Investigations In Gynaecology

Investigations range from the very simple to the highly sophisticated and complex and are outlined in Table 49.8. A mid-stream specimen of urine should always be sent for culture and sensitivity prior to further investigation. Although the patient's symptoms are unlikely to be caused by a urinary tract infection, they can be altered by one, and catheterization in the presence of an infection could result in septicaemia. In addition, the results of the investigations themselves may be inaccurate...

Gynaecologist Conclusion

We must not underestimate women's desire for a high quality of life in the menopause. Women will continue to demand HRT or a safe, effective alternative for their symptoms. It is, therefore, our duty to strive to provide the best therapy for women to achieve this goal. With every new study there appears to be a change in advice given by the regulatory agencies as to how we should advise our patients, leading to a great deal of confusion. Best practice should involve the following 1 Discussion...

Haemorrhage

Obstetric haemorrhage is one of the most common causes of major maternal morbidity and mortality 1,20,21 and the most recent triennial report raises the unhappy truth that these deaths have increased (from 7 in 1997-1999 to 17 in 2000-2002) due to a rise in post-partum haemorrhages (CEMACH). The confidential enquiries into maternal deaths in the UK have highlighted repeatedly the importance of clear local procedures and policies to trigger rapid and appropriate responses which should be...

Barrier methods

Barrier methods work by preventing the passage of sperm into the female genital tract. The male condom remains one of the most popular methods of contraception in the UK, 27 of couples use it as their main method (Table 32.1). Use increased significantly after the mid-1980s because of concern over the spread of HIV and AIDS. The latex condom is cheap, widely available over the counter and with the exception of the occasional allergic reaction, is free from side effects. Polyurethane condoms...

Fertility awareness methodsnatural family planning

Few couples in the UK use so-called natural methods of family planning (NFP) although in some parts of the world these methods are common. All involve the avoidance of intercourse during the fertile period of the cycle (periodic abstinence). Methods differ in the way in which they recognize the fertile period. The simplest is the calendar or rhythm method in which the woman calculates the fertile period according to the length of her normal menstrual cycle. The first day of the fertile period...

Epidemiology

In the general population, conception is expected to occur in 84 of women within 12 months and in 92 within 24 months (te Velde et al. 2000). Infertility is defined as the inability to conceive after one to two years of unprotected intercourse (Hull et al. 1985). Data from population-based studies suggest that 10-15 of couples in the Western world experience infertility (Templeton et al. 1990 Evers, 2003). Half of them (8 ) will subsequently conceive without the need for specialist advice and...

Deeply infiltrating disease

Rectovaginal Peritoneal Cavity

Several hypotheses explain the aetiology of DIE nodules which extend > 5 mm beneath the peritoneum and may involve the uterosacral ligaments, vagina, bowel, bladder and ureters. Donnez et al. suggested these are a form of adenomyosis arising in Mullerian rests in the rectovaginal septum 6 . Koninckx and Martin described three macroscopic types 7 . Type I (conical lesions with the largest area exposed to the peritoneal cavity) result from infiltration of superficial disease they should be...

Alternatives to HRT

In December 2004, the European Medicines Agency ruled that HRT should no longer be used as a first line treatment for osteoporosis. This advice was mirrored by the MHRA in the UK who proclaimed that the long-term risks of HRT outweighed the benefits and that alternative preparations should be used for osteoporosis prophylaxis and treatment. The National Institute for Clinical Excellence (NICE) has recently carried out a technology appraisal for three of the main alternatives to HRT,...

Mechanical heart valves

Most women with prosthetic heart valves have sufficient cardiovascular reserve to accomplish pregnancy safely. The optimal strategy for anticoagulation in women with metal heart valve replacements in pregnancy is controversial since the interests of the mother and the fetus are in conflict. These women require life-long anticoagulation and this must be continued in pregnancy because of the increased risk of thrombosis. If the international normalized ratio (INR) is meticulously controlled...

Presentation and assessment

In general primary dysmenorrhoea appears 6-12 months after the menarche when ovulatory cycles begin to become established. The early cycles after the menarche are usually anovular and tend to be painless. The pain usually consists of lower abdominal cramps and backache and there may be associated gastrointestinal disturbances such as diarrhoea and vomiting. Symptoms occur predominantly during the first 2 days of menstruation. The diagnosis of primary dysmenorrhoea is one of exclusion (Table...

Induction of labour for prolonged pregnancy

Obstetricians have responded in various ways to the apparently increased perinatal mortality and morbidity associated with prolonged pregnancy. Management options include induction at term to prevent pregnancies reaching 42 weeks, routine induction at 42 weeks or shortly before and selective induction at 42 weeks in cases identified by tests as being at risk of adverse outcome. Fortunately, the benefits and hazards of some of these strategies have been evaluated in randomized controlled trials....

Invasive prenatal diagnosis

Once a woman has been given a high risk of aneuploidy based on a Down screening, a structural anomaly detected on scan or because of her previous history an obstetrician would normally counsel the women on the options of invasive karyotyping. This counselling should be based on the Table 17.4 Meta-analysis performed by Wimalasundera et al. 6 T 21 ( ) T18 ( ) T 13 ( ) 45XO ( ) Other ( ) 22q11 deletion Cardiomyopathy Cardiosplenic syndromes DIV Data expressed as overall rate of aneuploidy ( ) for...

Incontinence of urine

Urinary incontinence will occur in many women immediately following delivery and approximately 15 of women will have urinary incontinence which persists for 3 months after birth 8 . However, a recent study by Glazener et al. 9 showed that three quarters of women with urinary incontinence 3 months after childbirth still have this 6 years later. Urinary incontinence is more frequently seen following instrumental delivery and least frequently seen after elective Caesarean section. Urinary fistulae...

