OB-GYN Concerns
From the University of Minnesota Medical School’s Family Medicine Review—Update 2005
| Newer Issues in Obstetrics —Virginia R. Lupo, MD, Assistant Professor of Obstetrics, Gynecology, and
Women’s Health, University of Minnesota Medical School, and Chair, Department of Obstetrics and Gynecology, Hennepin
County Medical Center, Minneapolis
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| Screening for gestational diabetes: some organizations recommend risk-based strategies, some organizations recommend
screening all pregnant women; >90% of pregnant women fit into risk category; screen women in late second or
early third trimester; treatment should result in glucose excursions similar to those of women without diabetes
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| Management strategies: articles show improved outcomes with lower glucose levels during any time of day; aim to
mimic nondiabetic women; “the lower the better, although ketones aren’t great”
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| Gestational diabetes: glucose 2 SDs beyond mean average; in nondiabetic pregnant women, morning fasting blood glucose
(FBG) ≈83 mg/dL (≥95 mg/dL indicates 2 SDs over most pregnant women); almost all pregnant women have serum
glucose <140 mg/dL 1 hr after breakfast, <120 mg/dL 2 hr after; lower serum glucose with glyburide, insulin, diet,
and exercise; treatment should improve maternal morbidity and decrease stillbirths, injury and trauma during birth,
neonatal complications, elevated bilirubin, fussy feeding, high calcium levels, and caesarean delivery rate; progression
to overt diabetes—develops in ≈66% of gestational diabetic women within 16 yr of delivery; risk factors include ethnicity
(eg, rates higher in Hispanic women than in Scandinavian women); greatest conversion in women with highest
glucose levels in pregnancy, obese women, and women diagnosed with diabetes early in pregnancy
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| Recognizing gestational diabetes: spectrum of glucose intolerance; some women diabetic only with pregnancy and
some women probably diabetic before pregnancy and finally recognized during pregnancy; diabetes may have preexisted
in women with FBG >126 mg/dL, history of diabetes during first pregnancy, or diabetes during past pregnancy
with no postpartum evaluation; recognize women who have been diabetic during pregnancy, and test for type 2 diabetes
after delivery
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 | Postpartum screening: do not test sooner than 6 wk after delivery; diagnosis—2 measurements of serum glucose ≥126
mg/dL, or glucose >200 mg on glucose tolerance test (GTT); ask for GTT using 75-g glucose load for nonpregnant
women and 2-hr test; high (but <126 mg/dL) FBG or slightly elevated (140-200 mg/dL) 2-hr glucose level indicates
impaired glucose tolerance (patients should be tested every year)
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| Insulin resistance: gestational diabetes is period of insulin resistance and poor β-cell compensation; pregnant women secrete
more insulin in response to glucose load than nonpregnant women, gestational diabetic women make even more in
response to glucose load; troglitazone—decreases insulin resistance so islet cells do not produce as much insulin in response
to food; chronic resistance to insulin may result in exhaustion of islet cells and overt diabetes (insulinopenic diabetic
state); study randomized Hispanic women with history of gestational diabetes to daily troglitazone or placebo; after
3 yr, annual incidence of conversion to overt diabetes 12% in placebo group, 5% in treated group; protection persisted
for ≥8 mo after end of treatment; troglitazone removed from market because of hepatic toxicity; gestational diabetes may
be indicator of risk for overt diabetes (interventions may be possible; screen women 6 wk postpartum); rate of progression
of impaired glucose tolerance to diabetes 16% per year; norethindrone—higher chance of conversion to overt diabetes
in women with gestational diabetes who breast feed; suggested not to prescribe progestin-only minipill to
postpartum gestational diabetics who are nursing; use intrauterine device (IUD) or barrier methods; after lactation established
for 2 mo, consider using low-dose combination pill
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| Periodontal disease: study found women who delivered prematurely had more severe periodontal disease than control
women; gingivitis—gum disease; effects visible; periodontal disease—occurs under gumline (not visible); gum disease
may be indicator of systemic inflammatory process that may trigger preterm delivery; fluid around gums contains
inflammatory mediators; calculus—tartar; hard buildup of bacteria over time; attracts more bacteria; major cause of
gum disease; disrupts tooth from gum and creates pocket that contains inflammatory mediators; periodontists measure
depth of pocket to determine loss of attachment and severity of disease; can lead to bone erosion
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| Obstetrics and Periodontal Therapy study: assessed women before 16-wk gestation for presence of periodontal disease;
