A 29-year-old female presents with increasingly severe menstrual cramps. Naproxen has provided only minimal relief. She has been unable to take oral contraceptives because of regular migraines.
Of the following alternative approaches that have been studied, the one with the best evidence of effectiveness for this problem is:
Correct Answer B:
NSAIDs are the initial therapy of choice for primary dysmenorrheal (strength of recommendation A). Treatments supported by limited-quality, patient-oriented evidence (strength of recommendation B) includes oral contraceptives, depot medroxyprogesterone, acupuncture, fish oil supplements, low-fat vegetarian diets, thiamine, toki-shakyaku-san (a Japanese herbal product), transcutaneous electrical nerve stimulation (TENS), and vitamin E.
Measures of uncertain effectiveness (strength of recommendation B) include behavioral interventions such as exercise, surgical interruption of pelvic nerves, and the use of glyceryl trinitrate, nifedipine, and terbutaline. Spinal manipulation has been shown to be ineffective (strength of recommendation B).
A 13-year-old patient has had regular menses for 1 year, with debilitating pain beginning in the lower abdomen a few hours before menses and lasting 24 hours. Physical examination is completely normal.
Optimal management at this time is:
Correct Answer D:
Dysmenorrhea is defined as a severe painful cramping sensation in the lower abdomen, often accompanied by other biologic symptoms, including sweating, tachycardia, headaches, nausea, vomiting, and diarrhea. All of these occur during or just before menses. The term primary dysmenorrheal is reserved for women with no obvious pathologic condition, and this is due to the effects of endogenous prostaglandins.
→ Dysmenorrhea in a 13-year-old is usually due to the effects of endogenous prostaglandins.
→ Usually, no visible peritoneal pathology can be found in primary dysmenorrheal.
→ Although OCPs have been used for this condition, they are not as effective as prostaglandin synthetase inhibitors.
→ This pain is debilitating to the patient. Reassurance with follow-up evaluation most likely will not decrease her pain and discomfort.
A 16-year-old female presents with a complaint of pelvic cramps with her menses over the past 2 years. She describes her periods as heavy, and says they occur once a month and last for 7 days, with no spotting in between. She has never been sexually active and does not expect this to change in the foreseeable future. An abdominal examination is normal.
Which one of the following would be the most appropriate next step?
This patient is experiencing primary dysmenorrhea, a common finding in adolescents, with estimates of prevalence ranging from 20% to 90%. Because symptoms started at a rather young age and she has pain only during menses, endometriosis or other significant pelvic pathology is unlikely. An infection is doubtful, considering that she is not sexually active and that symptoms have been present for 2 years. In the absence of red flags, a pelvic examination, laboratory evaluation, and pelvic ultrasonography are not necessary at this time. However, they can be ordered if she does not respond to simple treatment.
NSAIDs such as naproxen have a slight effect on platelet function, but because they inhibit prostaglandin synthesis they actually decrease the volume of menstrual flow and lessen the discomfort of pelvic cramping. Acetaminophen would have no effect on prostaglandins.
Which one of the following indicates that a patient has entered the second stage of labor?
For many women, labor will be preceded by several hours, or even days, by “bloody show”. So-called “false labor”, or Braxton Hicks contractions, consists of weak, irregular, regional contractions that usually occur for weeks before the onset of actual labor and abate with time, analgesia and sedation. Spontaneous chorioamnionic membrane rupture precedes the onset of labor in about 10% of pregnancies, and amniotic fluid leaks through the cervix and out the vagina.
The second stage of labor is defined as the period from complete cervix dilation to complete delivery of the baby. When the cervix is completely dilated, the patient usually experiences the urge to push with contractions. The third stage of labor begins with the delivery of the baby and ends with the delivery of the placenta.
Which one of the following is characteristic of the first stage of labor?
The first stage of labor begins with the onset of regular contractions and ends with complete cervical dilation. The change in the shape of the uterus from discoid to globular, along with a rise in fundal height, an apparent lengthening of the umbilical cord, and a gush of vaginal bleeding are signs of spontaneous separation that occurs in the third stage of labor. It is not uncommon for the first stage of labor to last around 18-20 hours in nulliparas and 14-16 hours in multiparas.
The second stage of labor (the period between the complete dilation of the cervix to the delivery of the baby) usually lasts about 50 minutes in nulliparas and 20 minutes in multiparas. This stage of labor can be prolonged somewhat by the use of regional anesthesia. An episiotomy is an incision of the perineum used to facilitate vaginal delivery; it is useful for patients in whom the perineum does not readily stretch and/or when delivery must be expedited. It is part of the management of the second stage of labor. After the cervix becomes completely dilated (by definition, the second stage of labor), patients usually experience an urge to push with contractions. Regional anesthesia may partially or completely blunt this urge.
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