Nonsteroidal antiinflammatory drugs

The central role for prostaglandins and inflammatory cytokines in the aetiology of preterm labour suggests that non-steroidal anti-inflammatory drugs (NSAIDs) may be beneficial in preventing preterm delivery. NSAIDs work largely by inhibition of the cyclo-oxygenase enzymes which catalyse the synthesis of prostaglandins. However, various NSAIDs also have other mechanisms of action including effects on intracellular signalling pathways and on transcription factors including NF-kappa B. There are...

Key points

CHC is available in a range of delivery systems. The main action of CHC is to suppress ovulation. The length of the hormone-fnt free interval is crucial to efficacy. The COC reduces the risk of ovarian and endometrial cancer by 50 . CHC is contraindicated in women with arterial and venous disease. Third generation progestogens may increase the risk of venous thromboembolism. Current users of the COC have an increased risk of breast cancer (RR 1.24). The perfect-use failure rate for the COC is...

Ovarian endometriomas

Several variants on the implantation and metaplasia theories have been proposed to account for ovarian endometri-omas. It has been suggested that superficial lesions on the ovarian cortex become inverted and invaginated, and that endometriomas are derived from functional ovarian cysts or metaplasia of the coelomic epithelium covering the ovary. Endometriomas have features in common with neoplasia such as clonal proliferation, which is consistent with the endometriosis disease theory, and they...

Counselling and preassessment for abortion

Gestation is a major determinant of options available for terminating a pregnancy and a decision is usually reached by the woman in consultation with her medical carers and pregnancy counsellors. The termination method chosen has to be acceptable to the woman as well as being safe and effective. Full guidelines on good practice for the care of women requesting induced abortion have been published by the Royal College of Obstetricians and Gynaecologists (RCOG) 8 . Choice is an integral part of...

Advantages of breastfeeding

Enteromammary Pathway

Human milk is not a constant substancebecausecolostrum differs from mature milk and the milk of the early puerperium differs from the milk of late lactation. Indeed, the content of milk varies at differing stages of the same feed. Nevertheless, the approximate concentrations of human milk and cow's milk show substantial differences (Table 10.6) with human milk having less protein but more fat and lactose. A number of specific components also differ between human milk and formulae, such as the...

Frozen embryo replacement cycle

The first pregnancy resulting from a frozen human embryo was in 1985 and since then the use of frozen cycles has increased dramatically. Freezing surplus morphologically normal embryos allows the use of those embryos which otherwise may have been wasted. It therefore gives double benefit from one fresh cycle and significantly adds the cumulative conception rate per cycle when surplus embryos are frozen. Normally embryos are frozen on day 2 after the selected ones have been replaced fresh, but...

Physiology of lactation

Anterior Release Test

At puberty, the milk ducts which lead from the nipple to the secretory alveoli are stimulated by oestrogen to sprout, branch and form glandular tissue buds from which milk-secreting glands will develop (Fig. 10.2). During pregnancy, this breast tissue is further stimulated so that pre-existing alveolar-lobular structures hypertrophy and new ones areformed. At thesametimemilk-collecting ducts also undergo branching and proliferation. Both oestrogen and progesterone are necessary for mammary...

Epithelium of the genital tract

The anterior abdominal wall including the vulva, vagina and perineal areas are lined with squamous epithelium. The epithelium lining the endocervix and uterine cavity is columnar and the squamocolumnar junction usually arises at the ectocervix in women of reproductive age. This is an important site as it is the area from which cervical intraepithelial neoplasia (CIN) and eventually cervical malignancy arises. The bladder is lined by transitional epithelium which becomes columnar. The anal verge...

Trends in infant feeding in the UK

Because of the many advantages of breastfeeding, it is important that mothers are given accurate information and encouraged to breastfeed successfully whenever possible. Conversely, mothers who choose to bottle feed should be given proper instructions on best practice and to be supported in their decision. In the UK, about 69 of mothers overall start to breastfeed but many discontinue after a short time. The prevalence of breastfeeding in the UK in 2002 is shown in Table 10.7 and the figures...

The adrenal gland

Both the plasma total and the unbound cortisol and other corticosteroid concentrations rise in pregnancy from about the end of the first trimester. Concentrations of cortisol-binding globulin double. Excess glucocorticoid exposure in utero appears to inhibit fetal growth in both animals and humans. However, the normal placenta synthesizes a pregnancy-specific 11b-hydroxysteroid dehydrogenase, which inhibits transfer of maternal cortisol. The marked rise in secretion of the mineralocorticoid...

Urethral pressure profilometry

Detrosor Overactivity

The resting urethral pressure profile (UPP) is a graphical record of pressure within the urethra at successive points along its length. A number of measurements can be Fig. 49.11 Videocystourethrography demonstrating urodynamic stress incontinence. Subtracted filling cystometry showing no evidence of detrusor overactivity and synchronous screening demonstrating urethral sphincter incompetence on coughing. Fig. 49.11 Videocystourethrography demonstrating urodynamic stress incontinence....

Screening for maternal complications

Maternal iron requirements increase in pregnancy because of the demands of the developing fetus, the formation of the placenta and the increase in the maternal red cell mass. With an increase in the maternal plasma volume of up to 50 there is a physiological drop in the haemoglobin (Hb) concentration during pregnancy. It is generally recommended that an Hb level below 11 g dl up to 12 weeks' gestation or less than 10.5 g dl at 28 weeks signifies anaemia and warrants further investigation. A low...

Puerperal psychological disorders

Mild pyschological and transient depression is extremely common in the few days post-partum. This transient state of tearfulness, anxiety, irritation and restlessness has been variously described as 'the blues' and it may occur in up to 70 of women. It is usually resolved by day 10 post-natally and is probably associated with disruptive sleep patterns and the adaptation and anxiety of having a newborn baby. The changes in steroid hormone levels that occur immediately following delivery are not...