816 women randomized for treatment of periodontal disease or teeth cleaning; end point gestational age at delivery;
value of treating gum disease to prevent preterm delivery currently speculative; availability of basic dental care
limited for patients receiving public assistance
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| Gum disease and adverse pregnancy outcomes: study found women with severe preeclampsia had more severe gum disease
and more periodontal disease than women who were not preeclamptic; postpartum endometritis more associated with
women with gum disease; gum disease may be indicator of lower socioeconomic level and poor general health
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| Prevention of preterm delivery: multifactorial; progesterone to decrease recurring preterm delivery—under study;
study found giving progesterone once weekly starting at 16-wk gestation to women with history of premature delivery
decreased rate of recurrence from 56% to 39%, but 40% of women still delivered prematurely; progesterone may decrease
recurrence in small subset of women, but “not ready for prime time yet”
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| Methamphetamine use in pregnancy: effects of methamphetamine last 10 to 12 hr; ingestion causes massive dopamine
release with profound adrenaline response; causes increased heart rate, sweating, irritability, paranoia, depression, fatigue,
cognitive impairment, neuron damage, and long-lasting (≥1 yr) decrease in dopamine levels; severe paranoia and ongoing
psychosis develop after withdrawal; stresses of pregnancy and fatigue attract women to use methamphetamine;
addiction—chronic relapsing disease; treatable as other chronic diseases; complications in pregnancy—similar to
those of cocaine use; hypertensive episodes; placental abruption with vasoconstriction of uterine arteries and decreased
oxygenation of uterus; severe fetal distress; identify fragmentation of care (contact Child Protective Services); neonatal
withdrawal can be prolonged; principles of treatment—treatment must be readily available; medical detoxification alone
does little to change long-term drug use; enforced abstinence (eg, by incarceration) without drug abuse therapy (eg, group
counseling) unlikely to result in long-term changes; treatment threshold for significant improvement 3 mo; addiction and
coexisting mental disorders (eg, depression, schizophrenia) referred to as coexisting morbidities and must be treated in integrated
way; recovery from abuse can be long-term and may require multiple treatment episodes; motivational interviewing
may be helpful; summary—suspect and identify use; methamphetamine use during pregnancy falls under substance
abuse reporting guidelines (Child Protection Services must be contacted)
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| Gynecologic Infections —Michelle Van Vranken, MD, Medical Director, West Suburban Teen Clinic and Annex
Teen Clinic, and Staff Physician, Children’s Hospital and Clinics of Minnesota, Minneapolis
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| Increasing rates of chlamydia: rates increased in last 3 yr; 70% to 80% of cases occur in those aged 15 to 25 yr; rates tripling
in 30- to 45-yr age group; 1.0 to 1.5 times increase in 15- to 19-yr age group; rates doubling in 20- to 25-yr age group
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| Symptoms: patients often have no symptoms or symptoms vague; similar to gonorrhea, vaginitis, and urinary tract infection
(UTI; consider pelvic examination); screen women <25 yr of age yearly to prevent complications (eg, pelvic inflammatory
disease [PID]); if chlamydia missed, ≈33% of cases progress to PID, ≈20% develop fertility problems, and
≈10% with PID develop ectopic pregnancy
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| Diagnosis: DNA amplification studies standard of care; higher sensitivity with cervical sample testing than with urine
sample testing; tests-of-cure for patients with positive test results not recommended because medication cure rates 96%
to 97%; rates of reinfection ≤40% in adolescents; check for reinfection after 2 to 3 mo in young women with positive
diagnosis; wait 4 to 6 wk before retesting
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| Treatment options: 1 g of azithromycin (Zithromax); doxycycline for 1 wk; doxycycline cheaper, but compliance better
with azithromycin; fluoroquinolones
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| Gonorrhea: infection rates in black population improving; greatest increase in sexually active homosexual men; ask
women whether partner sleeping with other men; symptoms—discharge or burning sensation more likely in men;
women more likely asymptomatic; concerns include PID, infertility, and ectopic pregnancy; ≈2% develop disseminated
disease 3 wk after inoculation (consider in patients with 1-2 painful joints and associated rash)
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| Treatment: spectinomycin not readily available; cephalosporins mainstay of treatment; cefixime (1-dose pill) pulled off
market in 2002; ceftriaxone—1-time injection; must be used within 24 hr; to reduce development of resistance, 250-
