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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Gender Specific Issues Key Feature 3: When men and women present with stress-related health concerns, assess the possible contribution of role-balancing issues (ex: work-life balance or between partners). Skill: Patient Centered, Clinical Reasoning Phase: Hypothesis generation, History Sex Key Feature 1a: In patients, specifically pregnant women, adolescents, and perimenopausal women: Inquire about sexuality (ex: normal sexuality, safe sex, contraception, sexual orientation, and sexual dysfunction). Skill: Patient Centered, Clinical Reasoning Phase: History Key Feature 1b: In patients, specifically pregnant women, adolescents, and perimenopausal women: Counsel the patient on sexuality (ex: normal sexuality, safe sex, contraception, sexual orientation, and sexual dysfunction). Skill: Patient Centered, Communication Phase: Treatment Key Feature 2: Screen high-risk patients (ex: post-myocardial infarction patients, diabetic patients, patients with chronic disease) for sexual dysfunction, and screen other patients when appropriate (ex: during the periodic health examination). Skill: Selectivity, Clinical Reasoning Phase: Hypothesis generation, History Key Feature 3: In patients presenting with sexual dysfunction, identify features that suggest organic and non-organic causes. Skill: Clinical Reasoning Phase: Hypothesis generation, History Key Feature 4: In patients who have sexual dysfunction with an identified probable cause, manage the dysfunction appropriately. Skill: Clinical Reasoning Phase: Treatment Key Feature 5: In patients with identified sexual dysfunction, inquire about partner relationship issues. Skill: Patient Centered Phase: History Sexual problems are common. Despite this fact, for multiple reasons, they are often not talked about. At some level, I get it. It's not necessarily a fantastic conversation starter. But as a family doctor with patients who I will see regularly, I'm hoping I can break through the stigma and address sexual health much as any other component of wellbeing. As in a previous post where I discuss obesity, there is still much stigma regarding certain medical problems. Medical doctors (or at least family doctors in Canada) are moulded to view these issues within a biopsychosocial framework. Knowing the current stigma that exists, and the lengthy process required to break down stigma in society in reality, it really is up to doctors (and especially family doctors) to inquire about these issues that patients may feel too embarrassed to bring up without prompting. This is particularly true during periods of transition in life, when sexual concerns may more frequently arise, as is true with adolescence, pregnancy, and the menopausal transition. It can also be more common in males secondary to aging and underlying disease affecting the physiology of obtaining and maintaining an erection. These patients with chronic medical conditions can be at increased risk of sexual dysfunction as biological complications of their disease state but also as a consequence of psychiatric issues that can arise secondary to having chronic disease. As a family physician, it is my role to help the patient take care of their illness and promote wellness in all facets of life, and this includes sexual health. Patients need to be asked about sexual concerns in a safe environment. They need to be asked about safe sex practices and use of contraception and given tools to manage these that fit with their lifestyle. And, where we go less often, they need to be asked about sexual function/wellness. I screen for such concerns by stating that many patients have concerns regarding sexual functioning and sexual orientation, and that because of this I routinely ask about it with patients in my practice. I do this to shape a safe space for discussing issues the patient may feel are sensitive, to help them understand just how normal it is for the physician to talk about. Indeed, because of a lack of common discussion about these issues, some patients find that their "concerns" are really totally a part of the spectrum of normal sexuality. And for those whose concerns are true problems for them, there are effective treatment options that I can offer as a physician, whether they are psychologically based or organic or both. Once a patient has endorsed having a concern with sex that is indeed dysfunctional, it is my job to elucidate just what really is going on. Often there is more than one contributing factor. Reasons for sexual dysfunction include having a history of genital trauma, medication side effects, vascular insufficiency, neurologic dysfunction, hormonal problems, and psychological or emotional factors (including relationship difficulties). Each etiology creates problems in its own way, and can further lead to problems involving the psyche or other systems, and frequently affecting relationships; obtaining a good clinical assessment helps to create a tailored approach to treatment. Basically my history involves assessing whether any of the known causes may be contributing. In males complaining of erectile dysfunction, the classic question to ask to suss out whether this dysfunction is largely organic in nature is to ask if he still has nocturnal erections or other spontaneous erections. The absence of these does suggest the dysfunction is largely organic. As well, whenever erectile dysfunction is more sudden onset rather than gradually worsening with time, that suggests a non-organic etiology. And it is important to not assume that a male presenting with concerns regarding sex or infertility is having erectile dysfunction; although it is very common, there are other sexual concerns that are managed differently (ex: first-line treatments for ejaculatory disorders, which are considered psychiatric disorders, include SSRIs, topical anaesthetics, +/- psychotherapy).
