OB AND STD UPDATE
From An Intensive Review of Family Medicine, presented June 18-23, 2007, by the Medical University of South Carolina
| UPDATE IN PRECONCEPTION COUNSELING —Vanessa A. Diaz, MD, Assistant Professor and Women’s Health Coordinator,
Department of Family Medicine, Medical University of South Carolina, Charleston
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| Goals of prenatal care: anticipate and prevent problems; define health status of mother and developing fetus; determine
gestational age; identify at-risk patients; educate patients; preconception counseling
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| Contraception: intrauterine device (IUD), medroxyprogesterone (eg, Depo-Provera), and transdermal delivery systems
(ie, patches) require less patient compliance and have lower failure rates; ask, “how soon do you want to get pregnant?”
(consider that placement of IUD for 1 yr not cost-effective, and mean time to return to fertility after last medroxyprogesterone
injection, 11-18 mo); emergency contraception—establish time of intercourse; most effective when taken ≤72 hr
after intercourse; reasonable efficacy (≤80%) when taken ≤5 days after intercourse; perform pregnancy test to rule out
previous pregnancy; doses taken 12 hr apart; levonorgestrel (“Plan B”) or oral contraceptives (2-4 pills; ≈11 agents approved
by Food and Drug Administration [FDA] as emergency contraception); consider giving antiemetic before dose;
became available over-the-counter in August 2006 for patients >18 yr of age; other options include copper IUD, mifepristone
(RU-486), or single larger dose of levonorgestrel; copper IUD and mifepristone more effective when used after 5
days
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| Nutrition: encourage achieving normal body mass index (BMI) before pregnancy; once pregnant, women need additional
300 kcal/day; expected weight gain—25 lb for normal-weight women; 35 to 45 lb for underweight women; 15 lb for
obese women; folic acid supplementation—start supplementation before pregnancy; ≥400 mg daily (1 g if woman has
sickle cell disease); iron supplementation—important to check mean corpuscular volume (MCV); microcytic patients
with normal hemoglobin still can be iron deficient (check ferritin level)
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| Domestic abuse: often begins or escalates during pregnancy; affects ≤20% of pregnancies; causes 8.4% of deaths reported
to pregnancy-mortality system; risk factors include younger age, black ethnicity, and late or no prenatal care; psychosocial
screening—ask about 1) access to care; 2) moving (may indicate unstable environment); 3) feeling unsafe; 4)
going to bed hungry; 5) use of tobacco; 6) use of drugs or alcohol; 7) being hit or threatened; 8) level of stress; 9) timing
of pregnancy
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| Immunizations: check rubella and hepatitis B status; do not give active or live attenuated vaccines during pregnancy; if
exposure occurs, provide immune globulin; influenza vaccine recommended and can be given during pregnancy (except
for nasal mist [live attenuated vaccine]); breast-feeding not contraindicated; antiviral therapy not well studied and not
used; postpartum immunizations—tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed (Tdap)
and diphtheria and tetanus toxoids, combined (DT; Td) vaccines should not be used during pregnancy; provide DT vaccines
postpartum if woman immunized >10 yr earlier; postpartum Tdap recommended for younger women (11-18 yr of
age) if immunized ≥5 yr earlier, to decrease risk for pertussis transmission to infant; reasonable to ask mothers with infants
whether infants received immunizations
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| Medical history: diabetes; hypertension; thyroid disorder; sexually transmitted diseases (STDs); overweight or obesity;
history of preterm labor; previous placentae abruptio; fibroids
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| Birth spacing: best time interval 16 to 18 mo; waiting 18 mo to have another child (ie, 9 mo to become pregnant) associated
with decreased risk for preterm birth, low birth weight, fetus small for gestational age, fetal death, and early neonatal
death
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| Vaginal birth after cesarean delivery (VBAC): overall success rate 73%; risk for uterine rupture—with no history
of cesarean delivery, 0.04%; with repeat cesarean, 0.16%; with spontaneous labor and vaginal delivery, 0.52%; with
induction of labor without prostaglandins, 0.77% (with prostaglandins, 2.40%); with successful trial of labor (ie, vaginal
birth), 0.01% (with failed trial of labor, 2.30%); conditions for elective VBAC—women likely to have vaginal birth; history
of low transverse cesarean incision; adequate pelvis; no additional uterine scarring; ability to provide immediate
emergency cesarean delivery; woman with history of >1 low transverse cesarean delivery and >1 previous vaginal delivery
may undergo trial of labor; informed consent and discussion of risk essential
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| Genital herpes: recommendations—treat primary herpes simplex virus (HSV) infection with antiviral therapy; if active
