Author: Kristopher Maday PA-C

Ep-PAINE-nym

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Kruckenburg’s Tumor

Other Known Aliases – none

Definition – secondary ovarian malignancy

Clinical Significance – Most commonly arising from a gastric adenocarcinoma, but can occur from any metastatic cancer. 80% are bilateral and commonly manifest as pelvic pain, bloating, ascites, or dysparunea. Occasionaly, these tumor can be hormone producing and cause abnormal menstrual bleeding, hirsuitism, or virilization.

History – Named after Friedrich Ernst Krukenberg (1871-1946), who was a German physician and received his medical doctorate from the University of Marburg.  He was actually studying to become a ophthalmologist, when he happend to be spending time in the pathology lab under Felix Marchand.  It was in this department that Krukenberg described a fibrosarcoma of the ovary (using sections from tumors Marchand had found in 1879) and published his findings in an article entitled “Über das Fibrosarcoma ovarii mucocellulare (carcinomatodes)” in 1896 at the age of 25 as part of his doctoral thesis. He spent the rest of career in his hometown of Halle, Germany practicing as a ophthalmologist.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. F. E. Krukenberg. Über das Fibrosarcoma ovarii mucocellulare (carcinomatodes).  Archiv für Gynäkologie. 1896;50:287-321.

#47 – Obstetrical Screening

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*** LISTEN TO THE PODCAST HERE ***

Initial Prenatal Visit

  • Aneuploidy
    • American College of Obstetrics and Gynecology (ACOG) recommends:
      • All women should be offered screening before 20 weeks
      • All women should have the option for having a more invasive procedure instead of screening regardless of maternal age
        • Amniocentesis
        • Chorionic villus sampling
    • Two major categories of screening available
      • Specific maternal serum biomarkers
        • Primarily trisomy 21 and 18
      • Maternal circulation cell-free DNA
        • More sensitive
        • Assesses trisomy 21, 18, 13, and sex chromosome aneuploidies
  • Carrier Screening
    • ACOG recommends:
      • All women should be offered carrier screening for cystic fibrosis, spinal muscular dystrophy, thalassemias, and hemoglobinopathies
      • Fragile X
        • All women with a family history of intellectual disability, developmental delay, or autism
      • Each provider develop a screening strategies for ethnic-specific and panethnic populations
    • If there is a (+) screening test in the mother, then the reproductive partner should be offered screening
  • Standard Panel Laboratory Screening
    • ABO and Rh Screen
      • RhD(-) women should receive prophylactic anti(D)-immune globin at 28-weeks
    • Complete Blood Count and RBC Indices
      • 1st Screen for anemia
    • Documentation of Rubella and Varicella Immunity
      • Rubella IgG
      • Varicella IgG
    • Urinalysis and Urine Culture
      • Urine Protein – establish baseline to compare if patient develops pre-eclampsia or eclampsia
      • Untreated, asymptomatic has higher rates of developing pyelonephritis, pre-term birth
    • HIV Screen
      • ACOG recommends “opt-out” approach
    • Hepatitis B
      • HBsAg regardless of immunization status
    • Chlamydia
      • Nucelic Acid Amplification Test (NAAT) of endocervical/vaginal swab or urine
    • Syphilis
      • Can screen with either a non-treponemal or treponemal test, but a (+) screening test is confirmed with a treponemal test
  • Selective Screening in 1st Trimester
    • Thyroid Function – TSH only
    • Overt diabetes screening
      • Obtain HgbA1C if BMI > 25 (23 in Asian Americans) AND at least one of the following:
        • Gestational diabetes in previous pregnancy
        • HgbA1C > 5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing
        • 1st degree relative with diabetes
        • African-American, Latino, Native American, Asian American, Pacific Islander
        • History of cardiovascular disease
        • Hypertension (> 140/90 or on medication)
        • Age > 40yr
        • HDL cholesterol < 35 mg/dL or triglyceride > 250 mg/dL
        • PCOS
        • Physical inactivity
        • Other insulin resistance conditions
      • If HgbA1C > 6.5%, then treat as overt diabetes
      • If HgbA1C (-), then screen again at 24-28 weeks
    • Infections
      • Gonorrhea
        • NAAT from endocervical/vaginal swab
      • Hepatitis C
        • High risk patient should be screened with anti-HCV antibody or HCV RNA
      • Tuberculosis
        • Screen with tuberculin skin test or interferon-gamma release assay (IGRA) only if:
          • Suspicion for recent TB infection
          • Immunocompromised
      • Others
        • Toxoplasmosis, trichomonas, herpes simplex, cytomegalovirus, Zika, and Chagas are available for at risk patients or in endemic regions
    • Lead
      • Women with symptoms of lead exposure or risk factors