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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Gender Specific Issues Key Feature 5: Interpret and apply research evidence for your patients in light of gender bias present in clinical studies (ex: ASA use in women). Skill: Clinical Reasoning, Professionalism Phase: Hypothesis generation Ischemic Heart Disease Key Feature 2: In a patient with modifiable risk factors for ischemic heart disease (ex: smoking, diabetes control, obesity), develop a plan in collaboration with the patient to reduce her or his risk of developing the disease. Skills: Clinical Reasoning Phase: Treatment As a future family physician, a significant part of my role in the healthcare system will be to help patients understand the risks associated with cardiovascular disease (morbidity and mortality) and to assist patients to adopt behaviours that promote better health and quality of life. Ischemic heart disease is one of the cardiovascular diseases that has a large negative impact on the health of many, and very significantly so. In terms of mortality alone in developed countries, ischemic heart disease is responsible for at least one-third of the deaths in adults over the age of 35 (UpToDate). So what can be done to reduce one's risk of developing ischemic heart disease? The first part is helping patients understand what they can do to decrease their risk, and the second part is to promote those behaviours. The former is often done by use of a cardiovascular risk calculator if the patient is at least 40 years of age. According to UpToDate, "A number of multivariate risk models have been developed for estimating the risk of initial CVD events in apparently healthy, asymptomatic individuals based upon assessment of multiple variables. The choice of a specific risk model for CVD risk assessment should be individualized based on patient-specific characteristics (eg, age, gender, ethnicity).... While all of the risk models have advantages and disadvantages, no single risk model will be appropriate for all patients. We encourage clinicians to use a CVD risk calculator that has been locally endorsed and that has been validated for their locale and for patient-specific race and ethnic groups." Much of our strong evidence in medicine, having been studied for many years, was first originally collected on Caucasian males. This is a historical reality. This fact that many of our most "robust" tools and knowledge are not generalisable to every patient in front of us means we have to exercise clinical judgment, recognize the variability among various subsets of the population for different disease processes, different disease presentations, and the need to investigate accordingly. Screening tools still can be very useful to provide guidance, but they are not the be all end all. Ultimately, it is what it is, but it is important to try not to be complacent and really consider whether or not medical algorithms truly fit the individual patient. In Canada the most commonly accepted CVD risk calculator for the general population is the Framingham Risk Score (and yes, it is based on a cohort of middle-aged white men). After calculating a patient's risk and presenting them with the information, encouraging the behaviours that decrease their risk of acquiring cardiovascular disease is then as straightforward and as challenging as you'd think.
Piece of cake (that you can't eat).  Key Feature 4: Establish office policies and practices to ensure patient comfort and choice, especially with sensitive examinations (ex: positioning for Pap, chaperones for genital/rectal exams). Skill: Professionalism Phase: Physical Although many people think this test is synonymous with STI testing, it is completely not the same thing; the Papanicolaou (aka Pap) test examines purely for cervical cancer. Guidelines have been changing almost every other year it seems like. At the time of writing this blog, the Canadian national screening consensus is to begin Pap screening at the age of 25 (sooner if the patient has risk factors) and to screen every 3 years until the age of 69. There's no absolute contraindication to every doing this test per se, though the results may not be as accurate if there is current infection of the vaginitis, cervix, or pelvic inflammatory disease (so is in fact ideally NOT done when there is suspicion for an STI), or if the woman is menstruating. Not that if the bleeding is not a regular menstrual bleed but rather abnormal vaginal bleeding, obtaining a Pap would be important as a diagnostic as opposed to screening tool and would thus be indicated for that purpose. Equipment
Anatomy of a cervix
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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Gender Specific Issues Key Feature 1: In the assessment of clinical problems that might present differently in men and women, maintain an inclusive differential diagnosis that allows for these differences (ex: women with coronary artery disease, depression in males). Skill: Clinical Reasoning Phase: Hypothesis generation Pregnancy Key Feature 7a: In a pregnant patient presenting with features of an antenatal complication (ex: premature rupture of membranes, hypertension, bleeding): Establish the diagnosis. Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation, Diagnosis Key Feature 7b: In a pregnant patient presenting with features of an antenatal complication (ex: premature rupture of membranes, hypertension, bleeding): Manage the complication appropriately. Skill: Clinical Reasoning, Selectivity Phase: Treatment Vaginal Bleeding Key Feature 2a: In pregnant patients with vaginal bleeding: Consider worrisome causes (ex: ectopic pregnancy, abruption, abortion), and confirm or exclude the diagnosis through appropriate interpretation of test results. Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 2b: In pregnant patients with vaginal bleeding: Do not forget blood typing and screening, and offer Rh immunoglobulin treatment, if appropriate. Skill: Clinical Reasoning Phase: Treatment, Hypothesis generation Key Feature 2c: In pregnant patients with vaginal bleeding: Diagnose (and treat) hemodynamic instability. Skill: Clinical Reasoning Phase: Diagnosis, Treatment Common antenatal complications that can bring patients into the office or emergency department include decreased fetal movement, blood or fluid loss from the vagina, and cramping. Patients may also be found with signs suggestive of possible antenatal complications on routine prenatal assessment, including hypertension and symphysis-fundal height measuring small for gestational age. Here I will review how one might diagnose and manage these common antenatal complications. One common theme with all antenatal complications is the need to decide whether or not the complication is of high enough risk to the mother or fetus to warrant delivery vs the risk of watchful waiting. Many factors come into play, but of particular sway is the gestational age of the fetus. As well, for all possible concerns, a complete history and physical examination is always warranted, and when there is confirmation of a concern to fetal or maternal wellbeing, most of the time consultation with an obstetrician is warranted. Note that the all of the information below comes from a conglomeration of various resources, including the SOGC ALARM course, many UpToDate articles, resources provided on maternity care and obstetrical rotations, and from my own experience in clerkship and residency in seeing how these issues are managed in real life. DECREASED FETAL MOVEMENT -DDx: If a pregnant woman presents with concern about decreased fetal movement, this could mean there really is decreased or absent fetal movement (which could reflect an unwell fetal state, or worse), or it could be that she has noticed decreased movement during a time when the fetus is asleep or less active. -Hx: Asking about fetal movement is a routine part of any obstetrical encounter. If ever patients are concerned about decreased fetal movement, they should count the number of kicks they feel in a 2 hour period while laying on their side. If they count less than 6, they should seek medical attention. -PE: Fetal heart rate assessment by Doppler can be reassuring, but even a normal FHR auscultated this way isn’t sufficient to rule out concerns of fetal wellbeing after mom has been concerned about decreased fetal movement. Standard of care is to asses FHR by Doppler and to proceed regardless with further investigations. -Ix: If a woman has presented for medical attention with a concern of decreased fetal movement, obtaining a non-stress test (NST) is always warranted. If this appears normal and the woman feels return of fetal activity, no further investigations are needed. However, if the non-stress test is normal but the woman continues to perceive decreased fetal activity, the next step is to get an ultrasound (US) exam within 24-48 h for further assessment. Ultrasound examination should include assessment of fetal activity, breathing, tone, and amniotic fluid volume, as well as fetal growth and anatomic survey if not recently performed. If both the non-stress test and ultrasound are unremarkable, but there is persistent perception of decreased fetal movement, then obtaining a biophysical profile (non-stress testing and ultrasound examination that assesses the above-listed 4 parameters) in women under 37 weeks’ gestation on a biweekly basis is appropriate. Once at 37 weeks' gestational age, consideration may be given to inducing labour before the EDD. -Tx: Decreased fetal movement can be a general sign of poor fetal wellbeing. If investigations confirm fetal compromise, determining and attempting to treat any reversible etiologies is warranted, or else delivery may be indicated. NST results are classified as either reactive (i.e., normal, showing a healthy fetus) or nonreactive, which may suggest impaired fetal oxygenation, but on the differential is also maternal medication or substance use including smoking close to the time when the test is performed, fetal neurologic or cardiac anomalies, and sepsis. As well, it is important to know that up to 50% of nonreactive NSTs are false positives, so other tests are useful to confirm compromised fetal status, particularly US assessment. Abnormal investigations prompt decision-making as to whether or not delivering the infant sooner rather than later is best, if the circumstances leading to abnormal fetal assessment are not correctable. SMALL FOR DATES -DDx: In the patient who measures small for gestational age on routine symphysis-fundal height assessment, this may suggest there is intrauterine growth restriction. Alternatively, the fetus may simply be constitutionally small, but further workup is always warranted to investigate for growth impairment. -Hx: A complete history is warranted to look for risk factors for intrauterine growth restriction. These include known fetal genetic or structural abnormalities, ischemic placental disease or placental/cord abnormalities, maternal medical and obstetrical disease including structural uterine abnormalities and a history of prepregnancy radiation or trauma, risk associated with medication or substance use, extremes of maternal age, use assisted reproduction technologies or multiple gestation, and risk factors for fetal infection. -PE: On examination, symphysis fundal height is measured as abnormal if it differs by greater than 2 cm from from the gestational age. Other physical exam maneuvers include all of those done on routine antenatal assessment. (An aside: Although typically less worrisome, a fetus may measure large for dates, and the reasons for this include multiple pregnancy, molar pregnancy, inaccurate dates, hydramnios, macrosomia, fibroid uterus, adnexal and/or abdominal masses. Investigations tend to be similar as for a fetus