >500 ml blood loss (7 ml/kg in children)? No Yes Yes Not applicable No Yes, and equipment/assistance available No Yes, and two IVs/central access and fluids planned Yes Yes Yes
This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged. Confirm all team members have introduced themselves by name and role. Has antibiotic prophylaxis been given within the last 60 minutes? Anticipated critical events To surgeon: How long will the case take? What is the anticipated blood loss? Yes Not applicable Is essential imaging displayed? Yes Not applicable What are the critical or non-critical steps? To anaesthetist: How long will the case take? Are there any patient-specific concerns? Confirm the patient’s name, procedure, and where the incision will be made.
To nursing team: Are there equipment issues or concerns? Has sterility (including indicator results) been confirmed? Nurse verbally confirms: The name of the procedure Completion of instrument, sponge, and needle counts Specimen labeling (read specimen labels aloud, including patient name) Whether there are any equipment problems to be addressed To surgeon, anaesthetist, and nurse: What are the key concerns for recovery and management of this patient? http://whqlibdoc.who.int/publications/2009/9789241598590_eng _Checklist.pdf http://whqlibdoc.who.int/publications/2009/9789241598590_eng _Checklist.pdf 10 PA R T 1 Introduction overlooked area of value-based practice. The famous American humorist, Will Rogers, said many years ago that people should only pay their doctors when
they are well and not sick. This suggests a frustration that he was reflecting publicly that medical practice had neglected the promotion of wellness, resulting in a high cost of sickness. As health care treatment becomes more expensive and complex, there is a greater incen- tive for government, private industry, and individuals to invest in preventive services. There are several good examples of effective preven- tive interventions that are now available in obstetric and gynecologic practice. In obstetrics, the newer techniques for mitigating intrauterine fetal damage from chronic stress that may result in short- and long-term morbidity (see Chapters 7 and 9) are increasingly successful. And in gynecology, the vac- cination against human papillomavirus (HPV ) infec- tion to prevent cervical cancer (see Chapters 22 and 38) is a major advance. Box 1-1 contains a life- course perspective of other early, effective preventive opportunities. *For example, Kliegman R, Behrman R, Jenson H, et al: Nelson’s textbooks of pediatrics, ed 18, Philadelphia, 2007, Saunders. BOX 1-1
LIFE-COURSE PERSPECTIVE OF EARLY PREVENTION OPPORTUNITIES • Preconception counseling (see Chapter 7) • Antepartum care and nutrition counseling (see Chapter 7) • Intrapartum care and surveillance (see Chapters 9 and 10) • Newborn screening (see Chapter 8 and pediatric care textbooks*) • Well-baby visits, breastfeeding and nutrition counsel- ing (see pediatric care textbooks*) • Childhood and adolescent screening and Immuniza- tions (see pediatric care textbooks*) • Adult preventive health screening (see Table 1-2) TABLE 1-2 RECOMMENDED PREVENTIVE HEALTH SCREENING FOR WOMEN Intervention/Procedure Risk(s) Pap smear from age 21 irrespective of sexual activity: age 21- 29, every 3 yr; age 30-65, every 3 yr with cytology only or every 5 yr with HPV
testing added; age >65, only with history of significant CIN After total hysterectomy (corpus and cervix) cytology not needed (see Chapter 38) Cervical dysplasia/cancer Annual breast exam ages >39 and every 1-3 yr age 20-39; high risk women should consider annual exam; screening mammography annually starting at age 40; USPSTF recommends starting at age 50; breast self-exam not universally recommended (see Chapter 29) Breast cancer Smoking cessation counseling, warning about second-hand smoke exposure Lung cancer, heart disease, other health risks associated with smoking Sigmoidoscopy or colonoscopy (preferred) every 3-5 yr after age 50 Colorectal cancer Height and weight measurement for BMI calculation (see Box 2-2) Overweight and obesity Regular blood pressure screening (every 2 yr) Hypertension and stroke Cholesterol/lipid profile every 5 yr until age 65 Heart disease Total skin inspection and selective biopsies Skin cancer (sun
exposure) Diet and exercise counseling; BMD testing for all women > age 64, or younger if at least one risk factor for osteoporosis (see Chapter 35) Osteoporosis, fracture, and deformity Blood sugar study with family history, obesity, or history of gestational diabetes Diabetes mellitus; other comorbidities associated with obesity Cervical sampling for Chlamydia, N. gonorrhoeae, syphilis, and HIV based on history of high-risk behavior (see Chapter 26) Sexually transmitted infections TSH starting at age 50 (see Chapter 35) Thyroid disease PPD of tuberculin for high-risk women Tuberculosis BMD, Bone mineral density; BMI, body mass index; CIN, cervical intraepithelial neoplasia; HIV, human immunodeficiency virus; HPV, human papillomavirus; Pap, Papanicolaou test; PPD, purified protein derivative; TSH, thyroid-stimulating hormone; USPSTF, United States Preventive Services Task Force. C H A P T E R 1 A Life-Course Perspective for Women’s
Health Care 11 IMMUNIZATIONS AND PREVENTIVE HEALTH SCREENING Because public health recommendations for immuni- zations may change, it is best to check a reliable source periodically (e.g., www.cdc.gov) for the latest information before counseling patients. General rec- ommendations include the following for women aged 19 to 49: measles, mumps and rubella (MMR), hepatitis B, and varicella for women who are nonimmune. Addi- tionally, vaccination against HPV is currently recom- mended for girls and women aged 11 to 26, and a single dose of tetanus-diphtheria-pertussis (Tdap) for adults 19 to 64 years of age is now recommended to replace the next booster dose of tetanus and diphtheria toxoids (Td) vaccine. Influenza vaccine annually is recom- mended for all women older than age 50 and women aged 19 to 49 who are health care workers, who have chronic illnesses such as heart disease or diabetes mel- litus, or who are pregnant or planning to become preg- nant during the flu season. Pneumococcal vaccine
is recommended for all women aged 65 and older, and those with chronic illnesses, alcoholism, or who are immunosuppressed. Meningococcal and hepatitis A vaccines may be indicated in some women with risk factors. MMR, varicella, and HPV vaccines are contra- indicated during pregnancy. Table 1-2 contains preventive screening recommen- dations for women. These recommendations can change or be modified from time to time. The Ameri- can College of Obstetricians and Gynecologists (ACOG) and the United States Preventive Services Task Force (USPSTF) have websites that keep the recommenda- tions up to date. The promising area of preventive services in obstetrics and gynecology, as in health care generally, is transforming the practice of medi - cine in a very positive way. http://www.cdc.gov 12 2 Clinical Approach to the Patient C H
A P T ER JOSEPH C. GAMBONE ■ The clinical approach to obstetric and gynecologic patients requires sensitivity and an understanding that medical issues related to birth and reproductive care require a trusting relationship between a woman and her obstetrician and gynecologist as well as all health care professionals that she may encounter. ■ Recent changes in the acceptance of sexual roles in society mean that a nonjudgmental approach is needed. The physician should be careful not to assume that a casual and overly familiar approach is always acceptable to all patients, especially older ones. ■ The obstetric history and physical examination should be complete and carefully performed with the goal of
providing care that results in the best clinical outcomes for the mother and her child. ■ The gynecologic encounter may be for routine preven- tive care or may be to address a specific clinical problem that a woman may be having. Reproductive matters are of most interest during the early adult years. Concerns about chronic disorders typically arise later in life during the pre- and postmenopausal years. ■ The physician and all health care professionals should be aware that certain groups of women, such as the pediat- ric, geriatric, and disabled, have special needs and con- cerns. Women who are in same-sex relationships and transgender women may also have special needs. CLINICAL KEYS FOR THIS CHAPTER A careful history and physical examination should form the basis for patient evaluation and clinical man- agement in obstetrics and gynecology, as in other clini- cal disciplines. This chapter outlines the essential details of the clinical approach to, and
evaluation of, the obstetric and gynecologic patient. The clinical approach to female patients has evolved in recent years (see Chapter 28). It is important for the clinician who cares for women to refrain from making value judg- ments about sexual preferences and behavior, unless they are clearly unhealthy or dangerous. Some patients may have special needs in terms of their clinical care, and an accepting and understanding attitude is impor- tant. Pediatric and adolescent patients, the geriatric patient, as well as women with disabilities, also have unique gynecologic and reproductive needs and this chapter concludes with information about their evalu- ation and management. Obstetric and Gynecologic Evaluation In few areas of medicine is it necessary to be more sensitive to the emotional and psychological needs of the patient than in obstetrics and gynecology. By their very nature, the history and physical examination may cause embarrassment to some patients. The members
of the medical care team are individually and collec- tively responsible for ensuring that each patient’s privacy and modesty are respected while providing the highest level of medical care. Box 2-1 lists the appropri- ate steps for the clinical approach to the patient. While a casual and familiar approach may be accept- able to many younger patients, it may offend others and be quite inappropriate for many older patients. Different circumstances with the same patient may dictate different levels of formality. Entrance to the C H A P T E R 2 Clinical Approach to the Patient 13 the method of delivery in the present pregnancy. A difficult forceps delivery or a cesarean delivery may require a personal review of the labor and delivery records. 5. Duration of labor (recorded in hours). This may alert the physician to the possibility of an unusu- ally long or short labor. 6. Type of anesthesia. Any complications of anesthe- sia should be noted.
7. Maternal complications. Urinary tract infections, vaginal bleeding, hypertension, and postpartum complications may be repetitive; such knowledge is helpful in anticipating and preventing problems with the present pregnancy. 8. Newborn weight (in grams or pounds and ounces). This information may give indications of gesta- tional diabetes, fetal growth problems, shoulder dystocia, or cephalopelvic disproportion. 9. Newborn gender. This may provide insight into patient and family expectations and may indicate certain genetic risk factors. 10. Fetal and neonatal complications. Certain ques- tions should be asked to elicit any problems and to determine the need to obtain further information. Inquiry should be made as to whether the baby had any problems after it was born, whether the baby breathed and cried right away, and whether the baby left the hospital with the mother. MENSTRUAL HISTORY A good menstrual history is essential because it is the determinant for establishing the expected date of con- finement (EDC). A modification of Nägele rule for establishing the EDC is to add 9 months and 7 days to
the first day of the last normal menstrual period (LMP). For example: LMP: July 20, 2015 EDC: April 27, 2016 This calculation assumes a normal 28-day cycle, and adjustments must be made for longer or shorter cycles. Any bleeding or spotting since the last normal men- strual period should be reviewed in detail and taken into account when calculating an EDC. CONTRACEPTIVE HISTORY This information is important for risk assessment. Hor- monal contraceptives taken during early pregnancy have been associated with birth defects, and retained intrauterine devices (IUDs) can cause early pregnancy loss, infection, and premature delivery. MEDICAL HISTORY The importance of a good medical history cannot be overemphasized. In addition to common disorders, such as diabetes mellitus, hypertension, and renal disease, which are known to affect pregnancy outcome, all serious medical conditions should be recorded. BOX 2-1
APPROACH TO THE PATIENT The doctor should always: • Knock before entering the patient’s room. • Identify himself/herself. • Meet the patient initially when she is fully dressed, if possible. • Address the patient courteously and respectfully. • Respect the patient’s privacy and modesty during the interview and examination. • Ensure cleanliness, good grooming, and good manners in all patient encounters. • Beware that a casual and familiar approach is not acceptable to all patients; it is generally best to avoid addressing an adult patient by her first name. • Maintain the privacy of the patient’s medical informa- tion and records. • Be mindful and respectful of any cultural preferences. patient’s room should be announced by a knock and spoken identification. A personal introduction with the
stated reason for the visit should occur before any questions are asked or an examination is begun. The placement of the examination table should always be in a position that maximizes privacy for the patient as other health care professionals enter the room. Any cultural beliefs and preferences for care and treatment should be recognized and respected. Obstetric History A complete history must be recorded at the time of the prepregnancy evaluation or at the initial antenatal visit. Several detailed standardized forms are available, but this should not negate the need for a detailed chronologic history taken personally by the physician who will be caring for the patient throughout her preg- nancy. While taking the history, major opportunities will usually arise to provide counseling and explana- tions that serve to establish rapport and a supportive patient/physician encounter. PREVIOUS PREGNANCIES Each prior pregnancy should be reviewed in
chrono- logic order and the following information recorded: 1. Date of delivery (or pregnancy termination). 2. Location of delivery (or pregnancy termination). 3. Duration of gestation (recorded in weeks). When correlated with birth weight, this information allows an assessment of fetal growth patterns. The gestational age of any spontaneous abortion is of importance in any subsequent pregnancy. 4. Type of delivery (or method of terminating preg- nancy). This information is important for planning 14 PA R T 1 Introduction challenging during the early weeks after a missed menses. Urine pregnancy tests in the office are reliable a few days after the first missed period, and office ultra- sonography is used increasingly as a routine. SYMPTOMS OF PREGNANCY The most common symptoms in the early months of pregnancy are missed menses, urinary frequency, breast engorgement, nausea, tiredness, and easy fati- gability. A missed or abnormal menses in a
previously normally menstruating, sexually active woman should be considered to be caused by pregnancy until proven otherwise. Urinary frequency is most likely caused by the pressure of the enlarged uterus on the bladder. SIGNS OF PREGNANCY The signs of pregnancy may be divided into presump- tive, probable, and positive. Presumptive Signs The presumptive signs are primarily those associated with skin and mucous membrane changes. Discolor- ation and cyanosis of the vulva, vagina, and cervix are related to the generalized engorgement of the pelvic organs and are, therefore, nonspecific. The dark discol- oration of the vulva and vaginal walls is known as Chadwick sign. Pigmentation of the skin and abdomi- nal striae are nonspecific and unreliable signs. The most common sites for pigmentation are the midline of the lower abdomen (linea nigra), over the bridge of the nose, and under the eyes. Pigmentation under the eyes is called chloasma or the mask of pregnancy.
