Gynecology and Obstetrics: Merck Manual Professional

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Gynecology and Obstetrics

Approach to the Gynecologic Patient Symptoms of Gynecologic Disorders

Pelvic Mass
	Etiology
	Evaluation
		History
		Examination
		Testing
Pelvic Pain
	Etiology
		Gynecologic disorders
		Nongynecologic disorders
	Evaluation
		History
		Physical examination
		Red flags
		Interpretation of findings
		Testing
	Treatment
	Geriatrics Essentials
	Key Points
Vaginal Bleeding
	Pathophysiology
	Etiology
	Evaluation
		History
		Physical examination
		Red flags
		Interpretation of findings
		Testing
	Treatment
	Geriatrics Essentials
	Key Points
Vaginal Itching and Discharge
	Pathophysiology
	Etiology
		Children
		Women of reproductive age
		Women of all ages
	Evaluation
		History
		Physical examination
		Red flags
		Interpretation of findings
		Testing
	Treatment
	Geriatrics Essentials
	Key Points

Female Reproductive Endocrinology

Female Reproductive Endocrinology
	Puberty
	Ovarian Follicular Development
	Menstrual Cycle
		Follicular phase
		Ovulatory phase
		Luteal phase
	Cyclic Changes in Other Reproductive Organs
		Endometrium
		Cervix
		Vagina

Menstrual Abnormalities

Introduction
Amenorrhea
	Pathophysiology
	Etiology
		Anovulatory amenorrhea
		Ovulatory amenorrhea
	Evaluation
		History
		Physical examination
		Red flags
		Interpretation of findings
		Testing
	Treatment
	Key Points
Dysfunctional Uterine Bleeding (DUB)
	Pathophysiology
		Complications
	Etiology
	Symptoms and Signs
	Diagnosis
		Laboratory testing
		Additional testing
	Treatment
		Bleeding
		Endometrial hyperplasia
	Key Points
Dysmenorrhea
	Etiology
		Primary dysmenorrhea
		Secondary dysmenorrhea
	Evaluation
		History
		Physical examination
		Red flags
		Interpretation of findings
		Testing
	Treatment
	Key Points
Pelvic Congestion Syndrome
	Symptoms and Signs
	Diagnosis
	Treatment
Polycystic Ovary Syndrome (PCOS)
	Symptoms and Signs
	Diagnosis
	Treatment
	Key Points
Premature Ovarian Insufficiency or Failure
	Etiology
	Symptoms and Signs
	Diagnosis
		Classification
	Treatment
	Key Points
Premenstrual Syndrome (PMS)
	Etiology
	Symptoms and Signs
		Premenstrual dysphoric disorder (PMDD)
	Diagnosis
	Treatment
	Key Points

Menopause

Menopause
	Symptoms and Signs
		Vasomotor
		Neuropsychiatric
		Genital
		Other
	Diagnosis
	Treatment
		Hormone therapy

Vaginitis, Cervicitis, and Pelvic Inflammatory Disease (PID)

Introduction
Overview of Vaginitis
	Etiology
		Children
		Women of reproductive age
		Postmenopausal women
		Women of all ages
	Symptoms and Signs
	Diagnosis
	Treatment
	Key Points
Bacterial Vaginosis
	Symptoms and Signs
	Diagnosis
	Treatment
Candidal Vaginitis
	Symptoms and Signs
	Diagnosis
	Treatment
Inflammatory Vaginitis
	Symptoms and Signs
	Diagnosis
	Treatment
Cervicitis
	Symptoms and Signs
	Diagnosis
	Treatment
	Key Points
Pelvic Inflammatory Disease (PID)
	Etiology
		Risk factors
	Symptoms and Signs
		Cervicitis
		Acute salpingitis
		Complications
	Diagnosis
	Treatment
	Key Points

Endometriosis

Endometriosis
	Etiology and Pathophysiology
	Symptoms and Signs
	Diagnosis
	Treatment
		Drug therapy
		Surgery
	Key Points

Uterine Fibroids

Uterine Fibroids
	Symptoms and Signs
	Diagnosis
	Treatment
		Drugs
		Surgery
		Choice of treatment

