!

"#$%$&'(#
*+,
-.+%(!/!-.
&%0*/',* &%0'%1
2345
T0PICS
!"#$%$&'(#
! Fiist Pienatal Check-up
-.+%(!/!-.
! vaginal uischaige
! Lesions on exteinal genitalia
! Abnoimal uteiine bleeuing
! Bypogastiic pain

!
"
#
$
%
$
&
'
(
#

P
R
E
-
N
A
T
A
L
C
B
E
C
K
0
P

FIRST PRE-NATAL
CBECK 0P
Nenstuial Bistoiy
o LNP
Sexual Bistoiy
0bstetiic Bistoiy
u P (TPAL)
Nannei of ueliveiy
Complications
Beteimine
o Age of uestation
" LNP
" 0ltiasounu
o Estimateu uate of
ueliveiy
" Naegele's Rule
! +7, -S
67.#'(*/ %8*9'+*$'!+

Weight in pounus
Bieast examination
Abuomen:
o :;<=>? 7@>ABC
" Stait at 16-18 weeks
A0u
o /@DEDF=GH 9I<@;J@K
Stait at 28-Su weeks
" LN1 Funual giip
" LN2 0mbilical giip
" LNS Pawlik's giip
" LN 4 Pelvic giip
o :@CIF 7@IKC $D<@
Funuic Beight
67.#'(*/ %8*9'+*$'!+

Weight in pounus
Bieast examination
Abuomen:
o :;<=>? 7@>ABC
" Stait at 16-18 weeks
A0u
o /@DEDF=GH 9I<@;J@K
Stait at 28-Su weeks
" LN1 Funual giip
" LN2 0mbilical giip
" LNS Pawlik's giip
" LN 4 Pelvic giip
o :@CIF 7@IKC $D<@
LN 1 - Funual uiip
LN 2 - 0mbilical uiip
LN S - Pawlik's uiip
LN 4 - Pelvic uiip
FIRST PRE-NATAL CBECK 0P
Pelvic Examination
%LC@K<IF A@<>CIF>I
o Lesions
#E@?;F;M @LIM><IC>D<
o Besciibe the ceivix anu the vaginal uischaige
o Eg. Ceivix is violaceous, smooth, with minimal
whitish mucoiu non-foul smelling uischaige
'<C@K<IF %LIM><IC>D<
o Besciibe the ceivix, uteius anu aunexa
o Eg. Ceivix soft, long, closeu; uteius enlaigeu to 2
months size, no aunexal mass oi tenueiness
o Aunexae cannot be evaluateu if uteius is S
months size


Bangei Signs of Piegnancy
Peisistent heauache
Bluiiing of vision
Peisistent nausea anu vomiting
Fevei anu chills
Bysuiia
Bypogastiic pain
Bloouy vaginal uischaige
Wateiy vaginal uischaige
Becieaseu fetal movement
Euema of the hanus anu feet
Piesumptive Symptoms of Piegnancy
Nausea anu vomiting
Bistuibances in uiination
Fatigue
Peiception of fetal movement (quickening)
Bieast symptoms

Piesumptive Signs of Piegnancy
o Cessation of menstiuation
o Anatomical bieast changes
Bieast enlaigement anu vasculai engoigement
Bypeipigmentation of aieola
Nipples become laigei
o Change in vaginal mucosa - CBABWICK's sign
o Skin pigmentation - Chloasma, linea nigia,
stiiae giaviuaium
o Theimal signs - Incieaseu tempeiatuie

Piobable Signs of Piegnancy
o Abuominal enlaigement
o Changes in uteius anu ceivix
BEuAR's sign - softening of the uteiine isthmus
u00BELL's sign - cyanosis of the ceivix (4 weeks)
Softening of the ceivix (6-8 weeks)
Beaueu pattein of ceivical mucus (piogesteione effect)
o Biaxton-Bicks contiactions (28
th
week)
o Ballotement (2u
th
week)
o 0utlining of the fetus
o (+) piegnancy test - BCu
0nset: 8-9 uays aftei ovulation
Peak: 6u-7u uays
Nauii: 14-16 weeks A0u

