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Johns Hopkins Handbook Of Obstetrics And Gynecology 1st Edition Linda M. Szymanski
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at shop.lww.com (products and services). IN08/2020
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This work is no substitute for individual patient assessment based on health care professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data, and other factors unique to the patient. The publisher does not provide medical advice or guidance, and this work is merely a reference tool. Health care professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments.
Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and health care professionals should consult a variety of sources. When prescribing medication, health care professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects, and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used, or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.
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This Manual is not intended to substitute for the independent professional judgment of the patient’s treating clinicians, nor should it be considered a statement of the standard of care. This Manual is designed as an educational resource only. Use of this information is voluntary. This Manual should not be considered as inclusive of all appropriate treatments or methods of care. The condition of the patient, limitations of available resources, advances in knowledge or technology, and other factors may warrant variations in practice. The results of additional studies or advancements in knowledge or technology may warrant later revisions to the Manual. The Manual is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. The authors do not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither the authors nor Johns Hopkins University; Johns Hopkins Health System Corporation; nor their respective past and present agents (actual or apparent), corporate affiliates, parent corporations, or subsidiary corporations will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information contained herein. No use of any information or materials contained in this Manual shall be deemed to give rise to a physician-patient relationship; to replace the services of a trained physician or health care professional; or otherwise to be a substitute for professional medical and/or nursing advice, diagnosis, or treatment. Patients should consult a licensed physician or appropriately credentialed health care provider in their community in all matters relating to their health.
Dedication
We have dedicated previous editions to our mentors, mentees, and loved ones who energize and inspire us. We would be remiss not to recognize those groups again. We are honored to continue the tradition of this manual, to work with dedicated colleagues at Johns Hopkins and beyond, all in an effort to advance the health of women and families.
Andrew J. Satin, MD
Jessica Bienstock, MD, MPH
Betty Chou, MD
Preface
The history of the Department of Gynecology and Obstetrics extends over 130 years. We are very proud of our historic tradition of leadership in gynecology, obstetrics, and our subspecialties, dating back to Drs. Howard Kelly, J.W. Williams, Richard TeLinde, Nicholson Eastman, Howard and Georgeanna Jones, and so many others who have come before us. Our proud tradition inspires us today to advance our tripartite mission of clinical care, research, and education. In an era of economic and market challenges to academic medicine, we remain steadfast to ensuring advances in all arms of our tripartite mission. Now in its sixth edition, this manual continues to be created by the cooperative efforts of a resident or fellow, faculty preceptor, and a senior faculty editor at Johns Hopkins. It draws its strength from the collaboration of experienced faculty and insightful practical input from rising stars in our field. In using this edition, we hope you will appreciate the camaraderie in which the manual was created. This manual is truly a team effort. Over the years, this book has been a trusted companion carried in the lab coats of residents, medical students, and busy clinicians.
This edition contains several new chapters addressing contemporary topics affecting our patients. Substance abuse, specifically opioid use, in pregnancy has escalated dramatically in recent years. The rise of fetal therapy programs including management options for twin-to-twin transfusion led us to expand content on multifetal gestation. The recognition of the role of genetics prompted a new chapter on genetic and hereditary syndromes. In addition to new chapters in obstetrics addressing substance abuse and multifetal gestation we added chapters on psychiatric disorders, dermatologic disease, and neoplastic disease in pregnancy. New gynecologic chapters focus on organ prolapse, incontinence, and benign vulvar disease. Emphasis on safety sciences and value-based care is pervasive in modern medicine and is now incorporated throughout the practice of obstetricians and gynecologists. We dedicate a new chapter in this edition of the manual to this most important topic. As much as things change, we hope and trust that the content, readability, portability, format, and size continue to have great appeal for practicing clinicians and learners.
Andrew J. Satin, MD
Jessica Bienstock, MD, MPH
Betty Chou, MD
Online resources are not available with this text.
Contributors
All chapter first authors are current or former residents/clinical fellows of the Johns Hopkins Department of Gynecology and Obstetrics. All chapter senior authors are current or former faculty of the Johns Hopkins University School of Medicine.
