5/13/2013. Wendy L. Jackson M.D. University of Kentucky Department of Obstetrics and Gynecology 5/16/13

Transcription

1 Wendy L. Jackson M.D. University of Kentucky Department of Obstetrics and Gynecology 5/16/13 1

2 Identify common pediatric and adolescent gynecologic medical issues pertinent to the Pediatrician Extrapolate on these medical conditions Discuss the initial management of the conditions All leave empowered and ready to demonstrate our knowledge of PAG 101!!! North American Society of Pediatric and Adolescent Gynecology (NASPAG) Journal of Pediatric and Adolescent Gynecology (JPAG) ME!!!! (859) or UKMD s (859)

3 Adolescent Questionnaire Published by ACOG Fill out at every visit separated from guardian 3

4 Systematic approach Tanner stage, labia, clitoris, i urethra, hymen, anus Reference abnormalities in relationship to a clock face clock face 4

5 Rapport-without it the gyn exam is nearly impossible Approach: stirrups, frog leg, or knee chest Frog leg exam 5

6 Stirrups or Dorsolithotomy position Dorsolithotomy and Frog leg view 6

7 Knee Chest Knee chest view 7

8 Thoroughly evaluate the hymen Document estrogenized or not Defects, bumps, lesions Patent, imperforate, microperforate, cribiform, annular, crescentic, cyst, tags, fimbriated, redundant, septum, transections, bruising 8

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10 Imperforate 10

11 Don t forget to look for signs of abuse Usually incidental finding in asymptomatic pt 13-23mo Puberty=resolution secondary to estrogen No treatment unless infection, persistence into puberty Estrogen cream bid x6wks Monitor for breast buds Once separated need to continue estrogen v. emollient temporarily 11

12 Can be on various areas of the body with 10-15% have onset in childhood 15% have onset in childhood Tissue paper thin skin Subepithelial hemorrhages Pruritis Loss of architecture Figure of eight distribution May have painful urination and constipation Treatment: Temovate, Cutivate, and Aclovate ointment t bid -2wks with each potency then f/u 12

13 The single most common complaints of the prepubescent child prepubescent child Presentation-Irritation, redness, pruritis, discharge Don t treat like yeast unless it is yeast (this is very uncommon in this age group Because the vulva of these patients is thin, hairless, and sensitive they are prone to this inflammatory process In addition, neutral ph and poor hygiene Etiology: Infection-GAS, shigella, pinworms, yeast (rare), STDs (condyloma, gc/chl, trich) Tumors-rhabdomyosarcoma, polyps Foreign body-toilet paper=#1, crayons, charms, Barbie doll shoes, etc. 13

14 Collect a history: Acute prob infectious; chronic prob nonspecific Color: bloody=shigella or GAS, foreign body, condyloma; green=staph, strep, Haemophilus, gonorrhea, foreign body Odor:? foreign body If d/c seen culture it Calgi swab avoiding the hymen Send for aerobic cx, gonorrhea and chlamydia (specific laboratory method) KOH/wet prep 14

15 If no d/c then hygeine measures and magic barrier cream barrier cream If no improvement at f/u then irrigate vagina with pediatric feeding tube Cx performed on initial fluid If appreciate foreign body then get it out via flushing or rectal or I can take her to the OR. Treat based on cx results Mgmt: Hygeine measures wiping, cotton panties, positioning on toilet, hand washing, no soaps to vulva, loose clothing Sitz baths Magic Barrier Cream Not better in 48hrs empirically treat for pinworms and abx (10d) If persists month course abx, topical abx ointment, qhs premarin, EUA 15

16 DDX: Trauma-thorough h examination and r/o sexual abuse; depending on extent of injury pt may need EUA 2.Malignancy-i.e., rhabdomyosarcoma 16

17 3. Foreign body 4. Condyloma 17

18 5. Urethral prolapse 6.lichen sclerosus 7.precocious puberty 8.infection 9.exogenous estrogen 10.hemangioma, 11.hypothyroidism y 18

19 DO NOT perform unless the patient is : 1. 21yo 2. immunocompromised 19

20 May be simple or complex Incidental or Symptomatic (pain, bleeding, n/v, torsion, urinary sx, constipation, pelvic pain) DDX: GI pathology, reproductive anomaly, paratubal cyst, ovarian tumor, ectopic, abscess, cancer Mgmt: u/s pelvis in 3mo if simple and <6cm; >6cm or symptomatic then laparoscopic cystectomy; concern for malignancy then tumor markers and plan for removal Oral contraceptive pills may aid in prevention of other cysts, but will not resolve the existing one When ordering the u/s unless sexually active it should be ordered transabdominal u/s of pelvis 20