Positive Signs of Piegnancy
o Fetal Beait Tone
TvS: 6-8 weeks
Bopplei: 1u-12 weeks
Stethoscope: 18 weeks
o Peiception of active fetal movement by the
examinei
2u weeks
o Recognition of embiyo oi fetus by ultiasounu
uestational sac: 4-S weeks
Fetal heait beat: 6-8 weeks
CRL pieuictive of gestational age up to 12 weeks
What to Request.
0ltiasounu
o TvS - to ueteimine fetal viability anu aging (<12 weeks)
o Fetal biometiy (>1S weeks)
Laboiatoiy examinations
o CBC
o Physiologic anemia:
4
HC
CK>M@HC@KN O44 AP=/
2
<=
CK>M@HC@KN O43QR AP=/
5
K=
CK>M@HC@KN O44 AP=/
o Leukocytosis of piegnancy
o Bloou typing
o 0iinalysis
o BBsAg - neai teim
o Pap smeai

What to Request.
uL0C0SE SCREENINu
Aveiage iisk (ethnic gioup)
o 2ST2U V@@WH *!-
o R3 A !-($ N O 453MAP=/
Bigh iisk
o Stiong family histoiy of BN, 0bese
o Pievious histoiy of uBN, impaiieu glucose metabolism,
glucosuiia
o Excessive weight gain
433 A !-$$
:"# O XR MAP=/
4
HC
BD;K O 4U3 MAP=/
2
<=
BD;K O 4RR MAP=/
5
K=
BD;K O4S3 MAP=/
o Request at fiist visit, iepeat at 24-28 weeks A0u
New uuiuelines on uBN Scieening
o L0W RISK foi uBN
" No known uiabetes of fiist uegiee ielatives
" Age <2S yo
" Noimal weight befoie piegnancy
" No histoiy of abnoimal glucose metabolism oi histoiy of pooi
obstetiical outcome
o BIuB RISK foi uBN
" Seveie obesity
" Age >SS
" Stiong family histoiy of uiabetes
" Pievious histoiy of: uBN. hypeitension, glucosuiia, PC0S,
maciosomic infant
" Pooi 0B histoiy - fetal uemise, fetal malfoimation
" Cuiient use of steioius
Protocol for the Evaluation of
Diabetes in Pregnant Filipino Women
:>KHC 6K@<ICIF 0>H>C
&"#Y :"#Y 7Z*4?
:"# O X2 MAP=/
&"# O 233 MAP=/
7Z*4? O[QR\

+DKMIF
]R A !-$$ IC
2ST2U V@@WH
:"# ^ X2MAP=F I<= O 42[MAP=F
:"# ^ 42[ MAP=/
&"# ^ 233 MAP=/
7Z*4? ^ [QR\

-,9
!J@KC ,9
Protocol for the Evaluation of
Diabetes in HIGH RISK Pregnant Filipino Women
:>KHC 6K@<ICIF 0>H>C
]R A !-$$
:"# O X2 MAP=/
4
HC
7D;K O 4U3 MAP=/
2
<=
7D;K O 4R5 MAP=/