Benign Gynecologic Lesions Pelvic Relaxation Syndromes

	Overview of Pelvic Relaxation Syndromes
	Cystoceles, Urethroceles, Enteroceles, and Rectoceles
			Symptoms and Signs
			Diagnosis
			Treatment
	Uterine and Vaginal Prolapse
			Symptoms and Signs
			Diagnosis
			Treatment

Sexual Dysfunction in Women

Overview of Female Sexual Function and Dysfunction
		Physiology
			Arousal
			Genital congestion
			Orgasm
		Classification
		Etiology
			Primarily psychologic factors
			Primarily physical factors
		Diagnosis
		Treatment
Sexual Desire/Interest Disorder
		Treatment
			Systemic estrogen therapy
			Testosterone therapy
Sexual Arousal Disorders
		Etiology
		Diagnosis
		Treatment
			Subjective arousal disorder
			Genital arousal disorder
Orgasmic Disorder
		Treatment
Vaginismus
		Diagnosis
		Treatment
Dyspareunia
		Etiology
		Diagnosis
		Treatment
	Provoked Vestibulodynia (Vulvar Vestibulitis)
		Symptoms and Signs
		Diagnosis
		Treatment
Persistent Genital Arousal Disorder
		Treatment

Medical Examination of the Rape Victim

Medical Examination of the Rape Victim
	Symptoms and Signs
	Evaluation
		History and examination
		Testing and evidence collection
	Treatment
		Psychologic support
		Prevention of infections
		Prevention of pregnancy

Breast Disorders

Evaluation of Breast Disorders
	Evaluation
		History
		Breast examination
		Testing
Breast Lumps
	Etiology
	Evaluation
		History
		Physical examination
		Red flags
		Interpretation of findings
		Testing
	Treatment
	Key Points
Nipple Discharge
	Pathophysiology
	Etiology
	Evaluation
		History
		Physical examination
		Red flags
		Interpretation of findings
		Testing
	Treatment
	Key Points
Mastalgia (Breast Pain)
	Etiology
	Evaluation
		History
		Physical examination
		Red flags
		Interpretation of findings
		Testing
	Treatment
	Key Points
Breast Cancer
	Risk Factors
	Pathology
	Pathophysiology
	Symptoms and Signs
	Diagnosis
		Evaluation after cancer diagnosis
		Screening
	Prognosis
	Treatment
		Surgery
		Adjuvant systemic therapy
		Metastatic disease
	Prevention
Phyllodes Tumor

Gynecologic Tumors

Introduction
Ovarian Cancer
	Etiology
	Pathology
	Symptoms and Signs
	Diagnosis
		Imaging
		Tumor markers
		Biopsy
		Staging
		Screening
	Prognosis
	Treatment
	Prevention
Fallopian Tube Cancer
	Symptoms and Signs
	Diagnosis
	Treatment
Endometrial Cancer
	Etiology
	Pathology
	Symptoms and Signs
	Diagnosis
		Staging
	Prognosis
	Treatment
Uterine Sarcomas
	Symptoms and Signs
	Diagnosis
	Prognosis
	Treatment
Gestational Trophoblastic Disease
	Pathology
	Symptoms and Signs
	Diagnosis
	Treatment
Cervical Cancer
	Pathology
	Symptoms and Signs
	Diagnosis
		Staging
	Prognosis
	Treatment
		CIN and squamous cell carcinoma stage IA1
		Stages IA2 to IIA
		Stages IIB to IVA
		Stage IVB and recurrent cancer
	Prevention
		Pap tests
		HPV vaccine
Vaginal Cancer
	Symptoms and Signs
	Diagnosis
	Treatment
Vulvar Cancer
	Pathology
	Symptoms and Signs
	Diagnosis
		Staging
	Prognosis
	Treatment

Family Planning

Introduction
Contraception
	Oral Contraceptives
			Adverse effects
			Benefits
			Drug interactions
			Administration
	Barrier Contraceptives
			Condoms
			Diaphragm
			Cervical cap
			Vaginal spermicides
			Contraceptive sponge
	Periodic Abstinence
	Progestin Injections
	Transdermal and Intravaginal Steroid Contraceptives
	Subdermal Implants
	Intrauterine Devices
			Adverse effects
	Emergency Contraception
Sterilization
			Vasectomy
			Tubal ligation
Induced Abortion
			Instrumental evacuation
			Medical induction
		Complications

