HIV in the Non-Pregnant Patient

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We jump back to our STI saga to cover HIV today. ACOG PB 167 and CO 596 make for supplementary reading for this show.

The CDC and USPSTF recommend at least one-time HIV screening in most women. The CDC goes further to recommend up to annual screening in certain high-risk groups, including IV drug users, > 1 sex partner annually or known sex partner with HIV, those who exchange sex for money or goods, and MSM.

Screening is important, because almost 25% of new cases occur in women, and heterosexual intimate contact is the most common form of disease spreading. ACOG subscribes to a philosophy of “opt out” testing, by which HIV screening should be considered routine, with the patient able to opt out. Physicians need to document the reason for this in their notes. Screening tests are broken into rapid and confirmatory. A positive rapid screen should always be followed with a confirmatory test, as the rapid screens have high sensitivity, but lower specificity.

GYN care may vary somewhat with positive HIV status. For Pap smears, PB 167 describes an appropriate algorithm for dealing with initial screening and some positive results:

ACOG PB 167

ACOG PB 167

We spend some time reviewing the treatment of other STIs in the podcast briefly, all of which are reviewed in PB 167 as well. Highlights include:

  • Using 1 week rather than single-dose metronidazole treatment for trichomonal infections

  • Re-testing any positive GC/CT testing result at 3 months, due to high risk of re-infection

  • Screening for most STIs at entry to care for HIV-affected patients.

Birth control is also another important topic for HIV-affected patients. ACOG and the CDC recommend use of dual-contraception — that is, a barrier method and a hormonal method — to prevent viral spread. Certain forms of hormonal contraception may be affected by antiretroviral drugs:

  • CHCs: The NNRTI non nucleoside reverse transcriptase inhibitor efavirenz and certain protease inhibitors (-navir) may decrease efficacy of combined methods by reducing contraceptive hormone levels; however, they are considered US MEC Category 2.

    • The exception to this rule is fosamprenavir, as CHCs also lead to decreased levels of this protease inhibitor (US MEC 3).

  • Etonogestrel implant:  Similarly to CHCs, there are theoretical risks in decreased contraceptive effectiveness for patients on efavirenz; however, the implant remains US MEC 2.

  • DMPA: MEC category 1 for all users, except for those on fosamprenavir; there is limited evidence DMPA decreases fosamprenavir levels like CHCs (US MEC 2).

  • IUDs: MEC category 1 for all users!

  • Emergency contraception: for oral medicatons such as levenorgestrel and ulipristal, these should be offered to HIV-affected women as the benefits of emergency contraception are considered to outweigh the risks in this group. Similarly to CHCs, there is theoretical risk of decreased efficacy of these methods among women taking efavirenz.

Finally, in a preview to our next episode, we talk about preconception counseling for HIV-affected patients. The goal for any patient with HIV is to achieve a negative viral load, and for OB-GYNs, this is important to limit vertical transmission. Efavirenz has been associated with neural tube defects, so should be avoided in pregnancy if possible.

Conceiving is safest through artificial insemination. However, if natural conception is desired. OB-GYNs should discuss limiting unprotected intercourse to ovulatory times, and using pre-exposure prophylaxis for the patient, or her partner, in serodiscordant couples. This generally involves a daily regimen of tenofovir/emtricitabine (Truvada) for 1 month prior to, and 1 month after, conception. Risk reduction is estimated to be somewhere between 63-75%, and the best-available data suggests this is likely safe.

Uterovaginal Prolapse

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Today we sit down with Dr. Julia Shinnick, one of our co-residents at Brown University and future FPMRS specialist, to talk through prolapse!

The POP-Q tool from AUGS is a helpful web-based tool (also with iPhone/iPad apps!) that can help you understand prolapse, as well as illustrate prolapse to patients in your practice.

One common quiz question are the levels of support. These are:

  • Level I consists of the cardinal and uterosacral ligaments, and suspends the vaginal apex. Uterosacral/cardinal ligament complex, which suspends the uterus and upper vagina to the sacrum and lateral pelvic side wall. In a magnetic resonance imaging (MRI) study of asymptomatic women, the uterosacral ligaments were found to originate on the cervix in 33 percent, cervix and vagina in 63 percent, and vagina alone in 4 percent. Loss of level 1 support contributes to the prolapse of the uterus and/or vaginal apex.

  • Level II consists of the paravaginal attachments, are what create the H shape of the vagina. The anterior vaginal wall is suspended laterally to the arcus tendineus fascia pelvis (ATFP) or “white line,” which is a thickened condensation of fascia overlying the iliococcygeus muscle. The anterior Level II supports suspend the mid-portion of the anterior vaginal wall creating the anterior lateral vaginal sulci. Detachment of these lateral supports can lead to paravaginal defects and prolapse of the anterior vaginal wall. There are also more posterior lateral supports at Level II. The distal half of the posterior vaginal wall fuses with the aponeurosis of the levator ani muscle from the perineal body along a line referred to as the arcus tendineus rectovaginalis. It converges with the ATFP at a point approximately midway between the pubic symphysis and the ischial spine. Along the proximal half of the vagina, the anterior and posterior vaginal walls are both supported laterally to the ATFP. 

