OB/GYN Selective serotonin reuptake inhibitors (SSRI) are considered the first line therapy for PMS/PMDD; alprazolam

is a good alternative and is considered a secondline agent. The lifetime risk of a psychiatric disorder in patients with PMS approaches 80%. These mainly include mood and anxiety disorders. The standard panel of tests that are performed during the first prenatal visit are: 1. blood type and antibody screen 2. rhesus type 3. hematocrit and hemoglobin (CBC) 4. rubella status 5. screening for syphilis, chlamydia, and HIV 6. hepatitis B surface antigen 7. urine analysis and culture 8. Pap smear Parameters that are routinely measured on subsequent visits include: 1. blood pressure 2. weight 3. uterine fundal height 4. fetal heart tones 5. fetal presentation and activity 6. urine glucose and protein The Centers for Disease Control recommend that all pregnant women be screened for Chlamydia at the first prenatal visit. Women under age 25 and those at increased risk for chlamydial infection should have repeat testing in the third trimester. Chlamydia endometritis during pregnancy can lead to chorioamnionitis and premature delivery of the fetus. Untreated infection during pregnancy can also lead to conjunctivitis (ophthalmia neonatorum) and pneumonia in the newborn baby Chlamydia infections are susceptible to tetracyclines, macrolides, and

fluoroquinolones. Azithromycin (1 g PO as a single dose) and doxycycline (100 mg PO BID for 7 days) are the two most commonly used and recommended treatment regimens in the general population. Presumptive treatment of the partners is crucial in the management of these patients to prevent recurrence/reinfection. Doxycycline, the fluoroquinolones, and erythromycin estolate are contraindicated for use in pregnant women. The recommended regimens during pregnancy include erythromycin base (500 mg PO QID for 7 days) and amoxicillin (500 mg PO TID for 7 days). Azithromycin (1 gm as a single dose) is an alternative, though it has not been well tested in pregnancy. Gestational thrombocytopenia is a benign condition defined by the presence of five distinct criteria: mild and asymptomatic thrombocytopenia, development late in pregnancy, no history of thrombocytopenia outside of pregnancy, no evidence of fetal thrombocytopenia, and spontaneous resolution once the child is delivered. Idiopathic thrombocytopenic purpura is a more likely diagnosis if the platelet count is particularly low (<50,000/microL), or if the thrombocytopenia develops earlier in the pregnancy. It is important to determine whether the discharge is spontaneous or provoked, and whether it is unilateral or bilateral. In general,patients with a malignant cause have a spontaneous, unilateral and guaiac positive or grossly bloody discharge. In contrast, patients with an endocrine, medicationinduced or other physiologic causes tend to have a bilateral nipple discharge. Patients with a unilateral, spontaneous and guaiac positive or grossly bloody nipple discharge should be screened for breast cancer with a mammogram. Papular urticarial papules and plaques of pregnancy (PUPPP) is a relatively common pregnancy-associated dermatosis that is characterized by pruritic

erythematous papules within the striae gravidarum. The lesions may spread to involve the extremities. Pruritus is a very common complaint during pregnancy. It is reported to affect up to 20% of pregnant women. The symptom may be a manifestation of pregnancyassociated dermatosis, although there is usually no pathologic process present in most cases. Common pruritic locations are the scalp, anus, vulva, and abdomen (during the third trimester). Pregnancyinduced pruritus may be related to dermographism or urticaria, which are common in the last half of pregnancy. Topical steroids, antihistamines, oatmeal baths, emollients, and UVB are used to treat the condition. The rash of herpes gestationis is localized around the umbilicus and is characterized by papules, urticarial plaques and vesicles. Corticosteroids are the mainstay of therapy. In early and mild cases, topical mid-potency steroids (e.g., triamcinolone) are used. In more advanced cases or if topical steroids are not effective, systemic steroids are employed. Pustular psoriasis presents as erythematous plaques with surrounding pustules. The rash of papular urticarial papules and plaques of pregnancy (PUPPP) affects the abdominal striae and usually spares the periumbilical area. Topical steroids and antihistamines are widely used to treat many pregnancyassociated dermatoses, including papular urticarial papules and plaques of pregnancy (PUPPP); therefore, these are typically the correct choices for questions asking about the treatment of pregnancy-associated dermatoses! All women who wish to get pregnant should take 400 micrograms of folic acid daily at least one month before the projected date of conception. Oral contraceptive pills (OCPs) can be stopped at any time; however, conception may be delayed because the patient may continue

to have anovulatory cycles immediately after discontinuation. Exposure to the low-energy electromagnetic fields that are generated by video displays, power lines, and electronic devices has not been demonstrated to be dangerous to a fetus. Infants born to HBsAg-positive women should receive vaccine at birth, 1-2 month and 6 month of age. Hepatitis B immunoglobulin (HBIG) should also be given with the first dose of vaccine within 12 hours of birth, but preferably as soon as possible, because the immunoglobulins effectiveness decreases with time after birth. The infant should be tested for immunity to hepatitis B at 9-18 month of age. If the infant is found to be anti-HBs (antihepatitis B surface antigen antibody), then the infant is immune to HBV. If the infant is HBsAg positive, then the infant should be referred to a pediatric gastroenterologist for further management. There is no indication that cesarean section reduces the rate of maternal-infant transmission of HBV. Cervical trauma may result in cervical stenosis, a condition that jeopardizes future pregnancies. Frequent cervical examinations in the second trimester will aid in determining if either cerclage is necessary in the short term or cesarean section is necessary in the long term. Placement of cervical cerclage will likely be performed in the second trimester, typically at 13 to 17 weeks of gestation. This procedure prevents loss of pregnancy secondary to cervical incompetence. Bacterial vaginosis (BV) is an imbalance in the normal vaginal bacterial flora associated with increased numbers of Gardnerella vaginalis, Mycoplasma hominis, and anaerobic bacteria, and a corresponding decrease in the hydrogen peroxide-producing lactobacilli. BV is diagnosed when three of the following criteria are present: homogeneous vaginal discharge,

vaginal pH > 4.5, amine odor with application of KOH, or presence of clue cells on microscopic examination of a wet mount. Although many women are completely asymptomatic, BV frequently causes an excessive white or gray vaginal discharge or a foul, "fishy" odor, especially after unprotected intercourse. Of greater concern is the association between BV and pregnancy complications, including preterm delivery, premature rupture of membranes, and spontaneous abortion. A short course of antibiotic therapy will alter the microflora imbalance, but recurrences are common. Current studies suggest that adverse outcomes such as preterm labor are not improved when BV is screened for or treated in average-risk asymptomatic. Screening for bacterial vaginosis may be indicated if the patient is at high risk for preterm labor, and treatment with oral metronidazole or clindamycin is appropriate if a patient is either at high risk for preterm labor or is symptomatic. Oral metronidazole or clindamycin for two to seven days is the preferred form of treatment for BV. Untreated syphilis is associated with a very high prevalence of adverse fetal outcomes (up to 80%), including stillbirth, neonatal death, and mental retardation. Penicillin desensitization is considered to be the treatment of choice for pregnant, penicillinallergic patients with syphilis. Erythromycin is effective against T. pallidum, but it cannot cross the placenta; therefore, the use of erythromycin is not recommended. All pregnant drivers should wear seatbelts with lap and shoulder straps. Rh-incompatibility only occurs when a patient is Rh-negative. As long as the mother is Rh-positive, it does not matter what the father's Rh status is;

however, when a patient is Rh-negative, several other factors will determine the risk of hemolytic disease (aside from the father's Rh status). Hemolytic disease is very unlikely in the first pregnancy, as the mother is not sensitized. The mother becomes sensitized as a result of fetomaternal hemorrhage at or near the end of pregnancy. This risk of sensitization can be reduced by a RhoGAM injection within 72 hours of the delivery. Failure to adjust the dose of anti-D immune globulin after events that are associated with excessive feto-maternal hemorrhage (e.g., placental abruption) may result in maternal alloimmunization. A low dose of anti-D immune globulin postpartum is the most likely cause of anti-D immunization in this patient. Events that are associated with feto-maternal hemorrhage (such as placental abruption) may require adjustments in the dosage of anti-D immune globulin; therefore, the presence and the amount of feto-maternal transfusion should have been determined in this patient during her first pregnancy. The rosette test is a qualitative test that helps determine the presence of feto-maternal hemorrhage. If negative, the standard dose of anti-D immune globulin should be administered. If positive, the amount of hemorrhage can be evaluated using KleihauerBetke stain or fetal red cell stain using flow cytometry, and the dose of anti-D immune globulin should be corrected accordingly. A standard dose of anti-D immune globulin should be administered at 28 weeks of an uncomplicated pregnancy. Pregnancy testing is imperative prior to UTI treatment in any sexually active female of reproductive age, even if they claim to be using contraception, because pregnant patients require treatments that are safe for a developing fetus.

