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6QuestionsforEmergencyVaginalDelivery:

1.Duedate?
2.Prenatalcare?Where?
3.Problems(withprenatalcare)?
4.#baby?Vag/Csection?
5.Problems(withpreviousdelivery)?
6.Overallmedicalproblems?

PostCoitalbleedingddx:
Mostconcerning:
o Cancer(screenforcancer)
o Cervicitis/Vaginitis(testforcervicitispH,wetmount,KOH,G/C)
Other:
o Polyps,
o Vaginalatrophy,
o Pregnancy(increaseslikelihoodofpostcoitalspottingduetocervicalectropion):
Painless?Placentapreviauntilprovenotherwise.
Painful?Placentalabruptionuntilprovenotherwise.
o Prolapse
History:askaboutotherabnormaluterinebleeding,sxofinfection,lastcervicalcancertestresults
Physical:lookforsourcesofbleeding:polyps,prolapse,neoplasm,etc.
Labtesting:
o makesurePapsmearuptodate,
o G/Cscreeningifindicated,
o biopsyanygrosslyvisiblelesion

Menorrhagia>80mlbloodloss
Ddx:
Structural:
PALM(Polyps,Adenomyomas,Lyomyoma,Malignancy)
Nonstructural:
COIEN(Coagulopathy,Ovulatory(PCOS),Infection/Iatrogenic(exogenousestrogens,b/c),Endometrial,NOS)
Plan:
Ifyoung:
o Coagulopathy?(bloodtestsforcoagulopathies,PT,PTT,etc)
Ifyoung/postpubertal:
o PCOS?(testosteronelevel,etc)
If30s40s:Fibroids?
o (ultrasound/imaging)
Ifpostmenopausal:
o Cancer/hyperplasia?(endometrialbiopsy)
Nextsteps:
CBCforanemia,
pregnancytest,
pelvicUSforfibroids,
endometrialbiopsyifincreasedriskforcancer,askaboutfertilitydesires
Rx:
combinedOCPs,MIrena,NSAIDs,ablation,myomectomy,hysterectomy

Vaginitis
Ddx:
BV:fishyodor,thingraydischarge,highpH,cluecells,whiffpositive,treatMetro7days500mgBID(noalcohol)
o AnselsCriteria(atleast3):Graydischarge,pH>4.5,+aminewhifftest,>20%epithelialcellsareclue
Trich:yellowfrothydischarge,strawberrycervix,highpH,trichs,whiffpositive/norm,treatMetro2g1x(1dosedoesthe
trich)
Candida:white/cottagecheese,itchiness,erythema(sxworsetheweekbeforemenses),normalpH,buddingyeast,whiff
negative,treatFluconazole150mg1x

Contraception=PSENDWITHANDUSECONDOMSTOPREVENTSTIs
Areyouusingcontraception?
Areyoucurrentlybreastfeeding?
Areyouplanningapregnancy?
Whathaveyoutriedbefore?Whatworked?Whatdidntwork?
Howfaroutinthefutureareyouplanningtohaveachild?
Areyoucomfortablenothavingaperiod(we,asproviders,areverycomfortablewiththisidea)?
Mosteffectiveoptionoutthere:
LARCIUD(w/orw/outhormones),Nexplanon
3yrsnexplanon(unpredictablebleeding),5yrsmirena(chanceofexpulsion),10yrsparagard(donottakeawayperiodcancause
heavierbleeding/cramping)
IUD(noactiveSTI):
Mirenathickenscervicalmucusandatrophiesendometrium.
Copperinparaguardisspermicidal.
Contraindications:
o currentpregnancy,
o acuteinfection,
o copperallergy/wilsondisease(paraguardalone),
o currentbreastcancer(Mirenaalone).
o Mirenadecreasesmenorrhagiaanddysmenorrhea,
o decreaseriskforendometrialcancer
Depo
Every3months,irregularbleeding.Suppressesovulation,thickensmucus.50%haveamenorrheaafter1yearofuse.
Reversibledecreaseinbonemineralization.10monthdelayinreturntoovulationafteruse.
Pill/Patch/Ring:
suppressovulation(preventLH/FSHsurge).
Contraindications:
o thromboembolism,PE,coronaryarterydisease,stroke,smokersover35y/o,breast/endometrialcancer,hypertension.
o Benefits:reducedincidenceofovariancancer,endometrialcancer,benignbreastdisease,acne.Patchislesseffective
inwomenover198lbs!
o OCP:unscheduledbleedingoccursin30%ofwomeninthefirstmonth,butdecreasestolessthan10%bythethird
monthofuse.Riskisslightlyhigherwithlowdose.Stilleffectiveatcontraceptionwhenbleeding!
Condoms/DIaphragm/Spermicide:
Lesseffective(upto30%womengetpregnantinoneyear).
o Diaphragmmustbefittedbydoctor,doesnotprotectagainstHIV.
o CondomsaretheonlymethodofcontraceptionthatprotectagainstHIV!
Spermicide:mustwait30minafterapplicationbeforesex.MaymakeptmoresusceptibletoSTIsviavaginalirritation.
Progesteroneonly:
Pill(thickencervicalmucus,Depo,Nexplanon)dontusewithhxdepression
Permanent:Tuballigation,Essure,Vasectomy
ANDUSECONDOMSTOPREVENTSTIS!!
NoEstrogenifbreastfeedingormigraineswithaura.
Algorithm:Permanentortemporary?Iftemporary,longactingorshortacting?Continualactionsoronetimeprocedure?

WellWomanVisit,Screening
STItestingifsexuallyactiveG/C,HIV
Pap
At21,every3years
At30,every3yearsORcotestingevery5years
At65,canstopifnormalpaps
Mammogram
At40,annual(ACOG)
Colonoscopy
At50,every10years
Occultblood
At65,annual
DEXA
65,5065ifatriskforosteoporosis
Bloodpressureeverytwoyearsifnormal
Talkaboutcontraception,changesinfamilyhistoryandPMH.
GYN:menarche,perioddescription,LMP(menopause).
Sexual:Lifetimepartner,6months,STIs,contraception
OB:numberofpregnancies,delivery,etc.
Primarycare:uptodateonvaccines,cholesterol,bloodpressure
TDapeverytenyears
Gardasil
MMR
Fluvaccine

PossibleProblemsfortheList!
Rhnegative
GBSpositive
Previousrecurrentmiscarriage/pretermlabor
G/Cpositive
Syphilispositive
Herpes
HIVpositive
+Downscreen
+cysticfibrosis
ElevatedAFP
AbnmlanatomyUS(pericardialeffusion,etc)
Latetocare
IUGR
GestationalDiabetes
GestationalHTN/PEC
PPBC
Carseat,pediatrician,circumcision
Breast/bottlefeeding
Rubellanonimmune
Substanceabuse
Languagebarrier
IPV
Medicalproblems