Crystal Aguh, MD
Director, Ethnic Skin Fellowship
Assistant Professor
Johns Hopkins University School of Medicine Baltimore, Maryland
Abimbola Aina-Mumuney, MD
Assistant Professor
Division of Maternal Fetal Medicine
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Steve C. Amaefuna, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Jean R. Anderson, MD
Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Ana M. Angarita, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Maria Facadio Antero, MD
Clinical Fellow, Female Pelvic Medicine and Reconstructive Surgery
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Cynthia H. Argani, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Deborah K. Armstrong, MD
Professor, Department of Oncology
Professor, Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Ahmet Baschat, MD
Professor
Director, Johns Hopkins Center for Fetal Therapy
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Anna L. Beavis, MD, MPH
Assistant Professor
Kelly Gynecologic Oncology Service
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Jessica L. Bienstock, MD, MPH
Associate Dean for Graduate Medical
Education and Designated Institutional Official
Vice Chair for Education
Department of Gynecology and Obstetrics
Professor, Maternal Fetal Medicine
Johns Hopkins University School of Medicine Baltimore, Maryland
Clinical Fellow, Reproductive Endocrinology, Infertility, and Genetics
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Danielle B. Chau, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Katherine F. Chaves, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Chi Chiung Grace Chen, MD, MHS
Associate Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Mindy S. Christianson, MD
Assistant Professor
Medical Director, Johns Hopkins Fertility Center
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Jensara Clay, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Jenell S. Coleman, MD, MPH
Associate Professor
Division Director, Gynecologic Specialties
Medical Director, JHOC Women’s Health Center
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Chantel I. Cross, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Kristin Darwin, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Samantha de los Reyes, MD
Clinical Fellow, Maternal Fetal Medicine
Department of Gynecology and Obstetrics University of Chicago Chicago, Illinois
Rita W. Driggers, MD
Associate Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Jill Edwardson, MD, MPH
Assistant Professor
Division of Family Planning
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Cybill R. Esguerra, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Amanda Nickles Fader, MD
Associate Professor
Chief, Vice Chair of Gynecology Surgery Operations
Director, Center for Rare Gynecologic Cancers
Kelly Gynecologic Oncology Service
Johns Hopkins University School of Medicine Baltimore, Maryland
Tola Fashokun, MD
Medical Student Instructor
Department of Obstetrics and Gynecology
Johns Hopkins University School of Medicine Baltimore, Maryland
Jerome J. Federspiel, MD, PhD
Clinical Fellow, Maternal Fetal Medicine
Department of Obstetrics and Gynecology
Duke University Durham, North Carolina
Braxton Forde, MD
Clinical Fellow, Maternal Fetal Medicine
Department of Obstetrics and Gynecology
University of Cincinnati Medical Center Cincinnati, Ohio
Anja Frost, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Timothee Fruhauf, MD, MPH
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Stéphanie Gaillard, MD, PhD
Assistant Professor
Department of Oncology and Gynecology/ Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Nicole R. Gavin, MD
Clinical Fellow, Maternal Fetal Medicine
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Megan E. Gornet, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Ernest M. Graham, MD
Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Marielle S. Gross, MD, MBE
Hecht-Levi Postdoctoral Fellow
Berman Institute of Bioethics
Johns Hopkins University Bloomberg School of Public Health Baltimore, Maryland
Marlena Simpson Halstead, MD Physician
Complete Care for Women
Department of Obstetrics and Gynecology
Chippenham Hospital Richmond, Virginia
Esther S. Han, MD, MPH
Clinical Fellow, Minimally Invasive Gynecologic Surgery
Columbia University Medical Center
New York-Presbyterian Hospital
New York, New York
Katerina Hoyt, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Nancy A. Hueppchen, MD, MSc
Associate Professor
Associate Dean, Undergraduate Medical Education
Division of Maternal-Fetal Medicine
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Tochi Ibekwe, MD
Instructor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Angie C. Jelin, MD
Assistant Professor, Maternal Fetal Medicine/ Genetics
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Clark T. Johnson, MD, MPH
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Tiffany Nicole Jones, MD, MS
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Svena D. Julien, MD
Assistant Professor
Division of Maternal Fetal Medicine
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Chavi Kahn, MD, MPH
Physician
Planned Parenthood of Maryland Baltimore, Maryland
