In the postpartum period, secondary postpartum hemorrhage (SPPH) and endometritis are two conditions that frequently present to an obstetric triage unit. These complications may coexist and can occur from 24 hours postpartum to 6 weeks postdelivery. SPPH is typically not as severe as a primary bleeding episode. Postpartum women ultimately diagnosed with endometritis are generally stable, but less commonly can present in septic shock. This chapter discusses presenting symptomatology, history and data collection, physical examination, laboratory and imaging studies, differential diagnosis, and clinical management and follow-up of secondary postpartum hemorrhage and postpartum endometritis. Prompt treatment of both SPPH and postpartum endometritis can reduce maternal morbidity and mortality. SPPH is managed with the same guiding principles as primary postpartum hemorrhage. Initial treatment for postpartum endometritis is intravenous clindamycin and gentamicin.
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Pregnant women presenting with abdominal pain to an emergency department or obstetric triage setting frequently have a diagnostic ultrasound (US) to assess fetus, placenta, and adnexae. In the first trimester, symptomatic adnexal masses typically present with unilateral or bilateral pelvic cramping or pressure. Obtaining a history in a pregnant woman with abdominal pain is similar to doing so for the nonpregnant patient. In addition to routine cardiopulmonary examination, abdominal examination, and assessment for costovertebral angle tenderness, a sterile speculum and vaginal examination are performed to evaluate for adnexal or uterine tenderness, cervical dilation, and potential rupture of membranes. If a mass is suspected, US is the preferred imaging modality. Magnetic resonance imaging can be employed if additional imaging is needed. Differential diagnosis of abdominal pain in pregnant women must include other obstetric and nonobstetric causes of pain. This chapter describes clinical management and follow-up of pregnant women with adnexal masses.
Maternal sepsis is a common pregnancy-related condition; in the United States, it is a leading cause of maternal mortality, accounting for up to 28” of maternal deaths and up to 15” of maternal admissions to the intensive care unit. One contributing and modifiable factor to these deaths is failure to recognize sepsis, leading to delays in treatment. Therefore, rapid and accurate diagnosis and initial management of sepsis in pregnancy in the emergency department (ED) is paramount. Pregnancy poses a unique challenge given the baseline physiologic changes and the need to care for the mother while simultaneously caring for the fetus. Therefore, without clear pregnancy-specific data, recommendations are to follow the current guidelines for nonpregnant adults, yet be cognizant of the ways in which pregnancy may change maternal physiology and affect fetal well-being. Prompt identification and treatment of maternal sepsis will undoubtedly lead to the best possible maternal and neonatal outcomes.
Intimate partner violence (IPV) and sexual assault are common violent crimes perpetrated on women. Obstetric (OB) complications associated with trauma include miscarriage, preterm labor, and placental abruption. Ongoing mental health issues, including depression and anxiety, are more prevalent in pregnant women subjected to any form of IPV, whether or not direct physical violence is involved. One study showed that pregnant women subjected to verbal threats were twice as likely to deliver low-birth-weight infants. All women who present to an OB triage unit or an emergency department (not just those who present with an injury or complication) must be screened for IPV. An organized plan for providing the victim with resources must be readily available when a screen is positive. This chapter discusses presenting symptomatology, history and data collection, physical examination, laboratory and imaging studies, differential diagnosis, clinical management and follow-up care of IPV and sexual assault.
Intimate partner violence (IPV) is a global public health problem, linked to long-term health, social, and economic consequences. IPV is a preventable public health problem that includes physical and sexual violence, stalking, and psychological aggression directed at a woman by a person with whom she has, or has had, an intimate relationship. Violence against women interferes with the health of the woman and also affects the relationship with the primary care provider. This chapter explains in detail the assessment and health consequences of IPV. Most states have laws to protect women from their abusers. The courts in most states try to prosecute perpetrators. IPV continues to be a threat to the health of women and their families in the United States, at a cost $10 billion annually. The chapter’s goal is to provide sensitive, kind, well-informed, universal screening with appropriate referrals for all women who suffer from IPV.