Chlo- asma is also an occasional side effect of hormonal contraceptives. Probable Signs The probable signs of pregnancy are those mainly related to the detectable physical changes in the uterus. During early pregnancy, the uterus changes in size, shape, and consistency. Early uterine enlargement tends to be in the anteroposterior diameter so that the uterus becomes globular. In addition, because of asym- metric implantation of the ovum, one cornu of the uterus may enlarge slightly (Piskaçek sign). Uterine consistency becomes softer, and it may be possible to palpate or to compress the connection between the cervix and fundus. This change is referred to as Hegar sign. The cervix also begins to soften early in pregnancy. Positive Signs The positive signs of pregnancy include the detection of a fetal heartbeat and the recognition of fetal move- ments. Endovaginal ultrasound is capable of detecting
fetal cardiac activity as early as 6 weeks (from last menses) and fetal movement from about 7 to 8 weeks’ gestation. Modern Doppler techniques for detecting SURGICAL HISTORY Each surgical procedure should be recorded chrono- logically, including date, hospital, surgeon, and com- plications. Trauma must also be listed (e.g., a fractured pelvis may result in diminished pelvic capacity). SOCIAL HISTORY Habits such as smoking, alcohol use, and other sub- stance abuse are important factors that must be recorded and managed appropriately. The patient’s contact or exposure to domesticated animals, particu- larly cats (which carry a risk of toxoplasmosis), is important. The patient’s type of work and lifestyle may affect the pregnancy. Exposure to solvents (carbon tetrachlo- ride) or insulators (polychlorobromine compounds) in the workplace may lead to teratogenesis or hepatic toxicity. Obstetric Physical Examination GENERAL PHYSICAL EXAMINATION This procedure must be systematic and thorough
and performed as early as possible in the prenatal period. A complete physical examination provides an opportu- nity to detect previously unrecognized abnormalities. Normal baseline levels must also be established, par- ticularly those of weight, blood pressure, funduscopic (retina) appearance, and cardiac status. PELVIC EXAMINATION The initial pelvic examination should be done early in the prenatal period and should include the following: (1) inspection of the external genitalia, vagina, and cervix; (2) collection of cytologic specimens from the exocervix (or ectocervix) and superficial endocervical canal; and (3) palpation of the cervix, uterus, and adnexa. The initial estimate of gestational age by uterine size becomes less accurate as pregnancy pro- gresses. Rectal and rectovaginal examinations are also important aspects of this initial pelvic evaluation. CLINICAL PELVIMETRY This assessment, which is helpful for predicting poten- tial problems during labor, should be carried out
fol- lowing the bimanual pelvic examination and before the rectal examination. It is important that clinical pelvim- etry be carried out systematically. The details of clinical pelvimetry are described in Chapter 8. Diagnosis of Pregnancy The diagnosis of pregnancy and its location, based on physical signs and examination alone, may be quite C H A P T E R 2 Clinical Approach to the Patient 15 Abdominal Pain Many gynecologic problems are associated with abdominal pain. The common gynecologic causes of acute lower abdominal pain are salpingo-oophoritis with peritoneal inflammation, torsion and infarction of an ovarian cyst, endometriosis, or rupture of an ectopic pregnancy. Patterns of pain radiation should be recorded and may provide an important diagnostic clue. Chronic lower abdominal pain is generally associ- ated with endometriosis, chronic pelvic inflammatory disease, or large pelvic tumors. It may also be the first symptom of ovarian cancer.
Amenorrhea The most common causes of amenorrhea are preg- nancy and the normal menopause. It is abnormal for a young woman to reach the age of 16 without menstru- ating (primary amenorrhea). Pregnancy should be sus- pected in a woman between 15 and 45 years of age who fails to menstruate within 35 days from the first day of her last menstruation. In a patient with amenorrhea who is not pregnant, inquiry should be made about menopausal or climacteric symptoms such as hot flashes, vaginal dryness, or mild depression. Other Symptoms Other pertinent symptoms of concern include dys- menorrhea, premenstrual tension, fluid retention, leukorrhea, constipation, dyschezia, dyspareunia, and abdominal distention. Lower back and sacral pain may indicate uterine prolapse, enterocele, or rectocele. MENSTRUAL HISTORY The menstrual history should include the age at men- arche (average is 12 to 13 years), interval between periods (21 to 35 days with a median of 28 days), dura- tion of menses (average is 5 days), and character
of the flow (scant, normal, heavy, usually without clots). Any intermenstrual bleeding (metrorrhagia) should be noted. The date of onset of the LMP and the date of the previous menstrual period should be recorded. Inquiry should be made regarding menstrual cramps (dysmen- orrhea); if present, the age at onset, severity, and char- acter of the cramps should be recorded, together with an estimate of the disability incurred. Midcycle pain (mittelschmerz) and a midcycle increase in vaginal secretions are usually indicative of ovulatory cycles. CONTRACEPTIVE HISTORY The type and duration of each contraceptive method must be recorded, along with any attendant compli- cations. These may include amenorrhea or throm- boembolic disease with hormonal contraceptives; dysmenorrhea, heavy bleeding (menorrhagia), or pelvic infection with the intrauterine device; or contraceptive failure with the diaphragm, or other barrier method. the fetal heartbeat may be successful as early as 9 weeks and are nearly always positive by 12 weeks. Fetal heart tones can usually be detected with a stethoscope between 16 and 20 weeks. The multiparous
woman generally recognizes fetal movements between 15 and 17 weeks, whereas the primigravida usually does not recognize fetal movements until 18 to 20 weeks. LABORATORY TESTS FOR PREGNANCY Pregnancy Tests Tests to detect pregnancy have revolutionized early diagnosis. Although they are considered a probable sign of pregnancy, the accuracy of these tests is very good. All commonly used methods depend on the detection of human chorionic gonadotropin (hCG) or its β subunit in urine or serum. Depending on the spe- cific sensitivity of the test, pregnancy may be suspected even prior to a missed menstrual period. Diagnostic Ultrasonography The imaging technique of ultrasonography has made a significant contribution to the diagnosis and evalua- tion of pregnancy. Using real-time ultrasonography, an intrauterine gestational sac can be identified at 5 men- strual weeks (21st postovulatory day) and a fetal image can be detected by 5 to 6 weeks. A beating
heart is noted at 7 weeks or even sooner with the latest equipment. Gynecologic History Gynecologic history-taking must be systematic to avoid omissions, and it should be conducted with sensitivity and without haste. PRESENT ILLNESS The patient is asked to state her main complaint and to relate her present illness, sequentially, in her own words. Pertinent negative information should be recorded, and, as much as possible, questions should be reserved until after the patient has described the course of her illness. Generally, the history provides substantial clues to the diagnosis, so it is important to evaluate fully the more common symptoms encoun- tered in gynecologic patients. Abnormal Vaginal Bleeding Vaginal bleeding before the age of 9 years and after the age of 52 years is cause for concern and requires inves- tigation. These are the general limits of normal
men- struation, and although the occasional woman may menstruate regularly and normally up to the age of 57 or 58 years, it is important to ensure that she is not bleeding from uterine cancer or from exogenous estro- gens. Prolongation of menses beyond 7 days or bleed- ing between menses may connote abnormal ovarian function, uterine myomata, or endometriosis. 16 PA R T 1 Introduction General Appearance The patient’s body build, posture, state of nutrition, demeanor, and state of well-being should be recorded. Head and Neck Evidence of supraclavicular lymphadenopathy, oral lesions, webbing of the neck, or goiter may be pertinent to the gynecologic assessment. Breasts The breast examination is particularly important in gynecologic patients (see Chapters 30 and 32). Heart and Lungs
Examination of the heart and lungs is of importance, particularly in a patient who requires surgery. The pres- ence of a pleural effusion may be indicative of a dis- seminated malignancy, particularly ovarian cancer. Abdomen Examination of the abdomen is critical in the evalua- tion of the gynecologic patient. The contour, whether flat, scaphoid, or protuberant, should be noted. The protuberant appearance may suggest ascites. The pres- ence and distribution of hair, especially in the area of the escutcheon, should be recorded, as should the presence of striae or operative scars. Abdominal tenderness must be determined by placing one hand flat against the abdomen in the nonpainful areas initially, then gently and gradually exerting pressure with the fingers of the other hand (Figure 2-1). Rebound tenderness (a sign of peritoneal irritation), muscle guarding, and abdominal rigidity should be gently elicited, again first in the nontender areas. A “doughy” abdomen, in which the guarding OBSTETRIC HISTORY
Each pregnancy, delivery, and any associated compli- cations should be listed sequentially with relevant details and dates. SEXUAL HISTORY The health of, and current relationship with, the husband or partner(s) may provide insight into the present complaints. Inquiry should be made regarding any pain (dyspareunia), bleeding, or dysuria associated with sexual intercourse. Sexual satisfaction should be discussed tactfully. PAST HISTORY As in the obstetric history, any significant past medical or surgical history should be recorded, as should the patient’s family history. A list of current medications is important. SYSTEMIC REVIEW A review of all other organ systems should be under- taken. Habits (tobacco, alcohol, other substance abuse), medications, usual weight with recent changes, and loss of height (osteoporosis) are important parts of the systemic review. Gynecologic Physical Examination GENERAL PHYSICAL EXAMINATION
A complete physical examination should be performed on each new patient and repeated at least annually. The initial examination should include the patient’s height, weight, and arm span (in adolescent patients or those with endocrine problems) and should be carried out with the patient completely disrobed but suitably draped. A body mass index (BMI) should be calculated (Box 2-2) and recorded. The examination should be systematic and should include the following points. Vital Signs Temperature, pulse rate, respiratory rate, and blood pressure should be recorded. FIGURE 2-1 The abdomen is palpated by placing the left palm flat against the abdominal wall and then gently exerting pressure with the fingers of the right hand. *Data from the National Heart, Lung, and Blood Institute. BOX 2-2 CALCULATIONS AND DESIGNATIONS* OF BODY MASS INDEX Body mass index is calculated by dividing weight in kilo- grams (kg) by height in meters squared or weight in
pounds by height in inches squared times 703. Less than 18.5 = underweight 18.5 to 25 = normal weight 25 to 29.9 = overweight 30 to 34.9 = class one obesity 35 to 39.9 = class two obesity 40 or greater = extreme obesity C H A P T E R 2 Clinical Approach to the Patient 17 cated with warm water only, so as not to interfere with the examination of cervical cytology or any vaginal exudate. After gently spreading the labia to expose the introitus, the speculum should be inserted with the blades entering the introitus transversely, then directed posteriorly in the axis of the vagina with pressure exerted against the relatively insensitive perineum to avoid contacting the sensitive urethra. As the anterior blade reaches the cervix, the speculum is opened to bring the cervix into view (Figure 2-3). As the vaginal epithelium is inspected, it is important to rotate the speculum through 90 degrees, so that lesions on
the anterior or posterior walls of the vagina ordinarily covered by the blades of the speculum are not over- looked. Vaginal wall relaxation should be evaluated using either a Sims speculum or the posterior blade of a bivalve speculum. The patient is asked to bear down ( Valsalva maneuver) or to cough to demonstrate any stress incontinence. If the patient’s complaint involves urinary stress or urgency, this portion of the examina- tion should be carried out before the bladder is emptied. The cervix should be inspected to determine its size, shape, and color. The nulliparous patient generally has a conical, unscarred cervix with a circular, centrally placed os; the multiparous cervix is generally bulbous increases gradually as the pressure of palpation is increased, is often seen with a hemoperitoneum. It is important to palpate any abdominal mass. The size should be specifically noted. Other characteristics may be even more important in suggesting the
diagno- sis, such as whether the mass is cystic or solid, smooth or nodular, fixed or mobile, and whether it is associated with ascites. In determining the reason for abdominal distention (tumor, ascites, or distended bowel), it is important to percuss carefully the areas of tympany (gaseous distention) and dullness. A large tumor is gen- erally dull on top with loops of bowel displaced to the flanks. Dullness that shifts as the patient turns onto her side (shifting dullness) is suggestive of ascites. Back Abnormal curvature of the vertebral column (dorsal kyphosis or scoliosis) is an important observation in evaluating osteoporosis in a postmenopausal woman. Costovertebral angle tenderness suggests pyelonephritis, whereas psoas muscle spasm, which is associated with flexion of the hip, may occur with gynecologic infections, malignant infiltration, or acute appendicitis. Extremities The presence or absence of varicosities, edema, pedal pulsations, and cutaneous lesions may suggest patho- logic conditions within the pelvis. The height of
pitting edema should be noted (e.g., ankle, shin, to the knee, or above). PELVIC EXAMINATION The pelvic examination must be conducted systemati- cally and with careful sensitivity. The procedure should be performed with smooth and gentle movements and accompanied by reasonable explanations. Vulva The character and distribution of hair, the degree of development or atrophy of the labia, and the character of the hymen (imperforate or cribriform) and introitus (virginal, nulliparous, or multiparous) should be noted. Any clitorimegaly should be noted, as should the pres- ence of cysts, tumors, or inflammation of the Bartho- lin gland. The urethra and Skene glands should be inspected for any purulent exudates. The labia should be inspected for any inflammatory, dystrophic, or neo- plastic lesions. Perineal relaxation and scarring should be noted because they may cause dyspareunia and defects in anal sphincter tone. The urethra should be “milked” for any inflammatory exudates, which if
found should be cultured for pathologic organisms. Speculum Examination It is important to use an appropriately sized specu- lum (Figure 2-2), which should be warmed and lubri- FIGURE 2-2 A, Pediatric speculum. B, Pederson speculum. C, Graves speculum. The Pederson speculum has narrower blades and is more appropriate for examining a nulliparous patient. D, Parts of a speculum. A B D Upper & lower blades Thumb screw Thumb hinge Handle screw HandleC 18 PA R T 1 Introduction
colaou, or Pap, smear), liquid-based sampling, or DNA probe for human papillomavirus (HPV ) should be taken before the speculum is withdrawn. For the tradi- tional Pap smear the exocervix (or ectocervix) is gently scraped with a wooden spatulum or plastic broom, and the endocervical tissue gently sampled with a cytobrush. Bimanual Examination The bimanual pelvic examination provides informa- tion about the uterus and adnexa (fallopian tubes and ovaries). During this portion of the examination, the urinary bladder should be empty; if it is not, the inter- nal genitalia will be difficult to delineate, and the pro- cedure is more apt to be uncomfortable for the patient. The labia are separated, and the gloved, lubricated index finger is inserted into the vagina, avoiding the sensitive urethral meatus. Pressure is exerted posteri- orly against the perineum and puborectalis muscle, which causes the introitus to gape somewhat, thereby usually allowing the middle finger to be inserted as
well. Intromission of the two fingers into the depth of the vagina may be facilitated by having the patient bear down slightly. If insertion of two fingers causes undue patient discomfort, examination with the index finger alone may give more information. The cervix is palpated for consistency, contour, size, and tenderness to motion. If the vaginal fornices are and the os has a transverse configuration (Figure 2- 4). Any purulent cervical discharge should be cultured. Plugged, distended cervical glands (nabothian folli- cles) may be seen on the exocervix (or ectocervix). In premenopausal women, the squamocolumnar junc- tion of the cervix is usually visible around the cervical os, particularly in patients of low parity. Postmeno- pausally, the junction is invariably retracted within the endocervical canal. A cervical cytologic smear (Papani- FIGURE 2-3 Proper insertion of the speculum so that the uterine cervix may be visualized. FIGURE 2-4 Cervix of a nulliparous patient (A) and a multiparous patient (B). Note the circular os in the nulliparous cervix and the transverse os, resulting from lacerations at childbirth, in the
mul- tiparous cervix. A B MULTIPAROUS Nabothian follicle NULLIPAROUS C H A P T E R 2 Clinical Approach to the Patient 19 FIGURE 2-5 Bimanual evaluation of the uterus by exerting gentle pressure on the uterus with the vaginal fingers against the abdominal hand. FIGURE 2-6 Bimanual examination of the right adnexa. Note that fingers of the right hand are in the vagina. absent, as may occur in postmenopausal women, it is not possible to appreciate the size of the cervix on bimanual examination. This can be determined only on rectovaginal or rectal examination. The uterus is evaluated by placing the abdominal hand flat on the abdomen with the fingers pressing gently just above the symphysis pubis. With the vaginal fingers supinated in either the anterior or the posterior
