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Obstetrics and Gynaecology

Obstetrics and Gynaecology

von: Lawrence Impey, Tim Child

Wiley-Blackwell, 2016

ISBN: 9781119010807 , 379 Seiten

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Obstetrics and Gynaecology


 

Obstetrics & Gynaecology

5

Contents

7

Preface to the fifth edition

9

Preface to the first edition

9

Acknowledgements

11

List of abbreviations

12

About the companion website

15

Gynaecology

17

Chapter 1 The history and examination in gynaecology

19

The gynaecological history

19

Personal details

19

Presenting complaint(s)

19

Specific gynaecological questions

19

Other history

20

Other questions

20

Summarizing the history

21

The gynaecological examination

21

General examination

21

Breast and axillary examination

21

Abdominal examination

21

Vaginal examination

22

Rectal examination

23

Chapter 2 The menstrual cycle and its disorders

25

Physiology

25

Puberty

25

The menstrual cycle

25

Abnormal uterine bleeding (AUB)

26

Definition

26

Causes of AUB

26

Heavy menstrual bleeding (HMB)

28

Definition

28

Epidemiology

28

Aetiology

29

Clinical features

29

Investigations

29

Management

30

Irregular menstruation and intermenstrual bleeding

32

Epidemiology

32

Causes

32

Clinical features

32

Investigations

32

Management

32

Absent and infrequent menstrual bleeding (amenorrhoea and oligomenorrhoea)

33

Definitions

33

Classification of causes

33

Management

34

Postcoital bleeding

34

Definition

34

Aetiology

35

Management

35

Dysmenorrhoea

35

Causes and their management

35

Precocious puberty

35

Causes and their management

35

Ambiguous development and intersex

35

Increased androgen function in a genetic female

36

Reduced androgen function in a genetic male

36

Premenstrual syndrome

36

Epidemiology

36

Aetiology

36

Clinical features

36

Management

36

Further reading

37

Chapter 3 The uterus and its abnormalities

38

Anatomy and physiology of the uterus

38

Anatomy and function

38

Blood and lymph

38

The endometrium

39

Fibroids

39

Definition and epidemiology

39

Pathology and sites of fibroids

39

Pathology and sites of fibroids

39

Aetiology

39

Clinical features

39

Natural history/complications of fibroids

40

Fibroids and pregnancy

40

Hormone replacement therapy and fibroids

40

Investigations

40

Treatment

40

Adenomyosis

43

Definition and epidemiology

43

Pathology and aetiology

43

Clinical features

43

Investigations

43

Treatment

43

Other benign conditions of the uterus

43

Endometritis

43

Intrauterine polyps

43

Haematometra

44

Congenital uterine malformations

44

Endometrial carcinoma

44

Epidemiology

44

Pathology

45

Aetiology

45

Spread and staging

45

Investigations

46

Treatment

46

Prognosis

47

Uterine sarcomas

47

Further reading

47

Chapter 4 The cervix and its disorders

49

Anatomy and function of the cervix

49

Anatomy

49

Histology and the transformation zone

49

Blood supply and lymph drainage

49

Benign conditions of the cervix

49

Premalignant conditions of the cervix: cervical intraepithelial neoplasia

50

Definitions

50

Epidemiology

51

Aetiology

51

Pathology

51

Diagnosis: screening for cervical cancer

51

Treatment: prevention of invasive cervical cancer

53

Results and problems with screening for cervical cancer

53

Psychological aspects of cervical screening

53

Malignant disease of the cervix

53

Epidemiology

53

Pathology

53

Aetiology

54

Clinical features

54

Spread and staging

54

Investigations

54

Treatment of cervical malignancies

54

Prognosis

56

Further reading

56

Chapter 5 The ovary and its disorders

58

Anatomy and function of the ovaries

58

Ovarian symptoms

58

Ovarian cyst ‘accidents’

58

Disorders of ovarian function

58

Classification of ovarian tumours

59

Primary neoplasms

59

Secondary malignancies

60

Tumour-like conditions

60

Ovarian cancer

60

Epidemiology

60

Pathology (see classification of ovarian tumours)