Specific cardiac conditions

Asymptomatic acyanotic women with simple defects usually tolerate pregnancy easily. Many defects will have been treated surgically or by the interventional paedi-atric cardiologist but others are first discovered during pregnancy. Women with congenital heart disease are at increased risk of having a baby with congenital heart disease, and should therefore be offered genetic counselling if possible before pregnancy 8 and detailed scanning for fetal cardiac anomalies with fetal echocardiography...

Caesarean section

Delivery of the baby by an abdominal and uterine incision known as Caesarean section (CS) is increasingly used for safe delivery for fetal or maternal reasons either electively or as an emergency. A small proportion is contributed by maternal request for non-medical reasons 16 or by monetary incentives 17 . Advent of blood transfusion with minimal incidence of cross reactions, improved anaesthesia, aseptic and antiseptic techniques and the invention of antibiotics have made it a safe procedure....

Endocrine investigations Table 391

A baseline assessment of the endocrine status should include measurement of serum prolactin and gonadotropin concentrations and an assessment of thyroid function. Pro-lactin levels may be elevated in response to a number of conditions, including stress, a recent breast examination, or even having a venepuncture. The elevation, however, is moderate and transient. A more permanent, but still moderate elevation (greater than 700 mIU 1) is associated with hypothyroidism and is also a common finding...

Genetics of PCOS

The PCOS has long been noted to have a familial component 11 . Genetic analysis has been hampered by the lack of a universal definition for PCOS. Most of the criteria used for diagnosing PCOS are continuous traits, such as, degree of hirsutism, level of circulating andro-gens, extent of menstrual irregularity, and ovarian volume and morphology. To perform genetic analyses these continuous variables have to be transformed into nominal variables. Family studies have revealed that about 50 of...

Defining the polycystic ovary Fig 393

Normal Ovaries Ultrasound

Polycystic ovaries are commonly detected by ultrasound or other forms of pelvic imaging, with estimates of the prevalence in the general population being in the order of 20-33 8,9 . Although the ultrasound criteria for the diagnosis of polycystic ovaries have not, until now, been universally agreed, the characteristic features are accepted as being an increase in the number of follicles and the amount of stroma as compared with normal ovaries, resulting in an increase in ovarian volume. The...

Conditions in which pregnancy is contraindicated

There are some medical conditions in which pregnancy is contraindicated. There is a general reluctance to instruct women not to get pregnant as ultimately it is their decision. In the presence of pulmonary hypertension with up to a 50 risk of mortality it is reasonable to give explicit advice against conception and advise on contraception Antiepileptic drugs 13,16 Valproate 17 Probably all trimesters Uncertain (evidence mainly relates to first trimester) First trimester Warfarin embryopathy...

Anovulation

Insulin Pump Overweight Women

Women should be made aware of potential risks of multiple pregnancy and ovarian hyperstimulation. Male factor problems and tubal pathology should be excluded. In the absence of a history suggestive of tubal disease it may be reasonable to defer formal tubal patency tests for three cycles to allow less invasive treatment options such as clomifene to be used. In women with weight loss associated amenorrhoea, treatment should be deferred until a target BMI of 20 kg m2 is reached. The most...

References

Jeremy K, Luise C, Bourne T (2001) The characterization of common ovarian cysts in premenopausal women. Ultrasound Obstet Gynecol 17,140-44. 2. Timmerman D, Schwarzler P, Collins WP Claerhout P Coenen M Amant F et al (1999) Subjective assessment of adenexal masses using ultrasonography an analysis of intraobserver variability and experience. Ultrasound Obstet Gynecol 13,11-16. 3. Timmerman D (2004) The use of mathematical models to evaluate pelvic masses, can they beat an expert operator Best...

Augmentation of the active phase of labour

The active phase of labour may be augmented routinely, as in the 'active management of labour' introduced by O'Driscoll and co-workers in the 1960s 15 or selectively when labour progress is considered to be inadequate and the cause thought to be inadequate uterine efficiency. The active management of labour involved stringent criteria for the diagnosis of labour, amniotomy, oxytocin infusion and a commitment to the labouring woman of one-to-one presence of a member of the health-care team, and...

Diagnostic categories in infertility

Although single aetiologies may occur, some of these categories (e.g. anovulation and male factor) may coexist, and this will need to be taken into account when planning investigations or treatment. Table 45.3 Classification of disorders of ovulation ' Hypogonadotrophic Hypo-oestrogenic Normoprolactinaemic WHO type I Normogonadotrophic Normo-oestrogenic Normoprolactinaemic WHO type II Hypergonadotrophic Hyper-oestrogenic Normoprolactinaemic WHO type III Hyperprolactinaemic Low FSH* Normal...

Ovarian pregnancy

Ovarian Suspension Surgery Pictures

Ovarian pregnancy is defined as the implantation of the conceptus on the surface of the ovary or inside the ovary, away from the fallopian tubes. There are no direct risk factors associated with primary ovarian pregnancy. The role of IUCD as a direct risk factor for ovarian pregnancy is unclear 53 . The role of pelvic inflammatory disease and assisted reproduction as predisposing factors is also not clear. Chance might also have played a role in some cases, as recurrent cases of ovarian...

Health consequences of polycystic ovary syndrome

Obesity and metabolic abnormalities are recognized risk factors for the development of ischaemic heart disease (IHD) in the general population, and these are also recognized features of PCOS. The question is whether women with PCOS are at an increased risk of IHD, and whether this will occur at an earlier age than women with normal ovaries. The basis for the idea that women with PCOS are at greater risk for cardiovascular disease is that these women are more insulin resistant than...

