1. BLUEPRINTSOBSTETRICS &GYNECOLOGYSixth Edition

2. BLUEPRINTSOBSTETRICS &GYNECOLOGYSixth EditionTamara Callahan, MD, MPPAssistant ProfessorDepartment of Obstetrics and GynecologyDivision of Gynecologic SpecialtiesVanderbilt University Medical CenterNashville, TennesseeAaron B. Caughey, MD, MPP, MPH, PhDProfessor and ChairDepartment of Obstetrics and GynecologyOregon Health and Science UniversityPortland, Oregon 3. Acquisitions Editor: Susan RhynerProduct Manager: Jennifer VerbiarMarketing Manager: Joy Fisher-WilliamsVendor Manager: Bridgett DoughertyManufacturing Coordinator: Margie OrzechDesign Coordinator: Terry MallonProduction Services: S4Carlisle Publishing ServicesCopyright 2013 by Lippincott Williams & Wilkins, a Wolters Kluwer business.351 West Camden Street Two Commerce SquareBaltimore, MD 21201 2001 Market StreetPhiladelphia, PA 19103Printed in ChinaAll rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form orby any means, including photocopying, or utilized by any information storage and retrieval system without writtenpermission from the copyright owner. The publisher is not responsible (as a matter of product liability, negligence,or otherwise) for any injury resulting from any material contained herein. This publication contains informationrelating to general principles of medical care that should not be construed as specific instructions for individualpatients. Manufacturers product information and package inserts should be reviewed for current information,including contraindications, dosages, and precautions.Library of Congress Cataloging-in-Publication DataCallahan, Tamara L.Blueprints obstetrics & gynecology / Tamara L. Callahan, Aaron B. Caughey. 6th ed.p. ; cm.Obstetrics & gynecologyBlueprints obstetrics and gynecologyIncludes bibliographical references and index.ISBN 978-1-4511-1702-8 (alk. paper)I. Caughey, Aaron B. II. Title. III. Title: Obstetrics & gynecology. IV. Title: Blueprints obstetrics and gynecology.[DNLM: 1. Pregnancy Complications--Examination Questions. 2. Genital Diseases, Female--ExaminationQuestions. WQ 18.2]618.0076--dc232012028782DISCLAIMERCare has been taken to confirm the accuracy of the information present and to describe generally acceptedpractices.However, the authors, editors, and publisher are not responsible for errors or omissions or for anyconsequencesfrom application of the information in this book and make no warranty, expressed or implied, withrespect to the currency, completeness, or accuracy of the contents of the publication. Application of this informa-tionin a particular situation remains the professional responsibility of the practitioner; the clinical treatmentsdescribed and recommended may not be considered absolute and universal recommendations.The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth inthis text are in accordance with the current recommendations and practice at the time of publication. However, inview of ongoing research, changes in government regulations, and the constant flow of information relating to drugtherapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indicationsand dosage and for added warnings and precautions. This is particularly important when the recommended agent isa new or infrequently employed drug.Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA)clearancefor limited use in restricted research settings. 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ContentsPreface. xAcknowledgments. xiAbbreviations . xiiPART I: Obstetrics . 11 Pregnancy and Prenatal Care. 12 Early Pregnancy Complications. 133 Prenatal Screening, Diagnosis, and Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .254 Normal Labor and Delivery. 405 Antepartum Hemorrhage. 626 Complications of Labor and Delivery. 787 Fetal Complications of Pregnancy. 948 Hypertension and Pregnancy. 1119 Diabetes During Pregnancy. 12110 Infectious Diseases in Pregnancy. 13111 Other Medical Complications of Pregnancy . 14712 Postpartum Care and Complications . 161PART II: Gynecology. 17413 Benign Disorders of the Lower Genital Tract. 17414 Benign Disorders of the Upper Genital Tract. 18715 Endometriosis and Adenomyosis. 20416 Infections of the Lower Female Reproductive Tract. 21517 Upper Female Reproductive Tract and Systemic Infections. 23018 Pelvic Organ Prolapse. 23919 Urinary Incontinence. 25020 Puberty, the Menstrual Cycle, and Menopause. 26721 Amenorrhea. 28122 Abnormalities of the Menstrual Cycle. 29323 Hirsutism and Virilism . 30624 Contraception and Sterilization. 316v 5. vi Contents25 Elective Termination of Pregnancy. 33726 Infertility and Assisted Reproductive Technologies. 34627 Neoplastic Disease of the Vulva and Vagina. 36028 Cervical Neoplasia and Cervical Cancer. 36929 Endometrial Cancer. 38330 Ovarian and Fallopian Tube Tumors. 39231 Gestational Trophoblastic Disease. 40432 Benign Breast Disease and Breast Cancer. 416Questions . 434Answers. 450Index. 466 6. Jeff Andrews, MD, FRCSCAssociate ProfessorDepartment of Obstetrics and GynecologyDivision of General Obstetrics and GynecologyVanderbilt University School of MedicineNashville, TennesseeSuzanne BarakatMedical studentUniversity of North CarolinaChapel Hill, North CarolinaAlison Barlow, WHNPAssistant ProfessorDepartment of Obstetrics and GynecologyDivision of Midwifery and Advanced Practice NursingVanderbilt University School of MedicineNashville, TennesseeLisa Bayer, MDFellow, Family PlanningOregon Health & Science UniversityPortland, OregonDaniel H. Biller, MDAssistant ProfessorDepartment of Obstetrics and GynecologyDivision of Female Pelvic Medicine and ReconstructiveSurgeryVanderbilt University School of MedicineNashville, TennesseeYvonne W. Cheng, MD, PhDAssistant ProfessorUniversity of California, San FranciscoSan Francisco, CaliforniaHoward Curlin, MDDepartment of Obstetrics and GynecologyMadigan Army Medical CenterTacoma, WashingtonAmy Doss, MDFellow, Maternal-Fetal MedicineOregon Health & Science UniversityPortland, OregonSharon Engel, MDResident, Obstetrics and GynecologyOregon Health & Science UniversityPortland, OregonAbby Furukawa, MDResident, Obstetrics and GynecologyOregon Health & Science UniversityPortland, OregonKaren Gold, MD, MSCIAssistant ProfessorDirector of Resident EducationDepartment of Obstetrics and