vaginal fornix, the uterine corpus is pressed gently against the abdominal hand (Figure 2-5). As the uterus is felt between the examining fingers of both hands, the size, configuration, consistency, and mobility of the organ are appreciated. If the muscles of the abdominal wall are not compliant or if the uterus is retroverted, the outline, consistency, and mobility must be deter- mined by ballottement with the vaginal fingers in the fornices; in these circumstances, however, it is impos- sible to discern uterine size accurately. By shifting the abdominal hand to either side of the midline and gently elevating the lateral fornix up to the abdominal hand, it may be possible to outline a right adnexal mass (Figure 2-6). The left adnexa are best appreciated with the fingers of the left hand in the vagina (Figure 2-7). The examiner should stand side- ways, facing the patient’s left, with the left hip main- taining pressure against the left elbow, thereby
20 PA R T 1 Introduction adnexa. It is essential in evaluating the parametrium in patients with cervical cancer. Rectal examination may also be essential in differentiating between a rec- tocele and an enterocele (Figure 2-8). LABORATORY EVALUATION Appropriate laboratory tests normally include a uri- nalysis, complete blood count, erythrocyte sedimenta- tion rate, and blood chemistry analyses. Special tests, such as tumor marker and hormone assays, are per- formed when indicated. ASSESSMENT A reasonable differential diagnosis should be possible with the information gleaned from the history, physical examination, and laboratory tests. The plan of man- agement should aim toward a chemical or histologic confirmation of the presumptive diagnosis, and the appropriate therapeutic options, along with the ratio- nale for each option, should be recorded. Patients with Special Needs
PEDIATRIC AND ADOLESCENT PATIENTS Girls experience fewer gynecologic problems than do adult women, but their concerns need to be met effectively and skillfully in a way that will allay anxiety and create a positive attitude toward their gyneco- logic health. Unique complaints fall generally into a handful of categories: congenital anomalies, genital injuries, inflammation of the nonestrogenized genital tract, pubertal problems, and psychosexual concerns. Genital ambiguity, trauma, and vaginal bleeding in the prepubertal child are covered briefly in this chapter. GENITAL AMBIGUITY Dealing with genital ambiguity in the newborn requires a coordinated and timely response. The family’s psy- chological well-being must be addressed because they must feel confident in the gender identity of their child. Ambiguity can result from masculinization of a female child due to exogenous hormone ingestion or maternal or fetal overproduction of androgen. It may also result from incomplete virilization of a male infant, hormonal insensitivity, gonadal dysgenesis, or chromosomal anomalies (see Chapters 18 and 20). When assessing an infant with ambiguous genitalia, fluid and electrolyte balance should be monitored and blood drawn for 17-hydroxyprogesterone and
cortisol to rule out 21-hydroxylase deficiency. Life- threatening illness may be missed in children with the salt-losing form of congenital adrenal hyperplasia (see Chapter 33). TRAUMA Straddle injuries are the most common cause of trauma to the genitalia of a young girl, and the injuries have a providing better tactile sensation because of the relaxed musculature in the forearm and examining hand. The pouch of Douglas is also carefully assessed for nodu- larity or tenderness, as may occur with endometriosis, pelvic inflammatory disease, or metastatic carcinoma. It is usually impossible to feel the normal tube, and conditions must be optimal to appreciate the normal ovary. The normal ovary has the size and consistency of a shelled oyster and may be felt with the vaginal fingers as they are passed across the undersurface of the abdominal hand. The ovaries are very tender to compression, and the patient is uncomfortably aware of any ovarian compression or movement during the
examination. It may be impossible to differentiate between an ovarian or tubal mass or even a lateral uterine mass. Generally, left adnexal masses are more difficult to evaluate than those on the right because of the position of the sigmoid colon on the left side of the pelvis. An ultrasonic examination should be helpful for delineat- ing these features. RECTAL EXAMINATION The anus should be inspected for lesions, hemorrhoids, or inflammation. Rectal sphincter tone should be recorded and any mucosal lesions noted. A guaiac test should be performed to determine the presence of occult blood. A rectovaginal examination is helpful in evaluating masses in the cul-de-sac, the rectovaginal septum, or FIGURE 2-7 Bimanual examination of the left adnexa. Note that fingers of the left hand are in the vagina. C H A P T E R 2 Clinical Approach to the Patient 21 withdrawal. In such cases, there should be supportive evidence of a hormonal effect, such as the presence
of breast tissue and pale, engorged vaginal epithelium. Bleeding disorders are uncommon in this age group but should be considered. Vitamin K is routinely given to the newborn, but some parents may refuse the medication. Precocious puberty (see Chapter 32) may present with vaginal bleeding, although most commonly other evidence of maturation will have preceded the bleeding and will be evident on examination. At the very least, a pale, estrogenized vaginal epithelium will be seen, and cytology from the vagina will confirm the hormonal effect. Transient precocious puberty may occur in response to a functional ovarian cyst, and vaginal bleeding may be triggered by the spontaneous resolu- tion of the cyst. Exogenous hormonal exposure should be considered, because children have been known to ingest birth control pills. Ovarian tumors resulting in pseudoprecocious puberty should be ruled out. Vulvovaginitis is common but is a diagnosis of exclusion. When bleeding is present, it is necessary to assess the vagina and to rule out a foreign
body or vaginal tumor. seasonal peak when bicycles come out in the spring. The majority of these injuries are to the labia. Penetrat- ing vaginal injuries can cause major intraabdominal damage with minimal external findings. Sexual assault must always be considered. After a life-threatening condition is ruled out, an ice pack, chilled bag of intra- venous solution, or cool compress may be applied to the injured area and the child allowed to rest quietly for 20 minutes before being assessed further. Extensive injuries usually require examination under anesthesia and surgical repair. In any case of trauma, concurrent damage to the rectum or urinary tract should be considered. If there is any reason to suspect sexual or physical abuse, the child protection authorities must be notified, and the examination should include the collection of medico- legal evidence. VAGINAL BLEEDING IN THE PREPUBERTAL CHILD Vaginal bleeding is a frequent and distressing com- plaint in childhood. Although it will most often be of
benign etiology, more serious pathology must always be ruled out. Vaginal bleeding in the newborn is most often physiologic as a result of maternal estrogen FIGURE 2-8 Rectovaginal bimanual examination. During the Valsalva maneuver, an enterocele will separate the two fingers. 22 PA R T 1 Introduction mentally or physically disabled individuals with obstet- ric or gynecologic problems or attending for them in special institutions can be quite challenging. The woman with a disability is a person with special and unique needs, and communicating to her a sense of caring and respect is paramount. Lesbian, Gay, Bisexual, and Transgender Patients This group of patients is composed of lesbian, gay, bisexual, and transgender women and men and is known as LGBT. There is now recognition that women who are in a same-sex intimate relationship, as well as those who are transgender, need special consideration
and understanding for the health issues that they may encounter. The U.S. Office of Prevention and Health Promotion points out that LGBT individuals, possibly because of the discrimination that they encounter, have higher rates of psychiatric disorders, substance abuse, and suicide. The obstetrician and gynecologist should be particularly sensitive to the needs that these women may have regarding their reproductive health. More information about the health disparities that the LGBT community may have can be found at www. healthypeople.gov/LGBT. For more detailed informa- tion about the specific needs that lesbian and trans- gender women may have, the American College of Obstetricians and Gynecologists Committee Opinion Number 525, dated May 2012 and reaffirmed in 2014, can be consulted at www.ACOG.org. Vaginal tumors are the most serious possibility to be considered. Sarcoma botryoides classically pres- ents with vaginal bleeding and grapelike vesicles. For- tunately, this is a rare tumor. Geriatric Patients The gynecologic assessment of the elderly woman
may present a special challenge. Many older patients tend to underreport their symptoms, possibly because of a belief that any new physical problems are due to the normal aging process. Also, a fear of loss of their inde- pendence may contribute to this denial and this may lead to a delay of diagnosis and perhaps a worse prog- nosis. In addition to the routine gynecologic history and physical examination, these patients should be evaluated for any sensory impairments, such as visual or hearing loss, any impaired mobility, malnutrition, urinary incontinence, or confusion, which may be due to polypharmacy. Appropriate referral, when improve- ment can be reasonably expected, should be consid- ered for these problems once identified. Gynecologic conditions such as atrophic vaginitis, uterine and vaginal prolapse, and genital tract malig- nancies are among the more common problems encountered in the geriatric patient. Patients with Disabilities Women with developmental or acquired disabilities should receive the same high quality obstetric and
gynecologic care as anyone else, with a goal of sustain- ing their best level of functioning. Assisting families of http://www.ACOG.org 23 3 Female Reproductive Anatomy and Embryology C H A P T ER JOSEPH C. GAMBONE ■ The upper vagina, cervix, uterus, and fallopian tubes are formed from the paramesonephric (müllerian) ducts. The absence of the Y chromosome leads to the develop- ment of the müllerian (female) system with virtual total regression of the mesonephric (wolffian) or male system. With the Y chromosome present, a testis is
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httpst.meMedicalBooksStoreHPStampHacker & Mo

  • 1. https://t.me/MedicalBooksStore HP Stamp Hacker & Moore’s E S S E N T I A L S O F OBSTETRICS & GYNECOLOGY https://t.me/MedicalBooksStore Hacker & Moore’s E S S E N T I A L S O F OBSTETRICS & GYNECOLOGY Sixth Edition Neville F. Hacker, MD Professor of Gynaecologic Oncology Conjoint, University of New South Wales Director, Gynaecological Cancer Centre
  • 2. Royal Hospital for Women Sydney, Australia Joseph C. Gambone, DO, MPH, Executive Editor Professor Emeritus of Obstetrics and Gynecology David Geffen School of Medicine at UCLA Attending Physician, Ronald Reagan UCLA Medical Center Clinical Professor of Obstetrics and Gynecology Western University of Health Sciences College of Osteopathic Medicine of the Pacific Private Infertility and Reproductive Endocrinology Practice, Durango, Colorado Calvin J. Hobel, MD Miriam Jacobs Chair in Maternal-Fetal Medicine Cedars-Sinai Medical Center Professor of Obstetrics and Gynecology Professor of Pediatrics David Geffen School of Medicine at UCLA Los Angeles, California 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 HACKER & MOORE’S ESSENTIALS OF OBSTETRICS & GYNECOLOGY,
  • 3. SIXTH EDITION ISBN: 978-1-4557-7558-3 INTERNATIONAL EDITION ISBN: 978-0-323-34053-3 Copyright © 2016 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the
  • 4. safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2010, 2004, 1998, 1992, and 1986. Library of Congress Cataloging-in-Publication Data Hacker & Moore’s essentials of obstetrics & gynecology / [edited by] Neville F. Hacker, Joseph C. Gambone, Calvin J. Hobel.—6th edition. p. ; cm. Hacker and Moore’s essentials of obstetrics and gynecology Essentials of obstetrics and gynecology Preceded by Hacker and Moore’s essentials of obstetrics and
  • 5. gynecology / [edited by] Neville F. Hacker, Joseph C. Gambone, Calvin J. Hobel. Includes bibliographical references and index. ISBN 978-1-4557-7558-3 (pbk. : alk. paper)–ISBN 978-0-323- 34053-3 (international edition) I. Hacker, Neville F., editor. II. Gambone, Joseph C., editor. III. Hobel, Calvin J., editor. IV. Title: Hacker and Moore’s essentials of obstetrics and gynecology. V. Title: Essentials of obstetrics and gynecology. [DNLM: 1. Obstetrics–methods. 2. Genital Diseases, Female. 3. Pregnancy Complications. WQ 100] RG101 618—dc23 2015035364 Acquisitions Editor: James Merritt Developmental Editor: Julia Rose Roberts Publishing Services Manager: Catherine Jackson Project Manager: Rhoda Howell Design Manager: Renee Duenow Illustrations Manager: Nichole Beard Marketing Manager: Melissa Darling Printed in Canada Last digit is the print number: 9 8 7 6 5 4 3 2 1 http://www.elsevier.com/permissions This edition is dedicated to our wives, Estelle Hacker, Marge (Morris) Gambone, and Marsha Lynn
  • 6. Hobel. Their understanding and support for the time and effort required to complete this project was essential. https://t.me/MedicalBooksStore vii Contributors Carolyn J. Alexander, MD Southern California Reproductive Center Beverly Hills, California; Clinical Associate Professor David Geffen School of Medicine at UCLA University of California, Los Angeles Los Angeles, California Jonathan S. Berek, MD, MMS Laurie Kraus Lacob Professor Chair, Department of Obstetrics and Gynecology Stanford University School of Medicine Director, Stanford Women’s Cancer Center Director, Stanford Health Care Communication Program Stanford, California Lony C. Castro, MD, FACOG Specialist, Maternal-Fetal Medicine Professor and Chair, Department of Obstetrics and
  • 7. Gynecology COMP/Western University of Health Sciences Pomona, California Sara Churchill, MD Resident Physician Department of Obstetrics and Gynecolo gy Cedars Sinai Medical Center Los Angeles, California Daniel A. Dumesic, MD Professor, Department of Obstetrics and Gynecology Division Chief, Reproductive Endocrinology and Infertility David Geffen School of Medicine at UCLA University of California, Los Angeles Los Angeles, California Michael L. Friedlander, PhD, FRACP Conjoint Professor of Medicine Prince of Wales Clinical School University of New South Wales Sydney, Australia Brian J. Koos, MD, DPhil Professor, Department of Obstetrics and Gynecology David Geffen School of Medicine at UCLA University of California, Los Angeles Los Angeles, California Amy R. Lamb, PhD, CNM Nurse-Midwife and Researcher Obstetrics and Gynecology Cedars-Sinai Medical Center Los Angeles, California
  • 8. Anita L. Nelson, MD Professor, Department of Obstetrics and Gynecology David Geffen School of Medicine at UCLA University of California, Los Angeles Los Angeles, California; Medical Director, Research Division California Family Health Council Los Angeles, California William H. Parker, MD Health Sciences Clinical Professor Department of Obstetrics and Gynecology UCLA School of Medicine Santa Monica, California Andrea J. Rapkin, MD Professor of Obstetrics and Gynecology David Geffen School of Medicine at UCLA University of California, Los Angeles Los Angeles, California Bassam H. Rimawi, MD, FACOG Department of Gynecology and Obstetrics Division of Reproductive Infectious Diseases and Maternal Fetal Medicine Emory University School of Medicine Atlanta, Georgia viiiviii C O N T R I B U T O R S Ingrid A. Rodi, MD Health Sciences Clinical Professor
  • 9. Director, Fertility Services UCLA Medical Center Santa Monica, California Amy E. Rosenman, MD, FACOG, FPMRS Health Sciences Clinical Professor of Obstetrics and Gynecology David Geffen School of Medicine at UCLA University of California, Los Angeles Los Angeles, California David E. Soper, MD J. Marion Sims Professor Department of Obstetrics and Gynecology Medical University of South Carolina Charleston, South Carolina John Williams III, MD Clinical Professor Department of Obstetrics and Gynecology David Geffen School of Medicine at UCLA University of California, Los Angeles Director of Reproductive Genetics Department of Obstetrics and Gynecology Cedars-Sinai Medical Center Los Angeles, California Mark Zakowski, MD Associate Professor of Anesthesiology Adjunct, Charles Drew University of Medicine and Science Chief, Obstetric Anesthesiology, Cedars-Sinai Medical Center
  • 10. Los Angeles, California ix Preface It has been thirty years since the first edition of Essen- tials of Obstetrics and Gynecology was published. As stated in the Preface to the First Edition, there was then, and continues to be today, a need for a textbook that covers the essential aspects of the specialty of Obstetrics and Gynecology, which is written primarily for the student and resident physician training in the field. The text has become known as ”Hacker and Moore” over the years, as a tribute to the pioneering work of the original editors. The late J. George “Jerry” Moore was the Professor and Chairman of Obstetrics and Gynecology at the University of California at Los Angeles (UCLA), and the concept for the book was his. Neville Hacker was then an Assistant Professor in the Department and was in charge of the Student Clerk- ship. He was co-opted by Jerry to co-edit the book, after the entire UCLA faculty had agreed to participate in its writing. The first edition of any textbook contains the vision and forms the foundation of the intent of the work, as outlined in the original preface. The editors have always felt that a new edition should be published only when there was significant new clinical information to report. Based on that standard, we believe it is now time for the sixth and latest edition of “Hacker and Moore” to be published.