+DKMIF
]R A !-$$ IC
2ST2U V@@WH
:"# ^ X2 MAP=/
4
HC
7D;K ^ 4U3 MAP=/
2
<=
7D;K ^ 4R5 MAP=/

-,9
Nateinal Nutiition uuiing Piegnancy
o 2uuu kcaluay, auu Suu kcaluay in 2
nu
anu S
iu
tiimestei
o Noimal weight gain: 2S-SS lbs
" 1 lbweek
1. IR0N: 1 g entiie piegnancy
" Suu mg: fetus anu placenta
" Suu mg: expanuing mateinal hemoglobin mass
" 2uu mg: excieteu
! No supplementation in 1
st
tiimestei
! Su mg of elemental iion eveiyuay as supplieu by feiious
sulfate, gluconate oi fumaiate
2. CALCI0N
" Su g uepositeu in fetus
" 4uu-9uu mg Calcium supplementation
Nateinal Nutiition uuiing Piegnancy
S. 'D=><@ - uue to pievalence of u0ITER
" foi a 49 kg woman = 1uu micio g + 2S micio uay
4. _><?
" essential foi enzymatic activity iequiieu foi giowth,
biain uev't, sexual matuiation & immune function
" 12 mguay
S. 6BDHEBDK;H
" essential foi bone calcification
" absoiption impaiieu by antaciu intake
6. :DFIC@
" Contiibuting factoi foi anemia
" SSu mcguay

N0TRITI0N B0RINu PREuNANCY
o Caloiies - Suu kcaluay (2
nu
to S
iu
tii)
o CB0N - 9 guay
o CB0 - Su to 1uu guay
o Fats - 1S - 2S guay
Bietaiy Computation
Bt in cm - 1uu =. 1u% = BBW x SS (activity)
IBW
IBW + Suu kcal = TCR x .6 CB0 4
TCR x 1.S CB0N 4
TCR x .2S Fats 9
Pie-natal Check up
o Fiequency
Nonthly until 28 weeks
Eveiy 2 weeks until S6 weeks
Weekly S7 weeks onwaius

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o uYN 0PB F0RN
! Nenstiual histoiy
o Nenaiche
o Inteival
o Buiation
o Intensity
o Symptoms
! Sexual Bistoiy
o 0nset
o # paitneis
o Byspaieunia
o Post coital bleeuing
o Contiaception
o uYN 0PB F0RN
! Bieast Examination
! Abuominal
examination
! Pelvic Exam
" %LC@K<IF A@<>CIF>I
" #E@?;F;M
" '%
* Ask patient to voiu fiist
! If no sexual contact:
RECTAL
EXANINATI0N, B0N'T
B0 SPEC0L0N EXAN
! Bo Pap Smeai if
sexually active
Speculum Exam
Inteinal Examination - Ceivix anu 0teius
Inteinal Examination - Aunexa
Rectovaginal Examination
uYNEC0L0uY
Pelvic Examination
%LC@K<IF A@<>CIF>I
o Lesions
#E@?;F;M @LIM><IC>D<
o Besciibe the ceivix anu the vaginal uischaige
o Eg. Ceivix is pink, smooth with minimal whitish mucoiu
non-foul smelling uischaige
'<C@K<IF %LIM><IC>D<
o Besciibe the ceivix, uteius anu aunexa
o Eg. Ceivix fiim, long, closeu; uteius noimal-sizeu
anteveiteu, movable, nontenuei; no aunexal mass oi
tenueiness
&@?CDJIA><IF @LIMN if inuicateu
&%($*/ %8*9N ceivix fiim, long (cannot assess if ceivix is
closeu oi uilateu)


-
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.

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(
7
*
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-
%

Vaginal Discharge
o Physiologic
lactobacilli
estrogen
glycogen
Promotes
growth of
lactobacilli;
inhibits growth
of pathogenic
organisms
pH 3.8-4.2*
lactic acid
The vaginal Ecosystem
Infective vaginitis: Signs anu Symptoms
o vaginal uischaige
o Piuiitus
o 0uoi
o Buining sensation
o Bysuiia
o Byspaieunia
o Synuiome of unknown cause
chaiacteiizeu by uepletion of the
noimal lactobacillus population anu an
oveigiowth of vaginal anaeiobes
(!"#$%&#&''" )"*+%"'+,) accompanieu
by loss of usual vaginal aciuity.
Bacterial Vaginosis
Amsel's Ciiteiia (S out of 4)
! thin gieen oi giay-white
homogenous uischaige
! clue cells
! pB > 4.S
! Amine ouoi with 1u% K0B (Whiff
Test)