PCOS in younger women

The majority of studies which have identified the risk factors of obesity and insulin resistance in women with PCOS have investigated adult populations, commonly including women who have presented to specialist endocrine or reproductive clinics. However, PCOS has been identified in much younger populations 9 , in which women with increasing symptoms of PCOS, however, were found to be more insulin resistant. These data emphasize the need for long-term prospective studies of young women with PCOS...

Peritoneal endometriosis

Peritoneal endometriosis comprises superficial lesions scattered over the peritoneal, serosal and ovarian surfaces. Table 44.1 Prevalence rates at laparoscopy for different indications Table 44.1 Prevalence rates at laparoscopy for different indications American Society for Reproductive Medicine revised classification of endometriosis Stage 11 (mNd) 6-15 Laparoscopy_ Laparotomy_ Photography_ Stage 111 (moderate)16-40 Recommended treatment_ *If the fimbriated end of the fallopian tube is...

Therapeutic options

There is general agreement now that patients should be started on the minimum effective dose of oestradiol, increasing the dose only if needed to alleviate symptoms. Although there is no direct evidence that higher doses of exogenous oestrogen are associated with increased risk of breast cancer or heart disease there is a link with venous thromboembolic risk. Importantly, lower doses of oestrogen are less likely to produce breast tenderness and bleeding problems which will reduce continuance of...

Virilization

Acanthosis Nigrigans Vulva

A testosterone concentration greater than 5 nmol l should be investigated to exclude androgen secreting tumours Fig. 39.1 Acanthosis nigricans, as seen typically in the skin folds (axilla, neck, elbow, vulva). Reproduced from Infertility in Practice, 2nd edn., Balen & Jacobs, Churchill Livingstone 2003, with permission. Fig. 39.1 Acanthosis nigricans, as seen typically in the skin folds (axilla, neck, elbow, vulva). Reproduced from Infertility in Practice, 2nd edn., Balen & Jacobs,...

Patient assessment

The diagnosis of the menopause can usually be ascertained from a characteristic history of the vasomotor symptoms of hot flushes and night sweats and prolonged episodes of amenorrhoea. Measurement of plasma hormone levels in patients with classical symptoms are unnecessary, expensive, time consuming and of little clinical significance. However, in the young patient or in a woman after hysterectomy, where the diagnosis is more difficult and the metabolic implications are serious, measurement of...

Aetiology of primary amenorrhoea

From a clinical aspect it is probably best to classify the aetiologies of primary amenorrhoea based on the presence or absence of secondary sexual characteristics. This will be used as the basis of a classification system (Table 38.1), and finally there is a group of patients in whom there is heterosexual development. Table 38.1 Classification of primary amenorrhoea Secondary sexual characteristics normal Imperforate hymen Transverse vaginal septum Absent vagina and functioning uterus Absent...

Structural uterine abnormalities

The prevalence and reproductive implications of uterine anomalies in the general population have not been clearly established. Hence, it is difficult to assess the contribution that congenital uterine anomalies make to RM. The prevalence of uterine anomalies among women with RM has been reported to range between 1.8 and 37.6 30 . This wide range reflects the differences in criteria and techniques used for diagnosis and the fact that available studies have included women with two, three or more...

Introduction

Assisted conception is the facilitation of natural conception by some form of scientific intervention. It has been available for many years, but one of the first recorded and possibly best known instances of assisted conception was that performed by the eminent surgeon, John Hunter, in London in 1785. The husband, in this infertile couple, had hypospadias and artificial insemination of ejaculated sperm was performed on the wife. This resulted in a successful pregnancy and subsequent birth. This...

What the clinician needs to know about dialysis patients

Dialysis and the prospects for pregnancy and afterwards Despite reduced libido and relative infertility, women on dialysis can conceive and must therefore use contraception if they wish to avoid pregnancy. Although conception is not common (an incidence of 1 in 200 patients has been quoted), its true frequency is unknown because most pregnancies in dialysis patients probably end in early spontaneous abortion. The high therapeutic abortion rate in this group of patients, (although decreased from...

Vaginal delivery

Internal Podalic Version

Mode of delivery has traditionally been decided on the presentation of the first twin (cephalic in 70 , breech in 30 ), and fetal growth and well-being. Caesarean section has been advised where the first twin is breech, based on extrapolation from the term breech trial, and the desire to avoid the rare interlocking with head entrapment of a presenting breech above a second cephalic twin. The presentation of the second twin is of little relevance until after the birth of the first. Parturients...

Chorionicity and zygosity

Zygosity And Chorionicity Twins

Two thirds of twins are dizygous (DZ) and one third MZ. However, chorionicity, not zygosity, mediates the degree of perinatal risk in any individual multiple pregnancy. Perinatal mortality is 2-3 times higher in monochorionic Fig. 20.1 UK data showing temporal trend since 1985 in incidence of twin (solid line, left y axis) and triplet pregnancies (dashed line, right y axis) 1000 maternities (Source UK Office National Statistics). Triplet pregnancies 1000 maternities NOp p p jp nC > nC > r r...

What the clinician needs to know about chronic renal disease

Consensus now is that provided non-pregnant renal function is only mildly compromised, proteinuria not in the nephrotic range (3 g 24 h) and hypertension absent or minimal, then obstetric outcome is usually successful with little or no adverse effect on long-term renal prognosis. Renal dysfunction and the prospects for pregnancy and afterwards A woman may lose up to 50 of her renal function and still maintain an Scr less than 130 mol l because of hyperfiltration by the remaining nephrons but if...

Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHHS) can occur in any IVF cycle, but usually is only mild to moderate. Severe OHHS can be life threatening and should happen in less than 2 of cases. It generally occurs in specific at-risk groups, in particular in young patients who have polycystic ovaries. In these situations the starting dose of gonadotrophins should be lowered to take account of the increased sensitivity of the polycystic ovaries. Even in the best centres with the adequate monitoring...

Treatment

Pessary Ring Removal

Some women elect for non-surgical treatment of their prolapse either because 1 the prognosis offered for treatment is not sufficiently attractive 3 they wish to delay surgical treatment for other reasons. Conservative treatment may involve Lifestyle advice. This may include advice on diet and weight loss including avoidance of caffeine containing drinks, water intake, fibre content, laxative use and modification of drug regimes, e.g. diuretics. Avoidance of high-impact exercise and lifting may...

Endometriosisassociated pain symptoms

Severe dysmenorrhoea, deep dyspareunia, chronic pelvic pain, ovulation pain, cyclical or perimenstrual symptoms - often bowel or bladder related, causing dyschezia or dysuria - with or without abnormal bleeding, and chronic fatigue have all been associated with endometrio-sis. However, the predictive value of any one symptom or set of symptoms is uncertain as each can have other causes, and many affected women are asymptomatic. There is little correlation between disease stage and the type,...

Epidemiology of chronic pelvic pain

Initial reports relied on estimates from hospital series, naturally unrepresentative of the general population. Some population sample survey data are available a US study reported the responses of women interviewed by telephone 1 . The age range of respondents was 18-50. 17,927 households were contacted, 5325 women agreed to participate and of these 925 reported pelvic pain of at least 6 months' duration, including pain within the past 3 months. Having excluded those pregnant or...

Precocious puberty

Precocious puberty is defined as the onset of secondary sexual characteristics prior to the age of 8 years. The aetiology of this is varied, as seen in Table 37.2. In the vast majority of girls the cause is unknown. This idiopathic group constitutes 95 of all cases of precocious puberty. It is likely that this is solely due to initiation of the normal process of puberty at a premature age. As discussed in p., the onset is genetically predetermined. If this genetic determinant is inappropriately...

Uterine packing

Uterine Inversion

This is useful for placental bed bleeding but can also be used with uterine atony when there is an element of uterine tone present. The technique is not new, but rather than using a gauze pack an inflatable balloon has the advantage of being quick and expandable. Various balloon catheters have been reported for this technique including the Sengstaken-Blakemore, but the urological Rusch balloon catheter is cheaper and effective 23 . The balloon of a normal urinary catheter itself is not suitable...

Anterior Asynclitism

Asynclitism

Fig. 24.1 Anteroposterior diameters of the vertex in the well-flexed head (suboccipito-bregmatic - usually OA positions) and slightly deflexed head (occipito-frontal - usually occipito-posterior or transverse positions). (Reproduced from the 1st edition of Dewhurst's textbook of Obstetrics and Gynaecology for Postgraduates.) posterior - vice versa) when the saggital suture may be shifted more posteriorly or anteriorly (Fig. 24.2). Extension of the head with asynclitism presents a larger...

Alan Farthing

Thoracic Dermatone

This chapter aims to summarize the important aspects of the anatomy of the abdomen and the pelvis, which should be known to the Obstetric or Gynaecological specialist. Many of the investigations and treatments we order on a daily basis require good anatomical knowledge in order to be properly understood. The anterior abdominal wall can be divided into four quadrants by lines passing horizontally and vertically through the umbilicus (Fig. 1.1). In the upper abdomen is the epigastrium, which is...

High order multiples

Perinatal risk increases exponentially with increasing fetal number. Most high-order multiple pregnancies are the result of ART and thus should be preventable with closer monitoring of follicular response and stricter controls on IVF. Although triplet rates have fallen in several Northern European countries including the UK, there is still much work to be done in proscribing three embryo transfers in other settings. Every woman with a high-order multiple pregnancy should be counselled about the...

Karyotype and other tests

Woman Who Have Lost 100lbs With Pcos

Women with premature ovarian failure under the age of 40 years may have a chromosomal abnormality e.g. Turner's syndrome 45X, or 46XX 45X mosaic or other sex chromosome mosaicisms Plate 39.1 facing p. 562 . A number of genes have also been associated with familial POF, but are not assessed in routine clinical practice. An autoantibody screen should also be undertaken in women with a premature menopause, although it can be difficult to detect antiovarian antibodies many will have evidence of...

In vitro fertilization

Cumulus Oocyte Cultures

IVF is where the mature oocyte is surgically removed from the ovary and then fertilized with sperm in the laboratory. The world's first successful IVF baby was delivered by Patrick Steptoe in 1978 after a number of years collaborating with Robert Edwards. Over the last 25 years the success rates and types of IVF have greatly improved and at present there are well over 2 million babies born throughout the world by this technique. Severe tubal disease - tubal blockages Initially simple forms of...

Biochemical measurements

Pseudosac Ectopic

Serum human chorionic gonadotropin hCG measurements have traditionally been used as a secondary investigation in women with suspected ectopic pregnancy in whom ultrasound examination has failed to identify an Fig. 14.3 A longitudinal section through the uterus showing a normal early intrauterine pregnancy at 5 weeks' gestation. The sac is surrounded by a well-defined layer of trophoblast tissue and thick decidua. Fig. 14.4 Uterine cavity distended with fluid resembling an intrauterine pregnancy...

Urethral Pressure Profile

Rhabdosphincter

Extrinsic compression of the bladder by uterine fibroids uninhibited detrusor contraction and associated leakage Fig. 49.12 Videocrystourethrography Images. Bladder trabeculation, diverticulae and right sided vesico-ureteric reflux Multiple diverticulae, bladder trabeculation and an unprovoked contraction with leakage taken allowing an objective comparison of urethral function between patients and also before and after treatment. Although the concept of measuring the urethral pressure profile...

