Approximately 70 percent of cesarean deliveries in the United States are primary (first)

cesareans. The three most common indications for primary cesarean delivery in the
United States account for almost 80 percent of these deliveries [1]:
Failure to progress during labor (35 percent)
Nonreassuring fetal status (24 percent)
Fetal malpresentation (19 percent)

Cesarean delivery is not routinely indicated for low birth weight and most congenital
anomalies (see topic reviews on individual anomalies).

There are no absolute contraindications to cesarean delivery

Scheduled cesarean delivery at term should be performed at 39 weeks of

gestation. Medically/obstetrically indicated cesarean deliveries are performed when
clinically indicated, without assessment of fetal lung maturity. (See 'Timing'above.)

For all women undergoing cesarean delivery, we recommend preoperative

antibiotic prophylaxis rather than prophylaxis after cord clamping (Grade 1A).
Antibiotics are given 0 to 60 minutes before making the incision. We use a single
intravenous dose of a narrow-spectrum antibiotic, such as cefazolin (2 grams for
patients <120 kg and 3 grams for patients 120 kg) (table 2).
We use clindamycin and gentamicin for women with a serious penicillin allergy

For all women undergoing cesarean delivery, we suggest mechanical

thromboprophylaxis (Grade 2C).

For women undergoing cesarean delivery at high risk of venous thromboembolism

(VTE), we suggest mechanical thromboprophylaxis plus pharmacologic
thromboprophylaxis (Grade 2C).

These women may include those with

BMI >50 kg/m2,
previous VTE,
high-risk thrombophilia (inherited or acquired),
or 2 less prominent risk factors for VTE.

unfractionated heparin or low-molecular-weight heparin is started 6 to 12 hours

after cesarean delivery, if there is no significant bleeding.

Pneumatic compression devices are left in place until the patient is ambulatory
and until anticoagulation therapy has been restarted [46].

During cesarean delivery, the uterus is displaced at least 15 degrees to the left to
reduce aortocaval compression. (See'Uterine displacement' above.)

Routine postoperative hemoglobin testing is unnecessary in asymptomatic patients

after planned cesarean delivery, as the information does not lead to improved
outcomes. Routine evaluation of postdelivery hemoglobin is probably unwarranted
after uncomplicated intrapartum cesarean delivery.

Patient-controlled opioid analgesia followed by oral nonsteroidal antiinflammatory drugs provides adequate pain relief for most women.
Removal of the bladder catheter as soon as possible postpartum minimizes the risk
of infection.

Early ambulation (when the effects of anesthesia have abated) and oral intake
(within six hours of delivery) are encouraged. Women may slowly increase
aerobic training activities, depending on their level of discomfort and postpartum

complications. Pelvic floor muscle exercises can reduce urinary incontinence, if

present.
Dressings can be removed, and patients may shower within 48 hours of surgery.

The frequency of short-term complications after primary cesarean delivery is:

ileus (10 to 20 percent), endometritis (6 to 11 percent), wound complications (1 to 2
percent), hemorrhage requiring transfusion (2 to 4 percent), surgical injury (0.2 to 0.5
percent), and thrombotic events (246 per 100,000). (See 'Complications' above.)

Cesarean delivery does not appear to be an independent risk factor for future
unexplained stillbirth or subfertility

women with cervical dilation <6 cm are considered to be in latent phase and
those with cervical dilation 6 cm are considered to be in the active phase,
as cervical dilation is normally more rapid at this point.
labor may take more than six hours to progress from 4 to 5 cm and more
than three hours to progress from 5 to 6 cm, regardless of parity.
Arrest of labor in the first stage is diagnosed at cervical dilation 6 cm
dilation in a patient with ruptured membranes and:
no cervical change for 4 hours despite adequate contractions
or no cervical change for 6 hours with inadequate contractions
For women with poor labor progression over two hours in the first stage
after reaching 6 cm dilation, we recommend administering oxytocin (Grade
1B).
We monitor progress for another four hours if contractions are adequate
(>200 Montevideo units), or six hours if an adequate contraction pattern is
not achieved. If there is no cervical change despite oxytocin administration,
we proceed with cesarean delivery. If labor is progressing, either slowly or
normally, we continue oxytocin. (See 'Oxytocin augmentation' above.)
Oxytocin and amniotomy Amniotomy is often combined with oxytocin
augmentation to increase the frequency and intensity of contractions in
women with a protraction disorder, but the efficacy of this approach is
unproven.