that measures small for gestational age.) -Ix: If a fetus measures small for gestational age, or if there are risk factors for intrauterine growth restriction despite normal symphysis-fundal height measurement, further investigation by ultrasound is indicated. (Note that clinical assessment is not accurate enough to rule out restricted intrauterine growth in the presence of risk factors.) If a fetus measures small for gestational age on ultrasound (<10th percentile), further investigations are indicated to look for evidence as to whether there is restricted growth or if the fetus is well and just constitutionally small. This workup includes detailed ultrasound examination with umbilical artery Doppler for fetal, placental, and uterine abnormalities. If clinically suspected, maternal serum can be tested for evidence of infection. If fetal growth restriction is evident before 24 weeks’ gestation, or if there is evidence of structural feta anomalies, evaluation of the fetal karyotype to look for genetic abnormalities is indicated. Depending on the suspected cause and severity of fetal growth restriction, the decision to manage expectantly versus deliver must be evaluated. If the decision is made to manage expectantly, the fetus will need regular ongoing monitoring, one to seven times a week if there is concern about fetal wellbeing, or two to four times weekly to reevaluate growth progress in the absence of concern about fetal wellbeing. Monitoring is done by non-stress testing and biophysical profile assessment. -Tx: Any reversible causes for fetal growth restriction should be addressed, and in those cases in which the cause is not remediable, the risks must be pitted against the benefit of managing expectantly versus inducing delivery, taking into account gestational age and assessment of fetal wellbeing, among other factors. MALPOSITION -Fetal malposition is basically the finding that the fetus is positioned in any way other than head down (i.e., cephalic presentation). If suspected on physical exam by Leopold’s maneuvers (see image below), ultrasound assessment for confirmation is generally done as fetal malpositioning changes the approach to delivery. By 32 to 36 weeks’ gestation, the fetus has generally assumed it’s birth position, so if fetal malposition is confirmed by ultrasound and the birth position is expected to have been assumed based on gestational age, consultation with an obstetrician is warranted. The patient may choose to have a trial of external cephalic version, in which there is an attempt at turning the fetus in uterus into a cephalic presentation. Alternatively, the patient may choose to deliver by C-section or attempt a vaginal breech delivery. All 3 options have risks and benefits, and the choice must be based on informed discussion between the patient and the obstetrician, taking into account patient factors and clinician training.  VAGINAL BLEEDING
-DDx: Vaginal bleeding can occur for a number of different reasons. In the first trimester, these include: ectopic pregnancy; spontaneous abortion (aka miscarriage); subchorionic hematoma; gestational trophoblastic disease; pathology of the cervix, vagina, or uterus; or the physiologic “implantation bleed;”. In the second and third trimesters, these include: bloody show associated with labor (by definition, labour occurs after 20 weeks) or cervical insufficiency; spontaneous abortion (by definition, spontaneous abortion occurs before 20 weeks); placenta previa; placental abruption; and rarely, uterine rupture or vasa previa. Cervical, vaginal, or uterine pathology (ex: polyps, inflammation/infection, trophoblastic disease); non-tubal ectopic pregnancy; and marginal separation of the placenta are other etiologies to consider. -Hx: Before taking a thorough history, ensure the woman is stable. If there are signs of circulatory compromise, addressing this urgently in an emergency room setting is warranted. If and when stable, it is then important to get a thorough history of the bleeding. Although the quantity of bleeding is not predictive of the etiology per se, in that bleeding described as scant can still be how worrisome pathology presents, the heavier the bleeding, and if any clots/tissue have been passed, along with the presence of associated features such as pain, increase the likelihood that there is something ominous going on. Identifying any factors that may have precipitated the bleeding, such as trauma or intercourse, is important. -PE: When a women presents with a concern of vaginal bleeding, it is important to assess maternal general appearance and vital signs, along with performing an assessment of fetal status by auscultating for fetal heart rate with Doppler (which should be able to be detected after 12 weeks of gestation), measuring symphysis-fundal height, and assessing fetal position and presentation if in the third trimester. Performing an abdominal examination, complete pelvic examination (sterile speculum should be used, and if a woman has reached second trimester, digital examination should only be performed after an ultrasound assessment in second trimester that shows no placenta or vasa previa), and examination of any passed tissue is also helpful. -Ix: While the clinical assessment is important to narrow the differential and to triage the concern, all women with a complaint of vaginal bleeding warrant an ultrasound (transvaginal +/- abdominal) to assess fetal wellbeing and for information that is helpful in assessing etiology and for complications (ex: placenta previa, retained products of conception in the setting of suspected miscarriage). Other investigations to consider include quantitative beta-hCG, blood type & screen, CBC, and Kleihauer-Betke test (a test that can assess for fetal blood in the maternal blood stream). -Dx: Ectopic pregnancy, although not common, is serious and must always be ruled out. Confirmation of an intrauterine pregnancy makes this unlikely, although