61

Aetiology

61

Screening for ovarian cancer

61

Clinical features

61

Spread and staging

62

Investigations

62

Management of ovarian cancer

63

Follow-up and prognosis

64

Palliative care

65

Definition and aims

65

Organization of palliative care

65

Symptom control

65

Further reading

66

Chapter 6 Disorders of the vulva and vagina

67

Anatomy

67

Vulval symptoms

67

Miscellaneous benign disorders of the vulva and vagina

67

Lichen simplex (or chronic vulvaldermatitis)

67

Lichen planus

68

Lichen sclerosus

68

Vulvar dysaesthesia (vulvodynia) or the vulval pain syndromes

68

Infections of the vulva and vestibule

68

Bartholin’s gland cyst and abscess

69

Introital damage

69

Vaginal cysts

69

Vaginal adenosis

69

Premalignant disease of the vulva: vulval intraepithelial neoplasia

69

Carcinoma of the vulva

70

Epidemiology

70

Pathology

70

Aetiology

70

Clinical features

70

Spread and staging

70

Investigations

70

Treatment

70

Prognosis

71

Malignancies of the vagina

71

Further reading

71

Chapter 7 Prolapse of the uterus and vagina

73

Anatomy and physiology of the pelvic supports

73

Prolapse

73

Types of prolapse

73

Grading of prolapse

73

Epidemiology

74

Aetiology of prolapse

74

Clinical features

74

Investigations

76

Prevention

76

Management

76

Pessaries

76

Surgical treatment

76

Further reading

77

Chapter 8 Disorders of the urinary tract

78

Anatomy and function of the female lower urinary tract system

78

Neural control of the bladder and urethra

78

Continence

78

Micturition

78

Incontinence

78

Investigation of the urinary tract

79

Urinary stress incontinence

80

Definition

80

Epidemiology

80

Aetiology

80

Mechanism of incontinence

80

Clinical features

80

Investigations

81

Management

81

Overactive bladder

83

Definition

83

Epidemiology

83

Aetiology

83

Mechanism of incontinence

83

Clinical features

83

Investigations

83

Management

83

Other urinary disorders

84

‘Mixed’ USI and overactive bladder

84

Acute urinary retention

84

Chronic retention and urinary overflow

84

Painful bladder syndrome and interstitial cystitis

85

Fistulae

85

Further reading

85

Chapter 9 Endometriosis and chronic pelvic pain

86

Endometriosis

86

Definition and epidemiology

86

Pathology

86

Aetiology

86

Clinical features

86

Investigations

87

Management

88

Endometriosis and fertility

90

Chronic pelvic pain

90

Definition

90

Assessment and investigation

90

Possible causes of pain

90

Management

90

Further reading

90

Chapter 10 Genital tract infections

92

Infections of the vulva and vagina

92

Non-sexually transmitted infections

92

Sexually transmitted infections (STIs)

93

Infections of the uterus and pelvis

96

Endometritis

96

Acute pelvic infection and pelvic inflammatory disease

97

Chronic pelvic inflammatory disease

98

Vaginal discharge: causes and treatment

99

Further reading

99

Chapter 11 Fertility and subfertility

101

Definitions

101

Conditions for pregnancy

101

Counselling and support for the subfertile couple

101

Disorders of ovulation

101

Physiology of ovulation

101

Detection of ovulation

103

Causes of anovulation: polycystic ovary syndrome

103

Other causes of anovulation

105

Induction of ovulation

107

Male subfertility

108

Physiology of sperm production

108

Detection of adequate sperm production: semen analysis

108

Common causes of abnormal/absent sperm release

109

Investigations

109

Management of male factor subfertility

110

Disorders of fertilization

110

Physiology of fertilization

110

Causes of failure to fertilize: tubal damage

110

Other causes of failure to fertilize

111

Detection of tubal damage

111

Assisted conception

111

Intrauterine insemination (IUI)

112

Intracytoplasmic sperm injection (ICSI)

112

Oocyte donation

114

Preimplantation genetic diagnosis (PGD)

114

Surrogacy

114

Complications of assisted conception

115

Fertility preservation

115

Further reading

115

Chapter 12 Contraception

118

The ideal contraceptive

118

Efficacy of contraception

118

Safety of contraception

118

Compliance with contraception

118

Special patient groups

118

Hormonal contraception

119

Combined oral contraceptives

119

Other combined hormonal contraception

122

Progestogen-only pill (POP)

