1000-2000 5 ьшò

GENERALPREVENTION

Suppression of heavy menstruation and ovulation with oral contraceptives during adolescence may delay sequelae.

Some factors are considered protective:

–Fruits, green vegetables, n-3 long-chain fatty acids

–Aerobic exercise may decrease pelvic pain.

Early diagnosis and treatment might help prevent sequelae.

COMMONLYASSOCIATED CONDITIONS

Associated with increased risks for cancer of the ovary, breast, endometrium; increased risk for cutaneous melanoma, non-Hodgkin lymphoma, autoimmune diseases, asthma, and cardiovascular disease

DIAGNOSIS

History: dysmenorrhea (50–90% of cases) due to deep infiltrating endometrial implants

Dyspareunia due to lesions of the cul-de-sac, uterosacral ligaments, and posterior vaginal fornix

Dyschezia due to involvement of the rectosigmoid colon and rectovaginal regions

Chronic pelvic pain (≥6 months) that worsens with time and begins 1 to 2 days prior to menstrual cycles

Hematochezia

Cyclic nausea, abdominal distention

Infertility (late finding)

History of pelvic pain, infertility, and hysterectomy in firstor second-degree relative

PHYSICALEXAM

Focal pain/tenderness on pelvic exam is associated with endometriosis in 66% of patients.

Pelvic mass may be present.

Immobile pelvic organs (frozen pelvis)

Rectovaginal exam revealing uterosacral nodules, beading, or tenderness An exquisitely tender “barb” stabbing pain in the region of the uterosacral ligament is found in severe cases.

mebooksfree.com

DIFFERENTIALDIAGNOSIS

Differential diagnosis of pelvic pain includes all causes of acute abdomen and

Pelvic adhesions

Nonspecific dysmenorrhea

Acute salpingitis/pelvic inflammatory disease

Ruptured ovarian cyst

Uterine leiomyomas

Adenomyosis

Irritable bowel syndrome

Inflammatory bowel disease

Pelvic malignancy

Complications of intrauterine/ectopic pregnancy

Cystitis

Depression

History of sexual abuse

Chronic pain syndrome

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Labs are only useful to rule out other diagnoses; there are no useful labs to rule in endometriosis.

CA-125 levels are not recommended (2)[C] due to low sensitivity.

If history and physical exam reveal adnexal pain or tenderness with/without fullness on pelvic exam

–Transvaginal ultrasound (US) and MRI are equally effective in detecting ovarian endometriomas: sensitivity, 80–90%; specificity, 60–98% for both

–US is preferred (less costly).

–Both modalities are poor in detecting peritoneal implants and adhesions.

Diagnostic Procedures/Other

Definitive diagnosis is made by the gross and microscopic characteristics of tissue visualized and biopsied during laparoscopy or laparotomy.

Test Interpretation

Laparoscopically visualized red and blue-black lesions described as “powderburns,” adhesions, and “chocolate cysts” on the ovarian and peritoneal surfaces

mebooksfree.com

Histologically described endometrial glands and stroma on analysis of biopsied lesions

TREATMENT

GENERALMEASURES

Management is dependent on multiple factors:

Age and reproductive desires of the patient

The certainty of the diagnosis

The degree of degradation on quality of life due to pain and infertility

The threat to other organ systems: GI tract, bladder

MEDICATION

Medications are used to improve the patient’s quality of life through symptom relief and to prevent progression of the disease and its potential to cause organ dysfunction. Unfortunately, few studies of medical therapy report patientrelevant outcomes. Many women gain only limited or intermittent benefit from medical therapies (3)[A].

First Line

Women found to have endometriomas during incidental surgery or studies may not need any treatment. Others with minimal symptoms may find sufficient relief with NSAID medications. Increased exercise, especially aerobic, may help others.

NSAIDs initiated at the beginning or just before menses. Evidence is inconclusive on effectiveness (4)[B].

Cyclic combined oral contraceptive pills (OCPs) suppress ovulation.

Second Line

Low-dose OCPs or low-dose progestins with recommendations to switch from cyclic to continuous contraception for 3 to 6 months if symptoms persist or if there is chronic, noncyclic pelvic pain

–Levonorgestrel intrauterine device (IUD) (Mirena) found to decrease recurrence of painful menstruation (although not FDAapproved for this indication)

Medroxyprogesterone acetate 150 mg IM 3 months. Prolonged use may lead to loss of bone mineral density of uncertain clinical significance.

mebooksfree.com

Gonadotropin-releasing hormone (GnRH) agonists: inhibit pituitary gonadotropin synthesis and induce a hypoestrogenic state

Norethindrone acetate 5 mg PO once daily plus conjugated equine estrogen 0.625 mg PO once daily

Third Line

If symptoms and signs continue, physicians should be experienced in the use and side effects of GnRH analogues prior to their use (symptoms return in as many as 70% of treated patients):

Leuprolide acetate (Lupron Depot) 3.75 mg IM each month or 11.25 mg IM every 3 months (gluteal)

Nafarelin (Synarel) intranasal one spray (200 µg) in one nostril each morning and the other nostril each evening (start between days 2 and 4 of menstrual cycle)

Goserelin (Zoladex) implant 3.6 mg SC in upper abdominal wall every 28 days

Danazol: also effective, with side effects similar to GnRH analogs

Aromatase inhibitors (anastrozole and letrozole) prolong the remission induced by GnRH medications.