21 Human Papillomvirus sexually transmitted virus responsible for cervical cancer, some vaginal and vulvar cancers, genital warts, anal cancers, and some oropharyngeal cancers Gardasil approved in 2006 by FDA Ceravix approved in 2009 HPV types 16 and 18 are responsible for 70%of cervical cancer (third leading female cancer in the world) and 70% of anal cancers 21

22 HPV types 6 and 11 are responsible for 90% of genital warts genital warts The available vaccines are for females and males The are most efficacious in those HPV naïve patients hence the reason behind earlier vaccination (11-12yo but as early as 9yo and catch up 13-26) If for some reason the teen has prematurely had a pap smear and is found to HPV+ she should still have the vaccine b/c she is still at risk for other subtypes Side effects: pain at injection site, bruising, syncope, VAERS has documented VTE-the majority of the patients also had other risk factors for VTE; anaphylaxis has also been noted though rare Not to be administered during pregnancy despite it not containing live virus Efficacy data is not available for immunocompromised hosts however, the recommendations say to administer 22

23 If a patient starts the series and the administration is interrupted pick pick up where you left off Gardasil Quadrivalent Zero, two, and six mo Prevention of CIN2 in HPV naive=97-100% Prevention in HPV exposed=44% 2010 approval lby FDA for prevention of AIN and anal cancer in females Ceravix Bivalent Zero, one, and six mo Prevention of CIN2 in HPV naive=93% Prevention in HPV exposed=53% 23

24 Periods lasting greater than 7d More than 6 toiletries t i per day Missing school secondary to soiling clothing Epistaxis, gingival bleeding, or post op bleeding If she is experiencing these things and is being evaluated for pubertal menorrhagia she needs more than just ocp s 24

25 PBAC score greater than 100 warrants futher evaluation 25

26 U/S of pelvis-r/o granulosa cell tumor Labs: type and screen, tsh, coags, cbc, factor VIII level, von Willebrand factor antigen and level, PFA If bleeding heavy and no contraindications to ocp s then start a taper Start iron if anemic If no success with ocp s then consider mirena iud 26

27 Pain with menses what to do??? Primary-no with menarche occurs later-no pathology Secondary-associated with pelvic pathology (reproductive tract anomalies, endometriosis, adhesive disease) This cramping is initiated when the body releases prostaglandins that result in uterine contractions; 27

28 Peform H&P Initiate treatment with NSAIDs if no contraindications 24-48hrs prior to menses Provide heat in the way of heating pad or Thermacare Consider Mefenamic acid Hormonal mgmt is another option if conservative mgmt is failing Last resort-gyn will consider dx lap Oral contraceptive pills: Contraindications pertaining to adolescent- migraine with aura, stroke, VTE, MI, liver disease, thrombophilia Start cycle d#1 or Sunday after the bleeding starts Taken same time everyday; miss one pill take as soon as remember then take the one for that day; do that more than twice then have a period and start new pkg RTC in 3mo to ensure working well; If contraindication to combined pill then start micronor but remember no placebo pills and less efficacious 28

29 Contraceptive patch: Change patch th weekly for 3 wks then one patch th free wk Max wt=198lbs Vaginal ring: Place in vaginal for 3wks then remove for one ring free week Effective 7d after insertion 29

30 Depo Provera: Progestin only One injection every 3mo Monitor for wt gain, irregular bleeding, mood changes Counsel on effects of depo on bone; need ca2+ supplement IUD s Skyla-progestin only; good for 3yrs; smaller than mirena Mirena-progestin only; good for 5yrs; Paragard-hormone free; copper based; good for 10yrs 30

31 Implanon rod in arm 3yrs Monitor for irregular bleeding-#1 discontinuation reason Progestin only Barrier/Condom All adolescents should be using them because other methods on contraception are not preventing std s If latex allergic the polyurethane condoms Condom education for each pt. 31

32 Clinical Protocols in Pediatric and Adolescent Gynecology. Perlman, Nakajima, and Hertweck Pediatric and Adolescent Gynecology 5 th Ed. Emans et al Clinical Gynecologic Endocrinology And Infertility 7 th Ed. Speroff, et al Uptodate.com;