Infertility Prenatal Genetic Counseling and Evaluation Conception and Prenatal Development

	Conception and Prenatal Development
				Amniotic sac and placenta
				Embryo

Approach to the Pregnant Woman and Prenatal Care

Evaluation of the Obstetric Patient
	History
		Gravidity and parity
	Physical Examination
	Testing
		Laboratory testing
		Ultrasonography
		Other imaging
	Treatment
		Diet and supplements
		Physical activity
		Travel
		Immunizations
		Modifiable risk factors
		Symptoms requiring evaluation

Symptoms During Pregnancy

Pelvic Pain During Early Pregnancy
	Etiology
	Evaluation
		History
		Physical examination
		Red flags
		Interpretation of findings
		Testing
	Treatment
	Key Points
Vaginal Bleeding During Early Pregnancy
	Etiology
	Evaluation
		History
		Physical examination
		Red flags
		Interpretation of findings
		Testing
	Treatment
	Key Points
Nausea and Vomiting During Early Pregnancy
	Pathophysiology
	Etiology
	Evaluation
		History
		Physical examination
		Red flags
		Interpretation of findings
		Testing
	Treatment
	Key Points
Lower-Extremity Edema During Late Pregnancy
	Etiology
	Evaluation
		History
		Physical examination
		Red flags
		Interpretation of findings
		Testing
	Treatment
	Key Points
Vaginal Bleeding During Late Pregnancy
	Pathophysiology
	Etiology
	Evaluation
		History
		Physical examination
		Red flags
		Interpretation of findings
		Testing
	Treatment
	Key Points

Normal Pregnancy, Labor, and Delivery

Overview of Pregnancy
		Symptoms and Signs
		Diagnosis
Physiology of Pregnancy
			Cardiovascular
			Hematologic
			Urinary
			Respiratory
			GI and hepatobiliary
			Endocrine
			Dermatologic
Management of Normal Labor
			Beginning of labor
			Stages of labor
			Rupture of membranes
			Birthing options
			Admission
			Preparation for delivery
			Analgesia
	Fetal Monitoring
Management of Normal Delivery
		Anesthesia
			Regional anesthesia
			Local anesthesia
			General anesthesia
		Delivery Procedures
			Placenta
			Postdelivery

Drugs in Pregnancy

	Drugs in Pregnancy
			Vaccines
			Vitamin A
			Antidepressants
			Social and Illicit Drugs

Pregnancy Complicated by Disease

Anemia in Pregnancy
		Symptoms and Signs
		Diagnosis
		Treatment
	Iron Deficiency Anemia in Pregnancy
		Diagnosis
		Treatment
		Prevention
	Folate Deficiency Anemia in Pregnancy
		Diagnosis
		Treatment
		Prevention
	Hemoglobinopathies in Pregnancy
Asthma in Pregnancy
		Treatment
Autoimmune Disorders in Pregnancy
			Systemic lupus erythematosus
			Rheumatoid arthritis
			Myasthenia gravis
			Immune thrombocytopenic purpura (ITP)
Cancer in Pregnancy
			Rectal cancer
			Cervical cancer
			Other gynecologic cancers
			Leukemia and Hodgkin lymphoma
			Breast cancer
Diabetes Mellitus in Pregnancy (Gestational Diabetes)
		Treatment
			During pregnancy
			Management of complications
			Labor and delivery
			Postpartum
Fever in Pregnancy
Fibroids in Pregnancy
Heart Disorders in Pregnancy
		Pathophysiology
		Symptoms and Signs
		Diagnosis
		Treatment
			Arrhythmias
			Endocarditis prophylaxis
	Valvular Stenosis and Insufficiency
		Treatment
			Mitral stenosis
			Aortic stenosis
	Other Heart Disorders in Pregnancy
			Mitral valve prolapse
			Congenital heart disease
			Peripartum cardiomyopathy
Hepatic Disorders in Pregnancy
			Acute viral hepatitis
			Chronic active hepatitis
			Cholestasis (pruritus) of pregnancy
			Preeclampsia
			Chronic hepatic disorders
Hypertension in Pregnancy
		Diagnosis
		Treatment
			Drugs
Infectious Disease in Pregnancy
			Antibacterials
Renal Insufficiency in Pregnancy
Seizure Disorders in Pregnancy
Disorders Requiring Surgery During Pregnancy
			Appendicitis
			Benign ovarian cysts
			Gallbladder disease
			Intestinal obstruction
Thromboembolic Disorders in Pregnancy
		Diagnosis
		Treatment
Thyroid Disorders in Pregnancy
			Graves' disease
			Congenital Graves' disease
			Maternal hypothyroidism
			Hashimoto's thyroiditis
			Acute (subacute) thyroiditis
			Postpartum maternal thyroid dysfunction
Urinary Tract Infection in Pregnancy
		Diagnosis
		Treatment