15-24 Weeks

  • These are not universal and are options available to mothers
  • Quadruple Test
    • Maternal serum alpha-fetoprotein level
    • Unconjugated estriol
    • Human chorionic gonadotropin
    • Inhibin A
  • Fetal ultrasound
    • Can be used to screen for neural tube defects and other fetal anomalies, as well as screen the mother for a short cervical length (< 25mm) that can increased her risk of spontaneous preterm birth

24-28 Weeks

  • Gestational Diabetes Screening
    • Two-Step Approach
      • Step One – Screening
        • 50g, one-hour glucose challenge test REGARDLESS of time of day or last meal
      • Step Two – Diagnostic
        • 100g, three-hour oral glucose tolerance test
          • Traditionally diagnostic after 2 elevated values, but newer data suggests that one may be OK
        • 75g, two-hour oral glucose tolerance test
          • Diagnostic after a single elevated value, but patient must be fasting
Up-To-Date
Up-To-Date
  • Complete Blood Count with iron and folate studies
    • 2nd anemia screening

28-36 Weeks

  • Sexually Transmitted Infection Screening
    • HIV, syphilis, chlamydia, gonorrhea, hepatitis B and C
    • Based on either previous (+) result or evidence of risk factors
Up-To-Date
  • Screen for group B beta-hemolytic streptococcus
    • Vaginal and rectal swabs
    • (+) results treated with intrapartum prophylaxis
CDC – GBS Prophylactic Antibiotic Algorithm
  • Screen for Fetal Growth Restrictions (<10th percentile weight for gestational age)
    • Indicated in third trimester in pregnancies at high risk
      • Infections, fetal anomalies, preeclampsia, gestational HTN and DM, alcohol use, placental/cord abnormalities

References

  1. ACOG Practice Bulletin No. 77: screening for fetal chromosomal abnormalities. Obstetrics and gynecology. 2007; 109(1):217-27. [pubmed]
  2. ACOG Practice Bulletin No. 88, December 2007. Invasive prenatal testing for aneuploidy. Obstetrics and gynecology. 2007; 110(6):1459-67. [pubmed]
  3. ACOG Committee Opinion No. 752: Prenatal and Perinatal Human Immunodeficiency Virus Testing. Obstetrics and gynecology. 2018; 132(3):e138-e142. [pubmed]
  4. Roberts SW, Sheffield JS, McIntire DD, Alexander JM. Urine screening for Chlamydia trachomatis during pregnancy. Obstetrics and gynecology. 2011; 117(4):883-5. [pubmed]
  5. Hughes BL, Page CM, Kuller JA. Hepatitis C in pregnancy: screening, treatment, and management. American journal of obstetrics and gynecology. 2017; 217(5):B2-B12. [pubmed]
  6. ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus. Obstetrics and gynecology. 2018; 131(2):e49-e64. [pubmed]
  7. Centers for Disease Control.  Group B Strep (GBS).  https://www.cdc.gov/groupbstrep/guidelines/new-differences.html
  8. Bricker L, Medley N, Pratt JJ. Routine ultrasound in late pregnancy (after 24 weeks’ gestation). The Cochrane database of systematic reviews. 2015; [pubmed]

PAINE #PANCE Pearl – GYN

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Question

Polycystic ovarian syndrome (PCOS) can often be a clinical diagnosis due to the classic distinguishing features of hirsutism, obesity, menstrual irregularities, and infertility. What is the classic relationship between FSH and LH in a patient with PCOS?

Ep-PAINE-nym

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Pfannensteil Incision

Other Known Aliases – Kerr incision

Definition – 8-10cm transverse (slightly arched) incision made 2-3cm cephalad to the pubic symphasis. The rectus sheath is then retracted cephalad and the rectus abdominis muscle bellies are divided longitudinally to enter the peritoneum

Clinical Significance – This is the primary incision for cesarean sections because it follows the Langer Lines and can achieve excellent cosmetic results. There are also decreased rates of postoperative pain, fascial dehiscence, and incisional hernias noted.