Edward K. Kim, MD, MPH
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Benjamin K. Kogutt, MD
Clinical Fellow, Maternal Fetal Medicine
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Jaden R. Kohn, MD, MPH
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins Hospital Baltimore, Maryland
Lauren M. Kucirka, MD, PhD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Megan E. Lander, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Shari M. Lawson, MD, MBA
Assistant Professor
Division Director, Generalist Obstetrics and Gynecology
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Jessica K. Lee, MD, MPH
Assistant Professor
Department of Obstetrics, Gynecology and Reproductive Sciences
University of Maryland School of Medicine
Baltimore, Maryland
Judy M. Lee, MD, MPH, MBA
Adjunct Assistant Professor, Division of Gynecologic Specialties
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Kristen Ann Lee, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Kimberly Levinson, MD, MPH
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Melissa H. Lippitt, MD, MPH
Clinical Fellow, Gynecology Oncology
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
David A. Lovejoy, MD
Associate Professor
Department of Obstetrics and Gynecology
Mercer University School of Medicine Macon, Georgia
Jacqueline Y. Maher, MD
Assistant Research Physician and Staff Clinician
Division of Pediatric and Adolescent Gynecology
Division of Reproductive Endocrinology and Infertility
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
Bethesda, MD
Amanda C. Mahle, MD, PhD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Morgan Mandigo, MD, MSc
Obstetrician/Gynecologist
York Hospital
York, Maine
Melissa Pritchard McHale, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Meghan McMahon, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins Hospital Baltimore, Maryland
Lorraine A. Milio, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Christina N. Cordeiro Mitchell, MD
Clinical Fellow, Reproductive, Endocrinology, and Infertility
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Bernard D. Morris III, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Chailee Faythe Moss, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Reneé Franklin Moss, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
xvi CONTRIBUTORS
Lea A. Moukarzel, MD
Clinical Fellow, Gynecology Oncology
Department of Surgery
Memorial Sloan Kettering Cancer Center
New York, New York
Jamie Murphy, MD
Associate Professor
Director of Obstetrics, Gynecology and Fetal Anesthesiology Division
Department of Anesthesiology and Critical Care Medicine
Johns Hopkins University School of Medicine
Baltimore, Maryland
Emily Myer, MD
Urogynecologist
Department of Obstetrics and Gynecology
Minnesota Women’s Care
Woodbury, Minnesota
Shriddha Nayak, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Victoire Ndong, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Donna Maria Neale, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Christopher M. Novak, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Elizabeth Oler, MD
Physician and Surgeon
Department of Obstetrics and Gynecology
Evergreen Women’s Health
Roseburg, Oregon
Lauren M. Osborne, MD
Assistant Professor
Departments of Psychiatry and Behavioral Sciences
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Yangshu Linda Pan, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins Hospital Baltimore, Maryland
Prerna Raj Pandya, MD, MS
Clinical Fellow, Female Pelvic Medicine and Reconstructive Surgery
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Silka Patel, MD, MPH
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Kristin Patzkowsky, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Jennifer A. Robinson, MD, MPH, PhD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Linda C. Rogers, CRNP
Nurse Practitioner
Johns Hopkins Bayview Medical Center
Baltimore, Maryland
Isa Ryan, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Brittany L. Schuh, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Marla Scott, MD
Clinical Fellow, Gynecology Oncology
Cedars-Sinai Medical Center
Los Angeles, California
Rachel Chan Seay, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Angela K. Shaddeau, MD, MS
Clinical Fellow, Maternal Fetal Medicine
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Jeanne S. Sheffield, MD
Professor
Division Director, Maternal Fetal Medicine
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Wen Shen, MD, MPH
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Khara M. Simpson, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Anna Jo Smith, MD, MPH, MSc
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Malorie Snider, MD
Attending Physician
Department of Obstetrics and Gynecology
Tanner Clinic
Layton, Utah
Rebecca Stone, MD, MS
Associate Professor
Division Director, Kelly Gynecologic Oncology Service
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Carolyn Sufrin, MD, PhD
Assistant Professor
Division of Family Planning
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Stacy Sun, MD, MPH
Clinical Fellow, Family Planning
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Sunitha Suresh, MD