GynecologyDivision of Female Pelvic Medicine and ReconstructiveSurgeryUniversity of Oklahoma - TulsaTulsa, OklahomaMeghana Gowda, MDClinical InstructorDepartment of Obstetrics and GynecologyDivision of Female Pelvic Medicine and ReconstructiveSurgeryVanderbilt University School of MedicineNashville, TennesseeWilliam J. Kellett, DOAssistant ProfessorDepartment of Obstetrics and GynecologyDivision of General Obstetrics and GynecologyVanderbilt University School of MedicineNashville, TennesseeTamara Keown, MSN, WHNP-BCAssistant ProfessorDepartment of Obstetrics and GynecologyDivision of Midwifery and Advanced Practice NursingVanderbilt University School of MedicineNashville, TennesseeviiContributors 7. viii ContributorsDineo Khabele, MD, FACOG, FACSAssistant ProfessorDepartment of Obstetrics and GynecologyDivision of Gynecologic OncologyVanderbilt University School of MedicineNashville, TennesseeJohn Lucas, MDAssistant ProfessorDepartment of Obstetrics and GynecologyDivision of Reproductive Endocrinology and InfertilityVanderbilt University School of MedicineNashville, TennesseeLucy Koroma, MSN, WHNP-BCDepartment of Obstetrics and GynecologyDivisions of Reproductive Endocrinology andGynecologyVanderbilt University School of MedicineNashville, TennesseeErica Marsh, MDAssistant ProfessorDepartment of Obstetrics and GynecologyDivisions of Reproductive Endocrinology andInfertility and Reproductive Biology ResearchFeinberg School of Medicine - Northwestern UniversityEvanston, IllinoisJohn Mission, MDResidentObstetrics and GynecologyOregon Health and Science UniversityPortland, OregonMelinda New, MDAssistant ProfessorDirector of Resident EducationDepartment of Obstetrics and GynecologyDivision of GynecologyVanderbilt University School of MedicineNashville, TennesseeBrian Nguyen, MDResident, Obstetrics and GynecologyOregon Health & Science UniversityPortland, OregonRachel Pilliod, MDResident, Obstetrics and GynecologyBrigham & Womens HospitalBoston, MassachusettsStacey Scheib, MDAssistant ProfessorDepartment of Gynecology and ObstetricsDivision of Minimally Invasive GynecologyJohns Hopkins HospitalBaltimore, MarylandBrian L. Shaffer, MDDirector, Fetal Diagnosis & Treatment CenterOregon Health & Science UniversityPortland, OregonJonas Swartz, MDResident, Obstetrics and GynecologyOregon Health & Science UniversityPortland, OregonMay Thomassee, MDClinical InstructorDepartment of Obstetrics and GynecologyDivision of Minimally Invasive GynecologyVanderbilt University School of MedicineNashville, TennesseeSusan H. Tran, MDAssistant Professor, Maternal-Fetal MedicineOregon Health & Science UniversityPortland, OregonAshlie Tronnes, MDFellow, Maternal-Fetal MedicineUniversity of WashingtonSeattle, WashingtonGina Westhoff, MDFellow, Gynecologic OncologyUniversity of California, San FranciscoKeenan Yanit, MDResident, Obstetrics and GynecologyOregon Health & Science UniversityPortland, OregonJessica L. Young, MDAssistant ProfessorDepartment of Obstetrics and GynecologyDivision of General Obstetrics and GynecologyVanderbilt University School of MedicineNashville, TennesseeAmanda Yunker, DOAssistant ProfessorDepartment of Obstetrics and GynecologyDivision of Minimally Invasive GynecologyVanderbilt University School of MedicineNashville, Tennessee 8. Contributors toPrevious EditionsixStephanie Beall, MDSection Implantation & Oocyte PhysiologyNational Institutes of HealthBethesda, MarylandNicole S. Carroll, MDDepartment of Obstetrics and GynecologyWilmington HealthWilmington, North CarolinaAnnette Chen, MDDepartment of Obstetrics and GynecologyDivision of Gynecologic OncologyKaiser PermanenteOakland, CaliforniaBruce B. Feinberg, MDDepartment of Obstetrics and GynecologyDivision of Maternal-Fetal MedicineBrigham and Womens HospitalBoston, MassachusettsLinda J. Heffner, MD, PhDProfessor and ChairDepartment of Obstetrics and GynecologyBoston University Medical SchoolBoston, MassachusettsCeleste O. Hemingway, MDAssistant ProfessorDepartment of Obstetrics and GynecologyDivision of General Obstetrics and GynecologyVanderbilt University School of MedicineNashville, TennesseeSarah E. Little, MDFellowMaternal-Fetal MedicineBrigham and Womens HospitalBoston, MassachusettsSara Newmann, MD, MPHAssistant Clinical ProfessorDepartment of Obstetrics and GynecologySan Francisco General HospitalSan Francisco, CaliforniaSusan H. Tran, MDAssistant Professor, Maternal-Fetal MedicineOregon Health & Science UniversityPortland, OregonJing Wang Chiang, MDDepartment of Obstetrics and GynecologyDivision of Gynecologic OncologyStanford Womens Cancer CenterPalo Alto, California 9. In 1997, the first five books in the Blueprints series were published as board review for medical students,interns, and residents who wanted high-yield, accurate clinical content for USMLE Steps 2 and 3. Fifteenyears later, we are proud to report that the original books and the entire Blueprints brand of review materi-alshave far exceeded our expectations.The feedback weve received from our readers has been tremendously helpful and pivotal in decid-ingwhat direction the sixth edition of the core books would take. To ensure that the sixth edition ofthe series continues to provide the content and approach that made the original Blueprints a success, wehave expanded the text to include the most up-to-date topics and evidence-based research and therapies.Information is provided on the latest changes in the management of cervical dysplasia and cervical cancerscreening, abnormal uterine bleeding, hypertension in pregnancy, cervical insufficiency, and preterm labor.The newest and future techniques in contraception and sterilization and hormone replacement therapiesare covered, as are contemporary treatment options for uterine fibroids and invasive breast cancer.The succinct and telegraphic use of tables and figures was highly acclaimed by our readers, so we haveredoubled our efforts to expand their usefulness by adding updated and improved artwork, including thesection of color plates. In each case, we have tried to include only the most helpful and clear tables andfigures to maximize the readers ability to understand and remember the material.We have likewise updated our bibliography to include evidence-based articles as well as referencesto classic articles