The Intrauterine contraception (IUC) is a plastic contraceptive device that is inserted into the uterine cavity through the cervical canal. The IUC is for contraceptive use only. No IUC is intended to offer any protection against sexually transmitted infection transmission. There are five IUCs available in the United States, which includes copper IUC with white strings, levonorgestrel (LNG)-containing IUC with brown strings, LNG-containing IUC with blue strings. All types have a two-strand, polyethylene monofilament string that protrudes from the cervical os. Intrauterine contraception has been expanded to include not only the levonorgestrel containing Mirena, but also the new, smaller Kyleena device. Kyleena is an LNG-IUC system and provides continuous contraceptive protection for 5 years. A silver ring visible on ultrasound distinguishes Kyleena from other IUCs. The chapter also presents contraindications and management of side effects of IUC.
During the 1970s, there were several individual efforts to have a forum for lay midwives to share birth stories as well as their own stories of struggles, successes, and barriers to working as a midwife in the community. The 1977 El Paso meeting, the First International Conference of Practicing Midwives, was viewed by many as the beginning of the Midwives Alliance of North America (MANA) organization, though much work was to follow until MANA became an official midwifery organization in 1982. Shari Daniels, a self-taught practicing midwife, established the National Midwives Association (N.M.A) in June 1977 following the First International Conference of Practicing Midwives. Certified Nurse-Midwives (CNM) support was a need expressed throughout the development of MANA as a midwifery association. One of the key decisions made at the first interim MANA Board meeting with interim officers in 1982 was the adoption of a draft statement of philosophy.
Spontaneous or natural menopause is marked by the end of the reproductive stage of women’s life. It is a period of transition, and for most women is a normal, physiological, and developmental life event often perceived differently across various cultures. Menopause is the permanent cessation of menses after 12 consecutive months of amenorrhea, or when follicle- stimulating hormone levels are consistently elevated in the absence of other obvious pathologic causes. This chapter explains the physiology of menopause. The menopause transition, also referred to as perimenopause, is associated with fluctuating hormone secretion causing irregular menstrual cycles and ultimately, permanent cessation of menses. Only two major early symptoms are directly attributed to menopause: change in menstrual cycles and vasomotor symptoms (VMS). VMS is a global term referring to hot flashes, hot flushes, and night sweating. VMS are experienced by up to 75% of all perimenopausal women in the United States.
In females, the urinary and reproductive systems are completely separate, unlike in males. The internal female reproductive organs are located in the lower pelvis and are safely tucked inside the bony pelvis, behind the pubic bone. External genitalia collectively include the mons pubis, the labia majora, the labia minora, the vestibule, the clitoris, and the vaginal orifice. This chapter presents the structure, functions, and purposes of the organs of female reproduction. It explains the anatomy and physiology of the following: ovaries; fallopian tubes; uterus; vagina; pelvic support; uterine ligaments; and associated pelvic organs. The lower urinary tract system consists of the bladder and urethra. The bladder has three layers: outer layer—an adventitious layer of connective tissue that is covered by the peritoneum of the anterior wall of the pelvis; middle layer—consists of the detrusor muscle, which facilitates bladder emptying; and inner layer— lined with mucous membrane.
Polycystic ovarian syndrome (PCOS) is an endocrine disorder and one of the most commonly occurring endocrine disorders in women. PCOS is the most common cause of female subfertility. This chapter describes Rotterdam criteria for classification of PCOS. It then provides clinical screening for PCOS. The screening process includes physical examination such as hair distribution; breast examination; peripheral exam; laboratory analysis such as free testosterone; estradiol; serum prolactin; clinical intervention such as patient education; pharmacotherapy and pregnancy-related risks. The chapter describes the goals for management of PCOS. The goals are to lower insulin levels; restore/preserve fertility; treat hirsutism and/or acne; regulate menstruation; prevent endometrial hyperplasia and hence prevent development of endometrial cancer. The decision is driven by whether the woman is younger or older, as well as her desire for future conception.