6 Questions for Emergency Vaginal Delivery:

1. Due date?
2. Prenatal care? Where?
3. Problems (with prenatal care)?
4. # baby? Vag/C-section?
5. Problems (with previous delivery)?
6. Overall medical problems?
Post-Coital bleeding ddx:
Most concerning:
o Cancer (screen for cancer)
o Cervicitis/Vaginitis (test for cervicitis - pH,
wet mount, KOH, G/C)
Other:
o Polyps,
o Vaginal atrophy,
o Pregnancy (increases likelihood of postcoital spotting due to cervical ectropion),
o Prolapse
History: ask about other abnormal uterine bleeding,
sx of infection, last cervical cancer test results
Physical: look for sources of bleeding: polyps,
prolapse, neoplasm, etc.
Lab testing:
o make sure Pap smear up to date,
o G/C screening if indicated,
o biopsy with grossly visible lesion
Menorrhagia >80ml blood loss
Ddx:
Structural:
PALM (Polyps, Adenomyomas, Lyomyoma,
Malignancy)
Nonstructural:
COIEN (Coagulopathy, Ovulatory (PCOS),
Infection/Iatrogenic (exogenous estrogens, b/c),
Endometrial, NOS)
Plan:
If young:
o Coagulopathy? (blood tests for
coagulopathies, PT, PTT, etc)
If young/post-pubertal:
o PCOS? (testosterone level, etc)
If 30s-40s: Fibroids?
o (ultrasound/imaging)
If post-menopausal:
o Cancer/hyperplasia? (endometrial biopsy)
Next steps:
CBC for anemia,
pregnancy test,
pelvic US for fibroids,

endometrial biopsy if increased risk for cancer, ask

about fertility desires

combined OCPs, MIrena, NSAIDs, ablation,

myomectomy, hysterectomy

Rx:

Vaginitis
Ddx:
BV: fishy odor, thin gray discharge, high pH, clue
cells, whiff positive, treat Metro 7 days 500 mg BID
(no alcohol)
o Ansels Criteria (at least 3): Gray discharge,
pH>4.5, + amine whiff test, >20% epithelial
cells are clue
Trich: yellow frothy discharge, strawberry cervix,
high pH, trichs, whiff positive/norm, treat Metro 2g
1x (1 dose does the trich)
Candida: white/cottage cheese, itchiness, erythema
(sx worse the week before menses), normal pH,
budding yeast, whiff negative, treat Fluconazole
150mg 1x
Contraception = PS END WITH AND USE CONDOMS
TO PREVENT STIS
Are you using contraception?
Are you currently breastfeeding?
Are you planning a pregnancy?
What have you tried before? What worked? What didnt
work?
How far out in the future are you planning to have a child?
Are you comfortable not having a period (we, as providers, are
very comfortable with this idea)?
Most effective option out there:
LARC - IUD (w/ or w/out hormones), Nexplanon
3 - nexplanon (unpredictable bleeding), 5 - mirena (chance of
expulsion), 10- paragard (do not take away period - can cause
heavier bleeding/cramping)
IUD (no active STI):
Mirena thickens cervical mucus and atrophies
endometrium.
Copper in paraguard is spermicidal.
Contraindications:
o current pregnancy,
o acute infection,
o copper allergy/wilson disease (paraguard
alone),
o current breast cancer (Mirena alone).
o Mirena decreases menorrhagia and
dysmenorrhea,
o decrease risk for endometrial cancer
Depo
Every 3 months, irregular bleeding. Suppresses
ovulation, thickens mucus. 50% have amenorrhea

after 1 year of use. Reversible decrease in bone

mineralization. 10 month delay in return to ovulation
after use.
Pill/Patch/Ring:
suppress ovulation (prevent LH/FSH surge).

Contraindications:
o thromboembolism, PE, coronary artery
disease, stroke, smokers over 35y/o,
breast/endometrial cancer, hypertension.
o Benefits: reduced incidence of ovarian
cancer, endometrial cancer, benign breast
disease, acne. Patch is less effective in
women over 198lbs!
o OCP: unscheduled bleeding occurs in 30%
of women in the first month, but decreases
to less than 10% by the third month of use.
Risk is slightly higher with low dose. Still
effective at contraception when bleeding!
Condoms/DIaphragm/Spermicide:
Less effective (up to 30% women get pregnant in one
year).
o Diaphragm must be fitted by doctor, does
not protect against HIV.
o Condoms are the only method of
contraception that protect against HIV!
Spermicide: must wait 30min after application before
sex. May make pt more susceptible to STIs via
vaginal irritation.
Progesterone only:
Pill (thicken cervical mucus, Depo, Nexplanon) dont use with hx depression
Permanent: Tubal ligation, Essure, Vasectomy
AND USE CONDOMS TO PREVENT STIS!!
No Estrogen if breast-feeding or migraines with aura.
Algorithm: Permanent or temporary? If temporary, long acting
or short acting? Continual actions or one-time procedure?
Well Woman Visit, Screening
STI testing if sexually active - G/C, HIV
Pap
At 21, every 3 years
At 30, every 3 years OR co-testing every 5 years
At 65, can stop if normal paps

Mammogram
At 40, annual (ACOG)
Colonoscopy
At 50, every 10 years
Occult blood
At 65, annual
DEXA
- 65, 50-65 if at risk for osteoporosis
Blood pressure every two years if normal
Talk about contraception, changes in family history and PMH.
GYN: menarche, period description, LMP (menopause).
Sexual: Lifetime partner, 6months, STIs, contraception
OB: number of pregnancies, delivery, etc.
Primary care: up-to-date on vaccines, cholesterol, blood
pressure
- TDap every ten years
- Gardasil
- MMR
- Flu vaccine
Possible Problems for the List!
Rh negative
GBS positive
Previous recurrent miscarriage/preterm labor
G/C positive
Syphilis positive
Herpes
HIV positive
+ Down screen
+ cystic fibrosis
Elevated AFP
Abnml anatomy US (pericardial effusion, etc)
Late to care
IUGR
Gestational Diabetes
Gestational HTN/PEC
PPBC
Car seat, pediatrician, circumcision
Breast/bottle feeding
Rubella non-immune
Substance abuse
Language barrier
IPV
Medical problems