Primary care update for Ob/Gyns最新文献

Molar pregnancy is a not-uncommon diagnosis in our patient population, occurring in approximately 0.6 to 1.1 per 1000 pregnancies. As the age of childbearing increases, the additional risk increases as well, to 7.5-fold higher by age 40 years. Medical complications associated with molar pregnancies include pre-eclampsia, hypertension, electrolyte disturbances, anemia, and thyrotoxicosis. Serum β-human chorionic gonadotropin (β-hCG) levels of 50,000 mIU/mL are approximately equivalent to a thyroid-stimulating hormone level of 35 U/mL. Because of the cross-reactivity between BHCG and TSH and the high levels of BHCG produced in gestational trophoblastic disease, the rare complication of thyroid storm is one that we as obstetricians may be called to manage. The diagnosis of thyroid storm may carry a 1.8 to nearly 20% mortality rate in hospitalized patients and thus requires prompt diagnosis and intervention. Once treatment is administered, including high-dose propylthiouracil, iodine solution, and dexamethasone with appropriate supportive care, patients can be expected to improve clinically within 24–48 hours. A case demonstrating the clinical picture of an obstetrics and gynecology patient with thyroid storm is presented, with a review of thyroid hormone activity and the management of thyroid storm.

Breast cancer is an extremely prevalent disease that is estimated to affect one of every nine women, as predicted by lifetime risk in the year 2002. Diagnostic efforts to detect early disease and therapeutic advances including adjuvant therapies have contributed to an increased 5-year survival rate. Therefore, a gynecologist must be prepared for the diagnosis and treatment of typical sequelae after the treatment of breast cancer, as well as aware of health maintenance guidelines particular to this patient group. There are both intrinsic sequelae of breast cancer and side effects of breast cancer treatment, including depression, decrease of libido, vasomotor complaints, vaginal symptoms, and mechanical issues secondary to surgery. Additionally, the primary care physician must consider long-term health consequences of low estrogen states in women who experience menopause as a result of chemotherapy and adjuvant therapies such as aromatase inhibitors. There is need for an algorithm to direct continuing care by the primary care physician, including the gynecologist.

Poststreptococcal glomerulonephritis is a nonsuppurative sequela of streptococcal infection that occasionally complicates pregnancy. Although group A beta-hemolytic streptococci are responsible for the majority of cases, multiple groups of streptococci can cause postinfectious glomerulonephritis. Infection of the skin or pharynx with streptococci typically precedes kidney involvement by 6 days to 2 weeks. The risk of developing acute nephritis after streptococcal infection ranges from 1–15%. This disorder usually affects children, and is more frequent in males. Poststreptococcal glomerulonephritis is considered an immune complex disease because interactions between antigen–antibody complexes and the complement system result in glomerular injury. Patients present with a wide range of complaints including hematuria, edema, malaise, lethargy, nausea, fever, weakness, anorexia, cough, and dyspnea. The most common exam findings include hypertension, edema, and hematuria. The differential diagnosis includes multisystem disease, other primary glomerular diseases, nonstreptococcal postinfectious glomerulonephritis, and urinary tract infection. The diagnosis is confirmed by the detection of antistreptococcal antibodies, and renal biopsy showing hypercellularity and proliferation. Treatment is supportive, and renal function tends to improve rapidly. Antibiotics are indicated if the patient is concurrently infected. Penicillin is the drug of choice, but erythromycin can be used in the penicillin-allergic patient. Immunity is lifelong, but recurrences may develop after infection with a different nephritogenic strain. If signs of irreversible kidney damage are present, the disease is considered chronic. Presentation in pregnancy may be confused with preeclampsia as hypertension, edema, and proteinuria are presenting signs in both entities. Poststreptococcal glomerulonephritis may lead to preterm delivery but typically has a successful outcome.

Heart disease and stroke are among the leading causes of death in the United States. Coronary artery disease accounts for 30% of deaths in women. Hypertensive diseases affecting pregnant women constitute the most common medical problems during pregnancy. About 4 to 7% of pregnant women experience pre-eclampsia, and an equal number experience chronic hypertension. Care should be taken in choosing contraception for hypertensive women and when choosing antihypertensive medications for pregnant and breastfeeding women. Comorbid conditions such as diabetes and heart failure also influence the choice of medications. As primary care providers for women, obstetricians and gynecologists should be aware of the importance of detection, evaluation, and treatment of hypertension in women. Studies have shown that women tolerate hypertension better than men and have lower coronary mortality rates with any level of hypertension. Although higher pressures are needed to produce comparable harmful effects on women, women do suffer clinically significant consequences.