one must always consider a heterotypic pregnancy, particularly in the patient who has had in vitro fertilization. Vaginal bleeding with cramping is worrisome for spontaneous abortion, and this is also diagnosed/confirmed by ultrasound. Ultrasound may also detect a subchorionic hematoma. Gestational trophoblastic disease should be suspected when beta-hCG levels are elevated beyond that expected for the gestational age, and with absence of a viable intrauterine pregnancy. Bleeding from a cervical or vaginal source may be apparent on physical exam, but ensuring there is nothing else going on via ultrasound is prudent. Bleeding associated with labour may be a ‘bloody show’ that precedes onset of contractions, so this must be considered if the woman develops regular cramping/contractions. Cervical insufficiency is diagnosed via transvaginal ultrasound, as are placenta and vasa previa. Placental abruption and rupture are not routinely detected on ultrasound exam, and warrant high suspicion with associated risk factors (risk factors for placental abruption include prior placental abruption, trauma, smoking, cocaine use, hypertension, and preterm premature rupture of the membranes; risk factors for uterine rupture include previous cesarian or transmyometrial surgery) in the setting of vaginal bleeding with pain, with or without signs of maternal or fetal compromise. Implantation bleeds or attributing bleeding to marginal separation of the placenta are diagnoses of exclusion. Tx: If a women has had significant bleeding from any cause and is hemodynamically unstable, addressing this is the first priority, with attempts to first stabilize much as would be done with a nonpregnant patient. If maternal or fetal status continues to be compromised, delivery may be warranted. If the patient has an ectopic pregnancy, medical or surgical treatment is indicated. If the patient is diagnosed with spontaneous abortion, unless already complete, the management may be expectant, medical, or surgical. A finding of gestational trophoblastic disease is typically followed by surgical evacuation, with further management dependent on further disease classification. There are a number of possible causes of pathological bleeding from the vagina, cervix, or uterus (including trauma, vaginitis, warts, polyp, tumour, or uterine fibroids), that would need to be managed much as they would in a non-pregnant woman, although choice of management may differ in pregnancy. In the setting of cervical insufficiency, a cervical pessary, cerclage, or progesterone supplementation may be warranted, depending on cervical length and whether or not they have had previous preterm deliveries attributed to a shortened cervix. Most patients with placenta previa will have resolution by the third trimester. If the placenta previa does not resolve, delivery by C-section is warranted. Management of placental abruption depends on just how compromised the fetus and mom are, with options being to manage conservatively or plan for delivery. A diagnosis of uterine rupture alway warrants emergency C-section. A diagnosis of vasa previa also warrants delivery by C-section, although if it is diagnosed on US rather than following an active bleed, the timing of the C-section may be such that it is performed as a planned or elective procedure. Last but not least, for all causes of vaginal bleeding in pregnancy, if the woman is Rh- per the type and screen, she will need to be given Rh immune globulin to prevent Rhesus alloimmunization. The Kleihauer-Betke test quantifies how much fetal and maternal blood have mixed to be able to provide a sufficient dose of Rh immune globulin. HYPERTENSION -DDX: If a patient has hypertension in pregnancy, it can be classified as chronic (existing prior to pregnancy) or gestational (onset after becoming pregnant), and with or without pre-eclampsia or eclampsia (preeclampsia is a state that increases risk of seizure, while eclampsia is diagnosed if seizure has actually happened). Women with hypertension in pregnancy are also more likely to develop HELLP syndrome. -Hx: If hypertension is detected on routine prenatal assessment, it is important to assess for symptoms that may occur with preeclampsia (defined as hypertension with at least one of the three following features: proteinuria, maternal organ dysfunction, or uteroplacental dysfunction). Manifestations of preeclampsia to ask about include cardiovascular symptoms (chest pain or dyspnea, extremity swelling), hematological symptoms (bleeding), hepatic symptoms (RUQ or epigastric pain, severe nausea/vomiting), renal symptoms (decreased urine production), and neurologic symptoms (severe headache, visual disturbance, tremulousness). If there is uteroplacental dysfunction that is compromising the infant, the mom may have noticed decreased fetal movement. -PE: On examination, it is important to ensure accurate blood pressure assessment. This includes having the patient seated comfortably for 10 minutes prior to blood pressure assessment, and during measurement, her feet should be flat on the ground with her arm at heart level. The blood pressure cuff should be sized appropriately, and a manual sphygmomanometer should be used. Hypertension in pregnancy is diagnosed with a systolic blood pressure of 140 or greater, or a diastolic blood pressure of 90 or greater. The patient is diagnosed with severe hypertension is the systolic blood pressure is 160 or greater, or if the diastolic blood pressure is 110 or greater. The diagnosis is based on at least 2 readings separated by 15 min in the same arm. (The arm that reads highest for blood pressure should be the one used to perform all blood pressure checks.) If accurate blood pressure measurement confirms hypertension, looking for signs associated with preeclampsia is also important. The signs to look for, in the same order as per the history for associated symptoms, involve the cardiovascular system (SpO2, elevated