History – Named after Hans Hermann Johannes Pfannensteil (1862-1909), who was a German gynecologist and received his medical doctorate from the University of Berlin in 1885. He was an extraordinary surgeon and teacher and published extensively on many gynecological conditions. In 1900, he published an article describing the the advantages of his eponymous transverse fascial incision for gynecologic laparotomies. Dr. Pfannensteil unfortunately died from septicemia at the age of 47 after injuring his finger draining a tubo-ovarian abscess.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Pfannenstiel HJ. (On the advantages of the symphyseal transverse fascial incision for gynecological caliotomies as well as the contribution to the surgical indications). Samml Klin Vortr. 1900;268:1735-56

PAINE #PANCE Pearl – OB

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You have just assisted with a relatively uneventful spontaneous vaginal delivery of a 38-week newborn to a 29-year-old G1P0001 mother. During your immediate, postpartum maternal assessment, you notice a large amount of vaginal bleeding persisting.

Questions

  1. What is the most common cause of this condition?
  2. What are the two most important steps in managing this?
  3. What are some of the other etiologies to think about?

Answers

  • The most common cause of post-partum hemorrhage is uterine atony and is responsible for up to 75% cases. The amount of bleeding can also be much greater than what is visible due to the flaccid and dilated uterus.
  • The two most important steps in managing uterine atony are:
    • Performing bi-manual uterine massage to stimulate contraction
    • Administration of uterotonics
      • ALL women get oxytocin either:
        • 15 units in 250mL of LR
        • 10 units IM
      • If still bleeding after oxytocin:
        • Carboprost tromethamine (Hemabate) 0.25mg IM every 15min up to a max dose of 8mg
        • Methergine 0.2mg IM every 2-4 hours
        • Misprostol 400mcg (SL/buccal/rectal)
  • Uterine atony is the most common cause of post-partum hemorrhage, but is responsive to uterotonics in most instances, so it is not the most common cause of massive transfusion. Other etiologies to think about are:
    • Retained placenta/membranes
    • Lacerations or rupture
    • HELLP syndrome
    • Abnormal placentation

References

  1. Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesthesia and analgesia. 2010; 110(5):1368-73. [pubmed]

Ep-PAINE-nym

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Leopold’s Maneuvers

Other known aliases – Leopold-Handgrïff

Definition – Series of four distinct actions to systematically determine the lie and position of the fetus in utero:

  • First Maneuver – Fundal Grip
    • used to locate fetal position (breech vs vertex)
  • Second Maneuver – Umbilical Grip
    • used to locate the back of the fetus
  • Third Maneuver – Second Pelvic Grip
    • used to determine pelvic inlet position
  • Fourth Maneuver – First Pelvic Grip
    • used to locate the fetal brow

Clinical Significance – These are now an antiquated way to determine fetal positioning to predict difficult deliveries or need for cesarean section. These have largely been replaced by obstetrical ultrasound.

History – Named after Christian Gerhard Leopold (1846-1911), who was a German gynecologist and received his medical doctorate from the University of Leipzig in 1870. He spent the early part of his career teaching midwifery at the Frauenklinik in Leipiz before taking a professorship at the University of Leipzig in 1883. Later that same year, he took over as the Director of the Dresden Royal Gynaecological Infirmary and by the end of his tenure developed it into a leading hospital in Germany. He published his eponymous maneuvers in several articles (first in 1894) in the journal Archiv für Gynäkologie, for which he was a co-editor.

References

  • Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  • Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  • Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  • Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  • Up To Date. www.uptodate.com
  • Leopold CG – Die Leitung der regelmäßigen Geburt nur durch äußere Untersuchung. Arch Gynäkol. 1894; 45: 337–368
  • Kästner I, Kachlík D. German gynecologist and obstetrician Christian Gerhard Leopold (1846-1911). Ceska gynekologie. 2010; 75(3):218-21. [pubmed]

PAINE #PANCE Pearl – OB

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You have just assisted with a relatively uneventful spontaneous vaginal delivery of a 38-week newborn to a 29-year-old G1P0001 mother. During your immediate, postpartum maternal assessment, you notice a large amount of vaginal bleeding persisting.

Questions

  1. What is the most common cause of this condition?
  2. What are the two most important steps in managing this?
  3. What are some of the other etiologies to think about?