Clinical presentation

Rupture Ectopic Pregnancy

The clinical presentation of ectopic pregnancy is very variable and reflects the biological potential of pregnancy to develop beyond a very early stage. This in turn is largely determined by the location of pregnancy within the tube. In general, more proximal implantation to the uterine cavity shows more advanced development. Ampullary ectopics, which represent 70 of all tubal ectopics, rarely develop beyond a very early stage and clinical symptoms of tubal abortion may be present as early as 5...

Anterior vaginal wall prolapse

Anterior Vaginal Prolapse

In 1909, White 7 described the vaginal paravaginal repair to repair a cystocoele see Fig. 48.4 . Four years later Kelly 8 described the anterior vaginal repair with a central plication of the pubocervical fascia see Fig. 48.4 . The Kelly operation became the treatment of choice for anterior prolapse partly because of the simplicity of the procedure and partly because of Kelly's high standing in the surgical community. Debate about the relative merits of the Kelly type repair and the paravaginal...

Posterior vaginal wall prolapse

Posterior Wall Prolapse

The classical posterior vaginal repair involves not only plication of the fascia underlying the vaginal skin but also a central plication of the fascia overlying the pubo-coccygeus muscle even including the muscle itself. There can be little doubt that inclusion of the pubococcygeus fascia and muscle will create a more solid repair with accompanying intra- and post-operative morbidity but it is unclear whether the functional outcome is better. Kahn and Stanton 10 performed a 2-year follow-up of...

Performing surgical abortion

Good technique is fundamental and aseptic technique should be observed with careful and gentle instrumentation to avoid injury to cervix or uterus. The operation itself is straightforward with low complication rates but skill and experience are important so that serious complications are quickly recognized and remedied. Precise techniques vary among operators. After confirming the position, size and shape of the uterus by bimanual examination, it is usual to apply a volsellum or tenaculum to...

Termination of pregnancy

Although some conditions are amenable to fetal treatment, neonatal correction or surgery in infancy, for chromosomal anomalies and many structural abnormalities there is no treatment and the management issues are essentially limited to termination versus continuation of pregnancy. Unless the abnormality is trivial, termination of pregnancy is a management option that should be discussed in parental counselling. The RCOG Report on Termination of Pregnancy for Fetal Abnormality 17 advises that...

Infertility

Human Uterus And Polyps

Ultrasound has made significantimprovementin the modern management of infertility. It has a role in the initial assessment of the infertile woman, in monitoring of treatment cycles and the performance of ultrasound guided procedures. Fig. 36.13 Appearance of a normal early pregnancy of 8 weeks 1 day gestation. Fig. 36.13 Appearance of a normal early pregnancy of 8 weeks 1 day gestation. A TV ultrasound allows assessment of the uterus for any obvious abnormalities or for the presence endometrial...

Radiology investigations

Transvaginal ultrasound of the pelvis may be useful where there is diagnostic difficulty. There are no features, however, which are pathognomonic of acute PID. Free fluid in the Pouch of Douglas is a common normal finding and is therefore not helpful. Scanning may help to exclude ectopic pregnancy, ovarian cysts or appendicitis and can also identify dilated fallopian tubes or a tubal abscess. More recent work with power Doppler has suggested that inflamed and dilated tubes and tubal ovarian...

Milkejection reflex

Milk Ejection Reflex And Breastfeeding

Successful breastfeeding depends as much upon effective milk transfer from the breast to the baby as upon adequate Fig. 10.4 Pathway of oxytocin release from the posterior pituitary gland. Fig. 10.4 Pathway of oxytocin release from the posterior pituitary gland. milk secretion. The milk-ejection reflex is mediated by the release of oxytocin from the posterior pituitary gland see Fig. 10.4 . Oxytocin causes contraction of the sensitive myoepithelial cells which are situated around the...

Cervical function

With improved survival at early gestational ages, there is now overlap between second trimester pregnancy loss and early preterm delivery. Historically cervical incompetence was diagnosed in women who experienced persistent, often rapid and painless, late second trimester pregnancy loss. More recently the concept of cervical competence as a continuum has evolved. It is probable that cervical length Table 21.2 and strength together with the quality of the cervical mucus contribute towards the...

Intrapartum management

Delivery Breech Primigravida

Careful selection of patients for assisted vaginal delivery is essential to achieve optimal outcome. Frank and complete breech with fetal weights lt 4000 g are favoured while those with footling should be advised regarding increased chance of cord prolapse. Pelvic adequacy should not be in doubt and clinical estimation appears adequate with no evidence to suggest that CT or X-ray pelvimetry increases the chance of success. Spontaneous onset of labour is preferred. Induction of labour with...

Pregnancies located below the internal os cervical and Caesarean scar ectopics

Caesarean Scar Pregnancy

Cervical pregnancy is defined as the implantation of the conceptus within the cervix, below the level of the internal os. Caesarean scar pregnancy is a novel entity, which refers to a pregnancy implanted into a deficient uterine scar following previous lower segment Caesarean section 48 . Prior to the introduction of high resolution transvaginal scanning, the distinction between cervical and Caesarean section scar pregnancies was not possible. In older literature 33 of 'cervical' pregnancies...

Cardiotocography and biophysical assessment

Umbilical Artery Doppler Normal Values

The most reproducible method of assessing the fetal heart rate FHR is by computerized FHR analysis several software packages exist which allow storage, comparison Fig. 19.5 Assessment of umbilical artery Doppler. a Normal umbilical artery Doppler flow velocity waveform, b absent end-diastolic flow, c reversed end-diastolic flow. Fig. 19.5 Assessment of umbilical artery Doppler. a Normal umbilical artery Doppler flow velocity waveform, b absent end-diastolic flow, c reversed end-diastolic flow....

