Clinical Pearl

The vaginal examination assesses the anterior pelvis, whereas the rectal examination is directed at the posterior pelvis.

12. Laboratory assessment for obstetric patients: a. Prenatal laboratory tests usually include:

i. Complete blood count (CBC) to assess for anemia and thrombocytopenia.

ii. Blood type, Rh. and antibody screen are of paramount importance for all pregnant women; for women who are Rh negative,

Rho(D) immune globulin (RhoGAM) is administered at 28 weeks' gestation and at delivery (if the baby proves Rh positive) to prevent isoimmunization.

iii. Hepatitis B surface antigen: Indicates that the patient is infectious. At birth, the newborn should be given hepatitis B immune globulin (HBIG) and hepatitis B vaccine in an attempt to prevent neonatal hepatitis.

iv. Rubella titer: If the patient is not immune to rubella, she should be vaccinated immediately postpartum. Because it is a live-attenuated vaccine, this immunization is not given during pregnancy.

v. Syphilis nontreponemal test (rapid plasma reagin | RPR| or Venereal Disease Research Laboratory [VDRL]): Positive test result necessitates confirmation with a treponemal test, such as the microhemagglutination assay for Treponema pallidum (MHA-TP) or the fluorescent treponemal antibody absorption (FTA-ABS) test. Treatment during pregnancy is crucial to prevent congenital syphilis; penicillin is the agent of choice. Pregnant women who are allergic to penicillin usually undergo desensitization and receive penicillin.

vi. HIV test: Enzyme-linked immunosorbent assay (ELISA) usually is the screening test; a positive result necessitates Western blot or other confirmatory test.

vii. Urine culture or urinalysis: To assess for asymptomatic bacteri-uria, which complicates 6% to 8% of pregnancies.

viii. Pap smear: To assess for cervical dysplasia or cervical cancer: involves both ectocervical component and endocervical sampling (Figure 1-2). Many clinicians prefer the liquid-based media because it may provide better cellular sampling and allows for HPV subtyping.

ix. Endocervical assays for gonorrhea and/or Chlamydia trachomatis for high-risk patients.

b. Timed prenatal tests:

i. Serum screening for neural tube defects or Down syndrome offered and usually performed between 16 to 20 weeks' gestation with the Triple or Quad Screen. First-trimester screening for trisomies with serum pregnancy-associated plasma protein-A (PAPP-A), serum human chorionic gonadotropin (hC6), and nuchal translucency (NT) has gained popularity as well.

ii. Screening for gestational diabetes at 26 to 28 weeks; generally consists of a 50-g oral glucose load and assessment of the serum glucose level after 1 hour.

iii. Some practitioners repeat the CBC, cervical cultures, and/or syphilis serology in the third trimester.

Ectocervical

Ectocervical

Normal Size Endometrial Stripe

Cytobrush

Figure 1-2. Pap smear with ectocervical and endocervical components. The spatula is used to sample the exocervix. The endobrush is used to retrieve cells from the endocervix. and the cells are applied to the slide and fixative added.

Cytobrush

Figure 1-2. Pap smear with ectocervical and endocervical components. The spatula is used to sample the exocervix. The endobrush is used to retrieve cells from the endocervix. and the cells are applied to the slide and fixative added.

iv. If the culture strategy for group B streptococcus is adopted, then introital cultures are obtained at 35 to 37 weeks' gestation.

13. Laboratory tests for gynecologic patients:

a. Dependent on age. presence of coexisting disease, and chief complaint.

b. Common scenarios:

i. Threatened abortion: Quantitative human chorionic gonadotropin (hCG) and/or progesterone levels may help to establish the viability of a pregnancy and risk of ectopic pregnancy.

ii. Menorrhagia due to uterine fibroids: CBC, endometrial biopsy, and Pap smear. Endometrial biopsy is performed to assess for endometrial cancer and the Pap smear for cervical dysplasia or cancer.

iii. A woman 55 years or older with an adnexal mass: Cancer antigen (CA)-125 and carcinoembryonic antigen (CEA) tumor markers for epithelial ovarian tumors.

14. Imaging procedures:

a. Ultrasound examination:

i. Obstetric patients: Ultrasound is the most commonly used imaging procedure in pregnant women. It can be used to establish the viability of the pregnancy, number of fetuses, location of the placenta, or gestational age of the pregnancy. Targeted examinations can help to examine for structural abnormalities of the fetus.

ii. Gynecologic patients: Adnexal masses evaluated by sonography are assessed for size and echogenic texture; simple (fluid-filled) versus complex (fluid and solid components) versus solid. The uterus can be characterized for presence of masses, such as uterine fibroids, and the endometrial stripe can be measured. In postmenopausal women, a thickened endometrial stripe may indicate hyperplasia or malignancy. Fluid in the cul-de-sac may indicate ascites. The gynecologic ultrasound examination usually includes investigation of the kidneys, because hydronephrosis may suggest a pelvic process (ureteral obstruction). Saline infusion into the uterine cavity via a transcervical catheter can enhance the ultrasound examination of intrauterine growths such as polyps.

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