TMP-SMX is pregnancy risk category C/D because it affects folic acid metabolism during pregnancy. Ciprofloxacin is pregnancy risk category C because it causes fetal arthropathy. For pregnant patients with UTIs, amoxicillin, cephalexin or nitrofurantoin are preferred treatment options. In patients with G6PD deficiency, dose-related hemolysis may occur when using TMP/SMX, and a shorter treatment duration should be considered in such patients. There is currently no agreement about which anti-epileptic drug is most or least teratogenic; therefore, the drug that works best for the patient should be used. Early detection of neural tube defects by serum alpha-fetoprotein screening, amniocentesis or ultrasonography is important. If major abnormalities are present, the pregnancy can be terminated or an optimal management strategy can be planned. Switching to another drug is not recommended for this patient because: (1) it can precipitate a seizure, (2) it can increase the risk for the fetus due to overlapping effects with valproate, and (3) it has a minimal possible benefit because pregnancy has already been established for 12 weeks. Taking anti-epileptic medications is not a contraindication to breastfeeding. All anti-epileptic drugs are excreted into breast milk in measurable amounts; it is estimated that ethosuximide reaches 90% of its plasma concentration, whereas valproate reaches 5-10 % of its plasma concentration in milk. Spina bifida is an uncommon condition that usually occurs in one of every one thousand pregnancies in the United States. It is characterized by a cleft in the spinal column, which can be open or covered by the skin. Folic acid supplementation is very effective in reducing the risk for developing spina bifida. Nevertheless, the risk is always present, even though it is low, in patients who have first-degree relatives with this disease. Chorionic villous sampling (CVS) is done by performing a biopsy of the placenta for DNA or chromosomal analysis. CVS is useful for prenatal diagnosis of

genetic disorders such as Down's syndrome. It is not indicated for the diagnosis of neural tube defects because it does not measure alpha-fetoprotein (AFP) levels. Early amniocentesis (performed before 15 weeks of age) is associated with a greater risk of fetal loss, equinovarus foot, and amniotic fluid loss. Majority of patients with myelomeningocele also have hydrocephalus and Chiari II malformations. An urgent and thorough neurologic evaluation is needed. Surgical closure of the neural tube defect must be done immediately during the first 24 to 48 hours in order to prevent the occurrence of infections in the central nervous system. After a thorough neurosurgical evaluation, an orthopedic evaluation will be needed next in order to correct the orthopedic deformities, to preserve the patient's adequate posture, and to promote ambulation if possible.

Patients at term and with severe preeclampsia should be promptly managed with hydralazine (or labetalol) to lower the blood pressure, and MgSO4 to prevent progression to eclampsia. Once initial stabilization has been obtained, delivery should be carried out. For patients with mild preeclampsia, vaginal delivery is the preferred mode of delivery. For patients with severe preeclampsia, the preferred mode of delivery has not been evaluated. Cesarean section should be decided on an individual basis. The goal is to prevent thrombotic or embolic complications in the pregnant patient, while avoiding fetal or maternal harm due to anti-thrombotic agents. The most common indications are the presence of mechanical prosthetic heart valves or the history of venous thromboembolism. Because warfarin is teratogenic and can freely cross the placental barrier, a patient on anticoagulation therapy who plans to get pregnant should replace warfarin with subcutaneous unfractionated heparin or low-molecular-weight heparin in the first

trimester. This patient is suffering from Eisenmenger syndrome, which develops when a congenital lefttoright shunt (ventricular septal defect, atrial septal defect or patent ductus arteriosus) has been left untreated for a long period of time. In such settings, the pulmonary vascular resistance exceeded the systemic vascular resistance, which thereby led to reversal of the shunt (right-to-left) and cyanosis. The risk of complications in such patients is even higher if the patient has Eisenmenger syndrome (i.e., severe pulmonary hypertension and shunt reversal). Pregnancy in these patients is associated with a 30-50% risk of mortality. Majority of the maternal deaths occur during the first week after delivery; however, death can also occur during gestation, labor, or delivery since the sudden drop in systemic vascular resistance after delivery increases the right-to-left shunt, which may precipitate maternal cyanosis. The only surgical option available to this patient is a combined heart and lung transplantation or lung transplantation with intracardiac repair Dysfunctional uterine bleeding is typically the result of anovulation. In the absence of ovulation, there is no progesterone influence on the endometrium, so the normal signal for cyclic endometrial sloughing (menstrual bleeding) is absent. Estrogen, as a trophic hormone on the endometrium, causes endometrial overgrowth that ultimately outgrows its blood supply resulting in irregular sloughing that may be significant (hemorrhage). The treatment of dysfunctional uterine bleeding involves hormonal therapy to stabilize the endometrium. Estrogen should be used in all patients who are actively bleeding as it promotes hemostasis. High dose estrogen followed by progestin is the treatment of choice. For

less severe cases, oral contraceptives in doses 3 to 4 times the regular dose can be used as an alternative. Dilatation and curettage is used in rare situations where the patient continues to bleed excessively despite hormonal treatment or in patients who are unable to take estrogen. Intravenous conjugated estrogen is used in patients who cannot tolerate oral medications and in unstable patients with severe bleeding as it can induce hemostasis rapidly. Progestin-only therapy, such as medroxyprogesterone is used for girls with moderate bleeding who cannot tolerate or have contraindications to estrogen therapy. All healthy pregnant women with uncomplicated pregnancies are encouraged to exercise for 30 minutes daily at a moderate intensity that allows the mother to carry on conversation while exercising. Scuba diving is not recommended during pregnancy. Pregnancy is almost impossible, but there still remains a very small chance, in patients with Turner syndrome. Due to an increase in serum concentrations of TBG, pregnant women have high levels of T3 and T4. In order to determine if a patient has true hyperthyroidism, free T4, total T4 and TSH levels need to be determined. The thyrotropin (TSH) level is usually decreased in pregnancy, but in order to rule out hyperthyroidism, it needs to be evaluated with free T4 values Thyroid radioiodine uptake test is contraindicated in pregnant women. In order to diagnose a pregnant woman with hyperthyroidism, she must meet the following criteria:

1. high serum free T4 2. serum TSH value < 0.01 mU/L Gestational transient thyrotoxicosis (GTT) is diagnosed if the woman meets the following criteria: 1. mildly increased free T4 2. slightly decreased TSH levels at the end of the first trimester GTT is a medical condition that occurs approximately in 10% of women. It usually presents between 8 to 11 weeks of gestation, and does not occur after 14 weeks. It is due to the elevated levels of human chorionic gonadotropin (hCG), which has thyroidstimulating properties. Semen analysis is a simple test that helps to determine if a male factor has caused the infertility. Semen analysis is performed early in the evaluation of the infertile couple, and is usually the initial screening test.

Time of last Td booster 1. Unimmunized 2. >10 years 3. <10 years ACIP/ ACOG recommendations for routine immunization 1. Administer two doses of Td four weeks apart followed by TdaP postpartum 6-12 months after second dose of Td booster 2. Td booster preferably during second to third trimester of pregnancy 3. TdaP postpartum Minor and clean wound 1.Td only 2. Td only 3. None indicated

More severe and dirty wound 1. Td and TIG 2. Td and TIG 3. Td if last booster given >5 years ago Risk factors for PID include the following: 1. Oral contraception 2. No barrier contraception 3. Multiple sexual partners 4. Age < 35 years 5. History of previous episodes 6. African-American ethnicity Studies have shown that among all the PID risk factors, having multiple sexual partners is the one associated Down syndrome is the most common autosomal abnormality among live births and the most common cause of mental retardation in children. Most cases are caused by total trisomy 21, which typically arises from maternal meiotic nondisjunction. Since advanced maternal age (defined as 35 years of age or older) is associated with an increased risk of having offspring with Down syndrome, accurate prenatal screening for the condition is in high demand. At this time, the integrated test is considered the best overall screening test for Down syndrome, with a detection rate of 85% and a false positive rate of 1.2%. The integrated test is comprised of ultrasound measurement of nuchal translucency thickness at 10 weeks in combination with measurement of serum markers from the first trimester (PAPP-A) and the second trimester (alpha-fetoprotein, human chorionic gonadotropin, unconjugated estriol, and dimeric inhibinA); however, the actual diagnosis of Down syndrome can only be made by examining the fetal karyotype, which requires chorionic villus sampling or, more commonly, amniocentesis.