High-Risk Pregnancy

	Overview of High-Risk Pregnancy
	Risk Factors for Complications During Pregnancy
				Hypertension
				Diabetes
				Sexually transmitted diseases (STDs)
				Pyelonephritis
				Acute surgical problems
				Genital tract abnormalities
				Maternal age
				Maternal weight
				Maternal height
				Exposure to teratogens
				Prior stillbirth
				Prior preterm delivery
				Prior neonate with a genetic or congenital disorder
				Polyhydramnios (hydramnios) and oligohydramnios
				Multifetal (multiple) pregnancy
				Prior birth injury

Abnormalities of Pregnancy

Abruptio Placentae
			Risk factors
			Complications
		Symptoms and Signs
		Diagnosis
		Treatment
Cervical Insufficiency
		Etiology
			Risk factors
			Recurrence
		Symptoms and Signs
		Diagnosis
		Treatment
Intra–Amniotic Infection
			Risk factors
			Complications
		Symptoms and Signs
		Diagnosis
			Subclinical infection
		Treatment
Ectopic Pregnancy
		Etiology
		Pathophysiology
		Symptoms and Signs
		Diagnosis
		Prognosis
		Treatment
			Surgical resection
			Methotrexate
Erythroblastosis Fetalis
		Pathophysiology
		Diagnosis
		Treatment
		Prevention
Pemphigoid Gestationis
		Symptoms and Signs
		Diagnosis
		Treatment
Hyperemesis Gravidarum
		Diagnosis
		Treatment
Placenta Previa
			Risk factors
			Complications
		Symptoms and Signs
		Diagnosis
		Treatment
Preeclampsia and Eclampsia
		Etiology
		Pathophysiology
			Complications
		Symptoms and Signs
		Diagnosis
			Further evaluation
		Treatment
			General approach
			Mild preeclampsia
			Monitoring
			Mg sulfate
			Supportive treatments
			Delivery method
			Follow-up
Pruritic Urticarial Papules and Plaques of Pregnancy
		Symptoms and Signs
		Diagnosis
		Treatment
Spontaneous Abortion
		Etiology
		Symptoms and Signs
		Diagnosis
		Treatment
	Recurrent Pregnancy Loss
		Etiology
		Diagnosis
		Treatment
	Septic Abortion
		Symptoms and Signs
		Diagnosis
		Treatment
Stillbirth
		Etiology
			Complications
		Diagnosis
		Treatment

Abnormalities and Complications of Labor and Delivery

Introduction
Alternatives to Spontaneous Labor and Delivery
	Operative vaginal delivery
	Induction of Labor
			Indications
			Technique
	Cesarean Delivery
			Indications
			Technique
Amniotic Fluid Embolism
Fetal Dystocia
			Fetopelvic disproportion
			Occiput posterior presentation
			Face or brow presentation
			Breech presentation
			Transverse lie
			Shoulder dystocia
Inverted Uterus
		Treatment
Multifetal Pregnancy
Placenta Accreta
		Etiology
		Symptoms and Signs
		Diagnosis
		Treatment
		Key Points
Postpartum Hemorrhage
		Treatment
		Prevention
		Key Points
Postterm Pregnancy
Premature Rupture of Membranes (PROM)
		Symptoms and Signs
		Diagnosis
		Treatment
		Key Points
Preterm Labor
		Diagnosis
		Treatment
		Key Points
Protracted Labor
		Etiology
		Diagnosis
		Treatment
Umbilical Cord Prolapse
Uterine Rupture

Postpartum Care and Associated Disorders

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