  • 11. Medical education is continuously evolving, and has changed significantly since the first edition of this text- book was published in 1986. The internet with its world-wide web and other technologies have made information instantly available to students and resi- dents on a mobile phone or tablet during a clinical meeting. They are being taught to be life-long learners and information seekers. The classroom dynamics have been flipped in the past decade, in the sense that information transfer and gathering occurs before a seminar, with classroom time now increasingly devoted to discussions and problem solving by teams of stu- dents supported by diverse faculty mentors. This is appropriate, because health care is increasingly being delivered by multidisciplinary teams of professionals rather than by individual practitioners. With the ever- increasing complexity of medical and surgical care, this trend is expected to continue. Textbooks have the recognized disadvantage of not always containing the latest information on a topic and of having a limited “shelf life.” But just as newspapers and periodicals (printed or electronic) provide a “first and early draft” of human history and require frequent correction over time, medical texts should contain and document the time-tested facts of a discipline, along with newer information viewed through the prism of evidence-based and safe practice. It is our belief that textbooks will continue to provide the reliable essen- tials of all clinical practice, including the practice of obstetrics and gynecology. All of the 42 chapters in this edition have been updated. Some chapters have been completely rewrit- ten. Others have been modified due to changes in clini-
  • 12. cal practice. As was the case in previous editions of this text, we have worked to include only the “essentials” of obstetrics and gynecology, making difficult choices about the breadth and depth of the material presented. Every attempt has been made to include material con- sistent with the learning objectives and goals proposed by the Association of Professors in Gynecology and Obstetrics (APGO), available on their website at www. apgo.org. In addition to the authors and editors of this current edition, we wish to acknowledge and thank those who have contributed to all previous editions.* Their knowl - edge and wisdom contained in their words, some of *Contributors from all previous editions: Juan J. Arce, Carol L. Archie, Ricardo Azziz, Martha J. Baird, Richard A. Bashore, A. David Barnes, Michael J. Bennett, Narender N. Bhatia, Jennifer Blake, Clifford Bochner, J. Robert Bragonier, Charles R. Brinkman III, Michael S. Broder, Philip G. Brooks, John E. Buster, Maria Bustillo, Richard P. Buyalos, Mary E. Carsten (deceased), Anita Bachus Chang, R. Jeffrey Chang, George Chapman, Ramen H. Chmait, Gautam Chaudhuri, Kenneth A. Conklin, Irvin M. Cushner (deceased), Alan H. DeCherney, Cath- erine Marin DeUgarte, William J. Dignam (deceased), John A. Eden, Bruce B. Ettinger, Ozlem Equils, Robin Farias-Eisner, Larry C. Ford (deceased), Michelle Fox, Janice I. French, Ann Garber, Anne D.M. Graham, Paul A. Gluck, William A. Growdon, John Gunning (deceased), Lewis A. Hamilton, Hunter A. Hammill, George S. Harris, Robert H. Hayashi, James M. Heaps, Howard L. Judd (deceased),
  • 13. Continued http://www.apgo.org http://www.apgo.org xx P R E FA C E which remain in this edition, form the foundation of this work and will continue to enlighten future stu- dents of obstetrics and gynecology. We greatly appreciate, and wish to acknowledge, the support and professionalism of James Merritt and his excellent production staff, particularly Rhoda Howell, Rachel McMullen, Amy Meros, and Julia Roberts at Elsevier. We hope that the knowledge acquired from this book will encourage many to pursue a more in depth study of the specialty. Joseph C. Gambone (Executive Editor) Neville F. Hacker Calvin J. Hobel Daniel A. Kahn, Samir Khalife, Ali Khraibi, Matthew Kim, Oscar A. Kletzky (deceased), Grace Elizabeth Kong, Larry R. Laufer, Thomas B. Lebherz (deceased), Joel B. Lench, Ronald S. Leuchter, John K.H. Lu, Michael C. Lu, Donald E. Marsden, John Marshall, Ruchi Mathur, James A. McGregor, Arnold L. Medearis deceased) David R. Meldrum, Robert Monoson, J. George Moore (deceased), Thomas R. Moore,
  • 14. John Morris (deceased), Suha H.N. Murad, Sathima Natarajan, Lauren Nathan, John Newnham, Tuan Nguyen, Bahij S. Nuwayhid, Gary Oakes, Dotun Ogunyemi, Aldo Palmieri, Groesbeck P. Parham, Ketan S. Patel, Margareta D. Pisarska, Gladys A. Ramos, Anthony E. Reading, Robert C. Reiter, Jean M. Ricci (Goodman), Michael G. Ross, Edward W. Savage, William D. Schlaff, Mousa Shamonki, James R. Shields, Klaus J. Staisch (deceased), Eric Surrey, Khalil Tabsh, Christopher M. Tarnay, Maryam Tarsa, Nancy Theroux, Paul J. Toot, Maclyn E. Wade (deceased), Nathan Wasserstrum, Barry G. Wren, and Linda Yielding. 2 1 CHAPTE R CALVIN J. HOBEL • JOSEPH C. GAMBONE A Life-Course Perspective for Women’s Health Care Safe, Ethical, Value-Based Practice with a Focus on Prevention ■ Clinical practice in obstetrics and gynecology, based upon the principles of safe, ethical and value-based care, is facilitated by viewing wellness and sickness in the
  • 15. context of a life-course perspective. Effective clinical care of mother and child must begin early, even before conception, and continue throughout life. ■ Adaptive developmental plasticity and epigenetic modi- fication of genes during and after pregnancy can have a significant impact on chronic diseases later in life. ■ Clinicians should incorporate the major ethical princi- ples of nonmaleficence, beneficence, autonomy, and justice into their practices, along with the duties and ideals of confidentiality and multidisciplinary collaboration. ■ Regulatory, economic, and public pressure make assess- ment and improvement of safety and value essential in the delivery of women’s health care. Optimal health outcomes can only be achieved when principles from continuous quality assessment and high reliability orga- nizations are combined with the systematic approach of safety science and evidence-based medicine. ■ The promising area of clinical preventive services in
  • 16. obstetrics and gynecology, as in all heath care, is trans- forming the practice of medicine in a very positive way. CLINICAL KEYS FOR THIS CHAPTER This chapter of Essentials of Obstetrics and Gynecology is being revised at a time when the health and wellness of the population of the United States and some other developed countries of the world are being evaluated and questioned. A recent study by the Harvard Busi- ness School conducted by Professor Michael Porter and his team ranked the United States only 70th in the world in terms of overall health and wellness. Despite the fact that the United States spends far more on health care (nearly 18% of gross domestic product or GDP) than any other nation, it continues to be ranked only about 37th out of 191 nations for health status and health system performance. Further, the United States is ranked only 46th for average life- expectancy and 42nd for infant mortality by the World Health Organization (WHO). Clearly, the United States must strive to improve its standing on these and other mea-
  • 17. sures of performance. This is especially important at a time when the health care delivery system enters the era of the Affordable Care Act (ACA), and efforts to provide care to all citizens at a reasonable cost are underway. Obstetrics and gynecology is one of the most exciting and challenging areas of health care, with a number of significant opportunities for improvement such as infant and maternal mortality. The specialty provides students and young physicians in training with the knowledge and skills necessary to improve the health of women and their children very early in their lives. In this first chapter of the book, some basic principles and guidelines for improving health care are provided, and several important factors that are influ- encing the health of women and their children are suggested. Principles of Practice There are four basic principles for practicing and improving health care. First, the safety of our patients must always be paramount. In recent years we have
  • 18. made major improvements in patient safety, in large part by emphasizing teamwork and implementing practices proven to be effective in the airline industry. Second, we must be true to our personal pledge made when taking the Hippocratic Oath—to adhere to ethical practices. Third, we must transform to a value- based system of health care delivery. Because medi- cine has become very complex, we must be open to a C H A P T E R 1 A Life-Course Perspective for Women’s Health Care 3 structure include altered DNA methylation by both histone acetylation and methylation. Since the last edition of this text, investigators have determined that alterations in the in utero environ- ment during pregnancy may result in modifications to the chromatin structure. These modifications may lead to persistent changes in postnatal gene expression which may render the child more susceptible to early onset adult disease. The conditions during preg- nancy that account for these epigenetic changes are preeclampsia, preterm birth, intrauterine growth restriction (IUGR), obesity, diabetes, poor nutrition, smoking, and some cancers. Even the mothers with these pregnancy conditions are themselves at greater
  • 19. risk for cardiovascular disease, hypertension, and dia- betes later in life. The onset for these conditions occurs earlier in life compared to those women who have normal pregnancies. Thus having a normal pregnancy may be protective of disease later in life. It is now thought that the effect of harmful behav- iors and our environment on the expression of our genes may account for up to 40% of all premature deaths in the United States. Two of the top behavioral factors related to this premature death rate are obesity (and its usual physical inactivity) and smoking. Envi- ronmental exposures to metals, solvents, pesticides, endocrine disruptors, and other reproductive toxicants are also major concerns. Second, in human biology, a phenomenon called adaptive developmental plasticity plays a very impor- tant role in helping to adjust behavior to meet any environmental challenge. In order to understand human development over time (a life-course perspec- tive), one must first understand what is normal and what adverse circumstances may challenge and then change normal development of the fetus. These pro- tective modifications of growth and development which are programmed in utero to prevent fetal death, may become permanent. The price the fetus may pay for short-term survival is later vulnerability to
  • 20. conditions such as obesity, hypertension, insulin resis- tance, atherosclerosis, and even diabetes. In relation to individual X and individual Y with the same genomic makeup but different in utero environ- mental influences, metabolic changes that may be ini- tiated in utero in response to inadequate nutritional supplies (Figure 1-1) can lead to insulin resistance and eventually the development of type 2 diabetes. These adaptive changes can even result in a reduced number of nephrons in the kidneys as a stressed fetus conserves limited nutritional resources for more important organ systems in utero. This can then lead to a greater risk of hypertension later in life. This series of initially protective but eventually harmful developmental changes was first described in humans by David Barker, a British epidemiologist, who carefully assessed birth records of individuals more cost-effective multidisciplinary approach to both diagnostic and therapeutic practice. Performance improvement efforts, practice management skills, and effective communication are all necessary to efficiently optimize clinical outcomes and value. Fourth, and perhaps most importantly, we must focus on the pre- vention and early mitigation of disease, in addition to
  • 21. our continued focus on its treatment. This should occur in a patient-centered manner, meeting their needs and expectations. For this reason, we emphasize an approach called a life-course perspective for clinical practice, beginning with preconception health, continuing throughout pregnancy, the postpartum period (interconception health), and then giving children and their mothers a health perspective for adopting and maintaining healthy living. Before delving more deeply into these principles of practice (safety, ethics, value, and prevention), some newer concepts about the origins of disease are impor- tant to mention. LIFE-COURSE PERSPECTIVE When does disease begin and lead to pathology and illness during the course of life? First, although genetics is beginning to provide a much better understanding of the etiology of poor health, it probably accounts for only about one-third of the direct causes. Imprinted genes from both the mother and the father play an important role in passing on characteristics to the offspring. This imprinting process maintains the phenotype of the family in sub- sequent generations. However, some imprinted and nonimprinted genes can be upregulated or downregu-
  • 22. lated by subsequent epigenetic modifications, due to environmental influences. For example, person X with gene A has a disease but person Y with the same gene does not. Clearly there is more to human development and disease risk than genetic makeup. Currently it is thought that factors such as poverty or abnormal health behaviors (poor nutrition and smoking) and/or envi- ronmental conditions can influence the expression of gene A without actually changing its genomic makeup. This may occur directly or these factors may activate another gene, A-2 downstream, which may then affect gene A. This process whereby human cells can have the same genomic makeup but different characteristics is referred to as epigenetics (literally meaning “on top of genetics”), an exciting new frontier. The developmental origins of adult disease hypoth- esis (Barker hypothesis) postulates that perturba- tions in the gestational environment may influence the development of adult diseases such as cardiovas- cular disease, obesity, diabetes, and stroke. Current evidence suggests that this occurs through the repro- gramming of gene expression via epigenetic changes
  • 23. in chromatin structure. Epigenetic changes in chromatin 4 PA R T 1 Introduction Normally, as soon as the fight or flight is over, the stress response is turned off. The body’s sympathetic response is counteracted by a parasympathetic response, which fires a signal via the vagal nerve to slow down the heart, and the HPA axis is shut off by cortisol via negative feedback mechanisms. Negative feedback mechanisms are common to many biological systems and work very much like a thermostat. When the room temperature falls below a preset point, the thermostat turns on the heat. Once the preset tempera- ture is reached, the heat turns off the thermostat. Stress turns on the HPA axis to produce cortisol. Cortisol, in turn, turns off the HPA axis to keep the stress response in check. This stress response works well for acute stress but it tends to break down under chronic stress. In the face of chronic and repeated stress, the body’s stress response is always turned on, and over time will wear out. The body goes from being “stressed” to
  • 24. being “stressed out”—from a state of allostasis to allostatic overload. This describes the cumulative wear and tear on the body’s adaptive systems from chronic stress. Helpful physiologic mechanisms that initially protect may eventually be harmful. The life-course perspective synthesizes both the developmental programming mechanisms of early life events and allostatic overload mechanisms of chronic life stress into a longitudinal model of health development. It is a way of looking at life not as discon- nected stages, but as an integrated continuum. Thus to promote a healthy first pregnancy, preconception health should be a priority. To promote preconception health, adolescent health must be provided to young girls so that as women having children, they are free of diseases such as diabetes, hypertension, and obesity and have been encouraged to eat a healthy diet and to abstain from using tobacco products. Rather than episodic care that many women now receive, as a specialty we must strive toward disease prevention and health promotion over the continuum of a woman’s life.