The second trimester quadruple testing of alpha-fetoprotein, human chorionic gonadotropin, unconjugated estriol, and dimeric inhibin-A is an excellent screening method for Down syndrome, and is thought to detect 80-85% of all cases. Measurement of serum AFP can be offered as a screening test at 1620 weeks of gestation to detect open neural tube defects. An elevated AFP level (>2.5 MoMs) is frequently present in open spina bifida and anencephaly. However, it can also be present in other fetal abnormalities, such as congenital nephrosis, ventral wall defects, dermatologic disorders, and tumors. Factors such as improper fetal dating and multiple gestations can also raise the serum AFP level. A normal serum AFP level does not rule out all cases of spina bifida because serum AFP does not reflect cases of closed spina bifida. The positive predictive value of the test depends upon the degree of elevation. The positive predictive value of an elevated serum AFP level 2.5 MoMs is 4.5% but goes up to 13.5% when the level is >7 MoMs. An ultrasound is performed at most centers in all women around 20 weeks of gestation to obtain a detailed anatomic survey and would be particularly indicated in this patient given the abnormal screening serum AFP level. The ultrasound could also be helpful in clarifying fetal age and number of gestations, which could be causing the elevated AFP level. Ultrasonography is the best means of discerning bleeding between the endometrium and the gestational sac in the pregnant woman, a condition termed "subchorionic hematoma." Subchorionic hematomas appear on sonography as crescent-shaped hypoechoic regions adjacent to the gestational sac and are the most commonly identified source of first-trimester bleeding. Women with this condition are managed expectantly until the

symptoms resolve or additional findings develop. Once a subchorionic hematoma has been diagnosed, it should be re-evaluated with a repeat ultrasound one week later. Unfortunately, there are no known therapeutic interventions for the condition. Pregnant women who have subchorionic hematomas are at increased risk for experiencing spontaneous abortions. Preterm births, premature rupture of membranes, and growth restriction are also known to occur more commonly in association with first trimester bleeding of any cause. The prognosis is worse if the bleeding is significant or continues into the second trimester. older postmenopausal women on hormone replacement therapy are at an increased risk for myocardial infarction, deep venous thrombosis, strokes, and breast cancer. The findings of this study do not apply to younger patients with premature ovarian failure, such as the patient described in this vignette. Hormone replacement therapy in the form of conjugated equine estrogen and medroxyprogesterone with careful monitoring can be safely used in younger patients without any excessive cardiovascular risk. In this patient, treatment with a bone-specific agent is required because of a significantly low bone density of the lumbar spine and hip. Her risk for fractures is very high. The most reasonable regimen for this patient is a combination of conjugated equine estrogen and medroxyprogesterone administered either cyclically or continuously. Giving her estrogen will not only improve her bone mineral density, but also improve her hypoestrogenic symptoms, such as hot flashes. Estrogen is the "gold standard" treatment for hypoestrogenic symptoms. Improvement in her bone density and reduction in her bone turnover will significantly reduce

her risk for fragility fractures. The use of bisphosphonates in older, postmenopausal women has been extensively studied, and has been shown to be very useful in the treatment of low bone density. On the other hand, bisphosphonates are not very well studied in younger patients with low bone density. The long-term effects of bisphosphonates such as alendronate or etidronate are unknown in younger patients. Furthermore, although risedronate (bisphosphonates) may improve bone mineral density in this patient, it will not improve her hypoestrogenic symptoms; therefore, it is not the preferred drug regimen. If the father is affected by an X-linked recessive disease and the mother is not a carrier, none of their children will be affected by the disease, although all their female children will be silent carriers. Patients with sickle-cell disease are at a very high risk for complications during pregnancy. The possible complications include acute crisis, endometrial infection, pyelonephritis, and thromboembolic events. Up to 46% of sickle-cell patients have complications during pregnancy. Such patients therefore need a safe and very effective method to prevent undesirable pregnancies. In this patient, depot medroxyprogesterone appears to be the contraceptive of choice. Since medroxyprogesterone acetate is given every three months, this patient will most likely be compliant with the treatment. Furthermore, there are some studies which suggest that the use of medroxyprogesterone acetate in patients with sickle-cell disease decreases the risk of acute crisis. 25% of fetuses prior to 28 weeks gestation are in the breech presentation, and most of these assume the cephalic presentation by 34-36 weeks gestation. After 36 weeks, only 6% of fetuses will be in the breech position,

and approximately one-third of these will spontaneously convert to the cephalic position before delivery. External cephalic version should not be attempted until after 37 weeks gestation. Caesarian delivery is often used in breech presentations. Some indications for caesarian delivery include a large fetus, a hyperextended head, a footling breech and fetal distress.

Screening for cervical cancer by cytologic examination/Pap smear is an effective way of detecting early pre-invasive and invasive carcinoma. According to the revised American College of Ob/Gyn guidelines in 2009, screening for cervical intraepithelial neoplasia (CIN) or cancer should be started at age 21, irrespective of the age of initiation of sexual activity. This is due to the fact that high-grade cervical cytologic abnormalities due to human papillomavirus (HPV) usually do not occur until three to five years after HPV exposure. Also, cervical cancer is rare in women under the age of 21. The daughter in the above vignette became sexually active at age 15 and needs her first Pap smear at age 21 and then every 2 years until the age of 30. This interval can be increased to every 2-3 years after 3 consecutive negative Pap smears or age 30, whichever comes first. There is no reason to start screening her for cervical cancer by Pap smear at this time Nearly half of sexually active women and over half of adolescents in the US will have positive HPV tests within 3 years of the onset of sexual activity. Most females, especially adolescents, will clear the HPV infection within 8 months to 2 years. Colposcopy is indicated in women with abnormal Pap smears or a positive HPV

test to visualize the cervix, vagina, and vulva and identify suspicious areas for biopsy Levonorgestrel is the recommended method of emergency contraception if used soon enough after an unprotected sexual intercourse. It has maximal efficacy when used within the first 12 hours after intercourse, good efficacy within 48 hours, and appears to work up to 120 hours after intercourse. The copper intrauterine device is an effective emergency contraception tool that can be used if a patient presents more than 120 hours after unprotected intercourse. Antenatal corticosteroid therapy has been proven to be effective in reducing perinatal morbidity and mortality associated with preterm labor. It reduces the risk of infant respiratory distress syndrome and intraventricular hemorrhage. The two commonly employed regimens are betamethasone or dexamethasone administered intramuscularly. Intramuscular administration of steroids provides stable and predictable concentration of the drug in the blood that is required to achieve the desired fetal effects. This patient has acute pelvic inflammatory disease (PID). She has abdominal pain and tenderness on palpation of the adnexae and lateralization of the cervix. The presence of fever, chills, bandemia, leukocytosis, as well as nausea and vomiting, indicates that the infection is severe. PID can be a serious condition that needs to be treated immediately. Intravenous administration of cefoxitin and doxycycline is the best combination of all the given options.. Intramuscular ceftriaxone, oral azithromycin or oral doxycycline can be used if there is mild or moderate infection.