ALERT

Calcium (1,000 to 1,500 mg/day) with vitamin D 1,000 to 2,000 IU daily or low-dose estrogen with progestogen (5)[B] is recommended when using GnRH agonists to prevent calcium loss.

ISSUES FOR REFERRAL

Refer early to a physician with expertise in medical and surgical treatment of endometriosis, especially if the patient desires to conceive in the future. Indications for referral to a properly experienced gynecologist include the following:

–Need for definitive diagnosis

–Failure to respond to a conservative or first-line therapy

–Chronic pelvic pain

–Delayed fertility

ADDITIONALTHERAPIES

Regular exercise and counseling for pain-management strategies. Narcotics are contraindicated for chronic pain.

mebooksfree.com

SURGERY/OTHER PROCEDURES

Surgery (laparoscopy or laparotomy) is both diagnostic and therapeutic (first line or when conservative measures fail):

Peritoneal endometriosis: laser ablation/excision/fulguration

Ovarian endometriosis (endometriomas) >3 to 4 cm: ablation, excision, drainage

Lysis of adhesions (LOA)

Hysterectomy with bilateral salpingo-oophorectomy for debilitating symptoms refractory to other medical or surgical treatments:

–Relieves pain in 80–90%, but pain recurs in 10% within 1 to 2 years after surgery

–Postoperative HRT should include estrogen and progestogen or progesterone.

Interruption of nerve pathways: Laparoscopic ablations and presacral neurectomy improve dysmenorrhea.

Fertility procedures: Ablation or excision of lesions with LOAis recommended to treat infertility in stages I and II disease:

–Spontaneous conception should be attempted for 1 year prior to assisted reproduction techniques.

–Disease does not endanger in vitro fertilization (IVF) pregnancies.

ALERT

Surgery for endometriomas may decrease ovarian reserve in advanced disease.

COMPLEMENTARY& ALTERNATIVE MEDICINE

Osteopathic manipulative therapy found to improve quality of life (2)[C]

Postsurgical use of Chinese herbal medicine has been found to be effective. Acupuncture may be more effective than danazol to decrease pain, irregular menstruation, and perineal swelling (6)[B].

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Routine gynecologic care

mebooksfree.com

Patient Monitoring

Symptomatic and asymptomatic pelvic masses (http://www.acog.org/)

PROGNOSIS

Excellent, especially if diagnosis and treatment plans are initiated early in disease course

Poor for recovery of fertility if the disease has progressed to stage III/IV

Symptoms and signs improve after bilateral oophorectomy.

COMPLICATIONS

Sequelae include chronic pelvic pain, reduced quality of life, repetitive surgical intervention, depression, infertility, medication side effects and costs, and infertility.

REFERENCES

1.Brown J, Farquhar C. Endometriosis: an overview of Cochrane Reviews.

Cochrane Database Syst Rev. 2014;(3):CD009590.

2.Daraï C, Deboute O, Zacharopoulou C, et al. Impact of osteopathic manipulative therapy on quality of life of patients with deep infiltrating endometriosis with colorectal involvement: results of a pilot study. Eur J Obstet Gynecol Reprod Biol. 2015;188:70–73.

3.Becker CM, Gattrell WT, Gude K, et al. Reevaluating response and failure of medical treatment of endometriosis: a systematic review. Fertil Steril. 2017;108(1):125–136.

4.Allen C, Hopewell S, Prentice A, et al. Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis. Cochrane Database Syst Rev. 2009; (2):CD004753.

5.Giudice LC. Clinical practice. Endometriosis. N Engl J Med. 2010;362(25):2389–2398.

6.Zhu X, Hamilton KD, McNicol ED. Acupuncture for pain in endometriosis.

Cochrane Database Syst Rev. 2011;(9):CD007864.

ADDITIONALREADING

Davis L, Kennedy SS, Moore J, et al. Oral contraceptives for pain associated with endometriosis. Cochrane Database Syst Rev. 2007;(3):CD001019.

de Ziegler D, Borghese B, Chapron C. Endometriosis and infertility:

mebooksfree.com

pathophysiology and management. Lancet. 2010;376(9742):730–738.

Fujii S. MR imaging of endometriosis. In: Harada T, ed. Endometriosis: Pathogenesis and Treatment. Tottori, Japan: Springer; 2014.

Jacobson TZ, Duffy JM, Barlow D, et al. Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane Database Syst Rev. 2009; (4):CD001300.