  • 25. IMPACT ON PUBLIC HEALTH The public health implications of the Barker hypoth- esis and other life-course events are significant. This is the beginning of an exciting era in medicine where young physicians and other health care professionals can begin to take charge of these events and change our health care delivery system in a very positive way. Patients should be encouraged to take responsibility for improving their own health, particularly by prac- ticing healthy behaviors early in life. They should also be encouraged to improve and maintain a healthy “green” environment. Currently there are only a few environmental and behavioral factors that have been clearly identified as part of the Barker hypothesis. Many others are yet to be discovered. and linked low birth weight (<2500 grams) to the development of hypertension, diabetes, atheroscle- rosis, and stroke later in life. The association between poor fetal growth during intrauterine life, insulin resis- tance, and cardiovascular disease is known as the Barker hypothesis. The process whereby a stimulus or insult, at a sensitive or critical period of fetal develop- ment, induces permanent alterations in the structure
  • 26. and functions of the baby’s vital organs is now com- monly referred to as developmental programming. Third, another important concept in the life- course perspective is allostasis, which describes the body’s ability to maintain stability during physiologic change. A good example of allostasis is found in the body’s stress response. When the body is under stress (biological or psychological), it activates a stress response. The sympathetic system kicks in and adren- alin flows to make the heart pump faster and harder (with the end result of delivering more blood and oxygen to vital organs including the brain). The hypothalamic-pituitary-adrenal (HPA) axis is also activated to produce more cortisol, which has many actions to prepare the body for fight or flight. FIGURE 1-1 The potential effects of intrauterine nutrition on sub- sequent adult health. There are genetic, nutritional, and environ- mental causes of poor fetal growth leading to a small phenotype. Having a large phenotype at birth has advantages. These data form the basis of the “developmental origins of adult disease” hypoth- esis (Barker hypothesis). Having a low birth weight increases the risk for diseases and conditions such as hypertension, atheroscle- rosis, stroke, and diabetes later in life. For example, a nutritionally
  • 27. deprived fetus in utero may develop insulin resistance as an adap- tation to preserve glucose supply to the brain rather than releasing it from the circulation to other less important tissues. Later in life, the insulin resistance that was protective in utero could increase the risk of diabetes as an adult. (From Bateson P, Barker D, Clutton- Brock T, et al: Developmental plasticity and human health. Nature 430:419-421, 2004. Adapted by permission from Macmillan Pub- lishers Ltd.) HighLow Good Poor A d u lt h e a lth Nutritional level Large
  • 28. phenotype (Body size) Small phenotype (Body size) C H A P T E R 1 A Life-Course Perspective for Women’s Health Care 5 to an adverse drug reaction (ADR). The latter may account for 1 out of 5 injuries or deaths for hospitalized patients. ADRs commonly occur from an overdose, a side effect, or an interaction among several concomi- tantly administered drugs. In order to minimize ADRs, health care providers should avoid the following actions: 1. Prescribing unnecessary medications 2. Treating mild side effects of one drug with a second, more toxic drug 3. Misinterpreting a drug’s side effect for a new medical problem and prescribing another medication 4. Prescribing a medication when there is any uncer- tainty about dosing In the absence of automated systems, providers
  • 29. should strive to write legibly and use only approved abbrevia- tions and dose expressions. Most health care facilities publish and circulate an acceptable list of appropriate abbreviations, as a means of reducing medication errors. MEDICAL ERROR REPORTING According to the U.S. Agency for Healthcare Research & Quality (AHRQ), “Reporting is an important compo- nent of systems to improve patient safety.” Incident reporting is an important and inexpensive method to detect medical error and prevent future adverse events. Unfortunately, this method may fail to impact clinical outcomes effectively, because most hospital reporting systems do not capture the majority of errors. Report- ing should be considered a quality improvement process (focused on system failures) rather than a performance evaluation method (blaming individual providers). As a founding member of the National Patient Safety Foundation and the National Patient Safety Partnership, the Joint Commission on the Accredita-
  • 30. tion of Healthcare Organizations ( JCAHO), now more commonly known as The Joint Commission (TJC), has formed a coalition with the U.S. Pharmacopoeia (USP), the American Medical Association (AMA), and the American Hospital Association (AHA) to create patient safety reporting principles. Recognizing that fear of liability discourages error reporting, TJC has advised the U.S. Congress that federal statutory pro- tection must be afforded to those who report medical error. An anonymous nonpunitive environment will encourage reporting. Many states have implemented mandatory reporting systems for selected medical errors to improve patient safety and reduce errors. Others consider incident reporting and analysis as peer review activities immune from liability. The IOM report recommends that health care providers be required to report errors that result in serious harm. Information collected should be made available to the public. AHRQ publishes case summaries of Adaptive developmental plasticity will take place secondary to changes in genes as a result of environ- mental and behavioral practices. Even the controversial concept of climate change may play a role in this phe-
  • 31. nomenon. Biological processes are very powerful and frequently unpredictable. Physicians must increasingly strive for a safe, ethical, and value-based practice. In order to facilitate the improvement of the health and wellness of women and children, four basic prin- ciples of practice should guide our strategy: patient safety, ethical practice, value, and the need for a patient-centered focus on prevention, as follows. Patient Safety—The First Principle of Practice Safety in health care is not a new concept. Facilities have had safety programs in place since the early 1900s, but these programs have traditionally focused on emergency preparedness, environmental safety, secu- rity, and infection control. The term patient safety, meaning avoidance of medical error, was first coined by the American Society of Anesthesiologists in 1984, when they inaugurated the Anesthesia Patient Safety Foundation to give assurance that the effects of anes- thesia would not harm patients. Medical errors now rank as the fifth leading cause of death in the United States. The Institute of Medicine (IOM) published an alarming report in 1999
  • 32. called To Err Is Human: Building a Safer Health System. This report estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors. Error is defined as failure of a planned action to be completed as intended (e.g., failing to operate when obvious signs of appendicitis are present) or the use of a wrong plan to achieve an aim (e.g., wrong diag- nosis, wrong medication administered). Medication errors alone, occurring either in or out of the hospital, are estimated to account for over 7,000 deaths annu- ally. According to the National Council on Patient Information and Education, “more than 2/3 of all phy- sician visits end with a prescription.” An estimated 39-49% of all medication errors occur at the stage of drug ordering. Patient noncompliance also contrib- utes to medical errors. The U.S. Pharmacopoeia (USP) MedMARx error tracking service estimates that as many as 100,000 medication errors occur annually. Because reporting is voluntary and does not include all medical facilities in the United States, the scope of the problem is likely to be much larger. A preventable adverse drug event (ADE) is one type of medication error. Administering
  • 33. the incorrect drug, an incorrect dose, wrong frequency, or incorrect route may cause an ADE. A drug that cures one patient’s condition may be the one that causes another patient’s injury or death due 6 PA R T 1 Introduction ideals and the concepts derived from them are com- monly accepted and taken into account. Four such principles or ideals are nonmaleficence, beneficence, autonomy, and justice; these are generally accepted as the major ethical concepts that apply to health care. NONMALEFICENCE The principle of primum non nocere or “first, do no harm” originates from the Hippocratic school, and although few would dispute the basic concept, in day- to-day medical practice, physicians and their patients may need to accept some harm from treatment (such as necessary surgical trauma) in order to achieve a desired outcome. However, there is an ethical obliga- tion to be certain that recommended medical treat- ment, surgery, or diagnostic testing is not likely to cause more harm than benefit.
  • 34. BENEFICENCE The duty of beneficence, or the promotion of the welfare of patients, is an important part of the Hippo- cratic Oath. Most would see its strict application as an ideal rather than a duty, however. One could save many suffering people in a Third World country by practicing there or by giving a large portion of one’s income in aid, but few would consider it a moral duty to do so. On the other hand, when the concept of beneficence involves a specific patient encounter, the duty applies. A physi- cian prevented by conscience from participating in the performance of an abortion, for example, would gener- ally be expected to provide lifesaving care for a woman suffering complications after such a procedure— putting her welfare first. AUTONOMY The right of self-determination is a basic concept of biomedical ethics. To exercise autonomy, an individ- ual must be capable of effective deliberation and be neither coerced into a particular course of action nor limited in her or his choices by external constraints. Being capable of effective deliberation implies a level
  • 35. of intellectual capacity and the ability to exercise that capacity. There are a number of situations in which it may be reasonable to limit autonomy: (1) to prevent harm to others, (2) to prevent self-harm, (3) to prevent immoral acts, or (4) to benefit many others. The concept of informed consent is derived directly from the principle of autonomy, and from a desire to protect patients and research subjects from harm. There is general agreement that consent must be gen- uinely voluntary and made after adequate disclosure of information. As a minimum, when a patient con- sents to a procedure in health care, the patient should be informed about the expectation of benefit as well as the other reasonable alternatives and possible risks that are known. Table 1-1 provides a useful checklist reported medical errors and near misses on their website. DISCLOSURE OF MEDICAL ERROR The National Patient Safety Foundation (NPSF) was one of the first organizations to address the issue of disclosure. Their position, finalized in November
  • 36. 2000, states, “When a health care injury occurs, the patient and the family or representatives are entitled to a prompt explanation of how the injury occurred and its short- and long-term effects. When an error con- tributed to the injury, the patient and the family or representatives should receive a truthful and compas- sionate explanation about the error and the remedies available to the patient. They should be informed that the factors involved in the injury will be investigated so that steps can be taken to reduce the likelihood of similar injury to other patients.” The Joint Commission now requires hospitals to dis- close any serious harm caused by medical errors to the harmed parties. Disclosing an error can be very diffi- cult for physicians because they may struggle with intense feelings of incompetence, betrayal of the patient, and fear of litigation. Studies suggest that phy- sicians with good relationship skills are less likely to get sued. Furthermore, suits are settled more rapidly and for less money if errors are disclosed early. Simple rules for disclosing errors include: admit the mistake, acknowledge the listener’s anger, speak slowly, and stop frequently to allow the listener to talk. Usually, the attending physician is the one who should make the disclosure and offer an apology.
  • 37. Ethical Practice— The Second Principle Obstetrics and gynecology encompasses many high- profile areas of ethical concern such as in vitro fertiliza- tion (IVF) and other assisted reproductive technologies (ART), abortion, the use of aborted tissue for research or treatment, surrogacy, contraception for minors, and sterilization of persons with a mental illness. Neverthe- less, most ethical problems in the practice of medicine arise in cases in which the medical condition or desired procedure itself presents no moral problem. In the past, the main areas of ethical concern have related to the competence and beneficence of the physician. Current areas of ethical concern should include the goals, values, individual and appropriate cultural preferences of the patient, as well as those of the com- munity at large. Consideration of such issues enriches the study of obstetrics and gynecology by emphasizing that scientific knowledge and technical skills are most meaningful in a social and moral context. During the day-to-day consideration of ethical dilemmas in health care, a number of principles or
  • 38. C H A P T E R 1 A Life-Course Perspective for Women’s Health Care 7 considerations of autonomy but also helps promote beneficence, as is the case with honesty. In obstetrics and gynecology, conflicts can arise as in the case of a woman with a sexually transmitted infection who refuses to have a sexual partner informed, or a school- aged child seeking contraceptive advice or an abortion. There are many other situations in which conflicting responsibilities make confidentiality a difficult issue. The U.S. Health Insurance Portability and Accountabil- ity Act (HIPAA) mandates strict rules that physician practices and health care facilities must adhere to regarding the confidentiality and security of patient health care records. Some are concerned that these regulations could restrict the flow of information about patient care and may hinder efforts to improve overall performance. Caring for a pregnant woman creates a unique maternal-fetal relationship because the management
  • 39. of the mother inevitably affects her baby. Until recently, the only way by which an obstetrician could produce a healthy baby was by maintaining optimal maternal health, but as the fetus becomes more accessible to diagnostic and therapeutic interventions, new prob- lems emerge. Procedures performed on behalf of the fetus may violate the personal integrity and auton- omy of the mother. The obstetrician with a dual responsibility to mother and fetus faces a potential conflict of interest. Most conflicts will be resolved due to the willingness of most women to undergo consid- erable self-sacrifice to benefit their fetus. When a woman refuses consent for a procedure that presents her with significant risk, her autonomy will generally be respected. However, there may be cases in which an intervention that is likely to be efficacious carries little risk to the mother and can reasonably be expected to prevent substantial harm to the fetus. These have occa- sionally ended in a court-ordered intervention. Health care is a multidisciplinary activity and respectful and collegial relationships with other health professionals are very important. Although the physician has traditionally been the only decision maker, this situation has often caused concern among
  • 40. other health care professionals. There is increasing (PREPARED) that expands on the minimum informa- tion required. The exercise of autonomy may put considerable stress and conflict on those providing health care, as in the case of a woman with a ruptured ectopic pregnancy who refuses a lifesaving blood transfusion for religious reasons and dies despite the best efforts of the medical team. More complex questions may be raised by court- ordered cesarean deliveries for the benefit of the fetus. JUSTICE Justice relates to the way in which the benefits and burdens of society are distributed. The general princi- ple that equals should be treated equally was espoused by Aristotle and is widely accepted today, but it does require that one be able to define the relevant differ- ences between individuals and groups. Some believe all rational persons to have equal rights; others empha- size need, effort, contribution, and merit; still
  • 41. others seek criteria that maximize both individual and social utility. In most Western societies, race, sex, and reli- gion are not considered morally legitimate criteria for the distribution of benefits, although they too may be taken into account in order to right what are per- ceived to be historic wrongs, in programs of affirma- tive action. When resources are scarce, issues of justice become even more problematic. There are often com- peting claims from parties who appear equal by all rel- evant criteria, and the selection criteria themselves become a moral issue. Most modern societies find the rational rationing of health care resources to be appro- priate and acceptable (Figure 1-2). OTHER DUTIES OF ETHICAL PRACTICE Confidentiality is a cornerstone of the relationship between physician and patient. This duty arises from TABLE 1-1 THE PREPARED SYSTEM: A CHECKLIST TO GUIDE PATIENT AND PROVIDER IN THE PROCESS OF INFORMED CONSENT P lan The course of action being considered R eason The indication or rationale E xpectation The chances of benefit and failure
  • 42. P references Patient-centered priorities (utilities) and cultural preferences affecting choice A lternatives All other reasonable options R isks The potential for harm from treatment E xpenses All direct and indirect costs D ecision Fully informed collaborative choice and consent Modified from Reiter RC, Lench JB, Gambone JC: Consumer advocacy, elec- tive surgery, and the “golden era of medicine.” Obstet Gynecol 74:815–817, 1989. FIGURE 1-2 Representation of arbitrary rationing commonly based on access or ability to pay versus planned clinical resource management based on measured value. Explicit rationing is objec- tionable to many despite the fact that implicit rationing still occurs. Based on measured value Explicit (planned) Based on access or ability to pay
  • 43. Implicit (arbitrary) RationalIrrational RATIONING 8 PA R T 1 Introduction Value—The Third Principle of Practice The mandate from payers (government and employ- ers) and the public to measure and improve the effec- tiveness and efficiency (value) of health care services is clear. Unfortunately, change based on adoption of national standards derived from evidence-based prac- tice and randomized controlled trials (RCTs) alone may be too expensive and slow to meet this mandate. Furthermore, the results from RCTs may not always establish how diagnostic and therapeutic procedures actually work in clinical practice. For these reasons, health care organizations, including schools of public health and physician groups, must develop the tools to identify and adopt best practices and improve clin- ical outcomes locally. Value in health care is defined as “clinical outcomes considering the resources used,” or results divided
  • 44. by the costs of care. Figure 1-3 illustrates a collaborative process that may be used to involve the patient in the determination of value when decisions about treat- ments are being made. The past 40 years that have been devoted to the measurement and pursuit of quality improvement have not been successful in terms recognition that other clinicians involved in health care have a right to participate in any decision making. Physicians have not been as aware of the sen- sitivities of the nursing profession and other allied health professionals as they should have been. For example, the decision to either operate or not on a newborn with severe spina bifida inevitably leaves nurses with responsibilities to the infant, the parents, and the doctor that may be in direct conflict with their personal values. They may rightly request to be party to the decision-making process, and although the exact models whereby such a goal may be achieved are debatable, physicians must be aware of the legitimate moral concerns of nurses and others involved.