and textbooks in both obstetrics and gynecology. These references are now provided inelectronic format. It was also suggested that the review questions should reflect the current format of theboards. We are particularly proud to include new and revised board-format questions in this edition withfull explanations of both correct and incorrect options provided in the answers. In particular, we haveadded a section of case-based clinical vignettes questions at the end of each chapter to facilitate review ofthe topics and practice for the boards.That said, we have also learned from our readers that Blueprints is more than just board review forUSMLE Steps 2 and 3. Students use the books during their clerkship rotations, subinternships, and as aquick refresher while rotating on various services in early residency. Residents studying for USMLE Step3 often use the books for reviewing areas outside their specialty. Students in physician assistant, nursepractitioner, and osteopath programs use Blueprints as a companion to review materials in their own areasof expertise.When we first wrote the book, we had just completed medical school and started residency training.Thus, we hope this new edition brings both that original viewpoint as well as our clinical experience gar-neredover the past 15 years. However you choose to use Blueprints, we hope that you find the books inthe series informative and valuable to your own continuing education.Tamara L. Callahan, MD, MPPAaron B. Caughey, MD, MPP, MPH, PhDPrefacex 10. AcknowledgmentsI would like to express my sincere and deep appreciation to my coauthor, Dr. Caughey, and to the OB/Gynresidentsand faculties at Harvard and Vanderbilt who gave liberally of their time and expertise to make thisbook something of which we can all be proud. Without the extraordinary talent and commitment of thesephysicians and providers, this project would not have been possible. This accomplishment is also credited in nosmall part to an incredible core of family and friends who lovingly and selflessly allow me to follow my passionfor education and womens health. And to my children, Connor and Jaela, being your mother has been an inde-scribablehonor and an immeasurable joya blessing which I try to earn each and every day. I would also like toacknowledge my mentors, Dr. William F. Crowley, Jr., Dr. Janet Hall, Dr. Linda J. Heffner, Dr. Nancy Chescheir,Dr. Robert Barbieri, and Dr. Nancy E. Oriol, whose strength, insight, leadership, and drive are exemplary of whatit means to be an active contributor to academic medicine and womens health. Lastly, Id like to thank the manymedical students and residents who have shared their input and enthusiasm with us along this exciting journey.Their support has been paramount to the success of this project and to our quest to make this book the very bestit can be. It has truly been a privilege to be a small part of their never-ending learning experience.Tamara L. Callahan, MD, MPPI would like to acknowledge and extend my thanks to everyone involved in the sixth edition of our book, mostimportantly my coauthor, Dr. Callahan, as well as all of those who contributed to the first five editions, particu-larlyDrs. Chen, Feinberg, and Heffner, and the staff at both Blackwell and LWW. I would also like to thank mycolleagues and mentors for the supportive environment in which I work, in particular, the residents and facultyin the department of Obstetrics and Gynecology at OHSU as well as my mentors, Drs. Washington, Norton,Kuppermann,Ames, Repke, Blatman, Robinson, and Norwitz. I would also like to acknowledge the suggestionsand critiques from medical students around the country and particularly those at Harvard, UCSF, and OHSUwho keep pushing us to produce better editions of this work. I would also like to thank my parents, Bill andCarol, for their support for all these years. To my children, Aidan, Ashby, Amelie, and our little man, Atticusand of course, to my wife, Susan thank you for all your patience and support during all my projects. I loveyou all so very much.Aaron B. Caughey, MD, MPP, MPH, PhDxi 11. Abbreviations3-HSD 3-hydroxysteroid dehydrogenase5-FU 5-fluorouracil17-OHP 17-hydroxyprogesteroneACTH adrenocorticotropic hormoneAD autosomal dominantADH antidiuretic hormoneAED antiepileptic drugAFE amniotic fluid embolusAFI amniotic fluid indexAFLP acute fatty liver of pregnancyAFP -fetoproteinAGC atypical glandular cellsAIDS acquired immunodeficiency syndromeALT alanine transaminaseAMA advanced maternal ageAMH Antimullerian HormoneAPA antiphospholipid antibodyAR autosomal recessiveARDS adult respiratory distress syndromeAROM artificial rupture of membranesART assisted reproductive technologyASC atypical squamous cellsASC-H atypical squamous cells cannot exclude high-gradesquamous intraepithelial lesionASC-US atypical squamous cells of undeterminedsignificanceAST aspartate transaminaseAV arteriovenousAZT analogszidovudine-hCG beta human chorionic gonadotropinBID twice a dayBP blood pressureBPP biophysical profileBUN blood urea nitrogenBV bacterial vaginosisCAH congenital adrenal hyperplasiaCBC complete blood countCCCT clomiphene citrate challenge testCF cystic fibrosisCHF congestive heart failureCIN cervical intraepithelial neoplasiaCKC cold-knife conization (biopsy)CMV cytomegalovirusCNS central nervous systemCPD cephalopelvic disproportionCRS congenital rubella syndromeCSF cerebrospinal fluidCT computed tomography (CAT scan)CVA cerebrovascular accidentCVAT costovertebral angle tendernessCVD collagen vascular disordersCVS chorionic villus samplingCXR chest x-rayDA developmental ageD&C dilation and curettageD&E dilation and evacuationDCIS ductal carcinoma in situDES diethylstilbestrolDEXA dual-energy x-ray absorptiometryDHEA dehydroepiandrosteroneDHEAS dehydroepiandrosterone sulfateDHT dihydrotestosteroneDIC disseminated intravascular coagulationDMPA depot medroxyprogesterone acetate (Depo-Provera)DTRs deep tendon reflexesDUB dysfunctional uterine bleedingDVT deep venous thrombosisECG electrocardiogramEDC estimated date of confinementEDD estimated date of deliveryEFW estimated fetal weightEIF echogenic intracardiac focusELISA enzyme-linked immunosorbent assayEMB endometrial biopsyERT estrogen replacement therapyESR erythrocyte