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Cancer Screening
- Cervical: Age 21-65 Cytology q3yrs, co-test q5 if normal.
- ASCCP guidelines (there is an app! Or PDF: http://www.asccp.org/Assets/51b17a58-7af9-4667-879a-3ff48472d6dc/635912165077730000/asccp-management-guidelines-august-2014-pdf )
- Breast: ACOG: 40-75 annual mammogram
- Colon: Colonoscopy, FOBT, FIT. Begin at age 50. If first degree relative with colon cancer begin screening at age 40 or 10yrs prior to youngest diagnosis, whichever is younger.
- Lung: 55-80 with 30pack-year hx, annual low-dose CT
Vaccinations
- HPV: 3 dose series age 12-26
- Influenza: annual
- Pneumovax: 1 dose and 1 booster any age if risk factors. After age 65 if no risk factors
- Shingles: 2 dose age 50+
- Hep B: initial vaccination in youth, vaccination for anyone non-immune
- MMR: if not immune
- Varicella: if not immune
- Tdap: Booster at 10yrs, new parents
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Swab/Urine
- Chlamydia: usually asymptomatic. Screen routinely. Can cause infertility/PID and Fitz-hugh-curtis. Treat with Azithro x1
- Gonorrhea: often asymptomatic. Screen routinely. Can cause infertility/PID. Treat with Ceftriaxone and Azithromycin
- Trich: frothy/watery discharge. “Strawberry cervix” Can see trich moving on wet mount. Treat Flagyl 2g PO once.
- HPV: Cervical dysplasia/cancer and Genital warts. Topical treatments as needed.
Serum
- Syphilis: Painless chancre followed by latent, then secondary with palmar/plantar rash. If unsure stage, treat as if latent, PCN IM x3
- HIV: Universal screening. PREP if high risk. Referral to ID and counseling if positive.
- Hep B: Treatable, not curable. Routine serum screening.
No Routine Screening, diagnose if lesion
- HSV: Antivirals as needed for outbreaks, can prophylax if frequent outbreaks/immunosuppressed. Valacyclovir or acyclovir are most common.
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Why: ASCCP guidelines (there is an app! Or PDF)
Cervical dysplasia — caused by HPV
CIN I–CIN3 is a progression
Risk factors: Smoking, other STIs including HIV, immunodeficiency
Histology: Increased Nuclear: cytoplasmic ratio when abnormal
Acetic Acid: exact mechanism unknown, the higher N:C ratio cells (aka abnormal cells) reflect more light and appear white.
Lugols: Iodine rich-reacts with glycogen in normal squamous cells so they appear dark. Non-staining cells are abnormal.
HPV — changes
Colpo:
Increased vascularity, punctations, mosaicism, surface contour changes
LEEP:
Stain abnormality and know where abnormal biopsy was taken
Single pass is ideal–tag a side for orientation
+/- Top Hat depending on ECC result
CKC:
Higher up in cervical canal, but more complications
No electricity– okay if pregnant
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Every visit:
- Doptones, fundal height, vitals
- Four question: Vaginal bleeding, contractions, leaking fluid, fetal movement
By Weeks:
- 20wks – get and review anatomy US
- 24wks – order glucola, cbc (check for anemia), discuss normal growing pains
- 28wks – Tdap and Rhogam if needed, discuss kick counts
- 32wks – Discuss BCM, sign tubal papers if needed, discuss TOLAC if needed
- 36wks – GBS screening, birth expectations, US for position
- 38-40wks – VE, “sweep membranes”
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- Planned/Desired
- Options counseling if needed
- Exam/pelvic/pap
- Ultrasound for dating
- Screening options: QUAD, Sequential, NIPS, invasive testing
- Pregnancy guidelines
- Weight:
- BMI under 18.5 should gain 28–40 pounds.
- Normal-weight women (BMI, 18.5–24.9) should aim for 25–35
- Overweight women (BMI, 25–29.9) should aim for 15–25
- Obese women (BMI, 30 or more) should gain only 11–20
- Food: Avoid unpasteurized dairy, large fish (swordfish, shark, king mackerel, tilefish, bigeye tuna etc), uncooked meat/seafood, uncooked deli meat, EtOH
- Drugs: Nothing unless cleared by MD. Tylenol okay if needed, PNV, Colace, FeSO4. NO NSAIDs!
- Exercise: Nothing that could leave a bruise on your belly! Moderate exercise is great.
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Hysteroscopy = looking inside the uterus with a scope
Steps:
- Dilate the cervix
- Distend the uterus with fluid
- Look around, identify pathology, identify tubal ostia, remove pathology if using an operative scope or Myosure or another resectoscope.
Feared complication: Hyponatremia from excessive hypotonic fluid absorption.
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Intrapartum
Differential diagnosis for Temp >38.0C
- Epidural fever (transient), DVT/PE (if prolonged IOL or limited mobility), UTI, Intraamniotic infection (with or without ROM), etc
Chorioamnionitis aka IAI aka Triple-I (intrapartum intraamniotic Infection)
- One temp >39.0C
- One temp 38.0C-39.0C AND one or more risk factors
- Two temps >38.0C 30+ mins apart
Tx: the standard is Ampicillin/Gentamycin until delivery. Tylenol prn temp>38C, IVF for maternal/fetal tachycardia, cooling blanket if needed to decrease temp.
If mild PCN allergy: Ancef/Gent
If severe PCN allergy: gent/clinda or gent/vanc
If vaginal delivery: No evidence that continued abx postpartum provide benefit.
If c-section: Add clindamycin to Amp/Gent.
Continue at least 1 dose postpartum. Clinical judgment on when to d/c. Some do 1 dose, some 24hrs afebrile, until clinical improvement, etc.
Postpartum
Wind – PNA, atelectasis, URI
Womb – Endomyometritis — Gent/Clinda x 24hrs afebrile
Wound – Superficial wound infection, cellulitis — eval for collection, probe wound/fascia if able
Water – UTI, Pyelo — get UA
Walking – DVT/PE
Weening – Engorgement or mastitis
Wonder drugs