Clinical Fellow, Maternal Fetal Medicine
Department of Obstetrics and Gynecology University of Chicago Chicago, Illinois
Edward J. Tanner III, MD
Associate Professor
Department of Obstetrics and Gynecology
Northwestern University Chicago, Illinois
Lauren Thomaier, MD
Clinical Fellow, Gynecology Oncology
Department of Obstetrics, Gynecology and Women’s Health
University of Minnesota Minneapolis, Minnesota
Orlene Thomas, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Julia Timofeev, MD
Assistant Professor
Division of Maternal Fetal Medicine
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Connie L. Trimble, MD
Professor
Departments of Gynecology and Obstetrics, Oncology, and Pathology
Johns Hopkins University School of Medicine
Baltimore, Maryland
Sandy R. Truong, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Katelyn A. Uribe, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Arthur Jason Vaught, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Karen C. Wang, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins Hospital Baltimore, Maryland
Stephanie L. Wethington, MD, MSc
Assistant Professor, Gynecology Oncology
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
MaryAnn Wilbur, MD, MPH, MHS Instructor
Department of Obstetrics and Gynecology
Harvard Medical School Boston, Massachusetts
Tenisha Wilson, MD, PhD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Harold Wu, MD
Clinical Fellow, Minimally Invasive Gynecology
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine Baltimore, Maryland
Camilla Yu, MD
Resident Physician
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Howard A. Zacur, MD, PhD
Theodore and Ingrid Baramki Professor of Reproductive Endocrinology
Fellowship Director for Reproductive Endocrinology and Infertility
Division of Reproductive Endocrinology and Infertility
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, MarylandSixth Edition
17 Neurologic Diseases in Pregnancy 210
Ana M. Angarita and Irina Burd
18 Psychiatric Disorders in the Pregnant and Postpartum Patient 221
Jaden R. Kohn and Lauren M. Osborne
19 Substance Use Disorders in Pregnancy 237
Marielle S. Gross and Lorraine A. Milio
20 Hematologic Disorders of Pregnancy 254
Christopher M. Novak and Rita W. Driggers
21 Neoplastic Diseases in Pregnancy 281
Meghan McMahon and Jessica L. Bienstock
22 Skin Conditions in Pregnancy 294
Angela K. Shaddeau and Crystal Aguh
23 Surgical Disease and Trauma in Pregnancy 298
Bernard D. Morris III and Nancy A. Hueppchen
24 Postpartum Care and Breastfeeding 308
Timothee Fruhauf and Silka Patel
25 Obstetric Anesthesia 319
Kristen Ann Lee and Jamie Murphy Part II: General Gynecology
26 Primary and Preventive Care 329
Sandy R. Truong and Tochi Ibekwe
27 Infections of the Genital Tract 346
Amanda C. Mahle and Jenell S. Coleman
28 Contraception and Sterilization 373
Stacy Sun and Jennifer A. Robinson
29 Abortion 386
Jessica K. Lee and Chavi Kahn
30 First and Second Trimester Pregnancy Loss and Ectopic Pregnancy 391
Jill Edwardson and Carolyn Sufrin
31 Abnormal Uterine Bleeding 402
Katerina Hoyt and Jean R. Anderson
32 Chronic Pelvic Pain 416
Melissa Pritchard McHale and Khara M. Simpson
33 Uterine Leiomyomas and Benign Adnexal Masses 434
Esther S. Han and Mostafa A. Borahay
34 Breast Diseases 446
Harold Wu and Shriddha Nayak
35 Benign Vulvar Disorders 461
Megan E. Lander and Cybill R. Esguerra
36 Female Sexual Function and Dysfunction 469
Yangshu Linda Pan and Linda C. Rogers
37 Intimate Partner and Sexual Violence 478
Morgan Mandigo and Orlene Thomas
38 Pediatric Gynecology 487
Malorie Snider and Carla Bossano
Part III: Reproductive Endocrinology and Infertility
39 The Menstrual Cycle 503
Brittany L. Schuh and Chailee Faythe Moss
40 Infertility and Assisted Reproductive Technologies 507
Christina N. Cordeiro Mitchell and Mindy S. Christianson
41 Recurrent Pregnancy Loss 526
Kamaria C. Cayton Vaught and Mindy S. Christianson
42 Menstrual Disorders: Endometriosis, Dysmenorrhea, and Premenstrual Dysphoric Disorder 534
Camilla Yu and Jensara Clay
43 Evaluation of Amenorrhea 544
Victoire Ndong and Chantel I. Cross
44 Polycystic Ovary Syndrome and Hyperandrogenism 556
Jacqueline Y. Maher, Maria Facadio Antero, and Howard A. Zacur
45 Definitions and Epidemiology of Menopause 570
Jacqueline Y. Maher and Wen Shen
Part IV: Female Pelvic Medicine and Reconstructive Surgery
503
581
46 Urinary Incontinence and Lower Urinary Tract Symptoms 581
Prerna Raj Pandya and Chi Chiung Grace Chen
47 Pelvic Organ Prolapse 589
David A. Lovejoy and Chi Chiung Grace Chen
48 Anal Incontinence 598
Emily Myer and Tola Fashokun
Part V: Gynecologic Oncology 603
49 Cervical Intraepithelial Neoplasia 603
Anna L. Beavis and Connie L. Trimble
50 Cervical Cancer 615
Melissa Pritchard McHale and Kimberly Levinson
51 Cancer of the Uterine Corpus 633
Marla Scott and Amanda Nickles Fader
52 Ovarian Cancer 648
Lea A. Moukarzel and Edward J. Tanner III
53 Hereditary Cancer Syndromes 667
Anja Frost and Deborah K. Armstrong
54 Premalignant and Malignant Disease of the Vulva and Vagina 678
Megan E. Gornet and Rebecca Stone
55 Gestational Trophoblastic Disease 688
Danielle B. Chau and Kimberly Levinson