Preterm birth is an increasingly large public health problem, exacting a high societal cost. Reducing the rate of preterm birth is a priority. An inability to predict preterm delivery with any accuracy, or incomplete understanding of the etiologies of preterm birth, does not preclude effective preventive intervention. There is strong scientific evidence supporting the relationship between the physiologic stress response and pathologic pathways and cascades preceding preterm birth. A large, modifiable set of conditions facing the population of pregnant women can potentially activate this pathway. In the past 30 years, France has decreased its rate of preterm birth through a prevention program extended to the entire population of pregnant women. It is based on education, improvement of the social and working conditions of pregnant women, careful self-monitoring during pregnancy, and short-term lifestyle changes. A broad and unified approach to the problem of preterm birth in the United States, with changes in the culture surrounding pregnancy, including prenatal care, public attitude, and healthcare policy, is warranted.

The objective of this study was to ascertain whether vaginal preparation with povidone-iodine before Cesarean delivery would reduce the incidence of post-Cesarean related infection. Participants were randomized to vaginal preparation with either povidone-iodine (n = 80) or saline (n = 80). Post-cesarean related infections included 1) endometritis, defined as fever of >100.4°F on two separate occasions, 6 hours apart, >24 hours postoperatively or >101°F at any time with abdominal/uterine tenderness or 2) cellulitis, defined as advancing erythema around the incision. We calculated overall rates of post-cesarean related infection, relative risk, and 95% confidence intervals for the effect of vaginal preparation. As designed and reported, the trial had at least an 85% power to detect a 30% or greater absolute difference in rates of overall infection (two tailed, α = 0.05). There was no significant difference among group demographics (maternal age, parity, anesthesia, labor before current cesarean delivery, number of vaginal examinations during labor, prophylactic antibiotic use, or gestational age at delivery). The post-cesarean endometritis rate was (9.4%). The post-cesarean cellulitis rate was (6.8%). Vaginal preparation with povidone-iodine before Cesarean delivery reduced the rate of post-cesarean endometritis (P < .04). The rates of post-cesarean cellulitis between the two groups were similar (P = .12). In our study, vaginal preparation with povidone-iodine before cesarean delivery significantly reduced the incidence of post-cesarean endometritis but not of cellulitis.

Thrombophilias are defined as conditions that increase one’s risk of developing thromboembolic phenomena. Most patients with these conditions are asymptomatic, except when in the presence of a secondary trigger, namely a high-risk situation (both physiologic and otherwise). Over the past years, the importance of recognizing these conditions, and the effects of early intervention, have been emphasized. In particular, in the field of obstetrics and gynecology, thrombophilias play a major role. As will be described, there are several well-defined conditions in pregnancy that have been found to be associated with these conditions. Appropriate early intervention may have a significant impact on pregnancy outcome. It is the responsibility of the physician to be familiar with these syndromes, their detection, and appropriate management. The theory behind these syndromes, a brief review of the coagulation cascade, a review of the individual syndromes, and special circumstances will be described below in an attempt to assist the primary care physician in becoming familiar with these conditions.

There is a paucity of current literature exploring provider attitudes toward discussing sexual function in routine gynecological care. Our objective in this study was to evaluate provider attitudes about the importance of taking a sexual history, and perceived barriers to doing so. Additionally, we evaluated whether patients consider a sexual function history important to their care. Residents, attending physicians, and midwives at the University of New Mexico completed anonymous questionnaires, including demographic data as well as questions regarding attitudes and practices toward taking a sexual history. Patients presenting for routine gynecological care were asked what their expectations are of their provider in taking a sexual history. Despite demographic differences, all providers reported that time limitations and language barriers were the main reasons why they don’t ask patients about their sexual function. The majority of providers reported that they seldom know where to refer patients with sexual dysfunction. All providers underestimated the percentage of women having sexual dysfunction compared with the literature (P < .001). Both patients and providers agreed that asking questions about patient’s sex lives was important to patient care (P = .61). Patients felt that it was important for providers to ask specific detailed questions about their sexual function. We concluded that lack of time and language barriers were the two commonly cited reasons for the inability of providers to complete a sexual history. Additionally, all providers had inadequate education about where to refer patients with sexual dysfunction. Strategies to improve providers’ ability to elicit and manage sexual dysfunction might include education regarding concise but validated sexual history interview techniques, simple treatment paradigms, and education regarding referral.

Acute pharyngitis is a common illness in both children and adults, caused by a wide variety of microbial agents. In children, approximately 20% of pharyngitis is caused by group A beta-hemolytic streptococci (GABHS); in adults, 5% of pharyngitis is due to GABHS. The signs and symptoms of infection are variable, ranging from mild sore throat with minimal physical findings to high fever and severe pain. The differential diagnosis of GABHS pharyngitis is extensive. Most cases of acute pharyngitis in both children and adults are caused by viruses. The gold standard diagnostic test for GABHS remains the throat culture. It is important to select appropriate candidates for culture to maintain the sensitivity of the test. Penicillin is still recommended as first-line treatment for documented GABHS infections. Prompt treatment is important to prevent serious sequelae of infection.