We treat slow descent in the second stage (table 1) with oxytocin if the
uterus is hypocontractile. (See 'Second stage protraction' above.)
Arrest of the second stage of labor is defined as no progress (descent,
rotation)
after 4 hours for nulliparous women with epidural anesthesia (3 hours
without epidural anesthesia)
and after 3 hours for multiparous women with epidural anesthesia (2
hours without epidural anesthesia). Intervention is not indicated as long as
descent or rotation to a more favorable position is occurring and the fetal
heart rate pattern is reassuring.
Operative intervention is indicated for second stage arrest. Manual rotation
of occiput posterior or transverse positions to an anterior position is
reasonable before moving to operative delivery
The time to dilate 1 cm in latent phase is significantly longer in women
undergoing induction than in those in spontaneous labor, and can take many
hours. In contrast, the time to dilate from 6 to 10 cm is more rapid and
similar in both induced and spontaneous labors. There is no difference
in length of the second stage between induced and spontaneous labor.
(See 'Normal progress in induced labors' above.)
BENEFITS OF BREAST FEEDING
Visual function Several studies have indicated that human milk-fed term
and premature infants have improved visual function compared with formulafed infants. This benefit has been attributed to docosahexaenoic acid
(DHA), which is a component of phospholipids found in brain, retina, and red
cell membranes [111,112]. DHA is present in human milk but not in bovine
milk. The severity and incidence of retinopathy of prematurity are decreased
among breast-fed compared with formula-fed infants [113-115]. This
association may relate to the substantial antioxidant capacity of human milk
compared with formula [116]
Cognitive development There have been several reports that
breastfeeding slightly improves cognitive development later in childhood and
adolescence
Hearing function Auditory-evoked responses mature faster in breast-fed
premature infants [118].
Child behavior Data from the English Millennium cohort study based on
parental interview and survey suggested that breastfeeding for four months

or longer was associated with a lower risk of behavior problems in children at

five years of age compared with a shorter duration of breastfeeding [119].
Stress reduction There appears to be an analgesic effect of
breastfeeding, which may be due to the enhanced maternal-infant bonding.
Breastfed infants experience less stress during painful procedures than
formula-fed infants [120]. The lactation hormones, oxytocin and prolactin,
are important components of the stress axis and have a positive impact on
social behaviors, including maternal-infant bonding [121]. Another possible
explanation for the analgesic effect of breastfeeding is a higher cortisol
level in breast-fed compared with formula-fed infants [122]. Improved
bonding may reduce infant stress.
When compared with formula, human milk has been shown to:
1Increase the rate of gastric emptying [21,22].
2Increase the intestinal lactase activity in premature infants [23].
3Decrease the intestinal permeability early in life in premature infants [24].
4Decrease the risk of NEC in premature infants. Premature infants who
receive human milk have a lower incidence of NEC compared with those
receiving formula. However, human milk contains several previously
mentioned components that may have protective effects (ie,
immunoglobulins A and G, platelet activating factor-acetylhydrolase,
polyunsaturated fatty acids, EGF, interleukin-10, and intestinal
colonization with the favorable microbes of the Bifidobacteria and
Lactobacilli species).

Human milk protein, lipid, carbohydrate, vitamin, mineral, and trace element
content provides the necessary energy and nutrient requirements of the fullterm infant. Vitamin D supplementation, however, is recommended at
discharge from the birth hospital at a dose of 400 int. units/day.
Whey and casein There are two fractions of protein defined by their
solubility in acid: whey and casein. Approximately 70 percent of the proteins
in human milk are in the soluble whey fraction and 30 percent in the insoluble
casein fraction. In contrast, bovine milk protein contains 18 percent whey and
82 percent casein [9].
The high proportion of whey protein in human milk is beneficial for infants for
the following reasons:

Compared with casein, whey is more easily digested and is associated with
more rapid gastric emptying [10].
The whey protein fraction provides lower concentrations of potentially
deleterious amino acids, phenylalanine, tyrosine, and methionine. In high
levels, these amino acids may interfere with brain development. Infants fed
human milk have lower levels of these amino acids than infants fed bovine
milk [11-13]. In addition, human milk has higher levels of cystine (needed to
synthesize the antioxidant glutathione) and taurine (needed for bile
conjugation and brain development) than bovine milk [12-14].
The major human whey protein is lactalbumin. In bovine milk, the
major whey protein is lactoglobulin, which may contribute to milk protein
allergy and colic
Lactoferrin, lysozyme, and secretory immunoglobulin A are specific human
whey proteins that improve host defense [17-19]. Bovine milk only has trace
amounts of these proteins.

