Case 12 - 16 yo female with vagina bleeding and UCG

Question 1

Chlamydia epidemiology

Answer 1

most common bacterial STD in the US

Question 2

Chlamydia risk factors

Answer 2

age white

Question 3

Chlamydia course of disease

Answer 3

Often insidious and asx
In women: urethritis, cervicitis, PID, infertility, ectopic preg, chronic pelvic pain
Pregnant women: miscarriage, PROM, preterm labor, LBW, infant mortality

Question 4

Chlamydia screening test

Answer 4

NAAT with urine and vaginal swabs

Question 5

Chlamydia screening recommendations

Answer 5

Strongly recommend screening:
- all sexually active women under 24
- non-pregnant women over 25 at increased risk (hx of STDs)
Recommend screening:
- all pregnant women 24 and under
- pregnant women over 25 at increased risk

Advised against screening women over 25 if low risk regardless of pregnancy status

Insufficient evidence for or against screening men

Question 6

Characteristics of a good screening test

Answer 6

Sensitive, specific, condition has high prevalence, has latent stage of dz, effective treatment, minimal cost/effort/adverse effects

Question 7

Immunizations with pregnancy

Answer 7

• must wait 3 months after live attenuated vaccine to have protection from fetal complications (MMR, rubella, varicella)
• pneumococcal vaccine if high risk
• flu vaccine yearly

Question 8

Preconception counseling

Answer 8

Genetic: folic acid supplement, carrier screening
Infectious diseases: HIV, RPR, Hep B immunization, toxo counseling, CMV parvo counseling, rubella and varicella immunizations
Envi: occupational exposures, household, smoking cessation, alcohol/illegal drugs
Medical: optimize diabetes control, avoid ACEI, ARB, HCTZ, optimize epilepsy, take off warfarin, avoid benzos
Lifestyle: recommend exercise, obesity counseling, assess nutritional deficiencies, limit caffeine

Question 9

Sx of pregnancy

Answer 9

amenorrhea (only reported in 68% of pregnant adolescents) fatigue, n/v, breast changes, urinary frequency

Question 10

Gestational development

Answer 10

5 weeks - heartbeat
8 weeks - enlarged uterus palpable on bimanual exam
10-12 weeks - fetal heart tone on handheld doppler, uterine fundus palpable above pubic symphysis
18-20 weeks - fetal quickening
20-36 - uterine enlargement

Question 11

estimated delivery date

Answer 11

Naegele’s rule: LMP + 1 year, subtract 3 months, add 1 week

Question 12

Reproductive choice counseling

Answer 12

Continue pregnancy and raise child or create adoption plan

Terminate pregnancy with medication or aspiration

Question 13

Miscarriage epidemiology

Answer 13

1/2 of all miscarriages in first trimester due to chromosomal abnormalities
1/3 of all pregnancies end in miscarriage
87% of women who have had miscarriages have subsequent normal births

Question 14

First trimester bleeding epidemiology

Answer 14

1/4 pregnancies have bleeding in first trimester
women with significant first trimester bleeding have 25-50% chance of miscarriage
non-emergent if benign abd exam and stable hemodynamics
emergent if tachy or hypotensive, or if abd exam suggests intraperitoneal bleeding

Question 15

Adolescent interview: HEEADSSS

Answer 15

Home
Education/employment
Eating
Activities
Drugs
Sexuality
Suicide/depression
Safety/violence

Question 16

Goodell’s sign

Answer 16

softening of cervix

Question 17

Hegar’s sign

Answer 17

softening of uterus

Question 18

Chadwick’s sign

Answer 18

bluish-purple hue in cervix and vaginal walls caused by hyperemia

Question 19

What PE would support diagnosis of spontaneous abortion?

Answer 19

dilated cervical os with obvious bleeding

Question 20

Ectropion

Answer 20

No clinical significance, os appears red from endocervical epithelium protruding, common in women on OCPs

Question 21

DDx for 1st trimester bleeding - more likely

Answer 21

1. Spontaneous abortion
   - inevitable abortion - dilated os
   - incomplete abortion - some but not all intrauterine contents expelled
   - missed abortion - fetal demise without cervical dilation and/or uterine activity
   - septic abortion - with intrauterine infection
   - complete abortion - products of conception have been completely expelled
   - threatened abortion - a pregnancy complicated by bleeding before 20 weeks gestation
2. Ectopic pregnancy - can’t be ruled in or out on ultrasound
3. Idiopathic bleeding in normal pregnancy

Question 22

DDx for 1st trimester bleeding - less likely

Answer 22

1. molar pregnancy - characteristic appearance on ultrasound and markedly elevated hcgs
2. vaginal trauma and cervical pathology

Question 23

Studies for initial pregnancy eval

Answer 23

• serum hcg - to help diagnose pregnancy pathology, no need if pregnancy normal and urine hcg positive
• cbc - anemia/platelets
• rubella - look for IgG
• Hepatitis B surface antigen
• Blood type - detect if RH negative (if so, should receive RhoGAM
• RPR
• HIV

Question 24

Studies for 1st trimester bleeding

Answer 24

• CBC
• wet mount for GC/CT
• type and screen
• quant Hcg (should double every 48, be visible by U/S at 1500, is higher in molar preg, lower in ectopic or abortions)
• progesterone - levels >25 assoc with sustainable normal preg (<5 assoc with miscarriage or ectopic)
• U/S

Question 25

Ultrasound for estimating date of delivery

Answer 25

First trimester - crown-rump length measured

• If EGA and EDD from U/S within one week of LMP, then LMP measurement is used
• If EGA and EDD from U/S not within one week of LMP, EGA and EDD should be changed to U/s measurements

Second trimester - measure biparietal, head circumference, abd circumference, femur length (less precise than 1st trimester)

Third trimester - not very accurate for EGA/ EDD

Question 26

Management of spontaneous abortion

Answer 26

• Intrauterine contents seen when b-hcg >1500
• serial readings every 48-72 hrs
• evaluate for hemodynamic changes and/or ruptured ectopic

Question 27

Management of inevitable abortion

Answer 27

• watchful waiting is effective in 75% of cases but can take longer and therefore be complicated emotionally
• surgical options: D+C, vacuum aspiration
• medical management: vaginal administration of misoprostol, usually takes 3-4 days
• RhoGAM must be given to Rh negative patients if not previously administered