Tieatment
o 9@CKD<>=I`DF@ R33MAPCIZ 4 CIZ "', L ] =IaH
Alteinative iegimens
o Netioniuazole 2 g oially as single uose
o Clinuamycin Suu mg BIB x 7 uays
Tiichomoniasis
copious yellow-gieen fiothy
uischaige
pB > 4.S
stiawbeiiy ceivix
buining sensation
uyspaieunia

Wet mount (NSS) - motile
tiichomonaus
Whiff test (+)
&@?DMM@<=@= &@A>M@<
0 9@CKD<>=I`DF@ R33 MA CV>?@ =I>Fa bDK ] =IaH

*FC@K<IC>J@ &@A>M@<H
0 Netioniuazole 2 g oially in a single uose

0 Tiniuazole 2 g oially in a single uose


$K@IC H@L;IF EIKC<@K
Tieatment
Canuiuiasis
o -"%$+$" "'.+/"%,
o 0thei pathogenic species
0 -"%$+$" *'".#"0"
0 -"%$+$" 1"#"1,+'2,+,
0 -"%$+$" 0#21+/"'+,
0 -"%$+$" 3#4,&+
o Common among uiabetics,
piegnant women, patients on
chionic steioius oi bioau-
spectium antibiotics anu
0CP useis
Canuiuiasis
o Seveie vulvai piuiitus
o Cuiu-like, whitish vaginal
uischaige auheient to
vaginal walls
o No ouoi
o pB < 4.S
1u% K0B Smeai
Canuiuiasis
TREATNENT
! (FDCK>MI`DF@ JIA><IF CIZF@C
o 1uu mgtab 1 tab 0BBS x 7 uays
o 2uu mgtab 1 tab 0BBS x S uays
o Suumgtab 1 tab 0BBS single uose
! :F;?D<I`DF@ 4R3MAPCIZ 4 CIZ !,
! 9>?D<I`DF@ 433 MA JIA H;EE L ] =IaH
Clinical Featuies of vaginal Bischaige
"I?C@K>IF 0IA><DH>H (I<=>=>IH>H $K>?BDMD<>IH>H
SSx Foul smelling vaginal
uischaige
White thick vaginal
uischaige; piuiitus,
buining, uysuiia
Yellowish foul
smelling vaginal
uischaige, piuiitus,
uysuiis
PE
finuings
Thin whitish giay
homogenous
uischaige
Thick cuiu-like
uischaige auheient to
vaginal walls, vaginal
eiythema
Yellow, fiothy
uischaige with oi
without ceivical
eiythema
pB >4.S <4.S >4.S
Wet
Nount
Clue cells
Amine ouoi on K0B
(Whiff test)
Byphae oi spoies Notile tiichomonaus
0iganism "#$%&'$'((# )#*&#(*+ ,- #(.*/#&+ 0$*/1232&#+ )#4*&#(*+
Tieatment Netioniuazole Clotiimazole Netioniuazole
Nixeu vaginal Infection
! Niconazole + metioniuazole (Neopenotian)
vaginal suppositoiy 0BBS x 7 uays
! Nystatin + Netioniuazole (Flagystatin)
vaginal supposoiy 0BBS x 7 uays
Nucopuiulent Ceivicitis
(K>C@K>I
" gioss visualization of
yellow mucopuiulent
mateiial on a white
cotton swab
" > 1u pei micioscopic
fielu (magnification
1uuu) on uiam-
staineu smeais
obtaineu fiom the
enuoceivix

#>A<H I<= HaMECDMH
" hypeitiophic anu euematous ceivix
" vaginal uischaige, ueep uyspaieunia, anu
postcoital bleeuing
6ICBDA@<H
" ,1(#35%*# 6$#/123#6*+
" 7'*++'$*# 42&2$1'#'
Nucopuiulent Ceivicitis
Tieatment
-D<DKKB@I
Cefixime 4uu mg po 0B
Ceftiiaxone 12Smg IN

5678 -9'":;$+"' 09&#"1; *8 &26 $9('% 296
(BFIMa=>I
Azithiomycin 1 gm single uose
Boxycycline 1uu mg biu x 7uays
-
.
+
%
(
!
/
!
-
.

