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Thanks for your cooperation. This book provide over 60 real-life cases that illustrate essential concepts in this area of gynaecology and obstetrics. Full of high-yield clinical pearls which make this book easy to read. Every case includes a complete discussion, definitions of key terms as well as references.
If the link is not responding, kindly inform us through comment section. Constant wetness after a pelvic operation suggests a fistula, such as vesicovaginal fistula, which is best treated with surgical repair. Cystometric or urodynamic evaluation helps to differentiate genuine [rom urge incontinence. A postvoid catheterization showing a large residual volume suggests overflow incontinence. Loss of urine occurs when the intravesicular pressure equals: or exceeds the sphincter pressure. Essentials of obstetrics and gynecology, 3rd ed, Philadelphia: Saunders, Urogynecology: physiology of micturition, diagno- sis of voiding dysfunction and incontinence: surgical and nonsurgical treatment.
Compre- hensive gynecology, 4th ed. Her Menopause occurred at age 51 years, and she is currently taking an es- trogen pill along with a progestin pill cach day. The past medical his- tory is unremarkable. Her family history includes one maternal cousin with ovarian cancer. The thyroid is normal to palpation. Examination of her breasts reveals no ma or discharge.
The ab- dominal, cardiac, and lung evaluations are within normal limits. The pelvic examination shows a normal, multiparous cervix, a normal-sized s. She had undergone mammography 3 uterus, and no adnexal ma months previously. What is your next step? What would be the most common cause of mortality for this patient?
A mammogram has been performed 3 months previously. Most common cause of mortality: Cardiovascular disease. Analysis Objectives 1. Understand which health maintenance studies should be per- formed for a year-old woman, Nv Know the most common cause of mortality for a woman in this age group.
Understand that preventive maintenance consists of cancer screening. Considerations The approach to health maintenance includes three parts: 1 can- cer screening, 2 immunizations, and 3 addressi common dis- eases for the particular patient group.
Screening for hypercholesterolemia every 5 yr up to age 75 years, and fasting blood sugar levels every 3 yr are also recommended. Osteoporosis screening is indicated for women over the age of Fi- nally, the most common cause of mortality in a woman in this age group is cardiovascular disease. An optimal screening test has high sensitivity and specificity, is inexpensive, and is easy to perform.
Second: prevention: Actions taken to reduce morbidity or mortality once a disease has been diagnosed. Cost effectivenes: A comparison of resources expended dollars in an intervention versus the benefit, which may be measured in life-years, or quality-adjusted life yea Pi cl ical Approach In cach age group, particular screening tests are recommended Table Rationale When the patient does not have any apparent disease or complaint, then the goal of medical intervention is disease prevention.
For example, the most common cause of death for a year-old person is a motor vehicle ac- cident: hence the teenage patient would be well served by the physician encouraging him or her to wear seat belts and to avoid alcohol intoxi- cation when driving. Motor 1. Cardio- 1, Heart causes of accidents vehicle vascular disease mortality 2. Homicide accidents disease 2. Cancer 3. Suicide 2. Cardio- 2. Cerebrova: vascular cular disease disease 3.
Note: More than one answer may be used. A, Influenza vaccine B. Pneumococcal vaccine C. Barium enema with flexible sigmoidoscopy D. Mammography every year FE. Pneumococcal vaccine diograph G. Urinalysis H. Pap smear I. Fasting blood sugar J. Bone mineral density study A year-old girl engaged in one episode of sexual intercourse two years ago, but is currently not sexually active.
Answers H. A Pap smear should be initiated at age 18 years or when sex- ually active, whichever occurs first. A Pap smear for cancer screening is the only indicated test. After the age of 50 years, annual mammogra- phy, colon cancer sereening, and influenza vaccination are recommended. All the listed screening tests are in- dicated after age 65 years except chest x-ray.