There are different approaches for the evaluation of ASCUS. Among the above choices, HPV DNA testing is the most cost-effective, sensitive, and preferred next step in management in women over the age of 21. In this method, samples are collected both for cytology and reflex HPV DNA. If cytology results are negative, the sample for HPV DNA is discarded. If cytology results are positive, HPV DNA testing is performed. Patients who test positive for high-risk HPV type are then referred for an immediate colposcopy. If the test is negative for high-risk HPV type, the Pap smear is repeated after one year. This patient presents with her first abnormal Pap smear showing ASCUS and would be best managed with a reflex HPV DNA test. Colposcopy is indicated for ASC-H, in which either high-grade squamous intraepithelial lesion (HSIL) or lowgrade squamous epithelial lesion (LSIL) cannot be excluded. A high-grade neoplasia on colposcopy is treated appropriately while a low grade neoplasia or lower can be managed with serial Pap smears or HPV testing as shown above. Patients with persistently negative HPV can be followed with repeat pap smear in 12 months. The ultrasound is the test of choice in evaluating nephrolithiasis in those patients who should avoid radiation exposure (e.g., pregnant patients and children). Helical CT scan is the test of choice for suspected nephrolithiasis; however, a CT scan is associated with radiation exposure, and is not the best test in pregnant patients. Hypotonic uterine contractions is the most common cause of arrest disorders in the active phase of labor. Patients with such conditions should undergo an augmentation of labor using amniotomy and/or oxytocin infusion.

Condyloma acuminata is the dermatologic manifestation of an infection with the human papilloma virus, with over 90% of such condylomas arising from HPV subtypes 6 and 11 specifically. HPV is primarily transmitted through sexual contact, and the areas affected include the penis, vulva, vagina, cervix, perineum, and perianal region. Less frequently, HPV may be found in the oropharynx, larynx, or trachea secondary to oralgenital contact or secondary to vertical transmission from mother to infant during childbirth. One relatively common benign laryngeal tumor in children, recurrent respiratory papillomatosis, is caused by the acquisition of HPV during passage through the vaginal canal. However, since HPV is thought to be contracted by the infant in less than 1% of all childbirths to women who have condylomas, no intervention is usually undertaken severe preeclampsia, which was later complicated with eclampsia. Patients with severe preeclampsia are at greater risk of developing eclampsia. The first priority in patients with eclampsia or postictal coma is respiratory and cardiovascular resuscitation. Anticonvulsant medications can be administered after placing two large-bore needles in the patient. Although the most effective agent for hemodynamic and seizure control is magnesium sulfate, the most effective treatment to prevent further complications is to accelerate delivery. Eclampsia can cause several other complications besides seizures, such as disseminated intravascular coagulopathy, acute renal failure, hepatocellular injury, liver rupture, intracerebral hemorrhage, etc. Magnesium sulfate prevents seizures, but it will not stop the pathologic process. Retinal hemorrhage is an extremely ominous sign of preeclampsia/eclampsia. Opposite to normal pregnancy, the PGI 2 to Thromboxane A 2 ratio decreases

A deficiency in nitric oxide, as well as an increase in Endothelin-I, have also been incriminated -the former being a vasodilator and the latter a potent vasoconstrictor. Glomerular capillary endotheliosis is the typical glomerular lesion of preeclampsia/eclampsia. It involves a marked swelling of the glomerular capillary endothelium and deposits of fibrinoid material in and beneath the endothelial cells. On light microscopy, the glomerular diameter is increased, with endothelial and mesangial cell swelling. Microangiopathic hemolytic anemia can occur in preeclampsia and eclampsia, but it is not considered an ominous sign. It results from the injury of RBC by the damaged endothelium that is usually associated with the condition. Either hydralazine or labetalol are the drugs of choice for the acute management of hypertension during pregnancy. Methyldopa is preferred for oral therapy in mild to moderate hypertension during pregnancy. The best medication to prevent further seizures in a patient with eclampsia is magnesium sulfate. Diazepam or phenytoin can be added to the therapy if seizures persist, although the use of diazepam should be limited due to its depressant effects on the fetus. Maternal diabetes carries numerous risks for the fetus including macrosomia, hypocalcemia, hypoglycemia, hyperviscosity due to polycythemia, respiratory difficulties, cardiomyopathy and congestive heart failure. Most of these adverse effects can be avoided with strict glycemic control. In the case described, the infant is likely suffering from cardiomyopathy and congestive heart failure. Fetal cardiomyopathy and CHF result from excess glycogen deposition within the myocardium resulting in hypertrophy of the fetal heart musculature. The interventricular septum

is most commonly affected resulting in ventricular outflow obstruction. The interventricular myocardial hypertrophy and outflow obstruction that may occur in an infant born to a diabetic mother with poor glycemic control during gestation typically resolves spontaneously following birth. An atrialized right ventricle means Ebsteins anomaly. It is seen in infants of mothers who have taken lithium during pregnancy. Patients present with tricuspid regurgitation and cyanosis in infancy in severe cases. Once the first twin is delivered, the positioning and heart rate of the second twin must be assessed with ultrasound. If labor has halted, oxytocin should be administered. Postpartum endometritis is a polymicrobial infection of the decidua (the pregnancy endometrium) characterized by fever, uterine tenderness, foul-smelling vaginal discharge, and leukocytosis. As the infection is often produced by both aerobes and anaerobes from the genital tract, any treatment regimen must include broad-spectrum antibiotics that also cover beta-lactamase producing anaerobes. At this time, the gold standard of treatment for endometritis is clindamycin and gentamicin. Ceftriaxone and metronidazole and levofloxacin and metronidazole oth provide appropriate coverage for endometritis but contraindicated in contraindicated in breastfeeding mothers, neither combination should be used. the most important risk factor in the development of endometritis is the route of delivery. Several causes contribute to this finding, including contamination of the uterine cavity, prolonged rupture of membranes, and presence of sutures or other foreign objects.

Shoulder dystocia is commonly defined as a failure of the fetal shoulders to pass through the maternal pelvis once the fetal head has been delivered. It is diagnosed when the anterior shoulder cannot be delivered with mild, downward pressure. Risk factors for the development of shoulder dystocia include macrosomia, maternal diabetes mellitus, operative vaginal delivery, shoulder dystocias in previous deliveries, postdate pregnancies, male fetal gender, advanced maternal age, obesity and excessive weight gain, and disproportion between the fetal shoulders and maternal pelvis. However, more than 50% of cases of shoulder dystocia are not associated with any known risk factors. When shoulder dystocia occurs, appropriate support staff (eg, nursing, anesthesia, obstetrics, pediatrics) should be summoned. The mother should be told not to push while attempts are made to reposition the fetus. Suprapubic pressure directed downward and laterally should then be applied by an assistant. If that fails to deliver the anterior shoulder, then typically the McRoberts maneuver is attempted, though many other techniques work as well (eg, Rubin maneuver, Woods screw maneuver, delivery of posterior arm). The McRoberts maneuver requires that two assistants grasp both of the mother's legs and flex the thighs back against her abdomen. This maneuver has been shown to relieve the shoulder dystocia in 42% of patients. Before the maneuver is implemented, however, the mother should be told to stop pushing until everything is in place. The Zavanelli maneuver replaces the fetal head in the pelvis before performing a cesarean section. It is generally accepted that the physician has up to seven minutes to deliver a previously well-oxygenated infant before there is an increase in the risk of damage due to asphyxia. Therefore, the Zavanelli maneuver is normally employed when

other methods have failed and the "safe" period of seven minutes is dwindling. patient's cervix has not dilated beyond four centimeters in the past two hours, she is diagnosed with a failure to progress. Failure to progress is an indication to perform a cesarean section. Although this girl is a minor at age 16, most states have legislated that a physician can provide care for adolescents without parental consent when it comes to certain issues, including pregnancy, contraception, sexually transmitted diseases, substance use, and emotional illness. Therefore, the appropriate management of this situation entails recommending a cesarean section and seeking consent from the patient Abdominal paracentesis and ascitic fluid analysis is the most reliable way to differentiate between the different causes of ascites. The most common cause of ascites in the United States is hepatic cirrhosis. The differential diagnosis of ascites can be narrowed down by calculating the serum-ascites albumin gradient (SAAG), which is equal to the serum albumin value minus the ascitic fluid albumin value (not the ratio of the two). The SAAG value is useful in identifying the presence or absence of portal hypertension and has replaced the old transudative-exudative model of classifying ascitic fluid. A SAAG value 1.1 g/dL is known as high albumin-gradient ascitic fluid and indicates portal hypertension, while a value < 1.1 g/dL is known as low albumin-gradient ascitic fluid and indicates that the patient does not have portal hypertension. Clinical conditions associated with high SAAG (1.1 g/dL) include congestive heart failure cirrhosis and alcoholic hepatitis. Conditions associated with low (< 1.1 g/dL) albumin gradient include peritoneal carcinomatosis, peritoneal

tuberculosis, nephrotic syndrome, pancreatitis, and serositis. This patient has a SAAG of 0.6 g/dL, which indicates nonportal hypertensive etiology of her ascites. Given her clinical presentation, carcinomatosis from malignancy, such as ovarian cancer, would be a likely etiology. She should have further investigation to confirm the diagnosis. Budd-Chiari syndrome is one of the postsinusoidal noncirrhotic causes of portal hypertension and is caused by thrombosis of the hepatic veins and/or suprahepatic inferior vena cava. The SAAG value in patients with Budd-Chiari syndrome is 1.1 g/dL.