  • 45. Health care delivery takes place in a very complex environment and relationships with other interested parties is becoming increasingly important. Hospi- tals, health insurance companies, and governments all claim an interest in what services are made avail - able or paid for, and this may prevent individual patients from receiving what their physician may con- sider optimal care. This poses moral problems not only for physicians on a case-by-case basis but also for insurance companies and society as a whole. An atmo- sphere of mutual trust should be sought, earned, and practiced in these relationships. Finally, and very importantly, all physicians and other health care providers should be mindful of a potential conflict of interest that may occur during practice or during performance of committee work at the local or national level. Even the appearance of a conflict between a personal interest and the duty to put patient care interest first can undermine the confi- dence that patients and the public have in them. MALPRACTICE AND MALOCCURRENCE Medical malpractice refers to care that is negligent and
  • 46. below the accepted standard. When an undesired outcome occurs irrespective of the care that is given, it is referred to properly as medical maloccurrence. The system of tort law that currently applies to medical malpractice in the United States distorts the difference between these two events in many cases. Clearly there is preventable medical error resulting from negligent care, but many of these events are not properly addressed in our system. Too often medical maloccur- rence is judged to be malpractice. The interface of medicine and the law raises major ethical issues because legality and morality are not always synonymous. Professional liability insurance premiums for obstetricians are testimony to the rele- vance of legal issues to obstetric practice. Professional liability is affecting every major decision that is made by the practicing obstetrician and gynecologist, and under these conditions, the “tunnel vision” that ensues may obscure the ability to see clear answers to ethical questions. FIGURE 1-3 Involving the patient in the determination of value in decision making. Defining the Plan or Procedure along with its
  • 47. Reason or indication, its evidence-based Expectations, and the patient-centered Preferences for it helps to determine its effective- ness. Further defining of all other Alternatives, the associated Risks and complications along with all Expenses (Costs) determines its efficiency. Making a collaborative Decision based on this process helps to determine the Value of the treatment. (Modified from Gambone JC, Reiter RC, Hagey S: Clinical outcomes in gynecology: hysterectomy. Curr Probl Obstet Gynecol Fertil 16(4), 1993.) P lan R eason E xpectations P references A lternatives R isks E xpenses D ecision VALUE EFFICIENCY EFFECTIVENESS C H A P T E R 1 A Life-Course Perspective for Women’s Health Care 9
  • 48. making is replacing the older solo “captain of the ship” principle for high-risk, high-consequence health care activities. One checklist developed for health care for use in the operating room (Figure 1-4) was tested worldwide by the WHO and resulted in a 47% reduction in surgical mortality and a 36% reduction in inpatient complications. The use of medical teams in health care has resulted in similar reductions in both mor- tality and morbidity. Both of these interventions are relatively inexpensive when compared to the gains and both are highly effective. Patient-Centered Prevention— The Fourth Principle of Practice The prevention and mitigation of existing disease has become an extremely important and sometimes of reducing the high cost of care, particularly in the United States. Transforming health care organizations into high reliability organizations (HROs) that deliver patient-centered value has become the main focus of performance improvement today. HIGH RELIABILITY IN HEALTH CARE Recent progress in health care outcomes has been
  • 49. attained by introducing the concepts and tools of HROs into health care delivery facilities. The two industries that have led as HROs have been commercial aviation and nuclear power plants. In aviation, the adoption of checklists and crew resource management (CRM) has improved commercial aviation safety significantly. The concepts of CRM (called medical team manage- ment in health care) are now being adopted for high- risk procedures in trauma centers and operating rooms. The development of high reliability teams for decision- FIGURE 1-4 Surgical safety checklist. (Based on the WHO Surgical Safety Checklist: Available at http://whqlibdoc.who.int/publications/ 2009/9789241598590_eng_Checklist.pdf, © World Health Organization 2009. All rights reserved.) SURGICAL SAFETY CHECKLIST Before induction of anaesthesia Before skin incision Before patient leaves operating room (with nurse, anaesthetist, and surgeon)(with nurse, anaesthetist, and surgeon)(with at least nurse and anaesthetist) Has the patient confirmed his/her identity, site, procedure, and consent? Is the site marked?
  • 50. Is the anaesthesia machine and medication check complete? Is the pulse oximeter on the patient and functioning? Does the patient have a: Known allergy? Difficult airway or aspiration risk? Risk of >500 ml blood loss (7 ml/kg in children)? No Yes Yes Not applicable No Yes, and equipment/assistance available No Yes, and two IVs/central access and fluids planned Yes Yes Yes
  • 51. This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged. Confirm all team members have introduced themselves by name and role. Has antibiotic prophylaxis been given within the last 60 minutes? Anticipated critical events To surgeon: How long will the case take? What is the anticipated blood loss? Yes Not applicable Is essential imaging displayed? Yes Not applicable What are the critical or non-critical steps? To anaesthetist: How long will the case take? Are there any patient-specific concerns? Confirm the patient’s name, procedure, and where the incision will be made.
  • 52. To nursing team: Are there equipment issues or concerns? Has sterility (including indicator results) been confirmed? Nurse verbally confirms: The name of the procedure Completion of instrument, sponge, and needle counts Specimen labeling (read specimen labels aloud, including patient name) Whether there are any equipment problems to be addressed To surgeon, anaesthetist, and nurse: What are the key concerns for recovery and management of this patient? http://whqlibdoc.who.int/publications/2009/9789241598590_eng _Checklist.pdf http://whqlibdoc.who.int/publications/2009/9789241598590_eng _Checklist.pdf 10 PA R T 1 Introduction overlooked area of value-based practice. The famous American humorist, Will Rogers, said many years ago that people should only pay their doctors when
  • 53. they are well and not sick. This suggests a frustration that he was reflecting publicly that medical practice had neglected the promotion of wellness, resulting in a high cost of sickness. As health care treatment becomes more expensive and complex, there is a greater incen- tive for government, private industry, and individuals to invest in preventive services. There are several good examples of effective preven- tive interventions that are now available in obstetric and gynecologic practice. In obstetrics, the newer techniques for mitigating intrauterine fetal damage from chronic stress that may result in short- and long-term morbidity (see Chapters 7 and 9) are increasingly successful. And in gynecology, the vac- cination against human papillomavirus (HPV ) infec- tion to prevent cervical cancer (see Chapters 22 and 38) is a major advance. Box 1-1 contains a life- course perspective of other early, effective preventive opportunities. *For example, Kliegman R, Behrman R, Jenson H, et al: Nelson’s textbooks of pediatrics, ed 18, Philadelphia, 2007, Saunders. BOX 1-1
  • 54. LIFE-COURSE PERSPECTIVE OF EARLY PREVENTION OPPORTUNITIES • Preconception counseling (see Chapter 7) • Antepartum care and nutrition counseling (see Chapter 7) • Intrapartum care and surveillance (see Chapters 9 and 10) • Newborn screening (see Chapter 8 and pediatric care textbooks*) • Well-baby visits, breastfeeding and nutrition counsel- ing (see pediatric care textbooks*) • Childhood and adolescent screening and Immuniza- tions (see pediatric care textbooks*) • Adult preventive health screening (see Table 1-2) TABLE 1-2 RECOMMENDED PREVENTIVE HEALTH SCREENING FOR WOMEN Intervention/Procedure Risk(s) Pap smear from age 21 irrespective of sexual activity: age 21- 29, every 3 yr; age 30-65, every 3 yr with cytology only or every 5 yr with HPV
  • 55. testing added; age >65, only with history of significant CIN After total hysterectomy (corpus and cervix) cytology not needed (see Chapter 38) Cervical dysplasia/cancer Annual breast exam ages >39 and every 1-3 yr age 20-39; high risk women should consider annual exam; screening mammography annually starting at age 40; USPSTF recommends starting at age 50; breast self-exam not universally recommended (see Chapter 29) Breast cancer Smoking cessation counseling, warning about second-hand smoke exposure Lung cancer, heart disease, other health risks associated with smoking Sigmoidoscopy or colonoscopy (preferred) every 3-5 yr after age 50 Colorectal cancer Height and weight measurement for BMI calculation (see Box 2-2) Overweight and obesity Regular blood pressure screening (every 2 yr) Hypertension and stroke Cholesterol/lipid profile every 5 yr until age 65 Heart disease Total skin inspection and selective biopsies Skin cancer (sun
  • 56. exposure) Diet and exercise counseling; BMD testing for all women > age 64, or younger if at least one risk factor for osteoporosis (see Chapter 35) Osteoporosis, fracture, and deformity Blood sugar study with family history, obesity, or history of gestational diabetes Diabetes mellitus; other comorbidities associated with obesity Cervical sampling for Chlamydia, N. gonorrhoeae, syphilis, and HIV based on history of high-risk behavior (see Chapter 26) Sexually transmitted infections TSH starting at age 50 (see Chapter 35) Thyroid disease PPD of tuberculin for high-risk women Tuberculosis BMD, Bone mineral density; BMI, body mass index; CIN, cervical intraepithelial neoplasia; HIV, human immunodeficiency virus; HPV, human papillomavirus; Pap, Papanicolaou test; PPD, purified protein derivative; TSH, thyroid-stimulating hormone; USPSTF, United States Preventive Services Task Force. C H A P T E R 1 A Life-Course Perspective for Women’s
  • 57. Health Care 11 IMMUNIZATIONS AND PREVENTIVE HEALTH SCREENING Because public health recommendations for immuni- zations may change, it is best to check a reliable source periodically (e.g., www.cdc.gov) for the latest information before counseling patients. General rec- ommendations include the following for women aged 19 to 49: measles, mumps and rubella (MMR), hepatitis B, and varicella for women who are nonimmune. Addi- tionally, vaccination against HPV is currently recom- mended for girls and women aged 11 to 26, and a single dose of tetanus-diphtheria-pertussis (Tdap) for adults 19 to 64 years of age is now recommended to replace the next booster dose of tetanus and diphtheria toxoids (Td) vaccine. Influenza vaccine annually is recom- mended for all women older than age 50 and women aged 19 to 49 who are health care workers, who have chronic illnesses such as heart disease or diabetes mel- litus, or who are pregnant or planning to become preg- nant during the flu season. Pneumococcal vaccine
  • 58. is recommended for all women aged 65 and older, and those with chronic illnesses, alcoholism, or who are immunosuppressed. Meningococcal and hepatitis A vaccines may be indicated in some women with risk factors. MMR, varicella, and HPV vaccines are contra- indicated during pregnancy. Table 1-2 contains preventive screening recommen- dations for women. These recommendations can change or be modified from time to time. The Ameri- can College of Obstetricians and Gynecologists (ACOG) and the United States Preventive Services Task Force (USPSTF) have websites that keep the recommenda- tions up to date. The promising area of preventive services in obstetrics and gynecology, as in health care generally, is transforming the practice of medi - cine in a very positive way. http://www.cdc.gov 12 2 Clinical Approach to the Patient C H
  • 59. A P T ER JOSEPH C. GAMBONE ■ The clinical approach to obstetric and gynecologic patients requires sensitivity and an understanding that medical issues related to birth and reproductive care require a trusting relationship between a woman and her obstetrician and gynecologist as well as all health care professionals that she may encounter. ■ Recent changes in the acceptance of sexual roles in society mean that a nonjudgmental approach is needed. The physician should be careful not to assume that a casual and overly familiar approach is always acceptable to all patients, especially older ones. ■ The obstetric history and physical examination should be complete and carefully performed with the goal of
  • 60. providing care that results in the best clinical outcomes for the mother and her child. ■ The gynecologic encounter may be for routine preven- tive care or may be to address a specific clinical problem that a woman may be having. Reproductive matters are of most interest during the early adult years. Concerns about chronic disorders typically arise later in life during the pre- and postmenopausal years. ■ The physician and all health care professionals should be aware that certain groups of women, such as the pediat- ric, geriatric, and disabled, have special needs and con- cerns. Women who are in same-sex relationships and transgender women may also have special needs. CLINICAL KEYS FOR THIS CHAPTER A careful history and physical examination should form the basis for patient evaluation and clinical man- agement in obstetrics and gynecology, as in other clini- cal disciplines. This chapter outlines the essential details of the clinical approach to, and
  • 61. evaluation of, the obstetric and gynecologic patient. The clinical approach to female patients has evolved in recent years (see Chapter 28). It is important for the clinician who cares for women to refrain from making value judg- ments about sexual preferences and behavior, unless they are clearly unhealthy or dangerous. Some patients may have special needs in terms of their clinical care, and an accepting and understanding attitude is impor- tant. Pediatric and adolescent patients, the geriatric patient, as well as women with disabilities, also have unique gynecologic and reproductive needs and this chapter concludes with information about their evalu- ation and management. Obstetric and Gynecologic Evaluation In few areas of medicine is it necessary to be more sensitive to the emotional and psychological needs of the patient than in obstetrics and gynecology. By their very nature, the history and physical examination may cause embarrassment to some patients. The members
  • 62. of the medical care team are individually and collec- tively responsible for ensuring that each patient’s privacy and modesty are respected while providing the highest level of medical care. Box 2-1 lists the appropri- ate steps for the clinical approach to the patient. While a casual and familiar approach may be accept- able to many younger patients, it may offend others and be quite inappropriate for many older patients. Different circumstances with the same patient may dictate different levels of formality. Entrance to the C H A P T E R 2 Clinical Approach to the Patient 13 the method of delivery in the present pregnancy. A difficult forceps delivery or a cesarean delivery may require a personal review of the labor and delivery records. 5. Duration of labor (recorded in hours). This may alert the physician to the possibility of an unusu- ally long or short labor. 6. Type of anesthesia. Any complications of anesthe- sia should be noted.