56 Chemotherapy, Antineoplastic Therapy, and Radiation Therapy 701
Tiffany Nicole Jones and Stéphanie Gaillard
57 Palliative and End-of-Life Care 714
Melissa H. Lippitt and Stephanie L. Wethington
Part VI: Surgery in Obstetrics and Gynecology 727
58 Anatomy of the Female Pelvis 727
Katherine F. Chaves and Jean R. Anderson
59 Surgical Approaches in Gynecologic Surgery 740
MaryAnn Wilbur and Kristin Patzkowsky
60 Perioperative Care and Complications of Gynecologic Surgery 749
Katelyn A. Uribe and Karen C. Wang
61 Critical Care 767
Lauren Thomaier and Arthur Jason Vaught
62 Quality, Safety, and Value in Women’s Health 792
Anna Jo Smith and Judy M. Lee
Index 797
I Obstetrics
1
Prepregnancy
Counseling and Prenatal Care
PREPREGNANCY CARE AND COUNSELING
• Prepregnancy care is an important time during the women’s health continuum that can reduce maternal-fetal morbidity and mortality. It is an opportunity prior to conception to optimize health, identify and modify risk factors, and provide education about considerations and behaviors that could affect a future pregnancy. Preconception counseling is becoming ever more important as more women are diagnosed with chronic conditions such as hypertension, diabetes mellitus, obesity, autoimmune diseases, and psychiatric illness. Preconception counseling should be implemented into the routine medical care of all reproductive-aged women. Any encounter with nonpregnant women with reproductive potential is an opportunity to improve reproductive health and impact future obstetric outcomes.
• A thorough review of medical, surgical, psychiatric, gynecologic, and obstetric health can expose potential complications in a planned pregnancy or factors contributing to infertility.
• A full obstetric history should be taken during prepregnancy care and reviewed at the initial prenatal visit. Family planning and pregnancy spacing needs should be discussed, and women should be advised about the risks of interpregnancy intervals shorter than 6 months. Prior pregnancy complications should be discussed as well as the risk of recurrence and possible interventions that might decrease that risk.
• Prepregnancy care should include a review of age-appropriate cancer screening. If there is a history of inconsistent or outdated testing, this evaluation should be completed. Discussion about appropriate pregnancy timing should be considered to avoid delayed cancer diagnosis or treatment.
• Consultation with maternal-fetal medicine or reproductive endocrinology and infertility may be considered in women with a history of poor obstetric outcomes or chronic medical conditions.
Marlena Simpson Halstead and Rachel Chan Seay
Health Optimization and Medical Assessment
Approximately half of pregnancies are unintended or unplanned, so it is important to counsel all women with reproductive potential about wellness and healthy habits. In turn, a large portion of women consciously attempt pregnancy and actively seek counseling about health optimization, management of chronic illness, risk identification, and behavior modification prior to conception.
• Preconception care should include a thorough assessment of an individual’s medical problems and risk assessment (Table 1-1). Many chronic medical conditions have implications for fertility and pregnancy, and the goal of prepregnancy care is to identify and optimally manage these conditions prior to pregnancy. Referral to specialists, including maternal-fetal medicine, may be appropriate, both for health optimization and for discussion of potential effects of a pregnancy on the chronic medical condition. While there are many medical conditions that should be optimized before conception, we discuss three common conditions here:
• Diabetes mellitus. See chapter 11. Preconception counseling should include a review of current management in women with a prior diagnosis or a review of risk factors and recommendations to obtain diagnostic testing when applicable. Poorly controlled diabetes is associated with a risk of major fetal malformations. Pregestational diabetes mellitus is also associated with spontaneous abortion, preterm birth, and accelerated or excessive fetal growth.
• Chronic hypertension. See chapter 12. The assessment of chronic hypertension should include the duration of illness, current medication regimen, and its
Offer genetic screening for cystic fibrosis, spinal muscular atrophy
Urine dipstick
Age-appropriate cervical cancer screening (Pap smear HPV co-testing)
Hepatitis B surface antigen
Rubella IgG
Illicit drug screen
Recommended Screening for Some Women
Tuberculosis
Hepatitis C
Gonorrhea and chlamydia
HIV
Syphilis
Varicella IgG
Toxoplasmosis IgG
CMV IgG
Parvovirus B19 IgG
Consider genetic carrier screening for hemoglobinopathies, Tay-Sachs disease, Canavan disease, or other genetic diseases.
Lead level
Abbreviations: CMV, cytomegalovirus; HIV, human immunodeficiency virus; HPV, human papillomavirus; IgG, immunoglobulin G.
aAdapted from U.S. Department of Health and Human Services. Caring for Our Future: The Content of Prenatal Care. A Report of the Public Health Service Expert Panel. Washington, DC: U.S. Department of Health and Human Services; 1989.