Females who maintain a lower weight or body mass index (BMI) due to the sport or activity that they regularly engage in (e.g. ballet dancers, gymnasts, and runners) may become hypoestrogenic and present with exercise-induced amenorrhea. They are at special risk of developing osteopenia, and even osteoporosis. Spontaneous fractures have been reported in these types of patients, with osteoporosis or osteopenia confirmed through bone densitometry. Treatment consists of improving caloric intake; if this is not possible, patients are started on hormonal replacement with oral contraceptives and supplementation with calcium and vitamin D. there is a tendency toward hypercholesterolemia, not the opposite. There is no risk of early menopause, but exercise-induced amenorrhea can mimic early menopause because of estrogen deficiency. Exercise-induced amenorrhea is a diagnosis of exclusion. Thyroid hormone and prolactin level determinations are necessary in the evaluation of this patient because one/both of these may be the underlying cause (but not a

complication or aftermath) of the amenorrhea. Amenorrhea is thought to occur in female athletes when there is a relative caloric deficiency secondary to inadequate nutritional intake as compared to the amount of energy expended. Women athletes with this condition have been shown to have decreased levels of luteinizing hormone (LH) and gonadotropin-releasing hormone (GnRH), resulting in an estrogen deficiency. These amenorrheic women are therefore at increased risk for all conditions associated with estrogen deficiency, including infertility, vaginal atrophy, breast atrophy, and osteopenia. Kwashiorkor is a malnutrition disease caused by severe protein deficiency. This condition primarily occurs in children upon weaning from the breast, and is not the cause of amenorrhea in this woman. Testosterone deficiency occurs in disorders such as Klinefelter's syndrome and cryptorchidism. It is not the cause of amenorrhea in this woman. Progesterone is an important hormone in the middle to late luteal phase of the menstrual cycle and also serves in the maintenance of pregnancy. A deficiency in this hormone is not the cause of amenorrhea in this woman. High serum levels of prolactin can occur in pregnant or breastfeeding women or as the result of a prolactinoma. It is an extremely unlikely cause of amenorrhea in this woman. Bleeding is the most common short-term complication after cervical conization (cone biopsy). HGSIL revealed on Pap smear indicates a 1-2% probability of already having invasive cervical

cancer and a 20% probability of acquiring invasive cervical cancer if left untreated. Immediate referral for colposcopy and endocervical curettage is indicated. If colposcopy suggests HGSIL, a diagnostic excisional procedure should be performed. HPV testing may be indicated if cytologic examination reveals atypical squamous cells of undetermined significance (ASCUS). The results of HPV testing may influence the decision to proceed with a colposcopy in such cases. High-grade squamous intraepithelial lesions include CIN II, CIN III, moderate and severe dysplasia, and carcinoma in situ. High-grade squamous intraepithelial lesions are more likely to be progressive than low-grade lesions, and these should always be treated with ablation or excision. Ablation can be done using cryosurgery or laser, and excision can be done using knife conization, laser conization or Loop Electrosurgical Excision Procedure (LEEP). Loop Electrosurgical Excision Procedure (LEEP) is the treatment of choice for high-grade squamous intraepithelial lesion. LEEP is preferred because of its low cost, accuracy, and easiness to perform. It is a very successful procedure and can be performed in an office setting. Most of the low-grade squamous intraepithelial lesions (LSIL) or low-grade cervical intraepithelial neoplasia (CIN I) regress spontaneously; therefore, expectant management is preferred for biopsy proven CIN 1 with satisfactory colposcopic examination. A colposcopic examination is satisfactory when an entire lesion and a transformation zone are visualized. Expectant management includes repeat cytology at 6 and 12 months, or HPV DNA testing at

12 months. If there is progression during the follow-up, or lesions are persistent after one year, treatment is indicated. In the above patient, colposcopy examination is satisfactory; therefore, the next best step should be expectant management. All other choices would have been appropriate if colposcopic examination was unsatisfactory. When the colposcopic exam is unsatisfactory, the next step is always excision as this allows for histological examination. Even if colposcopic examination is satisfactory, treatment may be indicated if the patient is anxious about her disease, or if she seems to be non-compliant with follow-up. If the patient opts for treatment, available modalities are either ablation or excision. Ablation can be done with cryosurgery or laser, and excision can be done with knife conization, laser conization, or Loop Electrosurgical Excision Procedure (LEEP).

All pregnant patients should be screened for gestational diabetes between the 24th and 28th weeks of pregnancy. Both one and two stage glucose tolerance tests are options for screening in the pregnant population. The two stage screen involves an initial 50 g glucose challenge as in this case. This test does not require fasting. Blood glucose levels are checked one hour after the ingestion of 50 gm of glucose. Patients with blood glucose values of 130140 mg/dL or higher should be subjected to a 3-hour glucose tolerance test after the ingestion of 100 gm of glucose on a fasting state. The cutoff value for the initial test is somewhat controversial, as some now recommend the lower level of 130 mg/dL given its increased sensitivity. The recommended fasting blood glucose values in pregnant diabetic patients should be below 95 mg/dL and 2 hour postprandial blood glucose should be less than 120

mg/dL according to American College of Obstetrics and Gynecology (ACOG) guidelines. This patient's glucose values are therefore too high despite reasonable compliance with dietary modifications. This patient should be started on the intermediate acting NPH insulin (usually as a single dose at bedtime but a second dose can be used in the day if needed). Longer acting insulin such as glargine should be avoided because their safety in pregnancy has not been assured. The insulin dose and frequency is then adjusted, depending upon her glycemic control. Rapid acting insulin (regular or lispro) may be added for persistent postprandial sub-optimal blood glucose levels after increasing the patients basal insulin level with NPH. Glyburide and Metformin can be considered in select circumstances and are used more in countries outside the US in pregnant patients although there is still concern about their teratogenic effects and they should not generally be used instead of insulin. The most common cause of post partum hemorrhage (PPH) is uterine atony, and the first step in the management of all patients with PPH is to do a pelvic examination to identify any retained placental fragments. Uterine prolapse is typically seen in multiparous, postmenopausal woman with a history of multiple vaginal deliveries. The injury to the pelvic ligaments and loss of estrogen weakens the endopelvic fascia. The uterus and cervix descend down the vaginal canal towards the vaginal orifice (introitus). Patients usually complain of a sensation of pressure or heaviness in the pelvic area, which is relieved by lying down and aggravated by prolonged standing or exertion. Some patients may complain of low back pain, dyspareunia, or a visible mass at the introitus. In chronic cases, patients may have bleeding or discharge from ulcerative, superficial

epithelium. All symptomatic patients (constant sensation of heaviness, pain, or bleeding) should have surgical correction of the defect in the pelvic support. The aim of surgical treatment is to completely relieve the symptoms and prevent any future relapse. Vaginal hysterectomy is the procedure of choice for the treatment of uterine prolapse in postmenopausal woman. Endometrial biopsy is not necessary prior to the procedure. Rectocele is a relatively common condition in older women and is characterized by the displacement of the rectum through posterior vaginal wall defect(s). The condition is typically caused by damage to the rectovaginal septum incurred during vaginal childbirth and is exacerbated by periodic increases in intraabdominal pressure (e.g., when laughing or coughing) and the effects of gravity. Women with symptomatic rectoceles who are poor surgical candidates may be treated with pessaries, which are structures designed to support the vaginal wall. Pessaries should only be used in conjunction with vaginal estrogen; without it, these can cause chronic discharge and bleeding secondary to injury of the vaginal tissues. Surgical repair, most commonly via a posterior colporrhaphy, is an appropriate recommendation for women with symptomatic rectoceles. However, it is important to advise these patients that correction of the condition does not always provide symptomatic relief. Patients who are not good surgical candidates or who prefer not to undergo surgery should not be pressured to proceed. Rather, they should be advised about alternative treatment options (e.g., pessaries). Pelvic exercises are appropriate to recommend in women with