sedimentation rateFAS fetal alcohol syndromeFH fetal heartFHR fetal heart rateFIGO International Federation of Gynecology andObstetricsFIRS fetal immune response syndromeFISH fluorescent in situ hybridizationFNA fine-needle aspirationFSE fetal scalp electrodeFSH follicle-stimulating hormoneFTA-ABS fluorescent treponemal antibody absorptionFTP failure to progressG gravidityGA gestational ageGBS group B streptococcusxii 12. GDM gestational diabetes mellitusGFR glomerular filtration rateGH gestational hypertensionGI GastrointestinalGLT glucose loading testGnRH gonadotropin-releasing hormoneGTD gestational trophoblastic diseaseGTT glucose tolerance testGU genitourinaryHAART highly active antiretroviral therapyHb hemoglobinHbH hemoglobin H diseasehCG human chorionic gonadotropinhCS human chorionic somatomammotropinHct hematocritHDL high-density lipoproteinHELLP hemolysis, elevated liver enzymes, low plateletsHIV human immunodeficiency virushMG human menopausal gonadotropinHPL human placental lactogenHPV human papillomavirusHR heart rateHRT hormone replacement therapyHSG hysterosalpingogramHSIL high-grade squamous intraepithelial lesionHSV herpes simplex virusI&D incision and drainageICSI intracytoplasmic sperm injectionIg ImmunoglobulinIM IntramuscularINR International Normalized RatioITP idiopathic thrombocytopenic purpuraIUD intrauterine deviceIUFD intrauterine fetal demise or deathIUGR intrauterine growth restrictedIUI intrauterine inseminationIUP intrauterine pregnancyIUPC intrauterine pressure catheterIUT intrauterine transfusionIVC inferior vena cavaIVF in vitro fertilizationIVP intravenous pyelogramKB Kleihauer-Betke testKOH potassium hydroxideKUB kidneys/ureter/bladder (x-ray)LBW low birth weightLCHAD long-chain hydroxyacyl-CoA dehydrogenaseLCIS lobular carcinoma in situLDH lactate dehydrogenaseLDL low-density lipoproteinLEEP loop electrosurgical excision procedureLFT liver function testLGA large for gestational ageLGV lymphogranuloma venereumLH luteinizing hormoneLIQ lower inner quadrantLletz large loop excision of the transformation zoneLMP last menstrual periodLOQ lower outer quadrantLOT left occiput transverseLSIL low-grade squamous intraepithelial lesionLTL laparoscopic tubal ligationMAO monoamine oxidaseMESA microsurgical epididymal sperm aspirationMHATP microhemagglutination assay for antibodiesto T. pallidumMI myocardial infarctionMIF mllerian inhibiting factorMLK myosin light-chain kinaseMRI magnetic resonance imagingMRKH Mayer-Rokitansky-Kster-Hauser (syndrome)MSAFP maternal serum -fetoproteinMTHFR methyl tetrahydrofolate reductaseNPO nil per os (nothing by mouth)NPV negative predictive valueNRFT nonreassuring fetal testingNSAID nonsteroidal anti-inflammatory drugNST nonstress testNSVD normal spontaneous vaginal deliveryNT nuchal translucencyNTD neural tube defectOA occiput anteriorOCP oral contraceptive pillOCT oxytocin challenge testOI ovulation inductionOP occiput posteriorOT occiput transverseOTC over-the-counterP parityPCOS polycystic ovarian syndromePCR polymerase chain reactionPDA patent ductus arteriosusPE pulmonary embolusPFTs pulmonary function testsPID pelvic inflammatory diseasePIH pregnancy-induced hypertensionPMDD premenstrual dysphoric disorderPMN polymorphonuclear leukocytePMOF premature ovarian failurePMS premenstrual syndromePO per os (by mouth)POCs products of conceptionPOP progesterone-only contraceptive pillsPOP-Q pelvic organ prolapse quantification systemPPCM peripartum cardiomyopathyPPD purified protein derivativePPROM preterm premature rupture of membranesPPS postpartum sterilizationPPV positive predictive valuePROM premature rupture of membranesPSTT placental site trophoblastic tumorPT prothrombin timexiii Abbreviations 13. PTL preterm laborPTT partial thromboplastin timePTU propylthiouracilPUBS percutaneous umbilical blood samplingQD each dayQID four times a dayRBC red blood cellRDS respiratory distress syndromeROM rupture of membranesROT right occiput transverseRPR rapid plasma reaginRR respiratory rateSAB spontaneous abortionSCC squamous cell carcinomaSERM selective estrogen receptor modulatorSGA small for gestational ageSHBG sex hormone binding globulinSIDS sudden infant death syndromeSLE systemic lupus erythematosusSNRIs serotonin and norepinephrine reuptakeinhibitorsSPT septic pelvic thrombophlebitisSROM spontaneous rupture of membranesSSRIs selective serotonin reuptake inhibitorsSTD sexually transmitted diseaseSTI sexually transmitted infectionSVT superficial vein thrombophlebitisTAB therapeutic abortionTAC transabdominal cerclageTAHBSO total abdominal hysterectomy and bilateralsalpingo-oophorectomyTBG thyroid binding globulinTENS transcutaneous electrical nerve stimulationAbbreviations xivTFTs thyroid function testsTLC total lung capacityTNM tumor/node/metastasisTOA tubo-ovarian abscessTOLAC trial of labor after cesareanTOV transposition of the vesselsTPAL term, preterm, aborted, livingTRH thyrotropin-releasing hormoneTSE testicular sperm extractionTSH thyroid-stimulating hormoneTSI thyroid-stimulating immunoglobulinsTSS toxic shock syndromeTSST toxic shock syndrome toxinTTTS twin-to-twin transfusion syndromeUA urinalysisUAE uterine artery embolizationUG urogenitalUIQ upper inner quadrantUOQ upper outer quadrantUPI uteroplacental insufficiencyUS ultrasoundUTI urinary tract infectionV/Q ventilation/perfusion ratioVAIN vaginal intraepithelial neoplasiaVBAC vaginal birth after cesareanVD volume of distributionVDRL Venereal Disease Research LaboratoryVIN vulvar intraepithelial neoplasiaVSD ventricular septal defectVZIG varicella zoster immune globulinVZV varicella zoster virusWBC white blood cellXR x-ray 14. 