  • 63. 7. Maternal complications. Urinary tract infections, vaginal bleeding, hypertension, and postpartum complications may be repetitive; such knowledge is helpful in anticipating and preventing problems with the present pregnancy. 8. Newborn weight (in grams or pounds and ounces). This information may give indications of gesta- tional diabetes, fetal growth problems, shoulder dystocia, or cephalopelvic disproportion. 9. Newborn gender. This may provide insight into patient and family expectations and may indicate certain genetic risk factors. 10. Fetal and neonatal complications. Certain ques- tions should be asked to elicit any problems and to determine the need to obtain further information. Inquiry should be made as to whether the baby had any problems after it was born, whether the baby breathed and cried right away, and whether the baby left the hospital with the mother. MENSTRUAL HISTORY A good menstrual history is essential because it is the determinant for establishing the expected date of con- finement (EDC). A modification of Nägele rule for establishing the EDC is to add 9 months and 7 days to
  • 64. the first day of the last normal menstrual period (LMP). For example: LMP: July 20, 2015 EDC: April 27, 2016 This calculation assumes a normal 28-day cycle, and adjustments must be made for longer or shorter cycles. Any bleeding or spotting since the last normal men- strual period should be reviewed in detail and taken into account when calculating an EDC. CONTRACEPTIVE HISTORY This information is important for risk assessment. Hor- monal contraceptives taken during early pregnancy have been associated with birth defects, and retained intrauterine devices (IUDs) can cause early pregnancy loss, infection, and premature delivery. MEDICAL HISTORY The importance of a good medical history cannot be overemphasized. In addition to common disorders, such as diabetes mellitus, hypertension, and renal disease, which are known to affect pregnancy outcome, all serious medical conditions should be recorded. BOX 2-1
  • 65. APPROACH TO THE PATIENT The doctor should always: • Knock before entering the patient’s room. • Identify himself/herself. • Meet the patient initially when she is fully dressed, if possible. • Address the patient courteously and respectfully. • Respect the patient’s privacy and modesty during the interview and examination. • Ensure cleanliness, good grooming, and good manners in all patient encounters. • Beware that a casual and familiar approach is not acceptable to all patients; it is generally best to avoid addressing an adult patient by her first name. • Maintain the privacy of the patient’s medical informa- tion and records. • Be mindful and respectful of any cultural preferences. patient’s room should be announced by a knock and spoken identification. A personal introduction with the
  • 66. stated reason for the visit should occur before any questions are asked or an examination is begun. The placement of the examination table should always be in a position that maximizes privacy for the patient as other health care professionals enter the room. Any cultural beliefs and preferences for care and treatment should be recognized and respected. Obstetric History A complete history must be recorded at the time of the prepregnancy evaluation or at the initial antenatal visit. Several detailed standardized forms are available, but this should not negate the need for a detailed chronologic history taken personally by the physician who will be caring for the patient throughout her preg- nancy. While taking the history, major opportunities will usually arise to provide counseling and explana- tions that serve to establish rapport and a supportive patient/physician encounter. PREVIOUS PREGNANCIES Each prior pregnancy should be reviewed in
  • 67. chrono- logic order and the following information recorded: 1. Date of delivery (or pregnancy termination). 2. Location of delivery (or pregnancy termination). 3. Duration of gestation (recorded in weeks). When correlated with birth weight, this information allows an assessment of fetal growth patterns. The gestational age of any spontaneous abortion is of importance in any subsequent pregnancy. 4. Type of delivery (or method of terminating preg- nancy). This information is important for planning 14 PA R T 1 Introduction challenging during the early weeks after a missed menses. Urine pregnancy tests in the office are reliable a few days after the first missed period, and office ultra- sonography is used increasingly as a routine. SYMPTOMS OF PREGNANCY The most common symptoms in the early months of pregnancy are missed menses, urinary frequency, breast engorgement, nausea, tiredness, and easy fati- gability. A missed or abnormal menses in a
  • 68. previously normally menstruating, sexually active woman should be considered to be caused by pregnancy until proven otherwise. Urinary frequency is most likely caused by the pressure of the enlarged uterus on the bladder. SIGNS OF PREGNANCY The signs of pregnancy may be divided into presump- tive, probable, and positive. Presumptive Signs The presumptive signs are primarily those associated with skin and mucous membrane changes. Discolor- ation and cyanosis of the vulva, vagina, and cervix are related to the generalized engorgement of the pelvic organs and are, therefore, nonspecific. The dark discol- oration of the vulva and vaginal walls is known as Chadwick sign. Pigmentation of the skin and abdomi- nal striae are nonspecific and unreliable signs. The most common sites for pigmentation are the midline of the lower abdomen (linea nigra), over the bridge of the nose, and under the eyes. Pigmentation under the eyes is called chloasma or the mask of pregnancy.
  • 69. Chlo- asma is also an occasional side effect of hormonal contraceptives. Probable Signs The probable signs of pregnancy are those mainly related to the detectable physical changes in the uterus. During early pregnancy, the uterus changes in size, shape, and consistency. Early uterine enlargement tends to be in the anteroposterior diameter so that the uterus becomes globular. In addition, because of asym- metric implantation of the ovum, one cornu of the uterus may enlarge slightly (Piskaçek sign). Uterine consistency becomes softer, and it may be possible to palpate or to compress the connection between the cervix and fundus. This change is referred to as Hegar sign. The cervix also begins to soften early in pregnancy. Positive Signs The positive signs of pregnancy include the detection of a fetal heartbeat and the recognition of fetal move- ments. Endovaginal ultrasound is capable of detecting
  • 70. fetal cardiac activity as early as 6 weeks (from last menses) and fetal movement from about 7 to 8 weeks’ gestation. Modern Doppler techniques for detecting SURGICAL HISTORY Each surgical procedure should be recorded chrono- logically, including date, hospital, surgeon, and com- plications. Trauma must also be listed (e.g., a fractured pelvis may result in diminished pelvic capacity). SOCIAL HISTORY Habits such as smoking, alcohol use, and other sub- stance abuse are important factors that must be recorded and managed appropriately. The patient’s contact or exposure to domesticated animals, particu- larly cats (which carry a risk of toxoplasmosis), is important. The patient’s type of work and lifestyle may affect the pregnancy. Exposure to solvents (carbon tetrachlo- ride) or insulators (polychlorobromine compounds) in the workplace may lead to teratogenesis or hepatic toxicity. Obstetric Physical Examination GENERAL PHYSICAL EXAMINATION This procedure must be systematic and thorough
  • 71. and performed as early as possible in the prenatal period. A complete physical examination provides an opportu- nity to detect previously unrecognized abnormalities. Normal baseline levels must also be established, par- ticularly those of weight, blood pressure, funduscopic (retina) appearance, and cardiac status. PELVIC EXAMINATION The initial pelvic examination should be done early in the prenatal period and should include the following: (1) inspection of the external genitalia, vagina, and cervix; (2) collection of cytologic specimens from the exocervix (or ectocervix) and superficial endocervical canal; and (3) palpation of the cervix, uterus, and adnexa. The initial estimate of gestational age by uterine size becomes less accurate as pregnancy pro- gresses. Rectal and rectovaginal examinations are also important aspects of this initial pelvic evaluation. CLINICAL PELVIMETRY This assessment, which is helpful for predicting poten- tial problems during labor, should be carried out
  • 72. fol- lowing the bimanual pelvic examination and before the rectal examination. It is important that clinical pelvim- etry be carried out systematically. The details of clinical pelvimetry are described in Chapter 8. Diagnosis of Pregnancy The diagnosis of pregnancy and its location, based on physical signs and examination alone, may be quite C H A P T E R 2 Clinical Approach to the Patient 15 Abdominal Pain Many gynecologic problems are associated with abdominal pain. The common gynecologic causes of acute lower abdominal pain are salpingo-oophoritis with peritoneal inflammation, torsion and infarction of an ovarian cyst, endometriosis, or rupture of an ectopic pregnancy. Patterns of pain radiation should be recorded and may provide an important diagnostic clue. Chronic lower abdominal pain is generally associ- ated with endometriosis, chronic pelvic inflammatory disease, or large pelvic tumors. It may also be the first symptom of ovarian cancer.
  • 73. Amenorrhea The most common causes of amenorrhea are preg- nancy and the normal menopause. It is abnormal for a young woman to reach the age of 16 without menstru- ating (primary amenorrhea). Pregnancy should be sus- pected in a woman between 15 and 45 years of age who fails to menstruate within 35 days from the first day of her last menstruation. In a patient with amenorrhea who is not pregnant, inquiry should be made about menopausal or climacteric symptoms such as hot flashes, vaginal dryness, or mild depression. Other Symptoms Other pertinent symptoms of concern include dys- menorrhea, premenstrual tension, fluid retention, leukorrhea, constipation, dyschezia, dyspareunia, and abdominal distention. Lower back and sacral pain may indicate uterine prolapse, enterocele, or rectocele. MENSTRUAL HISTORY The menstrual history should include the age at men- arche (average is 12 to 13 years), interval between periods (21 to 35 days with a median of 28 days), dura- tion of menses (average is 5 days), and character
  • 74. of the flow (scant, normal, heavy, usually without clots). Any intermenstrual bleeding (metrorrhagia) should be noted. The date of onset of the LMP and the date of the previous menstrual period should be recorded. Inquiry should be made regarding menstrual cramps (dysmen- orrhea); if present, the age at onset, severity, and char- acter of the cramps should be recorded, together with an estimate of the disability incurred. Midcycle pain (mittelschmerz) and a midcycle increase in vaginal secretions are usually indicative of ovulatory cycles. CONTRACEPTIVE HISTORY The type and duration of each contraceptive method must be recorded, along with any attendant compli- cations. These may include amenorrhea or throm- boembolic disease with hormonal contraceptives; dysmenorrhea, heavy bleeding (menorrhagia), or pelvic infection with the intrauterine device; or contraceptive failure with the diaphragm, or other barrier method. the fetal heartbeat may be successful as early as 9 weeks and are nearly always positive by 12 weeks. Fetal heart tones can usually be detected with a stethoscope between 16 and 20 weeks. The multiparous
  • 75. woman generally recognizes fetal movements between 15 and 17 weeks, whereas the primigravida usually does not recognize fetal movements until 18 to 20 weeks. LABORATORY TESTS FOR PREGNANCY Pregnancy Tests Tests to detect pregnancy have revolutionized early diagnosis. Although they are considered a probable sign of pregnancy, the accuracy of these tests is very good. All commonly used methods depend on the detection of human chorionic gonadotropin (hCG) or its β subunit in urine or serum. Depending on the spe- cific sensitivity of the test, pregnancy may be suspected even prior to a missed menstrual period. Diagnostic Ultrasonography The imaging technique of ultrasonography has made a significant contribution to the diagnosis and evalua- tion of pregnancy. Using real-time ultrasonography, an intrauterine gestational sac can be identified at 5 men- strual weeks (21st postovulatory day) and a fetal image can be detected by 5 to 6 weeks. A beating
  • 76. heart is noted at 7 weeks or even sooner with the latest equipment. Gynecologic History Gynecologic history-taking must be systematic to avoid omissions, and it should be conducted with sensitivity and without haste. PRESENT ILLNESS The patient is asked to state her main complaint and to relate her present illness, sequentially, in her own words. Pertinent negative information should be recorded, and, as much as possible, questions should be reserved until after the patient has described the course of her illness. Generally, the history provides substantial clues to the diagnosis, so it is important to evaluate fully the more common symptoms encoun- tered in gynecologic patients. Abnormal Vaginal Bleeding Vaginal bleeding before the age of 9 years and after the age of 52 years is cause for concern and requires inves- tigation. These are the general limits of normal
  • 77. men- struation, and although the occasional woman may menstruate regularly and normally up to the age of 57 or 58 years, it is important to ensure that she is not bleeding from uterine cancer or from exogenous estro- gens. Prolongation of menses beyond 7 days or bleed- ing between menses may connote abnormal ovarian function, uterine myomata, or endometriosis. 16 PA R T 1 Introduction General Appearance The patient’s body build, posture, state of nutrition, demeanor, and state of well-being should be recorded. Head and Neck Evidence of supraclavicular lymphadenopathy, oral lesions, webbing of the neck, or goiter may be pertinent to the gynecologic assessment. Breasts The breast examination is particularly important in gynecologic patients (see Chapters 30 and 32). Heart and Lungs
  • 78. Examination of the heart and lungs is of importance, particularly in a patient who requires surgery. The pres- ence of a pleural effusion may be indicative of a dis- seminated malignancy, particularly ovarian cancer. Abdomen Examination of the abdomen is critical in the evalua- tion of the gynecologic patient. The contour, whether flat, scaphoid, or protuberant, should be noted. The protuberant appearance may suggest ascites. The pres- ence and distribution of hair, especially in the area of the escutcheon, should be recorded, as should the presence of striae or operative scars. Abdominal tenderness must be determined by placing one hand flat against the abdomen in the nonpainful areas initially, then gently and gradually exerting pressure with the fingers of the other hand (Figure 2-1). Rebound tenderness (a sign of peritoneal irritation), muscle guarding, and abdominal rigidity should be gently elicited, again first in the nontender areas. A “doughy” abdomen, in which the guarding OBSTETRIC HISTORY
  • 79. Each pregnancy, delivery, and any associated compli- cations should be listed sequentially with relevant details and dates. SEXUAL HISTORY The health of, and current relationship with, the husband or partner(s) may provide insight into the present complaints. Inquiry should be made regarding any pain (dyspareunia), bleeding, or dysuria associated with sexual intercourse. Sexual satisfaction should be discussed tactfully. PAST HISTORY As in the obstetric history, any significant past medical or surgical history should be recorded, as should the patient’s family history. A list of current medications is important. SYSTEMIC REVIEW A review of all other organ systems should be under- taken. Habits (tobacco, alcohol, other substance abuse), medications, usual weight with recent changes, and loss of height (osteoporosis) are important parts of the systemic review. Gynecologic Physical Examination GENERAL PHYSICAL EXAMINATION
  • 80. A complete physical examination should be performed on each new patient and repeated at least annually. The initial examination should include the patient’s height, weight, and arm span (in adolescent patients or those with endocrine problems) and should be carried out with the patient completely disrobed but suitably draped. A body mass index (BMI) should be calculated (Box 2-2) and recorded. The examination should be systematic and should include the following points. Vital Signs Temperature, pulse rate, respiratory rate, and blood pressure should be recorded. FIGURE 2-1 The abdomen is palpated by placing the left palm flat against the abdominal wall and then gently exerting pressure with the fingers of the right hand. *Data from the National Heart, Lung, and Blood Institute. BOX 2-2 CALCULATIONS AND DESIGNATIONS* OF BODY MASS INDEX Body mass index is calculated by dividing weight in kilo- grams (kg) by height in meters squared or weight in