We suggest administering insulin when fasting blood glucose concentration is

95 mg/dL (5.3 mmol/L) or one-hour postprandial blood glucose
concentration is 130 to 140 mg/dL (7.2 to 7.8 mmol/L), or two-hour glucose
is >120 mg/dL (6.7 mmol/L) on two or more occasions within a one-week
interval despite dietary therapy (Grade 2C). (See 'Glucose target' above.)
In women who require insulin therapy, we suggest monitoring glucose upon
awakening and one or two hours after each meal to guide medical
management (Grade 2B). Our goal for fasting blood glucose concentration is
<95mg/dL (5.3 mmol/L) and for one-hour postprandial blood glucose
concentration the goal is <130 to 140 mg/dL (7.2 to 7.8 mmol/L) and for two
hours postprandial <120 mg/dL (6.7 mmol/L). (See 'Timing and
frequency' above.)

Peripartum cardiomyopathy (PPCM) is defined as the development of

systolic heart failure towards the end of pregnancy or in the months
following pregnancy with left ventricular ejection fraction (LVEF) generally
less than 45 percent in the absence of another identifiable cause of heart
failure.
Risk factors
Age greater than 30 years [3,4,8,9]

African descent [43]

Pregnancy with multiple fetuses [8,44]
A history of preeclampsia, eclampsia, or postpartum hypertension [21]
Maternal cocaine abuse [45]
Long-term (>4 weeks) oral tocolytic therapy with beta adrenergic
agonists such as terbutaline [46].
There are conflicting data as to whether selenium deficiency is [47,48] or
is not [49] a risk factor for PPCM

SUMMARY AND RECOMMENDATIONS

In face presentation, the fetal face from forehead to chin is the leading fetal body part
descending into the birth canal (figure 4). The fetal neck is sharply deflexed and the
occiput may touch the back (see 'Definition' above). In brow presentation, the fetal
surface presenting in the birth canal extends from the anterior fontanelle to the brow
(orbital ridge), but does not include the mouth and chin (figure 7). The fetal neck is
extended, but not to the degree of a face presentation. (See 'Definition' above.)
Face and brow presentations are associated with multiparity, cephalopelvic
disproportion, prematurity, polyhydramnios, and fetal anomalies (eg, anencephaly,
anterior neck mass). (See 'Etiology and risk factors' above.)
The diagnosis of face and brow presentation is made by vaginal examination.
Palpation of the orbital ridge and orbits, saddle of the nose, mouth, and chin is
diagnostic of face presentation (figure 5) (see 'Diagnosis' above). Palpation of the
forehead, orbital ridge, orbits, and saddle of the nose, but not the mouth and chin is
diagnostic of brow presentation (figure 7). (See 'Diagnosis' above.)
The fetal heart rate is monitored continuously during labor, ideally with an external
device, because of the increased prevalence of fetal heart rate decelerations. An
internal device may cause facial or ophthalmic injuries if improperly placed. If internal
monitoring is required, the electrode should be carefully applied over a bony structure
to minimize the risk of trauma. (See 'Labor and delivery management' above.)
Over 75 percent of mentum anterior fetuses deliver vaginally; this rate is similar to
that for all fetuses in cephalic presentations. For face presentation with the mentum
anterior or transverse, we suggest a trial of labor rather than cesarean delivery (Grade
2C). Oxytocin augmentation may be administered in the setting of a normal fetus with
protracted labor, as long as the fetal heart rate pattern remains reassuring. (See 'Labor
and delivery management' above.)

The mentum posterior face presentation will not deliver vaginally unless spontaneous
rotation occurs, which is infrequent, or the fetus is very small or the pelvis very large.
As mentum posterior presentations are rare, we individualize management of such
situations. In a multiparous woman with an adequate pelvis and fetus estimated to
weigh less than her prior newborns, we follow labor progress closely and maintain a
low threshold for abandoning attempts at vaginal birth if labor does not progress
normally in the first or second stage. If the fetus is estimated to be larger than her prior
newborns or she is nulliparous, we perform cesarean delivery early in the labor course.
We recommend cesarean delivery rather than manual rotation (Grade 1C). (See 'Labor
and delivery management' above.)
Women with a fetus in brow presentation and a clinically adequate or proven pelvis
can undergo a trial of labor, with close monitoring and delivery by cesarean for
standard indications. The brow presentation is often a transitional state: 50 percent will
spontaneously convert to a face or occipital presentation. Fetuses with persistent brow
presentation should be delivered by cesarean since vaginal delivery is not possible
unless the fetus is very small