Table 1-1
degree of successful control. Further investigation into secondary causes of hypertension and other systemic sequelae may be needed, such as an assessment of baseline renal function or testing for ventricular hypertrophy. Recommendations should be made to alter current medication regimens to avoid angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, as these agents are contraindicated in pregnancy. Preconception counseling should include a discussion about the risk of adverse outcomes during the pregnancy, including superimposed heart failure, stroke, worsening underlying renal disease, preeclampsia, placental abruption, fetal growth restriction, and preterm delivery.
• Obesity. The incidence of obesity in reproductive-aged women is increasing. Obesity is associated with problems including but not limited to infertility, recurrent pregnancy loss, preterm delivery, pregnancy-induced hypertension, gestational diabetes, stillbirth, and higher rates of cesarean delivery.
¢ Optimal control and management obesity ideally occurs prior to conception. Improvement in medical comorbidities has been demonstrated in women with even modest weight loss prior to pregnancy. This weight loss can be achieved by medical or surgical means. Medications used for weight loss are not recommended during conception or pregnancy. Motivational interviewing to support healthy diet and physical activity has been used within the clinical setting to promote weight loss in this population.
¢ The number of bariatric surgical procedures performed annually is increasing, and the majority of these patients are reproductive-aged females. Higher fertility rates are seen following surgery as a result of the rapid weight loss and restoration of predictable ovulation. Women should be counseled regarding contraceptive options with the recommendation to avoid pregnancy for 12 to 24 months following bariatric surgery.
Substance Use Assessment
All patients should routinely be asked about their use of nicotine products, alcohol, and prescription as well as illicit substances. The preconception interview allows timely education about drug use and effects on pregnancy, informed decision making about the risks of using these substances at the time of conception and throughout pregnancy, and the introduction of interventions for women who need treatment (see chapter 19).
• Nicotine products. Tobacco use remains the single largest preventable cause of disease and premature death in the United States. Screening for tobacco use and providing cessation counseling are some of the most effective preventive health actions provided by health care providers.
• Tobacco use can negatively impact fertility and a future pregnancy by increasing rates of miscarriage, ectopic pregnancy, preterm birth, placental abruption, intrauterine growth restriction, low infant birth weight, and perinatal mortality. Tobacco exposure can continue to negatively impact the neonate, as children of smokers have increased risk of asthma, infantile colic, and childhood obesity.
• Tobacco cessation should be recommended prior to conception and readdressed throughout the pregnancy and postpartum period. Nicotine replacement therapy with either gum or transdermal patch can be considered for women attempting to stop smoking. These forms of replacement reduce fetal exposure to toxic chemicals like carbon monoxide. In general, emphasis on offering techniques to stop smoking rather than mandating cessation alone has been found to be a more successful strategy in counseling cessation.
• Alcohol. Alcohol is a well-established teratogen. There is no known safe amount of alcohol use during pregnancy or while trying to get pregnant. Ethanol freely traverses the maternal-fetal placental barrier and the fetal blood-brain barrier. Although the threshold for adverse events is not currently known, a dose-related relationship between alcohol and the consequences in pregnancy has been established. The US Surgeon General advises woman who are pregnant or planning pregnancy to abstain from drinking alcohol.
• Fetal alcohol spectrum disorder refers to a range of effects that can occur when a fetus is exposed to alcohol during pregnancy, including disturbances in intellect, learning abilities, behavior, growth, vision, and hearing. Alcohol can alter cardiac development, presenting as atrial or ventricular septal defects or conotruncal heart defects. Children born to women who abuse alcohol are at higher risk for skeletal, renal, and ocular defects than those not exposed to alcohol during pregnancy. Fetal alcohol syndrome represents the most severe form of the fetal alcohol spectrum disorder and is characterized by neurodevelopmental and central nervous system disturbances, growth deficiencies, and characteristic abnormal facial features. This group of conditions is preventable.
• All women should be screened annually for alcohol dependence and abuse, and all pregnant women should be screened as early as possible in pregnancy. American College of Obstetricians and Gynecologists (ACOG) recommends the use of short validated screening tools, such as the T-ACE tool (Table 1-2). Identifying at-risk behavior allows for early intervention and timely referral for treatment.