122

Long-acting reversible contraceptives (LARCs)

123

Progestogen-impregnated intrauterine system

123

Emergency contraception

123

The ‘morning-after pill’

123

Intrauterine device

124

Barrier contraception

124

Male condom

124

Female condom

124

Diaphragms and caps

124

Spermicides

124

Intrauterine contraceptive devices (‘the coil’)

124

Types of IUDs

124

Contraceptive efficacy

125

Indications

125

Complications

125

Advantages

126

Female sterilization

126

Contraceptive efficacy

126

Indications

126

Complications

127

Male sterilization

127

Male hormonal contraception

127

Natural contraception

127

Further reading

127

Chapter 13 The menopause andpostre productive health

130

Definitions

130

Postmenopausal bleeding

130

Definition

130

Causes

130

Management

130

Symptoms and consequences of the menopause

131

Cardiovascular disease

131

Vasomotor symptoms

132

Urogenital problems

132

Sexual problems

132

Osteoporosis

132

Investigations of the menopause

133

Follicle-stimulating hormone (FSH)

133

Anti-mullerian hormone

133

Other blood tests

133

Bone density estimation

133

Biochemical markers of bone metabolism

134

Treatment: hormone replacement therapy

134

Oestrogens

134

Progestogens

134

Tibolone

135

Androgens

135

Regimens of HRT

135

Benefits, risks and uncertainties of oestrogen-based HRT

135

Duration of therapy

136

Other treatments for the menopause

137

Non-oestrogen-based therapies

137

Alternative and complementary therapies

137

Further reading

137

Chapter 14 Disorders of early pregnancy

139

Physiology of early pregnancy

139

Spontaneous miscarriage

139

Definition and epidemiology

139

Types of miscarriage

139

Aetiology of sporadic miscarriage

140

Clinical features

140

Investigations

140

Management

141

Complications

142

Counselling after miscarriage

142

Recurrent miscarriage

142

Definition and epidemiology

142

Causes and their management

142

Unwanted pregnancy and therapeutic abortion

143

Definition

143

Methods of abortion

143

Complications of therapeutic abortion

144

Ectopic pregnancy

144

Definition and epidemiology

144

Pathology and sites of ectopic pregnancy

144

Aetiology

144

Clinical features

145

Investigations

145

Management

146

Complications

147

Hyperemesis gravidarum

147

Definition and epidemiology

147

Management

147

Gestational trophoblastic disease

147

Definitions, pathology and epidemiology

147

Clinical features

148

Investigations

148

Management and follow-up

148

Complications

148

Further reading

148

Chapter 15 Gynaecological operations

151

Endoscopy and endoscopic surgery

151

Diagnostic hysteroscopy

151

Hysteroscopic surgery

151

Diagnostic laparoscopy

151

Laparoscopic surgery

151

Hysterectomy

152

Types of hysterectomy

153

Other common gynaecological problems

153

Dilatation and curettage (D&C)

153

Evacuation of retained products of conception (ERPC)