/
%
#
'!
+
#
!
+

%
8
$
%
&
+
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/
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%
+
'$
*
/
'*

Conuyloma Acuminata
o BPv 6 & 11 - benign, waits
o BPv 16 & 18 - piemalignant anu malignant
lesions
o Sexual tiansmission oi autoinoculation
o Conuitions that pieuispose to BPv
" 'MM;<DH;EEK@HH>D<Y =>IZ@C@HY EK@A<I<?aY FD?IF
CKI;MI
o Signs anu symptoms
" Asymptomatic
" Pain, itching, bleeuing when fiiable
" Foul ouoi if seconuaiily infecteu
Conuyloma Acuminata
Tieatment
6D=Dc>FDL 3QR\
HDF;C>D< DK A@F
'M>d;>MD= R\ ?K@IM
eIF=IKIf
N0A Antimitotic Immune enhancei
Bose BIB foi S uays then 4
uays off up to 4 cycles
Baily anu BS, Sx a week
up to 16 weeks
Wash 6-1u min aftei
Siue effects Nilu to moueiate pain
Local iiiitation
Nilu to moueiate local
inflammation
Piegnancy N0 N0
Tieatment
(KaDCB@KIEa $K>?BFDKDI?@C>? I?>=
N0A Theimal-inuuceu
cytolysis
Chemical coagulation of
pioteins
Bose Weekly eveiy 1-2
weeks
Weekly
Siue effects Pain, neciosis,
blisteiing
Pain
Piegnancy YES N0
%F@?CKD?I;C@Ka DK #;KA>?IF %L?>H>D<
BPv
o Auvise CERvICAL CANCER
vACCINATI0N
" (%&0*&'8 g 760 4[ h 4U
" -*&,*#'/ g 760 [Y 44Y 4[ I<= 4U
o Age gioup: 1S-26 yo
o Nales can be given BPv vaccination
-@<>CIF iF?@KH
Syphilis
uenital heipes
Chancioiu
uianuloma inguinale (uonovanosis)
Lymphogianuloma veneieum
Clinical Featuies of uenital 0lceis
#aEB>F>H 7@KE@H (BI<?KD>=
Incubation 2-4 weeks (1-12 weeks) 2-7 uays 1-14 uays
1
u
lesion Papule vesicle Papule oi pustule
# lesions 0sually 0NE Nultiple Nultiple
Euges Shaiply uemaicateu,
elevateu, iounu oi oval
Eiythematous 0nueimineu, iaggeu,
iiiegulai




Bepth Supeificial oi ueep Supeificial Excavateu
Base Smooth, nonpuiulent Seious, eiythematous Puiulent
Inuuiation Fiim None Soft
Pain 0nusual Common veiy tenuei
Lymphaueno-
pathy
Fiim, nontenuei,
bilateial
Fiim, tenuei, bilateial Tenuei, may suppuiate,
unilateial
Clinical Featuies of uenital 0lceis
#aEB>F>H 7@KE@H (BI<?KD>=
Causative
oiganism
Tieponema palliuum BSv 1 anu 2 Baemophilus uucieyi
Biagnosis Scieening: vBRL anu
RPR
valiuation: FTA-ABS anu
NBA-TP
Tzanck smeai
viial cultuie
Seiology
uiam stain
Cultuie
Tieatment Piimaiy (Chancie)
PEN u 2.4 N unitsIN
single uose