JVP, edema), haematological system (evidence of bleeding or petechiae), hepatic pain manifesting as tenderness on abdominal examination of the right upper quadrant or epigastrium, and signs of neurological compromise (irritability, somnolence, hyperreflexia). Obstetrical assessment may reveal an abnormal fetal heart rate or a symphysis-fundal height measuring small for gestational age. If a woman reports a history of, or is seen to have seizure-like activity, this suggests eclampsia in a patient who does not have epilepsy. -Ix: Investigations that follow a diagnosis of hypertension include those to look for preeclampsia (urine studies to look for evidence of proteinuria) or associated complications including HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome or DIC (disseminated intravascular coagulopathy). Bloodwork includes: CBC, electrolytes, creatinine, urea, AST, ALT, LDH, type and screen (if blood type unknown), INR, PTT, fibrinogen. Urine studies can start with urine dipstick for protein, which are routinely done at every obstetrical assessment, and if 2+ protein is detected, this is significant and establishes the presence of proteinuria. If 1+ protein is detected, further measurement of a 24 hour urine collection for protein can be obtained. If dipstick is <1+ in the setting of new HTN, a random urinary protein to creatinine ratio should be ascertained <30 mg/mmol rules out proteinuria. To asses fetal status and for signs of uteroplacental dysfunction, obtain an ultrasound for fetal growth and amniotic fluid volume, with umbilical artery Doppler assessment if abnormal ultrasound findings are present. -Tx: Treatment of hypertension is to decrease the risk of stroke, which is increased once into the severely hypertensive blood pressure range. It is important understand that managing blood pressure does not lower risk of developing eclampsia or intrauterine growth restriction, so monitoring for these complications is important despite well-controlled blood pressure. The target treatment for systolic blood pressure is generally between 135 and 155 mmHg, and for diastolic blood pressure is generally between 80 and 105 mmHg, below the threshold for which stroke risk is elevated. Targets may vary in a patient who has other complicating comorbidities such as target-organ damage (left ventricular hypertrophy, microalbuminuria, retinopathy), dyslipidemia, maternal age over 40 years, history of stroke, previous perinatal loss, or diabetes. Antihypertensive medication options, if needed, include labetalol (starting dose 100 mg twice daily) or nifedipine extended-release (starting dose 20 mg once daily). If diagnosed with severe HTN, preeclampsia, eclampsia, or HELLP, women have increased risk of seizing, and so seizure prophylaxis is given: magnesium sulphate. This patient would also need monitoring in a hospital setting. A diagnosis of HELLP syndrome warrants consideration for blood and platelet transfusion, corticosteroids, and delivery within 48 hours from time of diagnosis. Last but not least, it is important to know that risk of seizure extends into the postpartum period, peaking on postpartum days 3-5. If a women is at risk for having hypertension, it is important to continue to monitor her blood pressure in the days following delivery. VAGINAL FLUID LOSS -DDx: If a pregnant woman notes vaginal fluid loss, this must be differentiated from normal physiologic discharge, which often increases during pregnancy, from pathological discharge attributed to infection of the genital tract, from the rupture of membranes that may precede the onset of labour (prelabour rupture of membranes) or that may occur after the onset of labour. -Hx: Rupture of membranes presents as a gush of fluid prior to or after the onset of labour (regular contractions leading to cervical change), and diagnostic accuracy of membrane rupture by history alone is 90%. In the setting of ongoing labour, no further workup is warranted, as membrane rupture is part of the natural history of labour. In the setting of vaginal fluid loss prior to the onset of labour, it is important to take a complete history of the nature of the fluid loss, including the presence of ongoing leaking, estimated total amount lost since onset, timing of the fluid loss, along with characteristic of the fluid itself such as odour and colour (green/brown suggests meconium, which can be a nonspecific sign that the fetus is doing so great). Taking a sexual history is important, as sexually transmitted infections can be a reason for prelabour rupture of membranes, particularly if preterm. Urinary tract infections can also increase risk of preterm labour, so asking about symptoms of a UTI is indicated. -PE: If there is suspicion for ruptured membranes, it is important to reduce sources of contamination that could increase risk for fetal infection. This means digital pelvic examination should be deferred unless membrane rupture has been excluded on further assessment. Instead, the pelvic examination is first performed visually with a sterile speculum to look for a pool of fluid in the vagina, with or without evidence of ongoing leaking from the cervix. If the pool test is positive, samples of this fluid can be used for investigations to confirm or rule out rupture of membranes. Swabs can also be taken for cultures and sensitivities in the preterm patient. -Ix: Vaginal fluid collected on sterile speculum exam can be assessed for membrane rupture via the nitrazine and ferning tests. If testing for membrane rupture is equivocal (there may be insufficient fluid for adequate testing, or there may be suspicion of a falsely positive or negative test), then followup testing with ultrasound to assess amniotic fluid volume can be helpful. In the setting of normal amniotic fluid volume, rupture of membranes is less likely. In the setting of suspected term prelabour rupture of membranes (TPROM), no other investigations are necessarily