153

Operations for cervical intraepithelial neoplasia

154

Operations for prolapse

154

Operations for urinary stress incontinence

154

Operations for fibroids

154

Precautions in major gynaecological surgery

155

Thromboembolism

155

Infection

155

Urinary tract

155

Further reading

155

Obstetrics

157

Chapter 16 The history and examination in obstetrics

159

The obstetric history

159

Personal details

159

Presenting complaint/present circumstances

159

History of present pregnancy

159

Past obstetric history

160

Other history

160

Other questions

161

The obstetric examination

161

General examination

161

Abdominal examination

162

Inspection

162

Palpation

162

Auscultation

164

Other features of relevance

164

The postnatal history andexamination

164

History

164

Examination

165

Basic neonatal assessment

166

Further reading

166

Chapter 17 Antenatal care

168

The aims of antenatal care

168

Preconceptual care and counselling

168

The booking visit

168

History

168

Examination

169

Booking visit investigations

169

Health promotion and advice

170

Routine later pregnancy tests

171

Ultrasound for structural abnormalities

171

Ultrasound screening for risk assessment

171

Other routine later pregnancy tests

171

Continuing antenatal care

171

Frequency of antenatal visits

171

Conduct of antenatal visits

172

‘Minor’ conditions of pregnancy

172

Further reading

173

Chapter 18 Congenital abnormalities and their identification

174

Screening and diagnostic tests

174

Terms describing screening tests

174

Performance of screening tests

175

Integration of risk factors

175

Methods of prenatal testing for congenital abnormalities

175

Maternal blood testing

175

Ultrasound

175

Fetal magnetic resonance imaging

176

3-D/4-D ultrasound

177

Invasive testing

177

Preimplantation genetic diagnosis

178

Chromosomal abnormalities

178

Down’s syndrome

178

Other chromosomal abnormalities

178

Deletions, translocations and ‘microarray’ abnormalities

178

Screening for chromosomal abnormalities

179

Diagnosis of chromosomal abnormalities

179

Structural abnormalities

179

Central nervous system abnormalities

179

Cardiac defects and fetal echocardiography

180

Abdominal wall defects

181

Chest defects

182

Gastrointestinal defects

182

Urogenital defects

182

Skeletal defects

182

Facial abnormalities

183

Fetal hydrops

183

Single gene disorders

184

Further reading

184

Chapter 19 Infections in pregnancy

187

Viruses

187

Cytomegalovirus

187

Herpes simplex

187

Herpes zoster

188

Rubella

188

Parvovirus

189

Hepatitis B

189

Hepatitis C

189

Human immunodeficiency virus

189

Influenza

191

ZIKA

191

Bacteria, parasites and others

191

Group A streptococcus

191

Group B streptococcus

191

Syphilis

192

Toxoplasmosis

192

Malaria

193

Listeriosis

193

Bacterial vaginosis

193

Other obstetric infections

193

Further reading

193

Chapter 20 Hypertensive disordersin pregnancy

196

Normal blood pressure changes in pregnancy

196

Classification of hypertensive disorders in pregnancy

196

Pregnancy-induced hypertension

196

Pre-existing or chronic hypertension

196

Pre-eclampsia

196

Definitions and classification

196

Pathophysiology

197

Classification and degrees of pre-eclampsia

198

Epidemiology

198

Aetiology

198

Clinical features

198

Complications of pre-eclampsia

199

Investigations

200

Screening and prevention

201

Management

201

Postnatal care of the pre-eclamptic patient

202

Pre-existing hypertension in pregnancy

203

Definitions and epidemiology

203

Aetiology

203

Clinical features

203

Complications

203

Investigations

203

Management

203

Further reading

203

Chapter 21 Other medical disorders in pregnancy

205

Diabetes and gestational diabetes

205

Physiology

205

Definition and epidemiology

205

Fetal complications

205

Maternal complications

206

Management of pre-existing diabetes in pregnancy

206

Preconceptual care for pre-existing diabetics

206

Monitoring and treating the diabetes

207

Monitoring or treating the complications of diabetes

207

Monitoring the fetus

207

Timing and mode of delivery

208

The neonate and puerperium

208

Detection of and screening for gestational diabetes

208

Management of gestational diabetes

208

Cardiac disease

209

Epidemiology

209

Principles of management

209

Types of cardiac disease and their management

209

Respiratory disease

210

Epilepsy

210

Management of epilepsy in pregnancy

210

Thyroid disease in pregnancy

210

Hypothyroidism

211

Hyperthyroidism

211

Postpartum thyroiditis

211

Liver disease

211

Acute fatty liver

211

Intrahepatic cholestasis of pregnancy

211

Renal disease

212

Chronic kidney disease

212

Urinary infection

212

Thrombophilias and the antiphospholipid syndrome

212

Antiphospholipid syndrome (APS)

212

Other prothrombotic disorders

213

Systemic lupus erythematosus

213

Venous thromboembolic disease

213

Management of VTE in pregnancy

214

Thromboprophylaxis

214

Obesity in pregnancy

215

Risks in pregnancy

215

Management of obesity in pregnancy

215

Mental illness in pregnancy

216

Bipolar affective disorder

216

Postpartum psychosis

216

Depression

216

Anxiety disorders

216

Schizophrenia

217

‘Recreational’ drugs in pregnancy

217

Illegal drugs

217

Legal drugs

217

Anaemias

218

Iron deficiency anaemia

218

Folic acid and vitamin B12 deficiency anaemia

218

Prophylaxis against anaemia

218

Influenza

219

Haemoglobinopathies

219

Sickle cell disease

219

Thalassaemias

219

Female genital mutilation (FGM)