Acyclovii 2uumg S x
uay 4uu mg tiu

Famciclovii 2Su mg tiu

valacyclovii 1uuu mg biu

7-1u uays
Azithiomycin 1 gtab
single uose

Ceftiaxone 2Su mg IN
single uose

Cipiofloxacin Suu mg BIB
x S u

Eiythiomycin Suu mg
q 6 his x 7 u

Clinical Featuies of uenital 0lceis
/aMEBAKI<;FDMI
0@<@K@;M
,D<DJI<DH>H
Incubation S uays-6 weeks 1-4 weeks (up to 6 months)
1
u
lesion Papule, pustule oi vesicle Papule
# lesions 0sually 0ne vaiiable
Euges Elevateu, iounu oi oval,
iiiegulai
Elevateu, iegulai
Bepth supeivicial, oi ueep Elevateu
Base vaiiable Reu anu iough "beefy"
Inuuiation 0ccasionally fiim Fiim
Pain vaiiable 0ncommon
Lymphaueno-
pathy
Tenuei, may suppuiate,
loculateu, usually unillateial
Pseuuoauenopathy
-
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0
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Befinitions
Oligomenorrhea
Bleeding occurs at intervals of > 35 days and usually is caused by a
prolonged follicular phase.
Polymenorrhea
Bleeding occurs at intervals of < 21 days and may be caused by a luteal-
phase defect.
Menorrhagia
Bleeding occurs at normal intervals (21 to 35 days) but with heavy flow
(>=80 mL) or duration (>=7 days).
Menometrorrhagia
Bleeding occurs at irregular, noncyclic intervals and with heavy flow
(>=80 mL) or duration (>=7 days).
Amenorrhea
Bleeding is absent for 6 months or more in a nonmenopausal woman.
Metrorrhagia or bleeding
intermenstrual
Irregular bleeding occurs between ovulatory cycles; causes to consider
include cervical disease, intrauterine device, endometritis, polyps,
submucous myomas, endometrial hyperplasia, and cancer.
Midcycle spotting
Spotting occurs just before ovulation, usually because of a decline in the
estrogen level.
Postmenopausal
bleeding
Bleeding recurs in a menopausal woman at least 1 year after cessation of
cycles.
Acute emergent
abnormal uterine
bleeding
Bleeding is characterized by significant blood loss that results in
hypovolemia (hypotension or tachycardia) or shock.
Dysfunctional uterine
bleeding
This ovulatory or anovulatory bleeding is diagnosed after the exclusion of
pregnancy or pregnancy-related disorders, medications, iatrogenic
causes, obvious genital tract pathology, and systemic conditions.
Abnoimal 0teiine Bleeuing
AN0v0LAT0RY 0v0LAT0RY
o '<bK@d;@<CY
>KK@A;FIK
o 9@<HCK;IF ZF@@=><A
CBIC JIK>@H ><
IMD;<CY =;KIC>D<
I<= ?BIKI?C@K I<=
<DC EK@?@@=@= Za
EK@M@<HCK;IF
MDF>M><I

o &@A;FIKY MD<CBFa
E@K>D=H CBIC IK@
B@IJa DK EKDFD<A@=
o iH;IFFa H@?D<=IKa
CD I HaHC@M>? DK I<
DKAI<>? E@FJ>?
EICBDFDAa
Abnoimal 0teiine Bleeuing
Anovulatoiy cycles
,aHb;<?C>D<IF ;C@K><@ ZF@@=><A
%<=D?K><@ =>HDK=@KH