Koga K, Yoshino O, Hirota Y, et al. Infertility treatment of endometriosis patients. In: Harada T, ed. Endometriosis: Pathogenesis and Treatment. Tottori, Japan: Springer; 2014.

Practice Committee of American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis. Fertil Steril. 2008;90(5 Suppl):S260–S269.

Schrager S, Falleroni J, Edgoose J. Evaluation and treatment of endometriosis. Am Fam Physician. 2013;87(2):107–113.

CODES

ICD10

CLINICALPEARLS

Severe dysmenorrhea and dyspareunia are never normal. Failure to respond to NSAIDs and/or OCPs warrants further investigation.

Arectovaginal exam can be useful in patients suspected of having endometriosis.

mebooksfree.com

ENDOMETRITIS AND OTHER

POSTPARTUM INFECTIONS

Justin P. Lavin Jr., MD Ayesha Hasan, MD Cassandra

Heiselman, DO, MPH

BASICS

DESCRIPTION

Endometritis (infection of the endometrium) is the most common postpartum infection.

Bacterial infection of genital tract, usually within the 1st week after delivery, can occur as late as 1 to 6 weeks postpartum.

Postpartum infections of the myometrium and parametrial tissues are less common. Vaginal and cervical infections, perianal cellulitis, pelvic cellulitis, septic pelvic vein thrombophlebitis, and parametrial phlegmon are other postpartum infections of the pelvic region that are relatively rare.

System(s) affected: reproductive

Synonym(s): postpartum infection; endometritis; endoparametritis; endomyometritis; myometritis; endomyoparametritis; metritis; metritis with pelvic cellulitis

EPIDEMIOLOGY

Incidence

Occurs in women of childbearing years

Prevalence

Occurs after 1–3% of all births

Infection 10 times more likely after cesarean section

–2–15% of infections occur prior to labor.

–30–35% occur after labor in absence of appropriate antibiotic prophylaxis; 2–15% occur after labor with appropriate prophylaxis.

–Fifth leading cause of maternal mortality, accounting for 11% of maternal deaths

mebooksfree.com

ETIOLOGYAND PATHOPHYSIOLOGY

Endometritis is more common in labors complicated by chorioamnionitis.

Other infections follow trauma to the perineum, vagina, cervix, and uterus. Postpartum infections are typically polymicrobial, involving organisms ascending from the lower genital tract:

–Aerobic isolates (70%): Streptococcus faecalis, Streptococcus agalactiae, Streptococcus viridans, Staphylococcus aureus, Escherichia coli

–Anaerobic isolates (80%): Peptococcus sp., Peptostreptococcus sp.,

Clostridium sp., Bacteroides bivius, Bacteroides fragilis, Fusobacterium sp. Other genital Mycoplasma

Consider herpes simplex virus and cytomegalovirus, particularly in immunocompromised patients failing to improve on appropriate antibiotics.

Thrombosis of any pelvic vein, including vena cava

Phlegmon on leaves of the broad ligament

RISK FACTORS

Cesarean delivery is the primary risk factor.

Chorioamnionitis

Bacterial vaginosis

Group B streptococcal colonization of genital tract

HIV infection

Prolonged labor

Prolonged rupture of membranes

Multiple vaginal examinations

Internal fetal monitoring during labor

Operative vaginal delivery; manual extraction of the placenta; care in a teaching hospital

Low socioeconomic status

Obesity

Anemia

GENERALPREVENTION

Vaginal delivery

–Avoid unnecessary vaginal examinations.

–Treat chorioamnionitis during labor.

–Avoid manual placental extraction and retained placental products.

–Consider antibiotic prophylaxis for thirdand fourth-degree laceration (1) [B].

mebooksfree.com

–Aseptic technique for operative vaginal delivery

–Antibiotic prophylaxis not necessary for operative vaginal delivery or manual removal of the placenta

Cesarean delivery

–Preoperative paint and scrub with 10% povidone-iodine scrub or an alcohol-based solution decreases puerperal infection by up to 38%.

–Prophylactic antibiotics before both emergency and scheduled cesarean deliveries prior to skin incision reduce postpartum infection (2)[A].

Administer antibiotics within 1 hour of the start of surgery (3)[B].

Appropriate administration of antibiotics results in a 40% reduction in postpartum maternal infections without any increase in neonatal infections (3)[B].

–Extended coverage with cephalosporin and macrolide may further decrease infection risk (4)[A].

–Vaginal preparation with povidone-iodine solution or alcohol-based solutions immediately before cesarean delivery reduces the risk of postoperative endometritis (5)[A].

–Weight-based antibiotic dosage helps ensure appropriate tissue concentrations prior to skin incision.

COMMONLYASSOCIATED CONDITIONS

Chorioamnionitis Wound infection

DIAGNOSIS

HISTORY

History of cesarean delivery or chorioamnionitis

Fever and chills

Malaise

Headache

Anorexia

Abdominal pain

Heavy vaginal bleeding or foul smelling lochia

PHYSICALEXAM

Oral temperature >38°C (100.4°F)

mebooksfree.com