  • Level III consists of the perineal body and includes interlacing muscle fibers of the bulbospongiosus, transverse perinei, and external anal sphincter.  Loss of level 3 support can result in a distal rectocele or perineal descent.  

Remember — the treatments are generally conservative with pelvic floor PT; devices, such as pessaries; or surgeries.

Emergency Contraception

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Today we spend some time with Dr. Leanne Free, who is one of Fei and Nick’s co-residents. As a rising PGY-4 at Brown, Leanne is interested in family planning fellowship and shares some of that interest with us today by talking emergency contraception!

Leanne breaks down for us the main types of emergency contraceptives — the copper IUD and pills. Much of the information Leanne shares is really nicely prepared in graphical format on the BedSider website:

One crazy thing we learned: many levonorgestrel EC formulations are available on Amazon! Though buyer beware, as there have been some news stories regarding these to be potentially expired medicines. Additionally, as Leanne states, EC is most effective immediately after unprotected intercourse, rather than the 48 hours it takes for Prime delivery. All levonorgestrel EC should be available over-the-counter without restrictions for purchase based on age, gender, or parental consent.

Additionally, patients can follow the Yuzpe method by taking birth control pills that they may already have at home. This can be useful for patients who for some reason do not have access to the emergency contraceptives we refer to in the podcast — though an annual visit is a great time to review and prescribe these options!

Progestins

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Today we welcome Dr. Ben Brown, who is an assistant professor in the Division of Emergency Obstetrics and Gynecology at Women and Infants Hospital and the Warren Alpert Brown School of Medicine. Dr. Brown is also completed a fellowship in Family Planning, and thus shares with us his expertise in progestin-based contraception!

We quickly reviewed initially that progesterone naturally serves as an inhibitory feedback to luteinizing hormone during the menstrual cycle. There were also a number of downstream effects of progesterone, including cervical mucus thickening, stabilizing the endometrial lining, and down-regulating both systemic progesterone and estrogen receptors — you can review all of these again with our episode on the menstrual cycle if you missed it. These mechanisms of action underlie the way progestins work clinically. We do not cover the anti-progestins (mifepristone) and selective progesterone receptor modulators (ulipristal) today.

We then reviewed the generations of progestins. As Dr. Brown states, knowing drosperinone as a 4th generation is probably a good thing, but otherwise some of this is just good to know as a “contraception nerd.” The generations are summarized below in a nice table:

We then spoke about the delivery methods beyond the drugs — pills, injections, IUDs, implants, and more!

Side effects and contraindications are important to know for all forms of contraception. Here are a few that we review:

  • Androgenicity: more apparent in combined-hormonal methods, due to upregulation of SHBG by estrogen. Some progestins (particularly 1st generation) also competitively bind androgenic receptors — even sometimes if given without estrogen, those progestins may actually produce androgenic side effects! That said, this is quite uncommon.

  • Thrombosis: this can be very confusing and controversial:

    • Estrogen-containing methods will raise risk of both venous and arterial clots.

      • Drosperinone and other later-generation progestins has received poor press due to higher risk of thrombosis in combined formulations. The risk is overall still very low: 7-13 events per 10,000 woman years. But compared to pregnancy as a competing outcome, 20-30 events/10k woman years, and postpartum 40-60/10k woman-years!

    • Progestins alone can also raise arterial thrombus risk.

      • These are patients who you consider to have significant endovascular risk factors — longstanding poorly-controlled diabetes, coronary disease, heavy smoking, etc. This is because progestins can shift lipid profiles to a more androgenic appearance - lower HDL, higher LDL and total cholesterol.

    • The CDC’s US MEC guidelines are an excellent tool to cross-reference comorbidities against contraceptive methods.

  • Breast cancer: current or prior is a relative contraindication to hormonal contraception.

  • Severe liver disease: contraindicated due to impaired hepatic processing of steroid hormone.

  • Bariatric malabsorptive procedures: may not be great candidates for progestin-only pills due to need for consistent dosing time.

Cardiotocography/EFM Part II: Management

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Today we are back with our midwifery colleagues Linda Steinhardt and Liz Kettyle, who shepherd us through the management of cardiotocography in labor.

We start this episode by quickly reviewing definitions, and defining categories of tracings, reviewed below:

Copyright UpToDate

Recall that category I tracings virtually exclude fetal acidemia, while category III tracings are associated with acidemia 25% of the time, but also have higher risk of cerebral palsy, neurologic injury, or fetal death. That said, the positive predictive value for bad outcomes of CTG is overall poor.

We review a number of scenarios and resuscitative measures for category II and III tracings. However, much of this episode draws on the 2013 Clark et al. article to describe the management of category II tracings. The algorithm is below:

Clark et al. (AJOG 2013)