indicated, although an NST is commonly done to assess fetal wellbeing. In the preterm prelabour rupture of membranes (PPROM), because of associated increased risk of infection, other investigations to obtain as part of standard care include swabs for culture and sensitivity (vaginal for yeast, bacterial vaginosis, and trichomoniasis; cervical for chlamydia and gonorrhea; anogenital for GBS if GBS status unknown), urine sample for urinalysis and culture and sensitivity, and a CBC. Ultrasound monitoring is also indicated to assess amniotic fluid volume and cervical status, among others. -Dx: A diagnosis of membrane rupture is typically clinical, with investigations supporting this diagnosis. Likewise, there may be a high clinical suspicion of infection, and empiric antibiotics may be initiated before confirmatory investigations have resulted. -Tx: Management of prelabour rupture of membranes will depend upon gestational age and other risk factors for whether to proceed with expectant management vs induction of labour. If full term, induction of labour is generally recommended, as the associated risks are outweighed by the risk of infection that can occur with prolonged rupture of membranes. If less than 34 weeks’ gestation, the risks of preterm labour generally outweigh the risk of infection, and expectant management is instead indicated (antibiotics are administered prophylactically, along with steroids to enhance fetal lung maturity should the woman go into preterm labour), and if less than 32 weeks’ gestation, a dose of magnesium sulphate may also be given for fetal neuroprotection. If the pregnancy is between 34 and 36 weeks’ gestation, the evidence is not conclusive as to the best approach to take, so careful consideration will need to be had by the care team and mother regarding best approach in the particular circumstance. If swabs are positive for infection, it can be treated as indicated, including for group B strep positivity. CRAMPING/ABDOMINAL PAIN -DDx: There is a good chance that a woman who presents after 20 weeks of gestation with a complaint of regular cramping is likely in labour and having uterine contractions. By regular, I mean having cramps that are no more than about 5 minutes apart, that last from 30 seconds to 1 minute at a time, and that have been going on for about 1 hour (aka the 511 rule, which I teach patients about in the second trimester of pregnancy). If patients are full term, this is the natural expectation of how labour will begin, and there is no need to necessarily rush to seek medical attention. If a patient is preterm however, seeking medical attention sooner rather than later is important as there are more investigations and interventions that will need to be undertaken to try to obtain the best outcomes possible for mom and baby. If cramping is only intermittent, not meeting the criteria of the 511 rule, while it may still be that the women is experiencing uterine cramping, it is unlikely that she is in labour per se (which is defined as starting once the onset of regular uterine contractions has begun that leads to cervical change). These women having intermittent uterine cramps are often labeled as having Braxton-Hicks contractions, which are normal and occur from time-to-time in the later stages of pregnancy as the woman gets closer and closer to being full term. If pain is characterized as constant rather than cramping, the differential diagnosis should focus on other obstetrical sources of pain. In the presence of vaginal bleeding or new-onset hypertension, consider the DDx associated with those signs and symptoms as mentioned above. If there is no bleeding or hypertension, then obstetrical emergencies must first be considered (ex: uterine abruption), and then a more comprehensive differential for abdominal pain in the woman of reproductive age must be considered.* -Hx: Obtaining a good history of the cramping or abdominal pain is critical in determining whether the pain is from uterine contractions that signify the onset of labour, or if the search for other diagnoses ought to begin. For a history of regular cramping, it is important to ask about their frequency, duration, when they started to occur regularly, and how the pattern has changed over time. Infection is a risk factor for preterm labour, so inquiring about symptoms of genitourinary infection is important in the patient who is preterm and having regular cramping. -PE: A complete obstetrical physical examination is indicated, including assessment of the cervix to look for changes associated with labour. -Ix: If a diagnosis of labour is made, the patient who is full term does not require any investigations (unless there is missing information from routine investigations done in the antenatal period, which may be the case in a preterm patient who has not reached gestational age at which tests such as GBS testing is done, or if a woman has risk factors that warrant further investigations). For most women, knowing their blood type based on their initial prenatal labs suffices. But in patients with increased risk of having a postpartum hemorrhage, it is recommended that a type and screen be repeated, or that a type and crossmatch be done, depending on their degree of risk. In the preterm patient, as for PPROM, we want to assess for possible infectious reasons for why the women may have gone into labour preterm. This includes assessing a CBC, urine for UA and C&S, vaginal swab for C&S, and cervical swab for Chlamydia and Gonorrhea C&S. Last but not least, in patients with risk factors for complications, getting a baseline NST tends to be standard of care, but is not indicated in an uncomplicated pregnancy. -Tx: The cure for labour is delivery! Standard practice is to admit women to the labour and delivery ward if they are in the active first stage of labour (meaning their cervix has dilated to approximately 4 cm), if their membranes have ruptured despite not yet being