mg dose recommended if not treating partner simultaneously; fluoroquinolone (1-time dose) can be used, but problems
with resistance developing; patients with gonorrhea have ≈20% chance of having chlamydia (cost-efficient to treat for
chlamydia); Zithromax used to treat gonorrhea and chlamydia, but 1 to 2 g often intolerable; fluoroquinolone not first-
line option for homosexual men; in patients with cervicitis, urethritis, or other symptoms, cultures often negative (treat
patients if inflammation present)
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| Pelvic inflammatory disease: patients may have pain, bleeding, fever, or chills; symptoms may be subtle; complications
include infertility, ectopic pregnancy, scarring, chronic pelvic pain, and Fitz-Hugh-Curtis syndrome; specifically, tubal
and ovarian tenderness (but not cervical motion tenderness) should be treated as possible PID; treatment—
fluoroquinolones; levofloxacin once daily; ofloxacin twice daily; expensive; ceftriaxone followed by doxycycline for 2
wk; pregnancy and doxycycline—risk at 9 to 10 wk gestation
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| Genital herpes: differential diagnosis includes syphilis, chancroid, and lymphogranuloma venereum (LGV); suspect herpes
when patient has painful ulcer; viral culture—best diagnostic test; obtain within first 5 days for first outbreak, 1 to
2 days for recurrent outbreak; false-negative results common (ask patient to return if symptoms recur); serologic
testing—not all oral herpes due to herpes simplex virus 1 (HSV-1), not all genital herpes due to herpes simplex virus 2
(HSV-2); serologic testing helpful for counseling patients during pregnancy; chancre—painless ulcer; first stage of
syphilis; perform rapid plasma reagin (RPR) testing when ulcer present (positive results for syphilis may not be seen
for 1 wk after chancre resolves); chancroid—caused by Haemophilus bacteria; no vesicles; halo; often starts as little
papule that erodes into vesicle (may see one large area); painful; treat with 1 g of Zithromax; LGV—caused by serotypes
of Chlamydia trachomatis; painless ulcer near urethra or in anus of homosexual men; significant adenopathy
may develop into buboes; treatment—differs in cost and ease of use; 7- to 10-day treatment for first episode; 5-day
treatment for recurrences; for patients with insurance coverage, use valacyclovir; acyclovir inexpensive; suppressive
treatment for patients who have 6 outbreaks per year, 3 to 4 outbreaks in 6 mo, or patients who want to reduce risk for
transmission to partners; use during pregnancy debatable
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| LGV and men: appearing in homosexual men; symptoms include rectal pain, rectal discharge, presence of pus, or rectal
bleeding; obtain culture for gonorrhea and Chlamydia (serotype specifically)
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| Genital warts: skin infection; ≤70% of college-aged people exposed and carry virus for brief period; ≈1% develop warts, 3%
to 4% develop abnormal Papanicolaou test (most cases resolve spontaneously); perianal examination; differential
diagnosis—condyloma lata (second stage of syphilis; moist, flatter, “kissing” lesions); molluscum (dimple on inside of lesion;
soreness; resolve quicker than human papillomavirus [HPV])
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| Questions and answers: podophyllin—provider-applied podophyllin no longer recommended for genital warts because
of higher rates of destruction to tissue and greater side effects with fewer benefits; trichloroacetic acid (TCA) equally
effective and inexpensive; podophyllin must be washed off after 4 hr; methamphetamine use—urine toxicity screen
remains positive for ≈3 days after use; methamphetamine contributes to tooth decay and gum disease; C-reactive
protein—higher during pregnancy; gestational diabetes—recurrence in subsequent pregnancy 50%; normal GTT 6 wk
after pregnancy does not indicate reduced risk for diabetes at older age; metformin undergoing studies; herpes—
serologic testing unnecessary for patients with known herpes, but may be helpful to test sex partners; data about suppression
therapy to prevent transmission emerging; amoxicillin and potassium clavulanate (Augmentin) for outpatient
PID treatment—GI discomfort with doxycycline, but patients may complain more with Augmentin; allergies to
doxycycline and fluoroquinolones uncommon; LGV—rare; caused by Chlamydia serotypes L1, L2, and L3 (must be
tested for specifically); consider in homosexual men who complain about rectal discharge, rectal bleeding, and tenesmus;
contact health department; treating gestational diabetes—glyburide effective; newer insulin preparations (eg,
insulin glargine [Lantus], insulin lispro) for gestational diabetes or type 1 diabetes in pregnancy acceptable; increased
libido during pregnancy—cause uncertain; may be due to elevated estrogen and progesterone levels and increased
vaginal lubrication
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Educational Objectives
| The goal of this program is to educate the listener about emerging issues in obstetrics and about gynecologic infections.