0vulatoiy cycles
Systemic causes
o "FDD= =aH?KIH>IY BaEDCBaKD>=>HMY F>J@K DK
K@<IF =>HDK=@K
Repiouuctive tiact
o *??>=@<CH Db EK@A<I<?a
o %<=DM@CK>IF EDFaE
o #;ZM;?D;H MaDMI
o *=@<DMaDH>H
o +@DEFIH>I g @<=DM@CK>IFY ?@KJ>?IFY JIA><IF
Abnoimal 0teiine Bleeuing
6 6DFaE
* *=@<DMaDH>H
/ /@>DMaDMI
9 9IF>A<I<?a I<= 7aE@KEFIH>I
( (DIA;FDEICBa
! !J;FICDKa ,aHb;<?C>D<
% %<=DM@CK>IF
' 'ICKDA@<>?
+ +DC ?FIHH>c>@=
CASE
o An 18 yeai olu nulligiaviu, no sexual contact, consulteu
because of iiiegulai menses. She hau menaiche at 11 yeais
olu. Bei menses weie coming eveiy Su-6u uays, S to S uays
uuiation, moueiate in amount. Fiom age 1S yeais, she
staiteu to have hei menses eveiy 2-S months. She was also
noteu to have gaineu weight foi the past 2 yeais. BNI 26,
with moueiate haii on the uppei lip anu chin, excessive haii
on the chest, infiaumbilical aiea, uppei anu lowei back anu
the thighs.
o Rectal exam: ceivix fiim, long; uteius noimal-sizeu,
anteveiteu; no aunexal mass oi tenueiness

Assessment: Abnoimal uteiine bleeuing piobably
anovulatoiy
Plan: TvS

P0LYCYSTIC 0vARIAN SYNBR0NE
1990 National
Institutes of Health
Criteria (NIH):
Requires both criteria
2003 ESHRE/ASRM
(Rotterdam):
Requires 2 of 3 criteria
2006 Androgen Excess
Society (AES):
Requires all 3 criteria
1 Chronic anovulation 1 Oligo-and/or
anovulation
1 Ovarian dysfunction
(oligo-ovulation and/or
polycystic ovaries)
2 Clinical and/or
biochemical signs of
hyperandrogenism
2 Clinical and/or
biochemical signs of
hyperandrogenism
2 Hyperandrogenism
(hirsutism and/or
hyperandrogenemia)
3 Polycystic ovaries 3 Exclusion of other
androgen excess
disorders
Exclusion of other androgen excess disorders
P0LYCYSTIC 0vARY
o 12 or more follicles
measuring <10 mm in
diameter
Follicles peripherally
located (subcapsular)
o increased ovarian volume
(>10 cm3)

o only one ovary fitting the
definition is required for
diagnosis



Lifestyle modification, targeting a
weight loss of 5-10% of initial body
weight, significantly improve
menstrual regularity and rate of
ovulation. Target BMI 20-25
NANAuENENT



NANAuENENT
Metformin should be used as an adjunct
to general lifestyle modification but not
as a replacement for weight loss,
improved diet and increased exercise in
treating abnormal uterine bleeding in
women with PCOS.
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Thickeneu enuometiium
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o Come back on Bay 1 oi Bay 2 of menses
o NPA 1u mgtab 1 tab 0B on ,IaH 4[T2R
of menses x 6 cycles
o Repeat TvS aftei tieatment
NANAuENENT - TvS
o Thin Enuometiium
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NANAuENENT - TvS
The use of oral contraceptive pills for 21-day
period followed by a 7-day pill free interval
improves menstrual regularity among women
with PCOS, regardless of body mass index.
NANAuENENT

The use of oral contraceptives is the
first choice in the treatment of hirsutism
in PCOS.
Estiogenic component of 0CPs
l
Suppiesses LB
l
Becieaseu ovaiian anuiogen piouuction
CASE
o An Su yo u2P2 (2uu2) consulteu because of
piolongeu anu piofuse menses of S months
uuiation. No othei symptoms.
o SE: ceivix pink, smooth, with minimal bleeuing pei
os
o IE: ceivix fiim, long, closeu. 0teius noimal-sizeu
anteveiteu, no aunexal mass oi tenueiness