1Part I ObstetricsChapter1 Pregnancy andPrenatal CarePREGNANCYPregnancy is the state of having products of conception im-plantednormally or abnormally in the uterus or occasionallyelsewhere. It is terminated by spontaneous or elective abortionor by delivery. A myriad of physiologic changes occur in apregnant woman, which affect every organ system.DIAGNOSISIn a patient who has regular menstrual cycles and is sexuallyactive, a period delayed by more than a few days to a week issuggestive of pregnancy. Even at this early stage, patients mayexhibit signs and symptoms of pregnancy. On physical exami-nation,a variety of fi ndings indicate pregnancy (Table 1-1).Many over-the-counter (OTC) urine pregnancy tests havea high sensitivity and will be positive around the time of themissed menstrual cycle. These urine tests and the hospitallaboratory serum assays test for the beta subunit of humanchorionic gonadotropin (-hCG). This hormone producedby the placenta will rise to a peak of 100,000 mIU/mL by 10weeks of gestation, decrease throughout the second trimester,and then level off at approximately 20,000 to 30,000 mIU/mLin the third trimester.A viable pregnancy can be confi rmed by ultrasound, whichmay show the gestational sac as early as 5 weeks on a transvagi-nalultrasound or at a -hCG of 1,500 to 2,000 mIU/mL. Fetalheart motion may be seen on transvaginal ultrasound as soon as6 weeks or at a -hCG of 5,000 to 6,000 mIU/mL.TERMS AND DEFINITIONSFrom the time of fertilization until the pregnancy is 8 weeksalong (10 weeks gestational age [GA]), the conceptus is calledan embryo. After 8 weeks until the time of birth, it is desig-nateda fetus. The term infant is used for the period betweendelivery and 1 year of age. Pregnancy is divided into trimesters.The fi rst trimester lasts until 12 weeks but is also defi ned asup to 14 weeks GA, the second trimester lasts from 12 to14 until 24 to 28 weeks GA, and the third trimester lastsfrom 24 to 28 weeks until delivery. An infant delivered priorto 24 weeks is considered to be previable, delivered between24 and 37 weeks is considered preterm, and between 37 and42 weeks is considered term. A pregnancy carried beyond42 weeks is considered postterm.Gravidity (G) refers to the number of times a woman hasbeen pregnant, and parity (P) refers to the number of preg-nanciesthat led to a birth at or beyond 20 weeks GA or ofan infant weighing more than 500 g. For example, a womanwho has given birth to one set of twins would be a G1 P1, asa multiple gestation is considered as just one pregnancy. Amore specifi c designation of pregnancy outcomes divides parityinto term and preterm deliveries and also adds the number ofabortuses and the number of living children. This is known asthe TPAL designation. Abortuses include all pregnancy lossesprior to 20 weeks, both therapeutic and spontaneous, as wellas ectopic pregnancies. For example, a woman who has givenbirth to one set of preterm twins, one term infant, and had twomiscarriages would be a G4 P1-1-2-3.The prefi xes nulli-, primi-, and multi- are used with respectto gravidity and parity to refer to having 0, 1, or more than 1,respectively. For example, a woman who has been pregnanttwice, one ectopic pregnancy and one full-term birth, wouldbe multigravid and primiparous. Unfortunately, this terminol-ogyoften gets misused with individuals referring to womenwith a fi rst pregnancy as primiparous, rather than nulliparous.Obstetricians also use the term grand multip, which refers to awoman whose parity is greater than or equal to 5.Dating of PregnancyThe GA of a fetus is the age in weeks and days measured fromthe last menstrual period (LMP). Developmental age (DA)or conceptional age or embryonic age is the number of weeksand days since fertilization. Because fertilization usually occursabout 14 days after the fi rst day of the prior menstrual period,the GA is usually 2 weeks more than the DA.Classically, the Nagele rule for calculating the estimateddate of confi nement (EDC), or estimated date of delivery(EDD), is to subtract 3 months from the LMP and add 7 days.Thus, a pregnancy with an LMP of January 16, 2012 wouldhave an EDC of 10/23/12. Exact dating uses an EDC calcu-latedas 280 days after a certain LMP. If the date of ovulationis known, as in assisted reproductive technology (ART), theEDC can be calculated by adding 266 days. Pregnancy datingcan be confi rmed and should be consistent with the examina-tionof the uterine size at the fi rst prenatal appointment. 15. 2 Blueprints Obstetrics & gynecologyOne such decision is whether to resuscitate a newborn at thethreshold of viability, which may be at 23 or 24 weeks of gesta-tiondepending on the institution. Another is the induction oflabor at 41 weeks of gestation. Approximately 5% to 15% ofwomen may be oligo-ovulatory, meaning they ovulate beyondthe usual 14th day of the cycle. Thus, their LMP dating mayoverdiagnose a prolonged (41 weeks gestation) or posttermpregnancy (42 weeks gestation). Thus, early verifi cation orcorrection of dating can correct such misdating.PHYSIOLOGY OF PREGNANCYCardiovascularDuring pregnancy, cardiac output increases by 30% to 50%. Mostincreases occur during the fi rst trimester, with the maximum be-ingreached between 20 and 24 weeks gestation and maintaineduntil delivery. The increase in cardiac output is fi rst due to anincrease in stroke volume and is then maintained by an increasein heart rate as the stroke volume decreases to near prepreg-nancylevels by the end of the third trimester. Systemic vascularresistance decreases during pregnancy, resulting in a fall in arte-rialblood pressure. This decrease is most likely due to elevatedprogesterone, leading to smooth muscle relaxation. There is adecrease in systolic blood pressure of 5 to 10 mm Hg and in dia-stolicblood pressure of 10 to 15 mm Hg that nadirs at week 24.Between 24 weeks gestation and term, the blood pressure slowlyreturns to prepregnancy levels but should never exceed them.PulmonaryThere is an increase of 30% to 40% in tidal volume (VT) duringpregnancy (Fig. 1-1) despite the fact that the total lung capacity(TLC) is decreased by 5% due to the elevation of the diaphragm.This increase in VT decreases the expiratory reserve volumeby about 20%. The increase in VT with a constant respiratoryrate leads to an increase in minute ventilation of 30% to 40%,which in turn leads to an increase in alveolar (PAO2) and arterial(PaO2) PO2 levels and a decrease in PACO2 and PaCO2 levels.PaCO2 decreases to approximately 30 mm Hg by 20 weeksgestation from 40 mm Hg during prepregnancy. This changeleads to an increased CO2 gradient between mother and fetus andis likely caused by elevated progesterone levels that either increasethe respiratory systems responsiveness to CO2 or act as a primarystimulant. This gradient facilitates oxygen delivery to the fetusand carbon dioxide removal from the fetus. Dyspnea