asymptomatic rectocele. Additional recommendations for this patient group include avoidance of activities related to increased intraabdominal pressure and regular usage of intravaginal estrogen to prevent tissue atrophy. Conservative treatment with the insertion of a pessary to hold the pelvic organs in place should be only used in patients who are poor candidates for surgical intervention. It does not correct the underlying defect, and there is a higher chance of relapse in active patients. severe form of preeclampsia called HELLP syndrome, which is characterized by microangiopathic hemolytic anemia, abnormal liver function tests, and thrombocytopenia (H-emolytic anemia, E-levated L-iver enzymes, Low Platelet count). Magnesium sulfate is the standard of care for patients with severe preeclampsia and HELLP syndrome, because it significantly reduces the risk of seizure and is relatively safe. Although 50% of all cases of eclampsia occur prior to term, the risk is significant within the first 24-48 hours after delivery; therefore, magnesium sulfate should be infused throughout this period. Most females rapidly lose considerable bone mass following menopause. Lifestyle modification, including weightbearing exercises and optimum calcium and vitamin D supplementation, prevents postmenopausal bone mass loss and possibly reduces the risk of fragility fractures. The National Academy of Science recommends daily supplementation of elemental calcium (1200 mg) and vitamin D (400 to 800 international units) in women after 50 years of age. This can be easily achieved by taking one multivitamin tablet (which contains 400 international units of vitamin D) with two tablets of calcium/vitamin D (containing 600 mg of elemental calcium and 200 international units of vitamin D) everyday.

A history of preeclampsia in the past increases the risk of developing this complication during a subsequent pregnancy. The risk is higher if the preeclampsia presented earlier (age of delivery was less than 32-33 weeks), or if the patient has renal disease or chronic hypertension. Antenatal corticosteroid therapy has been proven to be effective in reducing perinatal morbidity and mortality associated with preterm labor. It reduces the risk of infant respiratory distress syndrome by stimulating phospholipids (surfactant!) synthesis and accelerating morphologic lung development. In addition, antenatal corticosteroid therapy appears to reduce the risk of intraventricular hemorrhage in infants. For these reasons, it should be given to any pregnant woman from 24 to 34 weeks of gestation with intact membranes at high risk for preterm delivery. Two regimens of therapy are available: betamethasone and dexamethasone (some authors believe that betamethasone is preferred over dexamethasone). Most states have implemented laws that allow for a physician to provide certain types of medical care to adolescents without parental consent. Exempted areas typically include pregnancy, contraception, sexually transmitted disease, substance use, and emotional illness. Adolescents do not need consent from their parents for contraceptive services. Barrier methods should be used by all sexually active adolescents even if an additional method of contraception is being used.

Implantable and injectable contraceptives, including implantable levonorgestrel and depot medroxyprogesterone acetate, have the lowest rate of pregnancy (does

not exceed 2-3%). The actual pregnancy rate may be as low as 0.3%. Oral contraceptives are also very effective, but the actual pregnancy rate is higher than with implantable and injectable contraceptives due to inconsistent or incorrect use. Barrier methods of contraception such as diaphragms, cervical caps, and male condoms are moderately effective due to inconsistent or incorrect use. The actual pregnancy rate is 12-14%. Spermicides, if used alone, have a high failure rate. The clinical scenario described is suggestive of condylomata acuminata (anogenital warts). These can manifest with pruritus, bleeding, burning, tenderness, vaginal discharge and pain, depending on the location. Large lesions can interfere with defecation, vaginal intercourse and delivery. Small lesions are frequently accidental findings on physical examination or can be minimally symptomatic (such as in this patient). Visual inspection with application of acetic acid (lesions should turn white) is usually sufficient for making the correct diagnosis. The three major treatment modalities employed in patients with condylomata acuminata are chemical or physical destruction, immunotherapy, and surgical excision. Chemical destruction is preferred as the initial approach by many physicians. Trichloroacetic acid application destroys the lesion by protein coagulation. The clearance rate is not very high; therefore, repeated applications are usually necessary. Systemic or topical interferon is a form of immunotherapy that has been proven to be effective in patients with anogenital warts. A newer approach involves topical application of antimicrobials (e.g., cidofovir), but this requires further study.

Podophyllin has a similar effect as trichloroacetic acid, but is not indicated for internal use (i.e., it should not be applied to the mucosal surface). Podophyllin is also contraindicated during pregnancy. Spontaneous regression can occur, but is not common. Lesbian women have a lower risk of acquiring HPV infection and a lower chance of developing CIN and invasive cervical carcinoma. Perimenopause is the time extending from two to eight years preceding menopause until one year following the last menstrual period. This state is associated with normal ovulatory cycles interspersed with anovulatory cycles that vary in length. Because the hormone levels are inconsistent during perimenopause and estrogen is frequently unopposed, menses become irregular and heavy breakthrough bleeding may be reported. Endometrial hyperplasia can develop during lengthy intervals of anovulation. If a patient complains of an episode of heavy dysfunctional bleeding or of six or more months of irregular menses, then endometrial surveillance in the form of vaginal ultrasound (to ensure the endometrial thickness is <4mm) or endometrial biopsy is indicated. If the diagnosis of menopause is uncertain, the pathognomonic finding is an elevated level of follicle-stimulating hormone (FSH). The measurement of serum luteinizing hormone (LH) is of less help because serum LH concentrations may be elevated at certain points in the normal menstrual cycle and cannot be readily distinguished from a typical menopausal serum LH value. Menopause is defined as the presence of amenorrhea for six to twelve months in conjunction with the symptoms of menopause (eg, hot flashes, vaginal

dryness). If the clinical presentation is classic, then testing is unnecessary.Women with particularly severe symptoms may elect to initiate hormone replacement therapy, although this is usually recommended only for short-term use. The absolute contraindications to the use of oral contraceptives are the following: 1. history of thromboembolic event or stroke 2. active liver disease 3. history of estrogen dependent tumor 4. pregnancy 5. abnormal uterine bleeding 6. heavy smokers who are older than 35 7. hypertriglyceridemia Relative contraindications are the following: 1. migraine headaches 2. poorly controlled hypertension 3. anticonvulsant drug therapy

Hemophilia A is an X-linked recessive disease that is due to a deficit in coagulation factor VIII. The above pedigree illustrates that all daughters of affected men will all carry the "diseased" chromosome and be silent asymptomatic carriers, while half the sons will be unaffected and the other half asymptomatic carriers. All sons of affected women will have the disease while all daughters will be asymptomatic carriers (not shown above). In this case, the patient is a silent carrier of the disease. 50% of her sons will have the disease, and 50% of her daughters will be asymptomatic carriers. The probability of having a male child is 50%, which makes the overall probability of having an affected male child 25% (50% times 50%) and an unaffected male 25%. The chance of having a female child is also 50%, which makes the overall chance of having an asymptomatic carrier daughter 25% and an unaffected daughter also 25%. This makes the overall chances of 25% of having an

affected child, 25% for an asymptomatic carrier and 50% for an unaffected child (both male and female combined). The incidence of hemophilia in the general population is less than 1% while the probability is much higher in this patient given her strong family history and her carrier state for the disease. As soon as pregnancy is confirmed in hypothyroid patients who are receiving hormone replacement therapy, the dose of L-thyroxine should be increased. The causes of an increased requirement for L-thyroxine during pregnancy include increases in thyroxine-binding globulin (TBG) and the volume of the distribution of T4, and an increase in body mass.