• Marijuana. Marijuana is the most commonly used illicit substance during pregnancy, and marijuana use is increasing with marijuana legalization. The receptor on which marijuana acts has been found in the central nervous system of fetuses as early as 14 weeks’ gestation. Animal models have suggested that tetrahydrocannabinol is able to cross the placenta, and there is some evidence in human research that it is also present in breast milk. Emerging evidence suggests that prenatal exposure to marijuana may result in impaired cognition and possibly an increased susceptibility to other illicit or abused substances. Marijuana use in pregnancy may be associated with an increased risk of stillbirth, preterm delivery, and lower birth weights. In addition to potential physiologic effects, patients should also be informed of the potential ramifications of a positive toxicology screen result in pregnancy.
Tolerance How many drinks does it take to make you feel high?
Annoyed Have people annoyed you by criticizing your drinking?
Cut down Have you ever felt you ought to cut down on your drinking?
Eye-opener Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
aPositive score is 2 or more points. Two points are assigned if more than two drinks for the Tolerance question. One point is assigned if person responds “yes” to the Annoyed, Cut down, or Eye-opener question.
T-ACE Screening Tool for Alcohol Misusea Table 1-2
• Opioids. The prevalence of opioid use in pregnancy has increased dramatically in recent years. Opioid use disorder is a chronic disease that can be managed successfully when identified. Several validated screening tools exist, and ACOG recommends early universal screening in pregnancy for opioid use disorder.
• Opioids can be ingested orally, intravenously, or by inhalation. They can be swallowed, chewed, or placed as suppositories. All opioid substances may result in overdose, causing respiratory depression or death. Additionally, injected opioids carry the risk of blood-borne diseases such as human immunodeficiency virus (HIV) and hepatitis, and additional vaccination and testing should be considered. Opioid use disorder is also associated with concomitant psychiatric disorders such as depression, anxiety, and posttraumatic stress disorder. Thus, mental health screening is particularly important in these patients.
• The literature is inconsistent regarding the risk of congenital anomalies following prenatal opioid exposure. Chronic use during pregnancy is associated with an increased risk of fetal growth restriction, preterm birth, stillbirth, and placental abruption. Neonatal abstinence syndrome is the drug withdrawal pattern that may develop in neonates exposed to chronic maternal opioid use in utero. It may last days to weeks and is characterized by poor feeding, poor sleep, hypertonicity, sneezing, high-pitched cry, diarrhea, tremors, or seizure.
• Cocaine. Many of the adverse effects of cocaine are related to vasoconstriction or hypertensive events. Cocaine use is associated with cardiac ischemia, cerebral infarction or hemorrhage, and malignant hypertension and may lead to sudden cardiac death. Cocaine use in pregnancy is associated with spontaneous abortion, stillbirth, placental abruption, preterm labor, preterm rupture of membranes, and fetal growth restriction. Fetuses exposed to cocaine in utero have an increased risk of behavioral abnormalities, cognitive impairment, and impaired motor function.
• Amphetamine. Data are limited when looking specifically at methamphetamine use in pregnancy. Women who use methamphetamine frequently use other illicit drugs as well which can confound outcomes. As trends demonstrate an increase in use within the United States, it is important to be aware of this compound and its effects. Methamphetamine can be ingested orally, intravenously, or rectally as well as by inhalation or nasal insufflation. Intrauterine exposure has been consistently associated with infants who are small for gestational age and may increase the risk of early childhood neurodevelopmental abnormalities. At present, teratogenicity has not been demonstrated.
Psychiatric Health
Psychiatric illness during pregnancy is associated with a higher risk of postpartum psychiatric illness, less or inconsistent prenatal care, and poor maternal and infant outcomes. In addition, antidepressants and antipsychotic medications have been associated with decreased ovulation and infertility. Evaluation for psychiatric illness and optimization of a medical regimen should be encouraged prior to pregnancy (see chapter 18).
Review of Medications
All prescription medications, over-the-counter drugs, and dietary supplements should be reviewed. Male partners should also be screened for the use of androgens, which is associated with male factor infertility. If attempting pregnancy, it is important to review the safety of all current medications prior to conception. Secondary to the
oversimplification of safety profiles, the historic categories for medications in pregnancy have been replaced with descriptions that are felt to be more comprehensive. Assistance in answering questions about reproductive toxicology is available through the online database REPROTOX (http://www.reprotox.org). Potentially teratogenic medications should be adjusted in collaboration with the prescribing health care providers. Both the maternal and fetal risk of continuing or discontinuing medication should be considered. In some cases, discontinuation of a medication may be associated with a greater risk for maternal well-being when compared to potential medication-related risks to the fetus.