Persistent occiput transverse (OT) position is an OT position that persists for an hour or
more after complete cervical dilatation. It results from either constraint to rotation to occiput
anterior or occiput posterior by the bony pelvis or inadequate power. Arrest of descent is the
major consequence.
For persistent OT position with progressive descent, we suggest expectant management
(Grade 2C). If hypocontractile uterine activity is present, contractions should be increase
with oxytocin
cesarean delivery for management of high transverse arrest that persists despite
adequate uterine activity and maternal expulsive effort, except under rare circumstances.
Cesarean delivery, manual rotation, and instrumental rotation are options for
management of deep transverse arrest. If vaginal delivery is attempted, the clinician
should be experienced in manual or instrumental rotation and the prerequisites for operative
vaginal delivery should be met. We would attempt manual rotation before instrumental
rotation.

In developed countries, prolapse of the umbilical cord, fetal trauma, and prematurity are the
major adverse outcomes associated with transverse lie. In developing regions, uterine
rupture from prolonged labor in a transverse lie is also a major cause of maternal/perinatal
mortality and morbidity. (See 'Complications'
For patients with transverse lie prior to the onset of labor and in the absence of
contraindications to a vaginal delivery, we perform external version to cephalic presentation

at 38 to 39 weeks of gestation, followed by artificial rupture of the membranes while the

vertex is held in position, and induction of labor. (See 'Before onset of labor' above.)
For patients in early labor with a singleton fetus in transverse lie and intact membranes, we
attempt external version to cephalic presentation followed by artificial rupture of the
membranes while the vertex is held in position. (See 'Early labor' above.)
For patients with a transverse lie in active labor or with ruptured membranes, we perform a
cesarean delivery. (See 'Active labor' above and 'Transverse lie with ruptured membranes'
above.)
For patients with a transverse lie of the second twin after delivery of the first twin, we
perform internal version to breech presentation and breech extraction of the non-vertex
second twin. External version is also a reasonable approach. (See 'Transverse lie of second
twin after delivery of first twin' above.)
For patients with a fetal demise in transverse lie before labor or in early labor, we perform
external version to achieve a longitudinal lie followed by induction of labor or augmentation,
if appropriate. If the fetus is in transverse lie during active labor, internal podalic version by
an experienced practitioner is an option in the second stage If dystocia due to
malpresentation occurs, we perform cesarean delivery. (See 'Transverse lie with fetal
demise or previable fetus' above.)

Women with type 1 diabetes require insulin therapy. We suggest a combination of

lispro or aspart insulin and Neutral Protamine Hagedorn (NPH) insulin for therapy in
pregnancy, as opposed to other types of insulin (Grade 2C). (See
'Pharmacotherapy' above.)

For women with type 2 diabetes who are not able to achieve and maintain target glycemic
levels with medical nutritional therapy alone, we suggest insulin therapy rather than oral
anti-hyperglycemic drugs (Grade 2C). (See 'Oral anti-hyperglycemic agents' above.)
Recommendation for target glucose level::
ACOG [29]:
Fasting glucose concentrations 95 mg/dL (5.3 mmol/L)
Preprandial glucose concentrations no higher than 100 mg/dL (5.6 mmol/L)
One-hour postprandial glucose concentrations no higher than 140 mg/dL (7.8
mmol/L)
Two-hour postprandial glucose concentrations no higher than 120 mg/dL (6.7 mmol/L)
Mean capillary glucose 100 mg/dL (5.6 mmol/L) and glycated A1C 6 percent
During the night, glucose levels should not decrease to less than 60 mg/dL (3.3
mmol/L)
ADA [8]:

Preprandial, bedtime, and overnight glucose concentrations 60 to 99 mg/dL (3.3 to

5.4 mmol/L)
Peak postprandial glucose concentrations 100 to 129 mg/dL (5.4 to 7.1 mmol/L) one
to two hours after the beginning of the meal

The Endocrine Society suggests a

target fasting glucose <90 to 95 mg/dL (5 to 5.3 mmol/L),
one- and two-hour postprandial values <140 and 120 mg/dL (7.8 and 6.7 mmol/L), respectively,
and A1C 7 percent (ideally, 6.5 percent) [