of preg-nancyoccurs in 60% to 70% of patients. This is possibly secondaryto decreased PaCO2 levels, increased VT, or decreased TLC.With an uncertain LMP, ultrasound is often used to de-terminethe EDC. Ultrasound has a level of uncertainty thatincreases during the pregnancy, but it is rarely off by morethan 7% to 8% at any GA. A safe rule of thumb is that theultrasound should not differ from LMP dating by more than1 week in the fi rst trimester, 2 weeks in the second trimester,and 3 weeks in the third trimester. The dating done withcrownrump length in the fi rst half of the fi rst trimester isprobably even more accurate, to within 3 to 5 days.Other measures used to estimate GA include pregnancylandmarks such as auscultation of the fetal heart (FH) at20 weeks by nonelectronic fetoscopy or at 10 weeks by Dop-plerultrasound, as well as maternal awareness of fetal move-mentor quickening, which occurs between 16 and 20 weeks.Because ultrasound dating of pregnancy decreases in accu-racyas the pregnancy progresses, determining and confi rmingpregnancy dating at the fi rst interaction between a pregnantwoman and the health care system is imperative. A womanwho presents to the emergency department may not returnfor prenatal care, so dating should be confi rmed at that visit.Pregnancy dating is particularly important because a num-berof decisions regarding care are based on accurate dating.3.02.01.001.0LitersNonpregnant Late pregnancyTLCtotal lung capacityVCvital capacityICinspiratory capacityFRCfunctional residual capacityIRVinspiratory reserve volumeTVtidal volumeERVexpiratory reserve volumeRVresidual volumeIRV IRVTV TVERV ERVRV RVTLCICFRCVCFigure 1-1 Lung volumes in nonpregnant and pregnant women.j TABLE 1-1 Signs and Symptoms of PregnancySignsBluish discoloration of vagina and cervix (Chadwick sign)Softening and cyanosis of the cervix at or after 4 wk(Goodell sign)Softening of the uterus after 6 wk (Ladin sign)Breast swelling and tendernessDevelopment of the linea nigra from umbilicus to pubisTelangiectasiasPalmar erythemaSymptomsAmenorrheaNausea and vomitingBreast painQuickeningfetal movement 16. Chapter 1 / Pregnancy and Prenatal Care 3to the alpha subunits of luteinizing hormone (LH), follicle-stimulatinghormone (FSH), and thyroid-stimulating hormone(TSH), whereas the beta subunits differ. Levels of hCG doubleapproximately every 48 hours during early pregnancy, reach-inga peak at approximately 10 to 12 weeks, and thereafterdeclining to reach a steady state after week 15.The placenta produces hCG, which acts to maintainthe corpus luteum in early pregnancy. The corpus luteumproduces progesterone, which maintains the endometrium.Eventually, the placenta takes over progesterone productionand the corpus luteum degrades into the corpus albicans.Progesterone levels increase over the course of pregnancy.Progesterone causes relaxation of smooth muscle, which hasmultiple effects on the gastrointestinal, cardiovascular, andgenitourinary systems. Human placental lactogen (hPL) isproduced in the placenta and is important for ensuring a con-stantnutrient supply to the fetus. hPL, also known as humanchorionic somatomammotropin (hCS), induces lipolysis witha concomitant increase in circulating free fatty acids. hPL alsoacts as an insulin antagonist, along with various other placentalhormones, thereby having a diabetogenic effect. This leadsto increased levels of insulin and protein synthesis. Levelsof prolactin are markedly increased during pregnancy. Theselevels decrease after delivery but later increase in response tosuckling.There are two major changes in thyroid hormones duringpregnancy. First, estrogen stimulates thyroid binding globulin(TBG), leading to an elevation in total T3 and T4, but freeT3 and T4 remain relatively constant. Second, hCG has aweak stimulating effect on the thyroid, likely because its alphasubgroup is similar to TSH. This leads to a slight increase inT3 and T4 and a slight decrease in TSH early in pregnancy.Overall, however, pregnancy is considered a euthyroid state.Musculoskeletal and DermatologicThe obvious change in the center of gravity during pregnancycan lead to a shift in posture and lower back strain, whichworsens throughout pregnancy, particularly during the thirdtrimester. Numerous changes occur in the skin, including spiderangiomata and palmar erythema secondary to increased estro-genlevels and hyperpigmentation of the nipples, umbilicus, ab-dominalmidline (the linea nigra), perineum, and face (melasmaor chloasma) secondary to increased levels of the melanocyte-stimulatinghormones and the steroid hormones. Pregnancy isalso associated with carpal tunnel syndrome, which results fromcompression of the median nerve. The incidence in pregnancyvaries greatly and symptoms are usually self-limited.NutritionNutritional requirements increase during pregnancyand breastfeeding. An average woman requires 2,000 to2,500 kcal/day. The caloric requirement is increased by300 kcal/day during pregnancy and by 500 kcal/day whenbreastfeeding. Thus, pregnancy is not the caloric equivalentof eating for two; more accurately, it is approximately eatingfor 1.15. Most patients should gain between 20 and 30 lbduring pregnancy. Overweight women are advised to gainless, between 15 and 25 lb; underweight women are advisedto gain more, 28 to 40 lb. Unfortunately, a large proportionof women gain more than the recommended amount, whichcontributes to a number of complications in pregnancy pluspostpartum weight retention and downstream obesity. It isthe responsibility of each prenatal care provider to review dietand exercise during pregnancy.GastrointestinalNausea and vomiting occur in more than 70% of pregnancies.This has been termed morning sickness even though it can oc-curanytime throughout the day. These symptoms have beenattributed to the elevation in estrogen, progesterone, and hCG.They may also be due to hypoglycemia and can be treated withfrequent snacking. The nausea and vomiting typically resolveby 14 to 16 weeks gestation. Hyperemesis gravidarum refersto a severe form of morning sickness associated with weightloss (5% of prepregnancy weight) and ketosis.During pregnancy, the stomach has prolonged gastric emp-tyingtimes and the gastroesophageal sphincter has