The most common cause of mortality in a woman younger than 20 years is motor vehicle accidents. The most common cause of mortality of a woman older than 39 years is cardiovascular disease. Major conditions in women aged 65 years and older include osteoporosis, heart disease, breast cancer, and depression. Precis: primary and preventive care. Washington, DC: American College of Obstetricians and Gynecologists. Bone density screening for osivoporosis. CASE 3 After a 4-hour labor, a year-old G4 P3 woman undergoes an un- eventful vaginal delivery of a 7 Ib 8 oz infant over an intact perineum.
During her labor, she is noted to have mild variable decelerations and accelerations that increase 20 beats per min bpm above the baseline heart rate. At deliver the male baby has Apgar scores of 8 at min, and 9 at 5 min, Slight lengthening of the cord occurs after 28 min along with a small gush of blood per vagina.
As the placenta is being deliv- cred, a shaggy, reddish, bulging mass is noted at the introitus around the placenta What is the most likely diagnosis What is the most likely complication to occur in this patient? Most I kely d Uterine inversion. Analysis Objectives Know the signs of spontancous placental separation. Recognize the clinical presentation of uterine inversion Understand that the most common cause of uterine inversion is undue traction of the cord before placental separation.
The third stage of labor placental delivery reaches close to the upper limits of normal. The evidence for placental separation is never definite, The four signs of placental separation are: 1 gush of blood, 2 lengthening of the cord, 3 globular and firm shape of the uterus, and 4 the uterus rises up to the anterior abdominal wall. Abnormally retained placenta: — Third stage of labor that has ex- ceeded 30 min.
Because the uterus and placenta are no longer joined, the placenta is usually in the lower segment of the uterus, just inside the cervix, and the uterus is often contracted. The umbilical cord lengthens due to the placenta having dropped into the lower portion of the uterus. The gush of blood represents bleeding from the placental bed, usually coinciding with placental separation. If the placenta has not separated, ex ive foree on the cord may lead to uter- ine inversion, Massive hemorrhage usually results; thus, in this situa- tion, the practitioner must be prepared for rapid volume replacement Although it was classically taught by some that the shock was out of proportion to the actual amount of blood loss, this is not the case.
In other words, shock is due to massive hemorrhage! The best method of averting a uteri aversion tancous separation from the placenta from the uterus before plac- ing traction on the umbilical cord. Even afier one or two of the signs of placental separation are present, the operator should be cautious not to put undue tension on the cord.
Inverted uterus. Uterine inversion can occur when ex- cessive umbilical cord traction is exerted on a fundally implanted, un- separated placenta A. The grand-multiparous patient with the placenta implanted in the fundus top of uterus is at particular risk for uterine inversion. A placenta ac- ereta, an abnormally adherent placenta, is also a risk factor.
If the placenta has already separated, the recently inverted uterus may sometimes be replaced by using the gloved palm and cupped fingers. Two intravenous lines should be started as soon as possible and preferably prior to placental separation, since profuse hemorrhage may follow placental removal. Terbutaline or magnesium sulfate can also be utilized to relax the uterus if necessary prior to uterine replacement. Upon replacing the uterine fundus to the normal location, the relaxation agents are stopped, and then uterotonic agents, such as oxytocin, are given.
Placement of the clinician's fist inside the uterus to maintain the normal structure of the uterus is important. Note: Even with optimal treatment of uterine inversion, hemor- rhage is almost a certainty. Comprehension Questions [3.
Fundal B. Anterior Posterior D. Initiate oxytocin Wait for an additional 30 min. Hysterectomy Attempt a manual extraction of the placenta Estrogen intravaginally eee Here Which of the following is LEAST likely to be a risk factor for uterine inversion?
Short umbilical cord B. Atonie uterus C. Nonseparated placenta D. Attenuated umbilical cord E. Grand-multiparity A year-old G5 P5 woman who is being induced for preeclampsia delivers a 9 Ib baby. Upon delivery of the placenta, uterine inversion is noted. The physician attempts to replace the uterus, but the cervix is tightly contracted, preventing the fundus of the uterus from being repositioned.
