Gynecology ========== See also: Drugs and Pregnancy/Breastfeeding Ovarian Remnant Syndrome Ovarian Torsion PID Rape Exams STDs Vaginitis Plan B: max 5 days after intercourse þ OB/GYN Notation - TPAL terminology= A system used to describe obstetrics history of a patient. T=term infants P=premature infants A=abortions L=living children - Separate TPAL numbers by hyphens. Obstetric history: 4-2-2-4 - Alternatively, spell out the terms as follows: - Obstetric history: 4 term infants, 2 premature infants, 2 abortions, 4 living children - Sometimes, GPA terminology is combined with TPAL terminology: "The patient is gravida 3, 3-0-0-3." - GPA terminology with GPA as the abbreviation for gravida, para, abortus. Accompanied by arabic numbers, G, P, and A (or Ab) describe the patient's obstetric history. Roman numerals are not used. G gravida (number of pregnancies) P para (number of births of viable offspring) A or Ab abortus (abortions) nulligravida gravida 0 no pregnancies primigravida gravida 1, G1 1 pregnancy secundigravida gravida 2, G2 2 pregnancies nullipara para 0 offspring Separate GPA sections by commas. Alternatively, spell out the terms, using lower case. - Obstetric history: G4, P3, A1 or Obstetric history: gravida 4, para 3, abortus 1. - When one or more of the numbers is 0, the preferred form is to write out the terms. "gravida 2, para 0, abortus 2" þ DUB/Menorrhagia - for long bleeding: + Premarin 2.5 mg QID for 8 doses (Dr. Christie from OVGH says 1.25 mg daily for two days), then + Provera 10 mg daily for 10 days - May treat with Lo-Ovral (white pills only, with food): 4-4-4-4-4-3-1-1-1-1 (tapering over 10 days); risk or thromboembolism due to high dose, don't smoke with this! - IV estrogen (25 mg IV Q3H) -- doesn't work any better than oral - general principle: give estrogens to stop bleeding, then progesterones to stop endometrial growth. - Progesterone: give Provera 10 mg daily for 10 days, but only if haven't been bleeding for a long time, i.e., bleeding 3 days or less. - Danazol to reduce estrogen production -- has virilizing side effects, maybe not appropriate in the ED. - Lupron: GnRH antagonist -- suppresses LH and FSH, similar to Danazol. þ "Morning After" Pills - (dosage of estrogens for preventing pregnancy after rape): 4 Ovral (4 ethinyl estradiol 50 ug=200 ug) stat [Med Ltr 31:93, 1989; 34:885, 1992.] - The recommended regimen is Ovral 2 tabs stat and repeated in 12 hours. Ovral contains 0.5 mg norgestrel and 0.05 mg ethinylestradiol Lo-Ovral can also be used keeping in mind that each pill contains only 0.3 mg norgestrel and 0.03 mg ethinylestradiol and thus the correct doasge is Lo-Ovral 4 tabs stat repeated in 12 hours. There is a WWW server out of the Office of Population Research at Princeton that has information about post-coital contraception with literature references for those interested (they're there, however, even you're not interested). The URL is http://opr.princeton.edu/ec They list the following: + Ovral (one dose is 2 white pills) + Nordette (one dose is 4 light-orange pills) + Levlen (one dose is 4 light-orange pills) + Lo/Ovral (one dose is 4 white pills) + Triphasil (one dose is 4 yellow pills) + Tri-Levlen (one dose is 4 yellow pills) Each dose repeated once in 12 hours. þ On the market now: - "Plan B": packet of two 0.75 mg tablets of levonorgestrel - "Preven" Emergency Contraceptive Kit (four tablets, each with 50 mcg of ethinyl estradiol and 0.25 mg of levonorgestrel, and a pregnancy test to rule out preexisting pregnancy. - Both about $20. Medical Letter [1/24/00] says less side effects and better efficacy with "Plan B" þ Vaginal Lubricants When I looked into the 'science' behind this recommendation I came across one early 1976 study which found only slight inhibition of bacterial growth from the use of K-Y jelly (1). And even then only if the organisms were placed into direct contact with the lubricant. Something which I doubt even occurs in practice. A more recent study found that K-Y jelly had no toxicity towards chlamydia and only slight toxicity for GC (2). Similar findings were observed with regards to vaginal cultures for Group B strep (3). That the resident would have posed this question indicates to me that this decades old practice is still being taught. Does anyone know of any more recent or 'better' science on this issue? H. Louzon MD (1) Singh B, Cutler JC The effect of vaginal lubricants on Neisseria gonorrhoeae. Am J Obstet Gynecol 1976 Oct 1;126(3):365-9 The possible interference of vaginal lubricants in culture diagnosis of gonorrhea was investigated by studying in vitro effect of selected lubricants on Neisseria gonorrhoeae. Two lubricants widely used in family planning and other clinics were demonstrated to have a bactericidal effect on N. gonorrhoeae when tested with more than one method. Gonococci were killed on contact with Lubrifoam, even at a 10 per cent concentration, and an exposure time as short as one minute was sufficient to inhibit the growth on chocolate agar medium. The K-Y jelly showed less inhibitory effect than Lubrifoam. These findings suggest that certain vaginal lubricants have bactericidal effects and their presence can inhibit the growth of Neisseria gonorrhoeae. (2) Osborn MF, Johnson AP Effect of various analgesics and lubricants on isolation of Chlamydia trachomatis and Neisseria gonorrhoeae. J Clin Microbiol 1982 Mar;15(3):522-4 Five preparations used as analgesics or lubricants in surgical, obstetrical, gynecological, and investigative procedures were tested for their effec on the isolation of Chlamydia trachomatis. Three lignocaine preparations and a lubricating jelly containing 2% phenol were inhibitory to chlamydiae. In contrast, K-Y lubricating jelly was relatively nontoxic to chlamydiae. Since K-Y jelly also had only slight toxic activity against gonococci, it is recommended for the lubrication of instruments which need to be used for the efficient isolation of these microorganisms. (3) Brady K, Sizemore KL, Duff P, Aamodt LW The effect of bacteriostatic lubricant on group B streptococcal cultures of the female genital tract. Obstet Gynecol 1989 Dec;74(6):848-50 The purpose of this prospective investigation was to determine the effect of bacteriostatic lubricant on group B streptococcal cultures obtained from the lower genital tract of pregnant women. Fifty pregnant women with intact membranes who recently had genital tract cultures for group B streptococci were evaluated. The study group consisted of 25 women who had positive cultures, and the control group comprised 25 women who had negative cultures. All patients underwent examination with a sterile nonlubricated speculum within 7 days of the previously obtained cultures. Secretions from the endocervix and from the posterior vaginal wall near the introitus were collected with a sterile cotton-tipped applicator and inoculated directly onto a selective blood agar culture plate. The sterile speculum was removed and a digital examination performed using bacteriostatic lubricant. A second sterile speculum was then inserted into the vagina and another group B streptococcal culture was obtained. There was 100% correlation between the cultures obtained before and after the vaginal examination. We conclude that use of bacteriostatic lubricant does not alter the recovery of group B streptococci from the genital tract of pregnant women with intact membranes.