220

Further reading

220

Chapter 22 Red blood cell isoimmunization

225

Definition

225

Pathophysiology

225

Blood groups

225

Sensitization

225

Haemolysis

225

Prevention: using anti-D

225

Epidemiology

226

Manifestations of Rhesus disease

226

Management of isoimmunization

227

Identification

227

Assessing severity of fetal anaemia

227

Treatment of fetal anaemia: in utero transfusion

227

Further reading

228

Chapter 23 Delivery before term

229

Definitions and epidemiology

229

Complications

229

Aetiology of spontaneous preterm labour

229

Prediction of preterm labour

230

Prevention of preterm labour

231

Clinical features

233

Investigations

233

Management

233

Preterm prelabour rupture of the membranes

234

Definition

234

Complications

234

Clinical features

234

Investigations

234

Management

235

Further reading

235

Chapter 24 Antepartum haemorrhage

237

Placenta praevia

237

Definitions and epidemiology

237

Classification

237

Aetiology

237

Complications

237

Clinical features

237

Investigations

238

Management

238

Placental abruption

239

Definition

239

Pathology

239

Complications

240

Aetiology

240

Clinical features

240

Investigations

240

Management

241

Other causes of antepartum haemorrhage

241

Bleeding of undetermined origin

241

Ruptured vasa praevia

241

Uterine rupture

242

Bleeding of gynaecological origin

242

Further reading

242

Chapter 25 Fetal growth, health and surveillance

244

Fetal health and growth: terminology

244

Small for gestational age (SGA)

244

Intrauterine/fetal growth restriction (IUGR or FGR)