Which of the following is the best therapy for this patient? Vaginal hysterectomy B. Halothane anesthesia D. Discontinue the magnesium sulfate E. Infuse oxytocin intravenously Answers A.
A fundally implanted placenta predisposes to uterine inver- sion. After 30 min, the placenta is abnormally retained, and a man- ual extraction is generally attempted.
An attenuated umbilical cord leads to severing of the cord with traction and in a way protects against uterine inversion, whereas an unusually sturdy cord may predispose to uterine inversion.
A uterine relaxing agent such as halothane anesthesia is the best initial therapy for a nonreducible uterus. The signs of placental separation are 1 gush of blood, 2 lengthening of the cord, 3 globular-shaped uterus, and 4 the uterus rising to the anterior abdominal wall. Hemorrhage is a common complication of an inverted uterus. The upper limit of normal for the third stage of labor time be- tween delivery of the infant to delivery of the placenta is 30 min.
Essentials of obstetries nd gynecology, 3rd ed. Philadelphia: Saunders. In: Williams obstetrics, 21st ed. New York: MeGraw- Hill, A year-old woman complains of irregular menses over the past 6 months, feelings of inadequacy, vaginal dryness, difficulty sleeping, and episodes of warmth and sweating at night. The breasts are symmetric, without masses or discharge. Most likely diagnosis: Climacteric perimenopausal state. Understand the normal clinical presentation of women in the perimenopausal state.
Know that estrogen replacement therapy is usually effective in treating the hot flushes. Know the risks of continuous estrogen-progestin therapy. Considerations This year-old woman complains of irregular menses, feclings of in- adequacy, and intermittent sensations of warmth and sweating.
This constellation of symptoms is consistent with the perimenopause, or cli- macteric. Hot flushes, which are the typical vasomotor change due to de- sed estrogen levels, are associated with skin temperature elevation and sweating lasting for 2 to 4 min. The low estrogen concentration also has an effect on the vagina by decreasing the epithelial thickness, lead- ing to atrophy and dryness, Elevated serum FSH and LH levels are helpful in confirming the diagnosis of the perimenopause. Treatment for hot flushes includes estrogen replacement therapy with progestin.
Perimenopause climacteric : The transitional 2 to 4 yr spanning from immediately before to immediately after the menopause. Hot flushes: Irregular unpredictable episodes of increased skin temperature and sweating lasting about 3 to 4 min Premature ovarian failure: — The cessation of ovarian function due to atresia of follicles prior to age 40 years, At ages younger than 30 years, autoimmune diseases or karyotypic abnormalities should be considered.
Symptoms include ir- regular menses due to anovulatory cycles; vasomotor symptoms, such as hot flush nd decreased estrogen and androgen levels. Because ovar- ian inhibin levels are decreased, FSH levels rise even before estradiol levels fall.
The decreased estradiol concentrations lead to vaginal atro- phy, bone loss, and vasomotor symptoms. While most clinicians agree that estrogen replacement therapy is currently the best treatment for the vasomotor symptoms and to prevent osteoporosis, recent pub- lished data raises concerns about the risks of this therapy.
When there is cervical dilation but less than the minimum expected change, then this is called protraction of active phase. When the cervix does not dilate for 2 hr in the active phase, then it is called arrest of active phase. When there is cephalopelvie disproportion, where the pelvis is too small for the fetus either due to an abnormal pelvis or an excessively large baby. Clinically adequate uterine contrac- tions are defined as contractions every 2 to 3 min, firm on palpa- tion, and lasting for at least 40 to 60 sec Figure Some clinicians choose to use internal uterine catheters to evaluate the adequacy of the powers.
She has only changed her cervix from I-cm dilation to 2-em di- lation over 3 hr. A, Cesarean cervery B. Intravenous oxytocin C. Observation D. Fetal scalp pH monitoring. The occiput posterior position is frequently an anthropoid pelvi B. The labor progress is abnormal if the patient does not have an epidural catheter for analgesia, but is still within normal lim- its if epidural analges' being used.
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