decreasedtone. Together, these changes lead to reflux and possiblycombine with decreased esophageal tone to cause ptyalism,or spitting, during pregnancy. The large bowel also has de-creasedmotility, which leads to increased water absorptionand constipation.RenalThe kidneys increase in size and the ureters dilate during preg-nancy,which may lead to increased rates of pyelonephritis.The glomerular filtration rate (GFR) increases by 50% earlyin pregnancy and is maintained until delivery. As a result ofincreased GFR, blood urea nitrogen and creatinine decrease byabout 25%. An increase in the reninangiotensin system leadsto increased levels of aldosterone, which results in increasedsodium resorption. However, plasma levels of sodium do notincrease because of the simultaneous increase in GFR.HematologyAlthough the plasma volume increases by 50% in pregnancy,the RBC volume increases by only 20% to 30%, which leads toa decrease in the hematocrit, or dilutional anemia. The WBCcount increases during pregnancy to a mean of 10.5 million/mLwith a range of 6 to 16 million. During labor, stress may causethe WBC count to rise to over 20 million/mL. There is a slightdecrease in the concentration of platelets, probably second-aryto increased plasma volume and an increase in peripheraldestruction. Although in 7% to 8% of patients the plateletcount may be between 100 and 150 million/mL, a drop in theplatelet count below 100 million/mL over a short time is notnormal and should be investigated promptly.Pregnancy is considered to be a hypercoagulable state withan increase in the number of thromboembolic events. Thereare elevations in the levels of fibrinogen and factors VIIX.However, the actual clotting and bleeding times do not change.The increased rate of thromboembolic events in pregnancy mayalso be secondary to the other elements of Virchow triad, thatis an increase in venous stasis and vessel endothelial damage.EndocrinePregnancy is a hyperestrogenic state. The increased estrogen isproduced primarily by the placenta, with the ovaries contrib-utingto a lesser degree. Unlike estrogen production in the ova-ries,where estrogen precursors are produced in ovarian thecacells and transferred to the ovarian granulosa cells, estrogen inthe placenta is derived from circulating plasma-borne precur-sorsproduced by the maternal adrenal glands. Fetal well-beinghas been correlated with maternal serum estrogen levels, withlow estrogen levels being associated with conditions such asfetal death and anencephaly.The hormone hCG is composed of two dissimilar alphaand beta subunits. The alpha subunit of hCG is identical 17. 4 Blueprints Obstetrics & gynecologyIn addition to the increased caloric requirements, there areincreased nutritional requirements for protein, iron, folate,calcium, and other vitamins and minerals. The protein require-mentincreases from 60 to 70 or 75 g/day. Recommended cal-ciumintake is 1.5 g/day. Many patients develop iron defi ciencyanemia because of the increased demand on hematopoiesisboth by the mother and the fetus. Folate requirements increasefrom 0.4 to 0.8 mg/day and are important in preventing neuraltube defects.All patients are advised to take prenatal vitamins duringpregnancy. These are designed to compensate for the increasednutritional demands of pregnancy. Furthermore, any patientwhose hematocrit falls during pregnancy is advised to increaseiron intake with oral supplementation (Table 1-2).PRENATAL CAREPrenatal visits are designed to screen for various complica-tionsof pregnancy and to educate the patient. They includea series of outpatient offi ce visits that involve routine physicalexaminations and various screening tests that occur at differentpoints in the prenatal care. Important issues of prenatal careinclude initial patient evaluation, routine patient evaluation,nutrition, disease states during the pregnancy, and preparingfor the delivery.INITIAL VISITThis is often the longest of the prenatal visits because it involvesobtaining a complete history and performing a physical exami-nationas well as a battery of initial laboratory tests. It shouldoccur early in the fi rst trimester, between 6 and 10 weeks,although occasionally patients will not present for their initialprenatal visit until later in their pregnancy. At this visit, diet,exercise, and weight gain goals should also be discussed.HistoryThe patients history includes the present pregnancy, the LMP,and symptoms during the pregnancy. After this, an obstetrichistory of prior pregnancies, including date, outcome (e.g.,SAB [spontaneous abortion], TAB [therapeutic abortion],ectopic pregnancy, term delivery), mode of delivery, length oftime in labor and second stage, birth weight, and any complica-tions,should be obtained. Finally, a complete medical, surgi-cal,family, and social history should be obtained.Physical ExaminationA complete physical examination is performed, paying particu-larattention to the patients prior medical and surgical history.The pelvic examination includes a Pap smear, unless one hasbeen done in the past 6 months, and cultures for gonorrhea andj TABLE 1-2 Recommended Daily Dietary Allowances for Nonpregnant, Pregnant, and Lactating WomenNonpregnant Women by Age PregnantWomenLactating1114 y 1518 y 1922 y 2350 y 51+ y WomenEnergy (kcal) 2,400 2,100 2,100 2,000 1,800 +300 +500Protein (g) 44 48 46 46 46 +30 +20Fat-soluble vitamins 800 800 800 800 800 1,000 1,200Vitamin A activity (RE) (IU) 4,000 4,000 4,000 4,000 4,000 5,000 6,000Vitamin D (IU) 400 400 400 400 400Vitamin E activity (IU) 12 12 12 12 12 15 15Water-soluble vitaminsAscorbic acid (mg) 45 45 45 45 45 60 80Folacin (mg) 400 400 400 400 400 800 600Niacin (mg) 16 14 14 13 12 +2 +4Ribofl avin (mg) 1.3 1.4 1.4 1.2 1.1 +0.3 +0.5Thiamin (mg) 1.2 1.1 1.1 1 1 +0.3 +0.3Vitamin B6 (mg) 1.6 2 2 2 2 2.5 2.5Vitamin B12 (mg) 3 3 3 3 3 4 4MineralsCalcium (mg) 1,200 1,200 800 800 800 1,200 1,200Iodine (mg) 115 115 100 100 80 125 150Iron (mg) 18 18 18 18 10 +18 18Magnesium (mg) 300 300 300 300 300 450 450Phosphorus (mg) 1,200 1,200 800 800 800 1,200 1,200Zinc (mg) 15 15 15 15 15 20 25IU, International Unit. From Gabbe SG, Niebyl JR, Simpsen JL. Obstetrics: Normal and Problem Pregnancies, 4th ed. New York, NY: Churchill Livingstone;2002:196. 