The respiratory system

Functional Residual Capacity

Tidal volume rises by 30 in early pregnancy to 40-50 above non-pregnant values by term, with a fall in expiratory reserve and residual volume Fig. 2.3 6 . Neither FEV1 nor peak expiratory flow rate are affected by pregnancy, even in women with asthma. The rise in tidal volume is largely driven by progesterone, which appears to decrease the threshold and increase the sensitivity of the medulla oblongata to carbon dioxide. Respiratory rate does not change, so the minute ventilation rises by a...

Surgery

Clam Cystoplasty

For those women with severe detrusor overactivity which is not amenable to simple types of treatment, surgery may be employed. In the clam cystoplasty 234, 235 the bladder is bisected almost completely and a patch of gut usually ileum equal in length to the circumference of the bisected bladder about 25 cm is sewn in place Fig. 49.30 . This often cures the symptoms of detrusor overactivity 236 by converting a high-pressure system into a low-pressure system although inefficient voiding may...

Complete mole

In the majority of CMs all of the genetic material is male in origin and results from the fertilization of an 'empty' Genetic origin of hydatidiform moles A single sperm with 23 chromosomes fertilizes an egg with 23 chromosomes All 46 chromosomes are from the father May involve one or two sperm This results in a triploid conceptus with 69 chromosomes Dispermic complete mole Fig. 15.1 Genetic formation of hydatidiform moles. Fig. 15.1 Genetic formation of hydatidiform moles. oocyte lacking...

Weightrelated amenorrhoea

Weight can have profound effects on gonadotropin regulation and release. Weight and eating disorders are also common in women. A regular menstrual cycle will not occur if the BMI is less than 19 kg m2. Fat appears to be critical to a normally functioning hypothalamic-pituitary-gonadal axis. It is estimated that at least 22 of body weight should be fat to maintain ovulatory cycles 47 . This level enables the extra ovarian aromatization of andro-gens to oestrogens, and maintains appropriate...

Definition of fetal growth disorder

Fetal growth disorder is strictly defined as the failure of a fetus to grow according to its genetic potential. In practice this is never known and fetal growth is defined on the basis of the expected dimensions of the infant in relation to its gestational age. At birth, these measurements can be made directly. In fetal life, ultrasound is employed see p. 164 . Defining whether a given value of a continuous variable is normal, whether weight or an ultrasonic measurement, involves identifying a...

Pelvic floor Figs 19 and 110

Levator Ani Muscle

The obturator internus muscle sits on the medial side of the ischial bone and, together with the body of the pubis, forms a wall that supports the origins of the pelvic floor. The pelvic floor itself is a sling of various muscles which are pierced by the urethra, the vagina and the anal canal. Posterior to the vagina these muscles form the perineal body. The puborectalis muscle forms a sling around the junction of the anus and rectum and posterior to the anus, these fibres are made up by the...

Effect of induction of labour on risk of Caesarean section

Sanchez-Ramos et al. 63 report that induction of labour is associated with a reduction of the rate of Caesarean section odds ratio 0.88 95 CI 0.78-0.99 . Crowley reported a similar outcome, but interpreted it as evidence that a policy of 'routine' induction of labour does not increase the likelihood of Caesarean section. She believed that a postrandomization bias in the Hannah trial may have weighted the results towards a spurious reduction in risk of Caesarean section. Women in the expectant...

Instrumental vaginal deliveries

The incidence of instrumental vaginal deliveries IVD varies from 6 to 12 and depends on the institution and the population. Commonest indications are delay in the second stage of labour, poor maternal effort and fetal distress including cord prolapse in the second stage of labour. Maternal indications include severe cardiac, respiratory or hypertensive disease or intracranial pathology where bearing down effort may be detrimental for her health. Prolonged second stage may be due to inadequate...

Lacunar stage [12

At day 8-9 postconception, the syncytiotrophoblast generates a number of fluid-filled spaces within its mass. These spaces flow together forming larger lacunae lacunar stage and are finally separated by parts of the syncytiotro-phoblast trabeculae that cross the syncytial mass from the embryonic to the maternal side. The development of the lacunar system leads to the subdivision of the placenta into its three compartments. 1 the embryonically oriented part of the trophoblast will develop into...

Determination of gestational age

Accurate dating of pregnancy is important for a number of reasons, each of them constituting milestones which are more important than the prediction of the actual EDD itself 1 Antenatal screening. Values for serum tests for chromosomal abnormalities e.g. Down's syndrome , PAPP-A, HCG or oestriol are strongly related to gestational age and may give false readings if the 'dates' are wrong. This can result in missing that a pregnancy is at risk, or in providing false positives and in unnecessary,...

Management of puerperium

The morbidity associated with the puerperium is underestimated and an important review Table 10.2 shows that after childbirth mothers have high levels of post-partum problems. Thirty-one per cent of women felt that they had major problems for up to 8 weeks post-partum. In trying to reduce the impact of this morbidity there are a number of principles which need to be applied in planning post-natal care. These include 1 Continuity of care. An ideal pattern of care is one that offers continuity...

Secondary sexual characteristics normal

The imperforate hymen may present at two ages of development. It may present in early childhood when the infant presents with a bulging hymen behind which is a muco-cele, the vagina expanded by vaginal secretions of mucus. This is easily released and does not subsequently cause any problems following hymenectomy. It may also present in later life when a pubertal girl complains of intermittent abdominal pain, which is usually cyclical. The pain is due to dysmenorrhoea associated with the...