SUMMARY AND RECOMMENDATIONSMonoamniotic twin pregnancies

result from division of a single fertilized oocyte between days 8 and 12 postfertilization. The
fetal membranes consist of one amnion and one chorion
The incidence of monoamniotic twins is approximately 1 in 10,000 pregnancies. (See
'Incidence' above.)
Fetal mortality, which occurs in roughly 20 percent of all monoamniotic twin
pregnancies, is the most serious complication of monoamniotic placentation. Cord
entanglement is a majorcause of fetal death in these pregnancies. (See
'Outcomes' above.)
Congenital cardiac anomalies are more common in monoamniotic twins than
singletons. above.)
Monoamniotic twins have a lower rate of twin-twin transfusion syndrome (TTTS) than
diamniotic twins (2 to 6 percent versus 9 to 15 percent), but the risk is sufficient to
justify screening.
We administer antenatal corticosteroids at the time of hospital admission (at 28
weeks for otherwise uncomplicated monoamniotic twin pregnancies).
Given the high rate of fetal mortality in these pregnancies, we suggest cesarean
delivery between 32 and 34 weeks of gestation (Grade 2B). (See

Dicho/di and monocho/di

We suggest avoiding elective delivery of dichorionic/diamniotic twins prior to 38
weeks or after 40 weeks of gestation (Grade 2C).

We suggest delivery of monochorionic/diamniotic twins at 36 to 37 weeks of gestation

(Grade 2C). (See 'Timing' above.)
For vertex-vertex twins, we suggest vaginal delivery in the absence of standard indications
for cesarean delivery
When the first twin is not in vertex presentation, we suggest cesarean delivery (Grade 2C).
(See 'Nonvertex presenting twin' above.)
For vertex-nonvertex twins, we suggest breech extraction of the second twin only if the
obstetrician has the requisite experience and if the patient provides informed consent
Trial of vaginal after cesearian for Monochorionic twin pregnancy
Diamniotic Monochorionic placentation is not a contraindication to a trial of labor and
vaginal birth]. Cesarean delivery is performed when the presenting twin is not in vertex
presentation and for standard obstetric indications.
Monoamniotic Monoamniotic twins are usually delivered by cesarean.
MANAGEMENT Management of labor and delivery is the same for dichorionic and
monochorionic diamniotic twins.
The average duration of gestation for singletons, twins, and triplets is 39, 35, and 32 weeks,
respectively
Primary PPH occurs in the first 24 hours after delivery (also called early PPH) and
secondary PPH occurs 24 hours to 12 weeks after delivery
The strongest risk factor for retained placenta is gestational age less than 26 weeks
Retained placenta can be defined as lack of placental expulsion within 30 minutes of
delivery of an infant. This time period can be extended to 90 to 120 minutes for births in the
second trimester and third stages of labor managed without oxytocin. (See 'Definition'
above.)
The three etiologies of retained placenta are: the placenta may be trapped behind a
partially closed cervix (trapped or incarcerated placenta); the placenta may be adherent to
the uterine wall, but easily separated manually (placenta adherens); or the placenta may be
pathologically invading the myometrium (placenta accrete
Contraceptive choices during lactation
Barrier methods Nonhormonal methods of contraception (barrier contraception, copper
intrauterine contraception) are preferred in nursing mothers because they do not have systemic
effects.

Intrauterine contraception Breastfeeding women can safely use either the TCu380A IUD or
a levonorgestrel-releasing IUD. WHO suggests delaying insertion of a levonorgestrel-releasing
IUD to four to six weeks postpartum in breastfeeding women;
Progestin only methods ]. However, the timing of initiation of therapy (immediately versus six
weeks postpartum) is somewhat controversial [68]. Because falling progesterone levels trigger
lactogenesis, early initiation of progestin-only contraceptives theoretically could interfere with this
process, However, most available data suggest that early initiation of progestin-only contraception
does not impair (and may increase) lactation, and is not harmful to the neonate [67,70-76].
CDC Medical Eligibility Criteria provide the least restrictive guidance and indicate that progestinonly hormonal methods, including progestin-only pills, DMPA injections, and implants, are safe for
postpartum women, including women who are breastfeeding, and can be initiated immediately
postpartum (table 1) [54,77]. We agree with the CDC recommendations.
Estrogen-progestin contraceptives Theoretically, estrogen-progestin contraceptives (pills,
patch, ring) could suppress milk production in the early postpartum period]. However, there is no
strong evidence
[82]. Recommendations from the CDC and the WHO are discordant. The CDC
strongly recommends delaying initiation of estrogen-progestin contraceptives until 21
days postpartum in all women because of increased risks of VTE,) [54]. In women
with additional risk factors for VTE, estrogen-progestin contraceptives should not be
initiated until six weeks postpartum as long as the woman meets standard criteria for
use of combined hormonal contraception that apply to nonpregnant women. We agree
with this recommendation.
WHO recommends delaying the initiation of estrogen-progestin contraceptives until six months
postpartum (table 2) [78]. Between six weeks and six months, WHO states that the theoretical
or proven risks usually outweigh the advantages of initiating these drugs.
NONCONTRACEPTIVE BENEFITS ].
Menstrual cycle disorders
Menorrhagia (see "Hormonal contraception for suppression of menstruation")
Dysmenorrhea
Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD)
(continuous pills or pills with shortened pill-free interval); however, the pill is not
considered a first-line therapy for PMS/PMDD (see "Treatment of premenstrual
syndrome and premenstrual dysphoric disorder")
Prevention of menstrualmigraine (continuous pill)
Hyperandrogenism