Stress urinary incontinence (SUI) is a common problem in premenopausal as well as postmenopausal females. Some studies have reported that up to 50% of females suffer from some degree of stress urinary incontinence. Loss of vaginal support due to pelvic floor trauma during childbirth or vaginal atrophy following menopause causes urethral hypermobility that leads to stress urinary incontinence. It is important to differentiate stress urinary incontinence from urge incontinence due to detrusor muscle hyperactivity. Urge incontinence responds to biofeedback as well as treatment with anticholinergic agents. On the other hand, the use of anticholinergic agents such as oxybutynin is not very helpful in patients with SUI. Local estrogen creams can be used in patients with stress urinary incontinence who have low estrogen levels following menopause. Stress urinary incontinence due to vaginal atrophy may improve remarkably with local use of estrogen creams. This premenopausal

patient does not have hypoestrogenic symptoms and is unlikely to benefit from local estrogen use. Alpha-receptor agonists increase the tone of the lower urethral sphincter, which can lead to the improvement of symptoms in patients with stress urinary incontinence. Pure alpha-receptor agonists are not available in the United States. Amitriptyline/Imipramine has dual anticholinergic and alpha-agonist properties; these drugs can be sometimes used when pelvic floor exercises do not result in improvement of urinary incontinence. Surgical treatment is usually used as the last resort because of its invasive nature.

Cardiovascular Disease
Epidemiology of Cardiovascular Disease
Key Points
Cardiovascular disease is

the leading cause of death in the United States, and among persons 75 years and older, more than twice as many die from cardiovascular disease than from cancer-related causes. More women than men die of cardiovascular disease each year, and the number of women dying of cardiovascular disease has not decreased over time. The prevalence of cardiovascular disease and the death rate due to cardiovascular disease are 2 to 4 times higher among persons with diabetes than those without diabetes. Microalbuminuria in persons with diabetes is strongly associated with cardiovascular disease and poorer cardiovascular disease outcomes.

 Patients

treated with radiation therapy have higher than expected rates of valvular and coronary artery disease. Cardiomyopathy occurs in approximately 2% of patients treated with anthracyclines; it is directly related to the cumulative dose and is associated with a mortality rate of nearly 50%. Trastuzumab is associated with a high risk of cardiotoxicity, and cardiac function should be closely monitored during and after treatment. The term metabolic syndrome refers to the clustering of risk factors for cardiovascular disease and type 2 diabetes. The most commonly utilized definition in the United States is the presence of at least three of the following five risk factors: 1. Fasting plasma glucose level _110 mg/dL (6.11 mmol/L) 2. HDL cholesterol level <40 mg/dL (1.0 mmol/L) in men or <50 mg/dL (1.3 mmol/L) in women 3. Triglyceride level _150 mg/dL (1.7 mmol/L) 4. Waist circumference _102 cm (40 in) in men or _88 cm (35 in) in women 5. Blood pressure _130 mm Hg systolic or _85 mm Hg diastolic or drug treatment for hypertension Radiation therapy or chemotherapy for cancer may predispose the patient to cardiovascular disease. Patients with systemic inflammatory conditions are at greater risk of coronary artery disease, pericarditis, myocarditis or myocardial fibrosis, endocardial involvement causing valvular dysfunction or thrombus formation, coronary arteritis, pulmonary arterial hypertension, conduction abnormalities, and systemic hypertension Cigarette smoking is a risk factor for coronary artery disease, myocardial infarction, stroke, and peripheral artery disease. A dose-response relationship between cigarettes smoked and cardiovascular disease risk has been established, with heavy smokers having a relative risk of nearly 5.5 for fatal cardiovascular disease events compared with nonsmokers. Although moderate alcohol consumption (approximately one to three drinks daily) is associated with a lower risk of coronary artery disease, excessive alcohol intake accounts for approximately 4% of cases of dilated cardiomyopathy.

Cocaine use is associated with chest pain, myocardial infarction, left ventricular hypertrophy, cardiomyopathy, aortic dissection, and cardiac arrhythmias. The adverse cardiac effects of cocaine seem to be exacerbated by concomitant use of tobacco or alcohol. The use of methamphetamine has been associated with cardiovascular complications similar to those associated with cocaine use. The intravenous injection of any illicit drug is associated with a risk of infective endocarditis, particularly Staphylococcus aureus infection of the tricuspid valve resulting in tricuspid valve regurgitation. Although infection of the tricuspid valve is the most common site of involvement for endocarditis associated with injection drug use, infection of the mitral and aortic valves has been reported in 32% and 19%, respectively, of cases.

Extensions of the Physical Examination

Key Points
Transthoracic

echocardiography is the initial diagnostic test for suspected or known structural heart disease. Hand-held echocardiographic instruments may be helpful for triage when used by an appropriately trained and experienced individual. The appropriate diagnostic test for coronary artery disease is based on symptoms and an estimate of cardiovascular risk. Exercise and pharmacologic stress testing, using electrocardiography, echocardiography, or radionuclide myocardial perfusion imaging, remains the standard initial approach when coronary artery disease is suspected. Coronary angiography provides a definitive diagnosis of coronary artery disease severity and allows simultaneous intervention. The key to diagnosis of a cardiac arrhythmia is an ECG recorded during the event. Event monitors allow recording of infrequent but symptomatic arrhythmias. Syncope due to a cardiac arrhythmia is best evaluated with a loop recorder. Asymptomatic arrhythmias are best evaluated with a continuously monitored ECG, such as a 24-hour ambulatory ECG (frequent arrhythmias) or an implanted recorder (infrequent arrhythmias).

Structural Heart Disease

Transthoracic echocardiography is indicated for the following murmurs:

Any diastolic murmur A systolic murmur grade 3/6 or louder A murmur of any grade if associated with

possible cardiac symptoms or a history of

cardiac disease A normal flow murmur occurs with increased cardiac output, for example, in a patient with fever or anemia. A flow murmur also is present in more than 80% of normal pregnant women. Echocardiography is not needed for evaluation of these soft midsystolic murmurs in the absence of symptoms or other signs of cardiac disease. In addition, current guidelines do not recommend endocarditis prophylaxis in patients with native cardiac valve disease S3 has a 95% specificity for a left-ventricular ejection fraction below 50% or a filling pressure greater than 15 mm Hg. However, heart failure cannot be excluded in the absence of an S3 because sensitivity is only 30% to 50%. In addition, physical examination does not provide quantitative measures of ventricular function. In contrast, echocardiography provides quantitation of ventricular systolic function, assessment of other hemodynamic consequences (such as mitral regurgitation and pulmonary hypertension), and often provides clues to the cause of heart failure. Smaller, hand-held echocardiographic instruments can be used for limited bedside imaging in patients with chest pain, dyspnea, or other cardiac symptoms; for example, differentiating the chest pain patient with a large anterior myocardial infarction from the one with a pericardial effusion Transesophageal echocardiography is appropriate when transthoracic images are nondiagnostic and as the initial imaging test in some clinical situations, such as detection of left atrial thrombus, evaluation of prosthetic mitral valve dysfunction, evaluation of suspected aortic dissection, and in patients with a moderate to high pretest probability of endocarditis. Diagnostic Tests for Suspected or Known Structural Heart Disease******screen shot from page 57

Coronary Artery Disease

The standard diagnostic approach in patients with suspected or known coronary artery disease continues to be history and physical examination followed by stress testing when appropriate. Exercise stress testing is preferred because it provides an objective measure of functional status in addition to detection of ischemia. In patients who cannot exercise, stress testing with pharmacologic agents that increase the heart rateblood pressure product (such as dobutamine) or result in relative inequality in myocardial blood flow (such as adenosine) are appropriate. Exercise electrocardiographic (ECG) stress testing with ECG monitoring alone is appropriate when the resting ECG is normal. Any resting ST-segment changes reduce diagnostic accuracy, and ECG stress testing is not useful with conditions such as pre-excitation (WolffParkinsonWhite syndrome), greater than 1-mm ST-segment depression, and left bundle branch block. Following an abnormal resting ECG or with pharmacologic stress testing, echocardiographic or nuclear imaging is needed. Based on a recent meta-analysis, echocardiographic and nuclear stress imaging are equivalent for the diagnosis of ischemia with a negative predictive value of 98% for adverse cardiovascular outcomes over the next 3 years. Coronary angiography is appropriate when the stress test is consistent with CAD, particularly if there is a large area of myocardium at risk. In patients with a very high pretest probability of disease, coronary angiography is an appropriate initial diagnostic test. CT imaging, CMR imaging, and positron emission tomography (PET). CT can be used for measuring coronary artery calcium (CAC) and for noninvasive coronary angiographic imaging. CAC scores are measured from noncontrast CT images, whereas CT coronary angiography requires a radiocontrast agent and use of a high-resolution scanner, necessitating a higher radiation dose to the patient The CAC score correlates with cardiovascular risk but is not a direct measure of the severity of luminal coronary disease, and CAC scores are not indicated for routine screening. CAC measurement may be considered in asymptomatic patients with an intermediate risk of