lesions present at time of labor, perform cesarean delivery; to decrease chances of active lesions at time of delivery, consider
prophylaxis with antiviral therapy at 36 wk (concerns about asymptomatic shedding of virus without actual lesions)
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| Depression: prevalence ≥10%; 43% of women with history of depression relapse during pregnancy (risk increases from
26% to 68% if medication discontinued); adverse effects of untreated depression include low birth weight and developmental
delay; selective serotonin reuptake inhibitors (SSRIs)—risks include persistent pulmonary hypertension of newborn
(6-fold increase after 20 wk gestation) and poor neonatal adaptation (feeding problems, respiratory distress,
jitteriness, seizures); in 2005, FDA categorized paroxetine (Paxil) as class D agent, due to increased risk for birth defects
in first trimester; weigh risks of medication against risk for relapse; avoid paroxetine; try to discontinue use during third
trimester; consider bupropion (Wellbutrin; class C; no third trimester warning) or fluoxetine (Prozac; class C; most safety
data)
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| Prenatal screening: triple screening—screen for neural tube defects, Down syndrome, and trisomy 18; includes maternal
serum α-fetoprotein, estriol, and human chorionic gonadotropin ( β-hCG); detection rate, ≈69%; specificity, 95% (ie,
5% false-positive rate); quadruple screening—adds inhibin A screening to triple screening; higher accuracy in detecting
Down syndrome (detection rate 81%; increases with maternal age); first trimester screening—performed at 11 to 14 wk
gestation; ultrasonography (US) to look for nuchal translucency (amount of fluid in back of neck; detection rate 64%-
70%); combining US with β-hCG and pregnancy-associated plasma protein A (PAPP-A) testing increases detection rate
to 82% to 87%; using first- and second-trimester screening increases detection rate to 94% to 96%; first-trimester screening
recommended as long as appropriate quality control standards for US in place, with access to chorionic villus sampling
and appropriate counseling
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| Ultrasonography: routine—studies show no effect on morbidity or mortality outcomes; standard of care; first
trimester—improves fetal age assessment (crown-rump length); viability; limited anatomic studies; second trimester—
16 to 20 wk; “most bang for your buck”; shows anatomy with reasonable dating and may indicate other conditions; serial
monitoring for placenta previa and hypertension; third trimester—presentation; size; growth; anatomy; biophysical profile
(BPP) looks at respiration, movement, fetal tone, reactive heart rate, and amniotic fluid volume
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| Preterm labor: cervical effacement and/or dilatation with increased uterine irritability before 37 wk gestation; after 34
wk gestation, outcomes usually good; occurs in ≈10% of pregnancies; associated with 75% of neonatal deaths; infectious
risk factors—group B streptococci; bacterial vaginosis; trichomonas; patients with positive history during initial screening
should be rechecked at 28 wk (group B streptococci at 35-37 wk); appendicitis; pyelonephritis; peritonitis; anatomic
risk factors—incompetent cervix; fundal abnormalities; fetal anomalies; maternal risk factors—autoimmunity; pregnancy-induced
hypertension; screening—no identified screen for primiparous women; for multiparous women, check fetal
fibronectin (if negative, risk for delivery within next 7 days low; positive test equivocal), measure cervical length with
transvaginal US (>30 mm associated with less risk), and use Bishop scoring (looks at position, consistency, effacement,
dilatation, and station of head; score >8 indicates woman ready to deliver); treatment—prophylactic use of tocolysis
(usually used for premature rupture of membranes) prolongs latency for short time (days); no evidence of efficacy after
woman has begun experiencing contractions; steroids for fetal lung maturity; antibiotics indicated for ruptured membranes;
consider transfer to tertiary facility; 17 α-hydroxyprogesterone caproate (17P) injection—under review by
FDA; prevents preterm birth; rate of preterm labor and births 37% (55% with placebo) when used before 37 wk gestation;
concerns include possible increased risk for second-trimester miscarriage and fetal demise (especially when used at 24-
25 wk gestation), gestational diabetes, preeclampsia, oligohydramnios, and long-term effects on reproductive development
in children; use supported in women with previous preterm birth (<37 wk)
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| Preeclampsia: mild—manage with monitoring and bed rest; severe—associated with higher blood pressure, proteinuria,
headache, vision disturbance, upper abdominal pain, oliguria, thrombocytopenia, elevated creatinine, and intrauterine
growth restriction; manage with hospitalization and bed rest, daily monitoring, nonstress test (NST) or BPP to
assess fetal well-being, and magnesium and hydralazine prn
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| Baby blues: peak at 4 to 5 days after delivery; resolve by tenth postnatal day; baby blues and postpartum depression differ