Infectious Disease Screening
It is important to clarify a history of infectious diseases and assess past and current risk of exposure and need for screening. A woman should be screened based on age and risk factors for gonorrhea, chlamydia, syphilis, HIV, hepatitis, tuberculosis, toxoplasmosis, and Zika virus as appropriate. A history of herpes simplex virus, particularly genital involvement, should be assessed. Listeria infection is associated with obstetric and neonatal complications, and dietary recommendations should be reviewed.
Immunizations
Both prepregnancy and prenatal counseling should include a review of immunization status and recommendations for appropriate vaccination.
• Influenza. This vaccine is recommended annually during the flu season for all pregnant women regardless of gestational age. Patients with conditions that make them more susceptible to the illness, such as cardiopulmonary disorders, immunosuppression, and diabetes mellitus, should be especially urged to comply with this recommendation.
• Tetanus, diphtheria, and pertussis. The Centers for Disease Control and Prevention recommends administering the tetanus, diphtheria, and pertussis vaccine during each pregnancy between 27 and 36 weeks, preferably during the earlier part of this time period.
• Hepatitis B. Administration of the hepatitis B virus (HBV) vaccine or hepatitis B immune globulin is safe in pregnancy. Women at high risk for HBV who should receive the vaccine during pregnancy include those with a history of intravenous drug use, those at risk from sexual exposure (multiple sex partners, partners of hepatitis B surface antigen–positive persons, receiving treatment for another sexually transmitted disease) or occupational exposure, those who reside in places where adults have high risk for hepatitis B infection (dialysis unit, nursing institutions), and those who are recipients of clotting factor concentrates.
• Pneumococcal vaccine. This vaccine is indicated for pregnant women at high risk for this infection, such as women with heart disease, HIV infection, lung disease, sickle cell disease, and diabetes.
• Live vaccines should be administered either prior to or after pregnancy.
• The measles, mumps, and rubella vaccine contains live attenuated antigens. This vaccine should be administered outside of pregnancy and optimally more than 4 weeks prior to conception.
• The varicella vaccine is a live attenuated vaccine and should be administered outside of pregnancy to those without a clinical history of the chicken pox or verified immunity.
• The human papillomavirus vaccination is not currently recommended during pregnancy.
Social Assessment
• Violence, intimate partner violence, and reproductive coercion. Women of all ages may experience violence, but those of reproductive age are at highest risk. Screening for violence and intimate partner violence is a core part of women’s preventive health and should routinely be included in prepregnancy and prenatal care. In addition to maternal trauma, physical abuse during pregnancy has been associated with fetal injury, stillbirth, antepartum hemorrhage, placental abruption, and preterm labor. All patients should be screened early and often, and patients should be made aware that all patients are screened. Legal and community resources should be provided to women who disclose abuse or reproductive coercion (see chapter 37).
• Housing and food security. Patients should be asked about social support and screened for housing and food security. Referral to social work and appropriate assistance programs should be incorporated into care as needed.
• Insurance coverage and financial difficulties. Many women do not know the eligibility requirements or extent of maternity coverage provided by their insurance carrier or may lack medical insurance coverage altogether. Referral for medical assistance programs should be part of preconception planning as needed.
Family History
• The preconception evaluation should include a thorough family history of the patient and her partner, including genetic disorders; congenital or chromosomal anomalies; mental disorders; consanguinity; and breast, ovarian, uterine, and colon cancer. Ethnic background of a couple may help guide recommendations for carrier screening. Referral to a genetics counselor may be considered.
• Early identification of carrier status can help guide reproductive goals and plans for attempting pregnancy; performing testing before, during, and after pregnancy; or using assistive technologies to achieve pregnancy.
Maternal Age
• Women who will be 35 years or older at the time of delivery are considered to be of advanced maternal age and are at increased risk for fetal aneuploidy, infertility, stillbirth, and other pregnancy-associated diseases such as hypertension and diabetes. Patients should be counseled on their options for aneuploidy screening and diagnostic testing.
Nutritional Assessment
• Folic acid. All women of reproductive age should take folic acid supplementation. Adequate folic acid intake decreases the risk for defects related to complete closure of the neural tube (NTDs). Average-risk women should consume 400 g daily. Most prenatal multivitamins contain sufficient folic acid for average-risk women. Women who take antiepileptic medications or have had a prior pregnancy affected by an NTD are at higher risk and should consume higher levels (4 mg daily) of folic acid.
• Excessive use of supplements containing vitamin A should be avoided. At dosages of more than 20,000 IU daily, vitamin A carries a risk of teratogenic effects.
• Eating habits and disorders. Patterns in eating (eg, fasting, caloric restriction, use of nutritional supplements) should be discussed. Women at risk of eating disorders should be counseled, and multimodal treatment teams should ideally be established prior to pregnancy and include a nutritionist and a mental health provider.