Assessment: Abnoimal uteiine bleeuing tc
enuometiial pathology

Plan: TvS
Enuometiial Polyp
o Symptoms
" Inteimenstiual spotting
" Beavy menstiual bleeuing
" No pain
o PE finuings
" Can be noimal
" SE: pinkish to ieuuish smooth
polypoiu mass piotiuuing out
of the ceivical os
Nyoma
Symptoms
o 0nly submucous
myoma will cause A0B
o Intiamuial, subseious
" Pelvic heaviness,
hypogastiic mass,
voiuing symptoms
" Will piesent with pain
only if with
uegeneiation
Nyoma
PE finuings
o Subseious oi Intiamuial
" IE: uteius nouulaily enlaigeu
to S months size, fiim,
movable, nontenuei
o Submucous
" Nay be noimal
" SE (piolapseu): Reuuish,
meaty tissue piotiuuing out
of the ceivical os; with
minimal vaginal bleeuing
Auenomyosis
Symptoms
o Beavy menstiual bleeuing
o Piogiessive uysmenoiihea

PE finuings
o IE: uteius symmetiically
enlaigeu, uoughy, tenuei
Enuometiial Cancei
Patient Piofile
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PE finuings
o Nay be noimal
Nanagement
o TvS: thickeneu enuometiium > Smm
o Enuometiial biopsy oi cuiettage
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Fiequency of Acute Pelvic Pain Biagnosis
Bypogastiic Pain
0TI
Enuometiiosis
Pelvic inflammatoiy uisease
0vaiian newgiowth with complication -
twisting oi leaking oi iuptuieu
Enuometiiosis
o Symptoms
" Piogiessive uysmenoiihea
" Byspaieunia
" Byschezia
" Infeitility
o PE finuings
" IE: fixeu ietioveiteu uteius
" RvE: nouulaiities in cul ue sac
" Aunexal mass - if with enuometiial
cyst
Pelvic Inflammatoiy Bisease
N. gonorrhea has
a rapid onset,
and the pelvic
pain usually
begins a few
days after the
onset of a
menstrual period.
C. trachomatis
alone often may
have an indolent
course with slow
onset, less pain,
and less fever.
Risk Factois
Age at first
intercourse
Multiple
partners
High
frequency
of sex
Coitus
during
menses
Lack of
contraception
Douching
Risk Factois
Previous PID -
25%
IUD occurs
only at the time
of insertion and
in the first 3
weeks after
placement
Smoking /
substance
abuse
Lower genital
tract infections

CBC uuiuelines foi Biagnosis of Acute PIB Clinical
Ciiteiia foi Initiating Theiapy

Empiric treatment should be initiated
if one or more of the minimum criteria are present
and no other cause(s) for the illness can be
identified
Sexually active young women and those at risk for
STDs if they present with lower abdominal pain
Minimum criteria
Cervical motion tenderness
Uterine tenderness
Adnexal tenderness
Auuitional Ciiteiia to Inciease
Specificity of Biagnosis
Temperature >38.3C (101F)
Abnormal cervical or vaginal
mucopurulent discharge
WBCs on saline wet prep
Elevated ESR
Elevated CRP
Gonorrhea or chlamydia test
positive
Nanagement
Medical
Out patient
In patient
Surgical
Conservative
Radical
0utpatient Regimen A
Ceftriaxone 250 mg IM once
Doxycycline 100 mg orally twice a day for 14
days, with or without Metronidazole 500 mg
orally twice a day for 14 days.
PLUS

Ciiteiia foi Bospitalization
Surgical
emergencies
Pregnancy
Non-response to
oral therapy
Inability to tolerate
an outpatient oral
regimen
Severe illness,
nausea and
vomiting, high fever
or tubo-ovarian
abscess
HIV infection with
low CD4 count
Inpatient Regimens
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- Cefotetan 2 g Iv q 12 houi
- Cefoxitin 2 g Iv q 6 houis
5678
- Boxycycline 1uu mg oially
Iv q 12 his
Inpatient Regimens
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- Clinuamycin 9uu mg Iv q 8 houi 5678
- uentamicin loauing uose IvIN (2 mgkg)
followeu by maintenance uose (1.S mgkg) q 8
houis. Single uaily uosing may be substituteu.
Continue either of these regimens for at least 24 hours
after substantial clinical improvement
Complete a total of 14 days therapy with
Doxycycline (100 mg orally twice a day) OR
Clindamycin (450 mg orally 4 times a day