After hearing and assimilating this program, the participant will be better able to:
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| 1. Recognize gestational diabetes and the risk for progression to overt diabetes.
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| 2. Provide sufficient therapy for methamphetamine addiction.
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| 3. Identify and treat chlamydial infections.
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| 4. Select appropriate treatment for gonorrhea.
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| 5. Differentiate and diagnose genital ulcers.
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Discussed on This Program
Acyclovir (acycloguanosine) [Zovirax]
Amoxicillin and potassium clavulanate (co-amoxiclav) [Augmentin, Augmentin ES-600, Augmentin XR]
Azithromycin [Zithromax, Zmax]
Cefixime [Suprax] (discontinued)
Ceftriaxone sodium [Rocephin]
Doxycycline (several trade names) Glyburide (glibenclamide) [DiaBeta, Glynase PresTab, Micronase]
Insulin glargine [Lantus] Insulin lispro, human (rDNA) [Humalog, Humalog Mix 75/25]
Levofloxacin [Levaquin, Quixin]
Metformin HCl [Fortamet, Glucophage, Glucophage XR, Riomet]
Norethindrone acetate [Aygestin]
Ofloxacin [Floxin, Floxin Otic, Ocuflox Ophthalmic Solution] Podophyllum resin (podophyllin) [Podocon-25, Podofin]
Progestin-only products (several trade names)
Spectinomycin [Trobicin]
Trichloroacetic acid [Tri-Chlor] Troglitazone [Rezulin] (withdrawn)
Valacyclovir HCl [Valtrex]
Suggested Reading
Cook RL et al: Prevalence of chlamydia and gonorrhoea among a population of men who have sex with men. Sex
Transm Infect 78:190, 2002; Fox PA et al: Human papillomavirus: burden of illness and treatment cost considerations.
Am J Clin Dermatol 6:365, 2005; Langer O: Management of gestational diabetes: pharmacologic treatment options and
glycemic control. Endocrinol Metab Clin North Am 35:53, 2006; Manavi K et al: Genital infection in male partners of
women with chlamydial infection. Int J STD AIDS 17:34, 2006; Moscicki AB: Impact of HPV infection in adolescent
populations. J Adolesc Health 37:S3, 2005; Offenbacher S et al: Progressive Periodontal Disease and Risk of Very Preterm
Delivery. Obstet Gynecol 107:29, 2006; Qureshi A et al: Periodontal infection: a potential risk factor for pre-term
delivery of low birth weight (PLBW) babies. J Pak Med Assoc 55:448, 2005; Salimans MM et al: Use of urine samples
as controls for treatment of a Chlamydia trachomatis infection. J Med Microbiol 55:245, 2006; Schaefer-Graf UM et al:
Clinical predictors for a high risk for the development of diabetes mellitus in the early puerperium in women with recent
gestational diabetes mellitus. Am J Obstet Gynecol 186:751, 2002; Wouldes T et al: Maternal methamphetamine use
during pregnancy and child outcome: what do we know? N Z Med J 117:U1180, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty
reported nothing to disclose.
Drs. Lupo and Van Vranken spoke in Minneapolis on May 26, 2005, at the 31st Annual Family Medicine Review Update
2005, presented by the University of Minnesota Medical School. The Audio-Digest Foundation thanks the
speakers and the University of Minnesota Medical School for their cooperation in the production of this program.
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