Trophoblast cell columns [12

Intervillous Space

During penetration of the syncytial trabeculae, the cytotro-phoblast cells reach the maternal endometrial tissues while the following mesenchymal cells do not penetrate Trophoblastic cell column O Interstitial trophoblast O Intramural endovacular trophoblast Trophoblastic cell column O Interstitial trophoblast O Intramural endovacular trophoblast Fig. 3.3 Schematic representation of the developing embryo and its surrounding tissues at about 8-10 weeks of pregnancy. The amnionic cavity with the...

Counselling for women with medical disorders

Women with serious medical disorders require specific care and counselling prior to pregnancy. The aim is to provide seamless care from chronic disease state to early conception to delivery and back to long-term care. This has not been achieved within many traditional patterns of care. The aims of prepregnancy care in this context are outlined in Table 5.2. It is important for women with certain medical problems that consideration is given to first trimester complications. Women with bleeding...

The role of ultrasound

Dermoid Cyst Benign Ultrasound

Ultrasound is an extension of the clinical examination in gynaecology it is unlikely that a woman with a normal pelvic examination and negative ultrasound has a significant gynaecological abnormality. Ultrasound should only be used when there is a clinical question to be answered. Incidental findings such as ovarian cysts are not uncommon in asymptomatic women and if ultrasound findings are taken in isolation they can be misleading. Ultrasound is of paramount importance in evaluating a...

What the clinician needs to know about kidney allograft recipients

Transplantation and the prospects for pregnancy and afterwards Renal, endocrine, and sexual functions return rapidly after transplantation and assisted conception techniques are also available. About 1 in 50 women of childbearing age with a functioning transplant become pregnant during their remaining childbearing era. Of the conceptions, about 25 do not go beyond the initial trimester because of spontaneous or therapeutic abortion, but of those pregnancies in well women that do, 97 end...

Doppler ultrasound

Pulsed and colour Doppler ultrasound are valuable techniques for placental assessment. Umbilical cord flow can be seen at 7-8 weeks, though end-diastolic flow EDF is not established until 14 weeks. Early-onset IUGR pregnancies may be characterized by absent EDF in the umbilical arteries 41 , associated with small malformed placentas, and defective angiogenesis in the gas-exchanging terminal placental villi 42 . Amajor role for Doppler ultrasound in placental assessment is to determine maternal...

Fetal arterial and venous Doppler

The decision to deliver a small for gestational age infant is based on a combination of investigations. Fetal arterial and venous Doppler assessment has shown itself to be useful and reproducible in tracking the cardiovascular responses to hypoxia and acidaemia in the fetuses compromised through uteroplacental insufficiency. Fetal vessels most commonly assessed are the umbilical and middle cerebral arteries, thoracic aorta and the ductus venosus. Meta-analysis of randomized controlled trials...

Detrusor overactivity

Cystometrogram Picture

Detrusor overactivity is defined as a urodynamic observation characterized by involuntary contractions during the filling phase which maybe spontaneous or provoked 2 . It is the second commonest cause of urinary incontinence in women and accounts for 30-40 of cases. The incidence is higher in the elderly and after failed incontinence surgery. The actual cause of detrusor overactivity is unknown and in the majority of cases it is idiopathic, occurring when there is a failure of adequate bladder...

Intrauterine device

Seven copper-containing intrauterine devices IUD are currently available in the UK. Six have a plastic frame with copper wire wound round the stem or copper sleeves on the end of the arms. The amount of copper varies from 250 to 375 mm2. One IUD is frameless GyneFix and consists of six copper beads on a nylon thread. A knot at the top end of the thread is inserted into the fundal myometrium, the top and bottom copper beads are crimped to hold the string of beads in place. In all devices a tail...

Investigations

What Pipelle Endometrial Aspirator

A full blood count should be performed in all women complaining of menorrhagia, since it is a common cause for anaemia 1 . Ferritin is not recommended routinely. Testing for bleeding disorders should only be undertaken if clinically indicated, for example, menorrhagia since the menarche and a history of bleeding after dental extractions and childbirth 4,6 . Thyroid function tests should only be undertaken if clinically indicated. No other endocrine investigations are warranted. Transvaginal...

Haemolytic disease of the newborn

The Rh antigens on red cells result from the action of two genes RhD and RhC RhE , leading to two haplo-types combining c or C, D or no D, e or E . Of these, RhD is the most important in obstetrics. Around 15 of Caucasians are RhD negative. If an RhD negative mother carries an RhD positive child, the transplacental passage of blood and immunoglobulin may result in the development of maternal anti-RhD antibody that passes to the fetus. Indeed, there is a one in six chance of maternal anti-RhD...

Temporary causes of urinary incontinence

Lower urinary tract infections cystitis or urethritis may uncommonly cause incontinence of urine which is temporary and will resolve once treatment with the appropriate antibiotics has been employed. Diuretics, especially in the elderly, may also be responsible for urgency, frequency and incontinence. In older people, anything which limits their independence may cause urge incontinence where only urgency existed before. This applies particularly to immobility, and if an older person is unable...

Epidemiology of fetal growth disorder

The epidemiological associations with delivering an SGA infant are tabulated Table 19.1 . These can be classified as primarily genetic, environmental or mixed genetic and environmental, although clearly the distinctions are not absolute. Similar factors will be involved in determining a large fetus, although the associations will clearly be reversed. Fetal growth may also be affected by pathological processes. These in turn can be classified as maternal disease, abnormalities of the placenta...

Diseasespecific QoL questionnaires

To improve the sensitivity of QoL questionnaires disease-specific tools have been developed to assess particular medical conditions more accurately and in greater detail Table 49.5 . The questions are designed to focus on key aspects associated with lower urinary tract symptoms whilst scoring is performed so that clinically important changes can be detected. In general, perhaps the best solution when assessing women with urinary incontinence is to use a generic and a disease-specific...