in severity and duration (>14 days indicates postpartum depression); prevalence 26% to 85%; among women who
meet criteria for postpartum depression 6 wk after delivery, two-thirds found to have had baby blues; screen for postpartum
depression at appropriate time; Edinburgh Postnatal Depression Scale—10-question survey; score >12 has 100%
sensitivity, 95.5% specificity; talk to patients with scores >10; questions include, “are you able to find the funny side of
things?” and “are you feeling overwhelmed taking care of your child?”; management—reassurance; counseling; psychotropic
medications (including SSRIs; excreted in breast milk, but no need to advise woman against breast-feeding; SSRIs
first-line therapy for lactating women); bupropion also reasonable, but less safety data
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| Drug classes: class A—no risk in pregnancy; class B—no evidence of risk; 20% of medications; class C—risk cannot
be ruled out; promethazine (eg, Phenergan; used for morning sickness); class D—evidence of risk; eg, paroxetine
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| Management of common conditions: morning sickness—small frequent meals; avoid spicy foods; metoclopramide
(eg, Reglan; class B); vitamin B6 ; acupuncture; heartburn—behavioral changes; H2 -receptor antagonists and antacids
generally safe; constipation—increase fluid intake; stool softener (class C, but commonly used); hemorrhoids—
conservative treatment; avoid surgery; pain—acetaminophen (eg, Tylenol; class B); aspirin and nonsteroidal anti-inflammatory
drugs (NSAIDs) contraindicated; narcotics; consider transdermal lidocaine (eg, Lidoderm patch) for superficial
muscle pain; ice; massage; infections—if using erythromycin (class B), avoid estolate salts; do not use quinolones
and tetracyclines; avoid sulfonamides in third trimester
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| Future health risks: gestational diabetes—≈10% of women with gestational diabetes develop diabetes in short-term,
70% develop within 10 yr; women with gestational diabetes should receive oral glucose tolerance test 6 to 8 wk after
pregnancy (if negative, repeat every 3 yr); preeclampsia—increased risk for cardiovascular disease or cerebrovascular
accident (worse if preeclampsia present with preterm delivery); screen for cardiovascular disease risk factors; provide interventions
to decrease risk; thrombophilia—5 to 6 times increased risk for blood clot postpartum; highest risk after delivery;
may be first manifestation of hereditary thrombophilia (present in 15%; underlies ≈50% of episodes in
pregnancy); work-up for hypercoagulable state
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| UPDATE IN STD TREATMENT —Kelly Ragucci, PharmD, Associate Professor of Pharmacy and Clinical Services,
Medical University of South Carolina, Charleston
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| Prevention strategies: educate and counsel patients at risk; identify asymptomatic (but infected) persons and symptomatic
individuals who might not seek help; effective diagnosis and treatment; evaluation, treatment, and counseling of sex
partners; preexposure vaccination for hepatitis B
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| Chlamydia: incidence increasing; more frequently reported by women than men; caused by Chlamydia trachomatis;
most common STD in United States; can lead to pelvic inflammatory disease (PID), ectopic pregnancy, and infertility
(in men and women) when untreated; screen all sexually active women ≤25 yr of age and sexually active women >25 yr
of age at high risk (ie, new or multiple sex partners); women often asymptomatic; men present with dysuria, urinary frequency,
and discharge; clinical presentation and culture most reliable methods of diagnosis; recommended regimens—
azithromycin (eg, Zithromax; 1 g, single dose); doxycycline (100 mg bid for 7 days) if patient cannot tolerate macrolide;
equally effective; alternative regimens—less effective; erythromycin; ofloxacin (eg, Floxin); levofloxacin (eg,
Levaquin); used for 7 days; advise patients to abstain from intercourse until treatment complete and treatment of partners
complete; new recommendations from Centers for Disease Control and Prevention (CDC) include giving extra antibiotics
for partners unlikely to seek care; treatment in pregnancy—azithromycin recommended; amoxicillin
acceptable; alternative regimens include erythromycin; avoid quinolones and doxycycline; follow-up—failures usually
due to nonadherence to medications; repeat testing in all pregnant women 3 wk after completion of therapy
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| Gonorrhea: rates increasing recently; caused by Neisseria gonorrhoeae; sequelae can result when untreated; screen all
sexually active women at increased risk; clinical presentation (similar to Chlamydia) and culture most reliable diagnostic
tools; recommended regimens —intramuscular (IM) ceftriaxone (Rocephin), 125 mg; cefixime (Suprax) single-dose suspension;
ciprofloxacin; ofloxacin; levofloxacin; alternative regimens—for patients allergic to penicillin; spectinomycin;