18. Chapter 1 / Pregnancy and Prenatal Care 5a sign of fluid retention and preeclampsia. Measurement ofthe uterine fundal height in centimeters corresponds roughlyto the weeks of gestation. If the fundal height is progressivelydecreasing or is 3 cm less than GA, an ultrasound is done tomore accurately assess fetal growth. After 10 to 14 weeks,Doppler ultrasound is used to auscultate the fetal heart rate(FHR). Urine is routinely dipped for protein, glucose, blood,and leukocyte esterase. The presence of protein may be indica-tiveof preeclampsia, glucose of diabetes, and leukocyte esteraseof urinary tract infection (UTI). Pregnant women are at an in-creasedrisk for complicated UTIs such as pyelonephritis, givenincreased urinary stasis from mechanical compression of theureters and progesterone-mediated smooth muscle relaxation.At each visit, the patient is asked about symptoms thatindicate complications of pregnancy. These symptoms includevaginal bleeding, vaginal discharge or leaking of fluid, and uri-narysymptoms. In addition, after 20 weeks, patients are askedabout contractions and fetal movement. Vaginal bleeding is asign of possible miscarriage or ectopic pregnancy in the firsttrimester and of placental abruption or previa as the preg-nancyadvances. Vaginal discharge may be a sign of infectionor cervical change, whereas leaking fluid can indicate rupturedfetal membranes. While irregular (Braxton Hicks) contrac-tionsare common throughout the third trimester, regularcontractions more frequent than five or six per hour may be asign of preterm labor and should be assessed. Changes in or ab-senceof fetal movement should be evaluated by auscultationof the FH in the previable fetus and with further testing suchas a nonstress test or biophysical profile in the viable fetus.First-Trimester VisitsDuring the first trimester, patientsparticularly nulliparouswomenneed to be familiarized with pregnancy. The symp-tomsof pregnancy and what will occur at each prenatal visitshould be reviewed. At the second prenatal visit, all of theinitial laboratory test results should be reviewed with thepatient. Those with poor weight gain or decreased caloricchlamydia. On bimanual examination, the size of the uterusshould be consistent with the GA from the LMP. If a womanis unsure of her LMP or if size and dates are not consistent, oneshould obtain an ultrasound for dating. Accurate dating is cru-cialfor all subsequent obstetrical evaluations and interventions.Diagnostic EvaluationThe panel of tests in the first trimester includes a completeblood count, primarily for hematocrit, blood type, antibodyscreen, rapid plasma reagin (RPR) or VDRL screening for syphi-lis,rubella antibody screen, hepatitis B surface antigen, urinaly-sis,and urine culture. If a patient has no history of chickenpox,a titer for varicella zoster virus (VZV) antibodies is sent. A puri-fiedprotein derivative (PPD) is usually placed during the first orsecond trimester to screen for tuberculosis in high-risk patients.A urine pregnancy test should be sent if the patient is not en-tirelycertain she is pregnant. If there has been any bleeding orcramping, a serum -hCG level should be obtained. While thereis some debate over the use of routine toxoplasma titers, theyare often ordered as well. All patients are counseled about HIV,and testing should be offered routinely (Table 1-3). In addition,first-trimester screening tests for aneuploidy with nuchal trans-lucency(NT) by ultrasound and serum markers are increasinglybeing obtained in most women via referral to a prenatal diagno-sisunit. In addition to this battery of tests, there are a variety ofother screens offered to high-risk patients (Table 1-4).ROUTINE PRENATAL VISITSBlood pressure, weight, urine dipstick, measurement of theuterus, and auscultation of the FH are performed and assessedon each follow-up prenatal care visit. Maternal blood pressuredecreases during the first and second trimesters and slowlyreturns to baseline during the third trimester; elevation maybe a sign of preeclampsia. Maternal weight is followed seriallythroughout the pregnancy as a proxy for adequate nutrition.Also, large weight gains toward the end of pregnancy can bej TABLE 1-3 Routine Tests in Prenatal CareInitial Visit and First Trimester Second Trimester Third TrimesterHematocrit MSAFP/triple or quad screen HematocritBlood type and screen Obstetric ultrasound RPR/VDRLRPR/VDRL Amniocentesis for womeninterested in prenatal diagnosisGLTRubella antibody screen Group B streptococcal cultureHepatitis B surface antigenGonorrhea cultureChlamydia culturePPDPap smearUrinalysis and cultureVZV titer in patientswith no history of exposureHIV offeredEarly screening for aneuploidy(NT plus serum markers) 19. 6 Blueprints Obstetrics & gynecologyj TABLE 1-4 Initial Screens in Specifi c High-Risk GroupsHigh-Risk Group Specifi c TestAfrican American, Southeast Asian, MCV 70 Sickle cell prep for African Americans; Hgb electrophoresisFamily history of genetic disorder (e.g., hemophilia,sickle cell disease, fragile X syndrome), maternalage 35 or older at time of EDCpreterm labor. Prenatal visits increase to every 2 to 3 weeksfrom 28 to 36 weeks and then to every week after 36 weeks.In addition, patients who are Rh negative should receive Rho-GAM at 28 weeks. Beyond 32 to 34 weeks, Leopold maneuvers(see Fig. 3-1) are performed to determine fetal presentation. Ei-theras a routine or if there is any question, an offi ce ultrasoundmay be used at 35 to 36 weeks to confi rm fetal presentation. Inthe setting of breech presentation, women are offered externalcephalic version of the fetus at 37 to 38 weeks of gestation.Beyond 37 weeks, which is considered term, the cervix isusually examined at each visit. Because a vigorous examinationof the cervix, known as sweeping or stripping the mem-branes,has been demonstrated to decrease the probability ofprogressing postterm or requiring an induction of labor, this iscommonly offered at all term pregnancy prenatal visits.Third-Trimester Laboratory Test ResultsAt 27 to 29 weeks, the third-trimester laboratory test resultsare ordered. These consist of the hematocrit, RPR/VDRL, andglucose loading test (GLT). At this time, the hematocrit isgetting close to its nadir. Patients with a hematocrit below 32%to 33% (hemoglobin