Acne (see "Hormonal therapy for women with acne vulgaris")

Hirsutism (see "Treatment of hirsutism")
Gynecologic disorders
Bleeding due to leiomyomas
Pelvic pain due to endometriosis)
Cancer risk reduction
Decreased risk of endometrial cancer and ovarian cancer;
Decreased risk of colon cancer
Ovarian cysts Although hormonal contraceptives are often prescribed to suppress large
functional ovarian cysts, a systematic review of available data concluded that functional cysts do
not regress more quickly with estrogen-progestin contraceptive therapy when compared with
expectant management

SUMMARY AND RECOMMENDATIONS Oral contraceptives (OCs) are a reliable form of

contraception and have noncontraceptive benefits, as well. Furthermore, the decrease in both
estrogen and progestin content in the last decade has led to a reduction in both side effects and
cardiovascular complications. (See "Risks and side effects associated with estrogen-progestin
contraceptives".)
While OCs have several mechanisms of action, the most important mechanism for
providing contraception is inhibition of the midcycle luteinizing hormone (LH)
surge, so that ovulation does not occur. Another potential mechanism of
contraceptive action is suppression of gonadotropin secretion during the follicular
phase of the cycle, thereby preventing follicular maturation. However, a substantial
number of women develop follicles while taking an OC that contains 20 to 35 mcg of
ethinyl estradiol. Progestin-related mechanisms include effects on the
endometrium, rendering it less suitable for implantation, and alterations in
cervical mucus, which becomes less permeable to penetration by sperm. (See
'Mechanisms of action' above.)
OCs can be started at any time during the cycle. The preferred approach is the quick
start method in which the woman begins taking OCs on the day that she is given the
prescription, as long as pregnancy is reasonably excluded. An alternative is the
Sunday start approach where the woman starts the pill on the first Sunday after her
period begins. (See 'Initiation' above.)
Missed pills (particularly if the missed pills are at the beginning of the pill pack) are a
common cause of contraceptive failure. We suggest that back-up contraception be

used for seven days after two missed pills, regardless of dose (Grade 2C). (See 'Effect
of missed pills' above.)
The metabolism of OCs is accelerated by any drug that increases liver microsomal
enzyme activity such as many of the anticonvulsant drugs, including phenytoin and
phenobarbital. As a result, the contraceptive efficacy of an OC is likely to be
decreased in women taking these drugs. In contrast, the metabolism of OCs is not
affected by antibiotics, with the exception of rifampin. (See 'Drug interactions' above.)
Dont use ocp with carbamazepine, barbiturates, primidone, topiramate
phenobarbital, phenytoin, griseofulvin, and rifampin, they decrease ocp effect .
However medroxyprogesterone can be used
There are several types of combination pills. Monophasic pills contain the same dose
of estrogen and progestin in each of the hormonally-active pills. Biphasic or triphasic
pills have varying doses of hormone across the cycle (usually the progestin). There are
no proven advantages to the multiphasic regimens. We suggest starting with a
monophasic pill.)
The estrogen component of nearly all OCs is ethinyl estradiol
Most available progestins have both progestogenic and androgenic activity (table 2
and table 1). A progestin with pure progestational activity would be ideal because the
androgenic activity is not needed for contraception and it increases side effects and
metabolic complications. However, more selective progestins have been developed;
some function as androgen receptor antagonists. To date, they have no proven clinical
advantages over traditional progestins, and some have been associated with a
possible higher risk of venous thromboembolism
For couples who desire permanent contraception (sterilization), we suggest vasectomy.
Vasectomy is as effective, but less morbid and costly than tubal occlusion.)
Women who request sterilization should be counseled about availability of LARC methods,
which are comparable to sterilization in terms of efficacy (table 5), but are non-surgical and
reversible.
For women who desire reversible contraception, we suggest LARC. Pregnancy rates are
comparable to sterilization (table 5), and they are more convenient than short-acting
methods.
SUMMARY AND RECOMMENDATIONS.