other cephalosporins and quinolones can be used (less data available); quinolones no longer recommended for treatment
of gonorrhea, due to increasing resistance (especially in men who have sex with men); test patients before they resume
sexual activity; providing antibiotics for the partner recommended; treatment in pregnancy—ceftriaxone; cefixime;
spectinomycin for patients with penicillin allergy
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| Herpes simplex virus: most recurrent cases of genital herpes caused by HSV-2; HSV-1 becoming more prevalent as
cause of first episode of genital herpes; inform patients that treatment can control symptoms but cannot affect risk, frequency,
or severity of future recurrences; education important; some false-negative results with culture; confirm with serologic
testing; recommended regimens—acyclovir (Zovirax); famciclovir (Famvir); valacyclovir (Valtrex); equally
effective; initial infections treated for 7 to 10 days, recurrent infections treated for 2 to 5 days (best when therapy started
≤24 hr after onset of lesions); 1-day regimen of famciclovir bid shown to be as efficacious as 5-day regimen of acyclovir;
suppressive therapy—for patients with ≥6 outbreaks per year; Valtrex, 500 mg or 1 g qd (1-g dose more effective in patients
with >10 infections per year); intravenous (IV) acyclovir for severe disease; evaluation and counseling of sex partners
important; treatment in pregnancy—suppressive therapy not recommended; wait for delivery; for first episode,
acyclovir recommended (use IV if severe)
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| Human papillomavirus (HPV): genital warts; >40 types infect mucosal surfaces; most infections asymptomatic or
unrecognized; treatment does not eliminate (but can help reduce) infection or infectivity; most common high-risk (ie, oncogenic
or cancer-associated) types, HPV-16 and HPV-18; most common low-risk types, HPV-6 and HPV-11; identify
lesions and confirm with biopsy; patient-applied treatment—imiquimod (Aldara) 3 times per week for ≤16 wk; podofilox;
provider-administered treatment—pregnant women should not use imiquimod or podophyllin products (use cryotherapy,
surgical removal, or laser surgery); management of sex partners not absolutely necessary because role of
reinfection minimal and treatment to reduce transmission not realistic; education and counseling important; follow-up
evaluation not mandatory unless patient returns with complaints; HPV recombinant vaccine, quadrivalent (Gardasil)—3
doses given in 6 mo; recommended for girls 11 to 12 yr of age (may be given as early as age 9 yr); girls and women 13 to
26 yr of age should be vaccinated, ideally before onset of sexual activity; does not eliminate need for Papanicolaou testing;
covers HPV-6, -11, -16, and -18 (90% of HPV and 70% of those that cause cervical cancer); duration of protection
unclear (data suggest effectiveness for 5 yr); $360 for 3 doses; mandatory in few states (eg, Virginia, Texas), with parental
opt-out
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Suggested Reading
Ardawi MS et al: Maternal serum free-beta-chorionic gonadotrophin, pregnancy-associated plasma protein-A and fetal
nuchal translucency thickness at 10-13(+6) weeks in relation to co-variables in pregnant Saudi women. Prenat Diagn
27:303, 2007; Campos-Outcalt D: Practice alert: CDC no longer recommends quinolones for treatment of gonorrhea. J
Fam Pract 56:554, 2007; Facchinetti F et al: Cervical length changes during preterm cervical ripening: effects of 17-alpha-hydroxyprogesterone
caproate. Am J Obstet Gynecol 196:453, 2007; e1-4; discussion 421.Lee DT et al: Postdelivery
screening for postpartum depression. Psychosom Med 65:357, 2003; McNeil SA et al: Influenza vaccine programs and
pregnancy: new Canadian evidence for immunization. J Obstet Gynaecol Can 29:674, 2007; Swearingen JA et al: Herpes
simplex virus: it's more than a cold sore. Mo Med 104:144, 2007; Weber CJ: Update on vaccination against human
papillomavirus (HPV). Urol Nurs 27:320, 2007.
Educational Objectives
| The goals of this program are to improve prenatal care and management of common sexually transmitted diseases. After
hearing and assimilating this program, the participant will be better able to:
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 | 1. Identify vaccinations and antidepressants that are contraindicated in pregnancy.
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| 2. Identify risk factors for preterm labor.
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| 3. Work up obstetric patients for future health risks such as diabetes.
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| 4. Choose effective agents for the treatment of Chlamydia and gonorrhea.
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| 5. Select appropriate therapy to suppress herpes simplex virus.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts
were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Diaz and Ragucci spoke in Kiawah Island, SC, at An Intensive Review of Family Medicine, presented June 18-23,
2007, by the Medical University of South Carolina. The Audio-Digest Foundation thanks the speakers and the sponsor for
their cooperation in the production of this program.
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