in labour, or if any complications are identified. If a woman is not yet in active labour but is having significant pain, she is usually given morphine 10-15 mg IM and dimenhydrinate 50 mg IM and sent home, to return when pain has significantly worsened again, membranes have ruptured, or if any concerns arise. If the patient is in preterm labour, she will be admitted straight away, and some interventions to think about include giving steroids if less than 34 weeks gestation to promote fetal lung development, giving magnesium sulphate if less than 32 weeks gestation for neuroprotection if delivery is imminent, and considering the use of a tocolytic to slow down contractions while a women is being transferred to a centre with higher capacity (such as with a NICU, as the preterm infant may need extra supports) or to allow a full 48 hours for steroids to work their magic. *Although we tend to focus in on pregnancy-related complications when a patient who is pregnant presents with a concern, it is important not to lose sight of the fact that this is still a normal person who may have any of a number of reasons for a presenting complaint just as a non-pregnant person. The same principle applies to examining any "special population." Yes, we need to consider the disease processes for which their population group is specifically at increased risk, but we cannot lose sight of other possibly life-threatening or common reasons for which they could be presenting as they are. Even when not part of a "special population" per se, just being male or female can alter risk for various disease processes (ex: being male is a risk factor for having a heart attack, more female are diagnosed with depression). Despite this, we need to consider the individual's risk factors without letting them tunnel our vision too much. UBC Objectives: Maternity Care, Priority Topic: Gender Specific Issues & Priority Topic: Pregnancy1/12/2018 By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Gender Specific Issues Key Feature 2: As part of caring for women with health concerns, assess the possible contribution of domestic violence. Skill: Clinical Reasoning Phase: Hypothesis generation, History Pregnancy Key Feature 4a: In a patient presenting with a confirmed pregnancy for the first encounter: Assess maternal risk factors (medical and social). Skill: Clinical Reasoning, Patient Centered Phase: Hypothesis generation, History Key Feature 4b: In a patient presenting with a confirmed pregnancy for the first encounter: Establish accurate dates. Skill: Clinical Reasoning Phase: Diagnosis Key Feature 4b: In a patient presenting with a confirmed pregnancy for the first encounter: Advise the patient about ongoing care. Skill: Clinical Reasoning Phase: Treatment So my 42 year old confirmed primp (confirmed with the handy dandy urine beta-hCG dipstick in office) wanted to go ahead with growing this baby. What next? I certainly didn't have a half hour available to go through a complete first prenatal visit at this time, but knowing well that there was now a developing embryo (or fetus) inside of this patient - one that may be exposed to risk factors that could compromise healthy development - performing an assessment of the most important risk factors was indicated now to prevent potential harm before the more comprehensive first prenatal visit. Information I gather to assess and mitigate serious and common risk includes history of the current pregnancy, past medical history, medication and substance review, and social history, detailed below.
After the above historical information is gathered and you have provided guidance to reduce risk as indicated, you want to establish the EDD and gestational age (GA) as accurately as possible, which in this day and age is by dating ultrasound, to be done straight away (sonography is most accurate at establishing EDD and GA if obtained between 7 and 10 weeks of gestation, although it continues to remain more accurate to establish EDD than using LMP in a woman with regular menstrual cycles until 22 weeks of gestation (UpToDate, 2017). This is important in planning the rest of the prenatal care throughout pregnancy as many interventions need to be timed according to gestational age, and accurate establishment of dates reduces morbidity and mortality for the mom and the infant. The mom can then be advised to return for her first prenatal appointment once the results of the dating ultrasound are back. She will continue to be seen monthly after the first prenatal appointment, eventually returning for followup every two weeks (generally in the second trimester) and afterward, every week (in the third trimester). Every visit should include some routine and some unique assessments that depend on the gestational age at the time of assessment. It is always important to screen for complications and provide anticipatory guidance including what symptoms should prompt the women to seek urgent medical attention. (Prenatal care recommendations vary regionally. For BC, see Perinatal Services BC, including this prenatal checklist for primary care providers that includes a list of the screening maneuvers and options for genetic testing to offer/provide to women according to gestational age.) If you are not providing obstetrical care, then the patient will need to be referred to an obstetrical care provider. The rest of her prenatal care then can either be with the obstetrical care provider or may consist of a dual relationship (for example, a primary care physician who does not deliver babies may assume the majority of care and only arrange transfer of routine prenatal visits after 20 weeks of gestation or so). *Note that while pregnancy is a risk factor for domestic abuse, many women (and men) who are not pregnant live in abusive circumstances, so it is important to screen for this opportunistically when gathering a social history. |
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