emergency contraception

Neither a physical examination nor laboratory testing is needed before prescribing

levonorgestrel or an estrogen-progestin regimen for emergency contraception.)
Pregnancy should be excluded and, if not conclusively excluded by history, pregnancy

testing should be performed, particularly before prescribing ulipristal or intrauterine

contraception.
We suggest administering emergency contraception as soon as possible, but up to
120 hours, after an episode of unprotected intercourse in women who wish to prevent
pregnancy (Grade 2C).
We suggest the copper intrauterine contraceptive device (IUD) as the preferred
choice for emergency contraception (Grade 2C).
For women who wish to avoid use of an IUD, we recommend ulipristal over
levonorgestrel (Grade 1B). Ulipristal is effective any time within 120 hours of
unprotected intercourse. (See 'Options' above.)
For women who choose hormonal emergency contraception, we recommend
levonorgestrel rather than an estrogen-progestin regimen (Grade 1A).
Levonorgestrel is more effective and has fewer side effects. We suggest a single dose
of levonorgestrel 1.5 mg for most women (Grade 2A). It is most effective if given
within 72 hours of unprotected intercourse.
Overweight and obese women should be informed that some studies have reported
reduced efficacy of oral emergency contraceptives at high bodyweights (75 kg or
80 kg.
IUD for obese
Menstrual bleeding after oral hormonal emergency contraception typically occurs
within one week of the expected time. A pregnancy test should be performed if
bleeding has not occurred within three to four weeks or if there is persistent
vaginal bleeding or abdominal pain

Endometriosis..

For women with no more than mild pelvic pain, we suggest nonsteroidal antiinflammatory
drugs over other medical interventions (Grade 2B). For women who also desire
contraception, we suggest oral contraceptives
For pain who are not achieving adequate pain relief with nonsteroidal antiinflammatory
drugs and/or combined oral contraceptives, and those with recurrent mild endometriosis and
pain, we suggest treatment with a GnRH agonistover other hormonal therapies (Grade
2B). (See 'GnRH agonists' above.)
Use of GnRH agonists avoids the bothersome side effects of
progestins (weight gain, irregular uterine bleeding, mood changes)

and danazol (weight gain, muscle cramps, decreased breast size, acne, hirsutism, oily skin,
mood changes).
For women who want to avoid the high cost and risk of bone loss associated with GnRH
agonists, we suggest treatment with a progestin ( Grade 2B). Progestins have a more
favorable side effect profile than danazol.
For women with symptoms that are severe, incapacitating, or acute (rupture or torsion of
an endometrioma), or who have advanced disease (eg, anatomic distortion of the pelvic
organs, endometriotic cysts, or obstruction of the bowel or urinary tract), we suggest
surgical rather than medical therapy (Grade 2C). We also suggest surgical intervention for
women whose symptoms have failed to resolve or have worsened under medical
management
Infertility
Male factor (hypogonadism, post-testicular defects, seminiferous tubule dysfunction)
26 percent
Ovulatory dysfunction 21 percent
Tubal damage 14 percent
Endometriosis 6 percent
Coital problems 6 percent
Cervical factor 3 percent
Unexplained 28 percent
The frequency of these factors in infertility is similar whether infertility is primary or secondary,
and has not changed significantly over the past 25 years in developed countries

The general consensus among infertility experts is that infertility evaluation should be
undertaken for couples who have not been able to conceive after 12 months of
unprotected and frequent intercourse, but earlier evaluation should be undertaken
based on medical history and physical findings, and in women over 35 years of age
Infertility is classically defined as
the failure of a couple to conceive after 12 months of frequent intercourse without use
of contraception in women under age 35,
and after six months in women over age 35.
Fecundability is the probability of achieving a pregnancy in one menstrual cycle

Ovulation induction : clomiphene citrate or letrozole

last one is pulsatile Gnrh

Aromatase inhibitors (letrozole) Letrozole, an aromatase inhibitor, blocks the

conversion of testosterone and androstenedione to estradiol and estrone, respectively
(unlike clomiphene which blocks estrogen action on estrogen receptor.
gonadotropin treatment should be stopped if there are an excess number of follicles
or extremely high serum estradiol concentrations.

Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of

controlled ovarian hyperstimulation (COH) for assisted reproduction. It is a broad
spectrum of signs and symptoms that include abdominal distention and discomfort,
enlarged ovaries, ascites, and other complications of enhanced vascular
permeability. (See 'Background' above.)
OHSS is a self-limited disease, although symptoms may be prolonged if pregnancy
has occurred. Management should be conservative and directed at symptoms; many
women can be managed as outpatients. However, women with severe or critical
OHSS require hospitalization
For women with mild OHSS, we suggest outpatient management that includes
analgesics (acetaminophen) and avoidance of heavy physical activity.
We suggest thromboembolism prophylaxis for all hospitalized patients with OHSS.)
OHSS may result in hypotension not hypertention
Medical treatment of severe hyperstimulation is directed at maintaining
intravascular blood volume. Simultaneous goals are correcting the disturbed fluid
and electrolyte balance, relieving secondary complications of ascites and
hydrothorax, and preventing thromboembolic events

The term hyperthecosis refers

to the presence of nests of luteinized theca cells in the ovarian stroma due to
differentiation of the ovarian interstitial cells into steroidogenically active luteinized
stromal cells, causing hyperandrogenism

Serum total testosterone concentrations >150 ng/dL (>5.2 nmol/L) [8-11]. It is the
single most important biochemical finding and it should prompt imaging of
adrenals and ovaries.
Normal or suppressed

luteinizing hormone (LH) and follicle-stimulating

hormone (FSH) [13].

Normal serum dehydroepiandrosterone (DHEA) or dehydroepiandrosterone
sulfate (DHEA-S) concentrations.
Normal prolactin and insulin-like growth factor 1 (IGF-1).
A serum total testosterone concentration <5.2 nmol/L (150 ng/dL) is likely to rule out
hyperthecosis.
US show increase in ovarian volume only , no or just few cyst unlike PCOS , more
solid appearance , increase in volume due to increase in stromal cells., hypointensity in
MRI
A single dose of long-acting GnRH-agonists can be used for diagnostic purposes to
confirm the ovarian origin of androgens. It will suppress testosterone level, indicating
that problem is LH dependent ,
And not independent like ovarian tumors ,however some tumors are gonadotropine
dependent so imaging is a must to confirm,
postmenopausal women and in premenopausal women who have completed childbearing:
Bilateral oophorectomy, as it provides a definitive solution for the
hyperandrogenism.or
Long-term gonadotropin-releasing hormone (GnRH)-agonist treatment
Treatment in premenopausal women is essentially the same as in women with the polycystic
ovary syndrome (PCOS).It includes treatment of hirsutism mainly by local therapy, oral
contraceptive

anti-androgens or GnRH-agonists combined with estrogen-progestin

replacement
For the treatment of anovulation and subsequent infertility: clomiphene,

The most common causes of primary amenorrhea include (see 'Background' above):
Chromosomal abnormalities causing gonadal dysgenesis (ovarian
insufficiency due to the premature depletion of all oocytes and follicles) 50
percent
Hypogonadotropic hypogonadism, including functional hypothalamic amenorrhea
20 percent

Primary amenorrhea is defined as the absence of menses at age 15 years in the

presence of normal growth and secondary sexual characteristics. Or age 13 years in
absence of secondary sexual characteristics.
The premenstrual syndrome (PMS) is by the presence of both physical and/or
behavioral (including affective) symptoms that occur repetitively in the second half of
the menstrual cycle and interfere with some aspects of the woman's life
The most common behavioral symptom of PMS is labile mood. Other frequent
behavioral complaints include irritability, anxiety/tension, sad or depressed mood,
increased appetite/food cravings, sensitivity to rejection, and diminished interest in
activities.)
The most common physical manifestations of PMS are abdominal bloating and an
extreme sense of fatigue. Other common symptoms include breast tenderness,
headaches, hot flash

The menopausal transition, or perimenopause, begins on average four years before

the final menstrual period (FMP
HOT flashes are the most common symptoms
Hot flashes typically begin as the sudden sensation of heat centered on the upper
chest and face that rapidly becomes generalized. The sensation of heat lasts from two
to four minutes, is often associated with profuse perspiration and occasionally
palpitations, and is sometimes followed by chills, shivering, and a feeling of anxiety.
Hot flashes may range from an average of less than one each day to as many as one
per hour during the day and night.
When hot flashes occur at night, women typically describe them as night sweats