CAD (10%-20% 10-year risk), because a high CAC score (>400) is an indication for more intensive preventive medical treatment. However, a low CAC score (score = 0) should not change intensity of treatment for cardiac risk factors. CAC scoring is not recommended in patients with low CAD risk (<10% 10-year risk of coronary events). In addition, CAC scores are not recommended in asymptomatic patients at high risk for CAD; these patients should receive appropriate risk factor reduction therapy. In symptomatic patients, CAC testing has a high negative predictive value (96%-100%); therefore, a patient with a CAC score of zero is highly unlikely to have obstructive CAD. A CAC score below 100 confers a low probability of abnormal perfusion (<2%) or significant obstruction (<3%). CAC testing, therefore, may benefit patients with atypical cardiac symptoms to help rule out obstructive CAD, although there are no direct comparisons to other diagnostic approaches in this clinical setting. CT or CMR coronary angiography is appropriate for identification of anomalous coronary arteries. CT coronary angiography also is appropriate to evaluate coronary anatomy in a patient with new-onset heart failure and in patients with acute chest pain syndromes when the risk of CAD is intermediate but cardiac enzyme results are negative. CT coronary angiography or CMR pharmacologic stress testing may be considered in symptomatic patients with an intermediate probability of CAD when the ECG is abnormal at baseline, the patient is unable to exercise, or previous test results are equivocal. Compared with SPECT, a PET study is shorter for the patient (45-90 minutes), results in a lower radiation dose, provides evaluation of both myocardial perfusion and function, and reduces interpretive uncertainty, particularly in obese patients. In addition, PET provides the option of quantification of absolute myocardial blood flow and can be combined with CAC scoring. Guidelines for diagnostic use of PET have not yet been established, but it is a reasonable

option when other tests are not diagnostic. The major risk of radiocontrast exposure is acute renal failure, which occurs in approximately 3% of patients undergoing coronary interventions but up to 25% of those with a baseline serum creatinine concentration greater than 2.0 mg/dL.

Relative Radiation Exposure for Diagnostic Imaging for Coronary Artery Disease
Procedure Relative Exposurea Stress echocardiography 0 Cardiac magnetic resonance coronary angiography 0 Coronary artery calcium score 20-40 Coronary angiography (diagnostic) 200-500 Nuclear perfusion imaging 100-500 Positron emission tomographic perfusion imaging 100-400 CT coronary angiography 700-2100 aCompared with the exposure with a chest radiograph (set at 1). Diagnostic Tests for Suspected or Known Coronary Artery Disease*******screen shot***********

Cardiac Arrhythmias
For patients whose history suggests a cardiac cause of syncope, after echocardiography is performed to evaluate for underlying structural heart disease, the key diagnostic test is an ECG recorded during the clinical event. In most patients, a resting ECG is not helpful; however, there are exceptions, such as the presence of a delta wave or a long QT interval. For infrequent arrhythmias that are brief or that prevent the patient from activating the monitoring device (such as syncope), a loop recorder is helpful. Some loop recorders can be set to save data based on heart rate parameters. If an arrhythmia cannot be captured on ECG during an event using standard event monitors or loop recorders, an implantable recorder can be used. This small device is surgically placed subcutaneously, similarly to a pacemaker, but there are no leads in the heart chambers.

Recording parameters are set based on heart rate and QRS width, and, like a pacemaker, the device can be interrogated noninvasively. ****screen shot**** Diagnostic Tests for Suspected or Known Cardiac Arrhythmias

Coronary Artery Disease

Key Points
Risk

factors for developing coronary artery disease include older age, male sex, elevated blood pressure, high serum cholesterol, cigarette smoking, and diabetes mellitus. SFHHAD The Framingham risk score is useful to evaluate whether a patient is at low, intermediate, or high risk of a coronary artery disease event in a 10-year period The benefit of assessing conditional risk factors for coronary artery disease (CAD), such as high-sensitivity C-reactive protein level, LDL particle size, lipoprotein(a), and homocysteine level in risk evaluation, has not been determined, and these tests are not recommended for routine screening for determining CAD risk. Noninvasive stress testing is most useful in patients with an intermediate pretest probability of coronary artery disease as determined by the patients age, sex, and description of the chest pain. Exercise electrocardiogram (ECG) is the preferred noninvasive test for patients who can exercise and have a normal resting ECG (that is, absence of left bundle branch block, <1 mm ST-segment depression, and no evidence of preexcitation). _-Blockers are first-line therapy for patients with chronic stable angina as well as those with a history of myocardial infarction. Patients with chronic stable coronary artery disease and without contraindications should take aspirin. Patients with reduced left ventricular ejection fraction (<35%) should be treated with an angiotensin-converting enzyme inhibitor. Statins should be given to most patients with established coronary artery disease. Percutaneous coronary intervention reduces the frequency and severity of angina but not future cardiovascular events; it should be reserved for patients with continued symptoms despite optimal medical therapy. Surgical revascularization is indicated for left main coronary artery disease and multivessel coronary artery disease with involvement of the left anterior descending coronary artery and reduced ejection fraction. Patients with medically refractory angina may benefit from external enhanced counterpulsation or spinal cord stimulation. Clopidogrel should be continued for a minimum of 1 year following drug-eluting stent placement and for a minimum of 1 month following bare metal stent placement. The risk of coronary stent thrombosis is approximately 0.7% and is increased with the

premature discontinuation of dual antiplatelet therapy (aspirin and clopidogrel). Patients who must undergo noncardiac surgery that cannot be delayed to allow completion of dual antiplatelet therapy should continue aspirin during the perioperative period and restart clopidogrel as soon as possible following the procedure. All unstable angina/nonST-elevation myocardial infarction patients without contraindications should be treated initially with aspirin, _-blockers, and nitrates. Unstable angina or nonST-elevation myocardial infarction patients with TIMI risk scores of 3 or more generally benefit from an early invasive approach. All unstable angina/nonST-elevation myocardial infarction patients without contraindications should be given antiplatelet therapy with aspirin and clopidogrel. Unstable angina/nonST-elevation myocardial infarction patients should receive early treatment with high-dose statins to achieve a target LDL cholesterol of less than 100 mg/dL (2.6 mmol/L) (optional goal <70 mg/dL [1.8 mmol/L]). ST-elevation myocardial infarction patients presenting to a hospital with percutaneous coronary intervention (PCI) capability should be treated with primary PCI within 90 minutes of first medical contact; those presenting to a hospital without PCI capability and who cannot be transferred to a PCI center and undergo PCI within 90 minutes should be treated with fibrinolytic therapy. Initial medical therapy for ST-elevation myocardial infarction includes general treatment measures (aspirin, analgesics, nitrates, and oxygen), therapy to reduce infarct size (_blockers and angiotensin-converting enzyme inhibitors), antithrombotic therapy (unfractionated or low-molecular-weight heparin), and antiplatelet therapy (clopidogrel and glycoprotein IIb/IIIa inhibitors). Clopidogrel should be added to standard medical and thrombolytic therapy, as it further reduces cardiovascular events without a significant increase in bleeding. Early complications after ST-elevation myocardial infarction include failure of thrombolytic therapy. Treadmill exercise electrocardiographic testing has a higher false-positive rate in women than men but remains the first-line noninvasive test for women with suspected coronary artery disease because of the low false-negative rate. Women with myocardial infarction treated with fibrinolytic, antiplatelet, and/or antithrombotic therapies have a higher rate of bleeding complications compared with men, and appropriate dosing of these medications should be based on patient weight and estimated glomerular filtration rate. An early invasive strategy in women with unstable angina or nonST-elevation myocardial infarction and high-risk features reduces major adverse cardiac events, but this approach in women with low risk features may be associated with an early excess risk. In patients with diabetes who experience angina, exercise electrocardiographic testing has similar diagnostic sensitivity and specificity as for nondiabetic patients. Although patients with diabetes mellitus are more likely to have coronary artery disease without symptoms (silent ischemia), outcome data do not support routine stress testing in asymptomatic patients.