  • 81. pounds by height in inches squared times 703. Less than 18.5 = underweight 18.5 to 25 = normal weight 25 to 29.9 = overweight 30 to 34.9 = class one obesity 35 to 39.9 = class two obesity 40 or greater = extreme obesity C H A P T E R 2 Clinical Approach to the Patient 17 cated with warm water only, so as not to interfere with the examination of cervical cytology or any vaginal exudate. After gently spreading the labia to expose the introitus, the speculum should be inserted with the blades entering the introitus transversely, then directed posteriorly in the axis of the vagina with pressure exerted against the relatively insensitive perineum to avoid contacting the sensitive urethra. As the anterior blade reaches the cervix, the speculum is opened to bring the cervix into view (Figure 2-3). As the vaginal epithelium is inspected, it is important to rotate the speculum through 90 degrees, so that lesions on
  • 82. the anterior or posterior walls of the vagina ordinarily covered by the blades of the speculum are not over- looked. Vaginal wall relaxation should be evaluated using either a Sims speculum or the posterior blade of a bivalve speculum. The patient is asked to bear down ( Valsalva maneuver) or to cough to demonstrate any stress incontinence. If the patient’s complaint involves urinary stress or urgency, this portion of the examina- tion should be carried out before the bladder is emptied. The cervix should be inspected to determine its size, shape, and color. The nulliparous patient generally has a conical, unscarred cervix with a circular, centrally placed os; the multiparous cervix is generally bulbous increases gradually as the pressure of palpation is increased, is often seen with a hemoperitoneum. It is important to palpate any abdominal mass. The size should be specifically noted. Other characteristics may be even more important in suggesting the
  • 83. diagno- sis, such as whether the mass is cystic or solid, smooth or nodular, fixed or mobile, and whether it is associated with ascites. In determining the reason for abdominal distention (tumor, ascites, or distended bowel), it is important to percuss carefully the areas of tympany (gaseous distention) and dullness. A large tumor is gen- erally dull on top with loops of bowel displaced to the flanks. Dullness that shifts as the patient turns onto her side (shifting dullness) is suggestive of ascites. Back Abnormal curvature of the vertebral column (dorsal kyphosis or scoliosis) is an important observation in evaluating osteoporosis in a postmenopausal woman. Costovertebral angle tenderness suggests pyelonephritis, whereas psoas muscle spasm, which is associated with flexion of the hip, may occur with gynecologic infections, malignant infiltration, or acute appendicitis. Extremities The presence or absence of varicosities, edema, pedal pulsations, and cutaneous lesions may suggest patho- logic conditions within the pelvis. The height of
  • 84. pitting edema should be noted (e.g., ankle, shin, to the knee, or above). PELVIC EXAMINATION The pelvic examination must be conducted systemati- cally and with careful sensitivity. The procedure should be performed with smooth and gentle movements and accompanied by reasonable explanations. Vulva The character and distribution of hair, the degree of development or atrophy of the labia, and the character of the hymen (imperforate or cribriform) and introitus (virginal, nulliparous, or multiparous) should be noted. Any clitorimegaly should be noted, as should the pres- ence of cysts, tumors, or inflammation of the Bartho- lin gland. The urethra and Skene glands should be inspected for any purulent exudates. The labia should be inspected for any inflammatory, dystrophic, or neo- plastic lesions. Perineal relaxation and scarring should be noted because they may cause dyspareunia and defects in anal sphincter tone. The urethra should be “milked” for any inflammatory exudates, which if
  • 85. found should be cultured for pathologic organisms. Speculum Examination It is important to use an appropriately sized specu- lum (Figure 2-2), which should be warmed and lubri- FIGURE 2-2 A, Pediatric speculum. B, Pederson speculum. C, Graves speculum. The Pederson speculum has narrower blades and is more appropriate for examining a nulliparous patient. D, Parts of a speculum. A B D Upper & lower blades Thumb screw Thumb hinge Handle screw HandleC 18 PA R T 1 Introduction
  • 86. colaou, or Pap, smear), liquid-based sampling, or DNA probe for human papillomavirus (HPV ) should be taken before the speculum is withdrawn. For the tradi- tional Pap smear the exocervix (or ectocervix) is gently scraped with a wooden spatulum or plastic broom, and the endocervical tissue gently sampled with a cytobrush. Bimanual Examination The bimanual pelvic examination provides informa- tion about the uterus and adnexa (fallopian tubes and ovaries). During this portion of the examination, the urinary bladder should be empty; if it is not, the inter- nal genitalia will be difficult to delineate, and the pro- cedure is more apt to be uncomfortable for the patient. The labia are separated, and the gloved, lubricated index finger is inserted into the vagina, avoiding the sensitive urethral meatus. Pressure is exerted posteri- orly against the perineum and puborectalis muscle, which causes the introitus to gape somewhat, thereby usually allowing the middle finger to be inserted as
  • 87. well. Intromission of the two fingers into the depth of the vagina may be facilitated by having the patient bear down slightly. If insertion of two fingers causes undue patient discomfort, examination with the index finger alone may give more information. The cervix is palpated for consistency, contour, size, and tenderness to motion. If the vaginal fornices are and the os has a transverse configuration (Figure 2- 4). Any purulent cervical discharge should be cultured. Plugged, distended cervical glands (nabothian folli- cles) may be seen on the exocervix (or ectocervix). In premenopausal women, the squamocolumnar junc- tion of the cervix is usually visible around the cervical os, particularly in patients of low parity. Postmeno- pausally, the junction is invariably retracted within the endocervical canal. A cervical cytologic smear (Papani- FIGURE 2-3 Proper insertion of the speculum so that the uterine cervix may be visualized. FIGURE 2-4 Cervix of a nulliparous patient (A) and a multiparous patient (B). Note the circular os in the nulliparous cervix and the transverse os, resulting from lacerations at childbirth, in the
  • 88. mul- tiparous cervix. A B MULTIPAROUS Nabothian follicle NULLIPAROUS C H A P T E R 2 Clinical Approach to the Patient 19 FIGURE 2-5 Bimanual evaluation of the uterus by exerting gentle pressure on the uterus with the vaginal fingers against the abdominal hand. FIGURE 2-6 Bimanual examination of the right adnexa. Note that fingers of the right hand are in the vagina. absent, as may occur in postmenopausal women, it is not possible to appreciate the size of the cervix on bimanual examination. This can be determined only on rectovaginal or rectal examination. The uterus is evaluated by placing the abdominal hand flat on the abdomen with the fingers pressing gently just above the symphysis pubis. With the vaginal fingers supinated in either the anterior or the posterior
  • 89. vaginal fornix, the uterine corpus is pressed gently against the abdominal hand (Figure 2-5). As the uterus is felt between the examining fingers of both hands, the size, configuration, consistency, and mobility of the organ are appreciated. If the muscles of the abdominal wall are not compliant or if the uterus is retroverted, the outline, consistency, and mobility must be deter- mined by ballottement with the vaginal fingers in the fornices; in these circumstances, however, it is impos- sible to discern uterine size accurately. By shifting the abdominal hand to either side of the midline and gently elevating the lateral fornix up to the abdominal hand, it may be possible to outline a right adnexal mass (Figure 2-6). The left adnexa are best appreciated with the fingers of the left hand in the vagina (Figure 2-7). The examiner should stand side- ways, facing the patient’s left, with the left hip main- taining pressure against the left elbow, thereby
  • 90. 20 PA R T 1 Introduction adnexa. It is essential in evaluating the parametrium in patients with cervical cancer. Rectal examination may also be essential in differentiating between a rec- tocele and an enterocele (Figure 2-8). LABORATORY EVALUATION Appropriate laboratory tests normally include a uri- nalysis, complete blood count, erythrocyte sedimenta- tion rate, and blood chemistry analyses. Special tests, such as tumor marker and hormone assays, are per- formed when indicated. ASSESSMENT A reasonable differential diagnosis should be possible with the information gleaned from the history, physical examination, and laboratory tests. The plan of man- agement should aim toward a chemical or histologic confirmation of the presumptive diagnosis, and the appropriate therapeutic options, along with the ratio- nale for each option, should be recorded. Patients with Special Needs
  • 91. PEDIATRIC AND ADOLESCENT PATIENTS Girls experience fewer gynecologic problems than do adult women, but their concerns need to be met effectively and skillfully in a way that will allay anxiety and create a positive attitude toward their gyneco- logic health. Unique complaints fall generally into a handful of categories: congenital anomalies, genital injuries, inflammation of the nonestrogenized genital tract, pubertal problems, and psychosexual concerns. Genital ambiguity, trauma, and vaginal bleeding in the prepubertal child are covered briefly in this chapter. GENITAL AMBIGUITY Dealing with genital ambiguity in the newborn requires a coordinated and timely response. The family’s psy- chological well-being must be addressed because they must feel confident in the gender identity of their child. Ambiguity can result from masculinization of a female child due to exogenous hormone ingestion or maternal or fetal overproduction of androgen. It may also result from incomplete virilization of a male infant, hormonal insensitivity, gonadal dysgenesis, or chromosomal anomalies (see Chapters 18 and 20). When assessing an infant with ambiguous genitalia, fluid and electrolyte balance should be monitored and blood drawn for 17-hydroxyprogesterone and
  • 92. cortisol to rule out 21-hydroxylase deficiency. Life- threatening illness may be missed in children with the salt-losing form of congenital adrenal hyperplasia (see Chapter 33). TRAUMA Straddle injuries are the most common cause of trauma to the genitalia of a young girl, and the injuries have a providing better tactile sensation because of the relaxed musculature in the forearm and examining hand. The pouch of Douglas is also carefully assessed for nodu- larity or tenderness, as may occur with endometriosis, pelvic inflammatory disease, or metastatic carcinoma. It is usually impossible to feel the normal tube, and conditions must be optimal to appreciate the normal ovary. The normal ovary has the size and consistency of a shelled oyster and may be felt with the vaginal fingers as they are passed across the undersurface of the abdominal hand. The ovaries are very tender to compression, and the patient is uncomfortably aware of any ovarian compression or movement during the
  • 93. examination. It may be impossible to differentiate between an ovarian or tubal mass or even a lateral uterine mass. Generally, left adnexal masses are more difficult to evaluate than those on the right because of the position of the sigmoid colon on the left side of the pelvis. An ultrasonic examination should be helpful for delineat- ing these features. RECTAL EXAMINATION The anus should be inspected for lesions, hemorrhoids, or inflammation. Rectal sphincter tone should be recorded and any mucosal lesions noted. A guaiac test should be performed to determine the presence of occult blood. A rectovaginal examination is helpful in evaluating masses in the cul-de-sac, the rectovaginal septum, or FIGURE 2-7 Bimanual examination of the left adnexa. Note that fingers of the left hand are in the vagina. C H A P T E R 2 Clinical Approach to the Patient 21 withdrawal. In such cases, there should be supportive evidence of a hormonal effect, such as the presence
  • 94. of breast tissue and pale, engorged vaginal epithelium. Bleeding disorders are uncommon in this age group but should be considered. Vitamin K is routinely given to the newborn, but some parents may refuse the medication. Precocious puberty (see Chapter 32) may present with vaginal bleeding, although most commonly other evidence of maturation will have preceded the bleeding and will be evident on examination. At the very least, a pale, estrogenized vaginal epithelium will be seen, and cytology from the vagina will confirm the hormonal effect. Transient precocious puberty may occur in response to a functional ovarian cyst, and vaginal bleeding may be triggered by the spontaneous resolu- tion of the cyst. Exogenous hormonal exposure should be considered, because children have been known to ingest birth control pills. Ovarian tumors resulting in pseudoprecocious puberty should be ruled out. Vulvovaginitis is common but is a diagnosis of exclusion. When bleeding is present, it is necessary to assess the vagina and to rule out a foreign
  • 95. body or vaginal tumor. seasonal peak when bicycles come out in the spring. The majority of these injuries are to the labia. Penetrat- ing vaginal injuries can cause major intraabdominal damage with minimal external findings. Sexual assault must always be considered. After a life-threatening condition is ruled out, an ice pack, chilled bag of intra- venous solution, or cool compress may be applied to the injured area and the child allowed to rest quietly for 20 minutes before being assessed further. Extensive injuries usually require examination under anesthesia and surgical repair. In any case of trauma, concurrent damage to the rectum or urinary tract should be considered. If there is any reason to suspect sexual or physical abuse, the child protection authorities must be notified, and the examination should include the collection of medico- legal evidence. VAGINAL BLEEDING IN THE PREPUBERTAL CHILD Vaginal bleeding is a frequent and distressing com- plaint in childhood. Although it will most often be of
  • 96. benign etiology, more serious pathology must always be ruled out. Vaginal bleeding in the newborn is most often physiologic as a result of maternal estrogen FIGURE 2-8 Rectovaginal bimanual examination. During the Valsalva maneuver, an enterocele will separate the two fingers. 22 PA R T 1 Introduction mentally or physically disabled individuals with obstet- ric or gynecologic problems or attending for them in special institutions can be quite challenging. The woman with a disability is a person with special and unique needs, and communicating to her a sense of caring and respect is paramount. Lesbian, Gay, Bisexual, and Transgender Patients This group of patients is composed of lesbian, gay, bisexual, and transgender women and men and is known as LGBT. There is now recognition that women who are in a same-sex intimate relationship, as well as those who are transgender, need special consideration
  • 97. and understanding for the health issues that they may encounter. The U.S. Office of Prevention and Health Promotion points out that LGBT individuals, possibly because of the discrimination that they encounter, have higher rates of psychiatric disorders, substance abuse, and suicide. The obstetrician and gynecologist should be particularly sensitive to the needs that these women may have regarding their reproductive health. More information about the health disparities that the LGBT community may have can be found at www. healthypeople.gov/LGBT. For more detailed informa- tion about the specific needs that lesbian and trans- gender women may have, the American College of Obstetricians and Gynecologists Committee Opinion Number 525, dated May 2012 and reaffirmed in 2014, can be consulted at www.ACOG.org. Vaginal tumors are the most serious possibility to be considered. Sarcoma botryoides classically pres- ents with vaginal bleeding and grapelike vesicles. For- tunately, this is a rare tumor. Geriatric Patients The gynecologic assessment of the elderly woman
  • 98. may present a special challenge. Many older patients tend to underreport their symptoms, possibly because of a belief that any new physical problems are due to the normal aging process. Also, a fear of loss of their inde- pendence may contribute to this denial and this may lead to a delay of diagnosis and perhaps a worse prog- nosis. In addition to the routine gynecologic history and physical examination, these patients should be evaluated for any sensory impairments, such as visual or hearing loss, any impaired mobility, malnutrition, urinary incontinence, or confusion, which may be due to polypharmacy. Appropriate referral, when improve- ment can be reasonably expected, should be consid- ered for these problems once identified. Gynecologic conditions such as atrophic vaginitis, uterine and vaginal prolapse, and genital tract malig- nancies are among the more common problems encountered in the geriatric patient. Patients with Disabilities Women with developmental or acquired disabilities should receive the same high quality obstetric and
  • 99. gynecologic care as anyone else, with a goal of sustain- ing their best level of functioning. Assisting families of http://www.ACOG.org 23 3 Female Reproductive Anatomy and Embryology C H A P T ER JOSEPH C. GAMBONE ■ The upper vagina, cervix, uterus, and fallopian tubes are formed from the paramesonephric (müllerian) ducts. The absence of the Y chromosome leads to the develop- ment of the müllerian (female) system with virtual total regression of the mesonephric (wolffian) or male system. With the Y chromosome present, a testis is