244

Fetal distress

244

Fetal compromise

245

Fetal surveillance

245

Aims of fetal surveillance

245

Problems with fetal surveillance

245

Identification of pregnancy risk

245

Methods of fetal surveillance

247

Routine pregnancy care

247

Ultrasound assessment of fetal growth

247

Doppler waveforms of the umbilical artery

248

Doppler waveforms of the fetal cerebral circulation

249

Doppler waveforms of the fetal venous circulation

249

Cardiotocography or non-stress test

249

Kick chart

249

The small for gestational age fetus and the IUGR fetus

250

Epidemiology

250

Aetiology

250

Complications

251

Diagnosis

251

Management of IUGR

251

Stillbirth

252

Definition and epidemiology

252

Aetiology

252

Diagnosis

253

Prevention of stillbirth

253

Potentially beneficial routine interventions

253

Management of stillbirth

253

The prolonged pregnancy

253

Epidemiology and aetiology

253

Risks

254

Management

254

Further reading

254

Chapter 26 Abnormal lie and breech presentation

256

Abnormal (transverse and oblique) lie

256

Definitions and epidemiology

256

Aetiology

256

Complications

256

Management

256

Breech presentation

256

Definitions and epidemiology

256

Aetiology

257

Diagnosis

258

Complications

258

Management

258

Further reading

259

Chapter 27 Multiple pregnancy

261

Epidemiology

261

Types of multiple pregnancy

261

Aetiology

261

Diagnosis

261

Maternal complications

261

Fetal antenatal complications

261

Antepartum management

265

Intrapartum management

266

Further reading

267

Chapter 28 Labour 1: Mechanism – anatomy and physiology

269

Mechanical factors of labour

269

The powers

269

The passage

269

The passenger

270

Cervical dilatation: the ‘stages’ of labour

272

Initiation and diagnosis of labour

272

The first stage

273

The second stage

274

Delivery

274

The third stage

274

Perineal trauma

274

Further reading

274

Chapter 29 Labour 2: Management

276

General care of the woman in labour

276

Physical health in labour

276

Mental health in labour

277

Progress in labour: problems and their treatment

277

Monitoring progress: the partogram

277

The powers

277

The passenger

279

The passage

281

The cervix

282

Care of the fetus

282

Fetal distress and hypoxia

282

Other causes of fetal damage and their treatment

286

Care of the mother

286

Pain relief in labour

287

Anaesthesia for obstetric procedures

288

Conduct of labour

288

Initiation and diagnosis of labour

288

First stage of labour

289

Second stage of labour

290

Third stage of labour

290

Perineal repair

291

Different approaches to delivery

292

Natural approaches to labour

292

Further reading

293

Chapter 30 Labour 3: Special circumstances

295

Induction of labour

295

Methods of induction

295

Induction with prostaglandins

295

Induction with amniotomy ± oxytocin

295

Natural induction

295

Indications for induction

295

Contraindications

296

Management of induced labour

296

Complications

296

Labour/vaginal birth after a previous caesarean section

297

Contraindications

297

Factors influencing vaginal delivery after one caesarean section

297

Safety of vaginal delivery after caesarean section

297

Management of labour after a caesarean section

298

Prelabour, term rupture of theme mbranes

298

Diagnosis of prelabour term rupture of the membranes

298

Risks of prelabour term rupture of the membranes

298

Management

298

Further reading

298

Chapter 31 Instrumental and operative delivery

300

Forceps or ventouse delivery

300

Ventouse

300

Obstetric forceps

300

Safety of ventouse and forceps

300

Indications for instrumental vaginal delivery

301

Prevention of instrumental vaginal delivery

301

Types of instrumental vaginal delivery

301

Low-cavity delivery

302

Mid-cavity delivery

302

Prerequisites for instrumental vaginal delivery

302

Failure of instrumental vaginal delivery

303

Caesarean section

303

Indications

303

Safety and complications of caesarean section

304

Further reading

305

Chapter 32 Obstetric emergencies

307

Shoulder dystocia

307

Definition and consequences

307

Risk factors and prevention

307

Management

307

Cord prolapse

307

Definition and consequences

307

Risk factors and prevention

307

Management

308

Amniotic fluid embolism

308

Definition and consequences

308

Risk factors

308

Management

308

Uterine rupture

308

Definition and consequences

308

Risk factors and prevention

309

Management

309

Other obstetric emergencies

309

Uterine inversion

309

Epileptiform seizures

309

Local anaesthetic toxicity

310

Massive antepartum haemorrhage

310

Massive postpartum haemorrhage

310

Pulmonary embolus

310

Further reading

310

Chapter 33 The puerperium

311

Physiological changes in thepuerperium

311

The genital tract

311

The cardiovascular system

311

The urinary tract

311

The blood

311

General postnatal care

311

Lactation

312

Physiology

312

Management

312

Primary postpartum haemorrhage

312

Definition and epidemiology

312

Aetiology

313

Prevention

313

Clinical features

313

Management

313

Other problems of the puerperium

314

Secondary PPH

314

Postpartum pyrexia

314

Thromboembolic disease

314

Psychiatric problems of the puerperium

315

Hypertensive complications

315

The urinary tract

315

Perineal trauma

316

Bowel problems

316

Further reading

316

Chapter 34 Birth statistics and audit

318

Audit

318

Perinatal mortality

318

Definitions and terms in the UK

318

Perinatal mortality rate

318

Risk factors for perinatal mortality

318

Causes of perinatal mortality

318

Maternal mortality

319

Definitions

319

Maternal death rate

319

Factors affecting maternal death rates

320

Causes of maternal mortality

321

Intervention in pregnancy and labour

321

Reasons why the caesarean rate is high

322

Further reading

322

Chapter 35 Legal (UK) and ethical issues in obstetrics and gynaecology

324

Consent

324

Consent to procedures

324

Refusal of medical treatment

324

Consent by children

324

Clinical negligence

325

Negligence claims in the UK

325

Avoiding litigation

325

Clinical governance

326

Risk management

327

Complaints procedure

327

Confidentiality

327

Regulation of fertility treatment

327

Reducing multiple births

327

Embryo testing

327

Embryo research

327

Regulation of abortion

327

Some ethical issues in obstetrics and gynaecology

328

Is there a right to have children?

328

Choosing embryos

328

Abortion

328

Further reading

329

Gynaecology management

331

Obstetric management

345

Appendix 1

361

Appendix 2

365

Index

367

EULA

379