Rapid Obstetrics and Gynaecology E-Book

Misha Moore

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Rapid
• Sprache: Englisch

Seitenzahl: 148

Veröffentlichungsjahr: 2011

Beschreibung

This pocket reference and revision guide is a must for all medical students and junior doctors preparing for major exams in obstetrics and gynaecology or needing a rapid reminder during a clinical attachment. Now thoroughly updated, this second edition has been re-ordered into three sections - covering obstetrics, gynaecology, and procedures – to provide a more systematic and ordered approach to learning that takes into consideration the natural division within the specialty.

Covering all key topics in Obstetrics and Gynaecology, this succinct account of the core and common conditions found in clinical settings and exams is the ideal refresher covering just the basic, relevant facts.

Leseprobe

Contents

Preface

List of abbreviations

Obstetrics

Acute fatty liver of pregnancy

Amniotic fluid embolism

Cardiac disease in pregnancy

Chronic hypertension in pregnancy

Cord prolapse

Diabetes in pregnancy

Eclampsia

Epilepsy in pregnancy

Fetal distress in labour

Group B streptococcal infection

HIV in pregnancy

Infections in pregnancy – chicken pox

Infections in pregnancy – cytomegalovirus

Infections in pregnancy – hepatitis B

Infections in pregnancy – herpes simplex

Infections in pregnancy – listeriosis

Infections in pregnancy – parvovirus B19

Infections in pregnancy – rubella

Infections in pregnancy – toxoplasmosis

Intrauterine death

Intrauterine growth restriction

Malposition

Malpresentation

Multiple pregnancy

Obstetric cholestasis

Oligohydramnios

Placental abruption

Placenta praevia

Polyhydramnios

Postnatal depression

Postpartum haemorrhage

Pre-eclampsia

Prelabour rupture of membranes (PROM) at term

Preterm prelabour rupture of membranes (PPROM)

Preterm labour (PTL)

Prolonged labour

Prolonged pregnancy

Rhesus isoimmunisation

Shoulder dystocia

Venous thromboembolism (VTE) in pregnancy

Gynaecology

Amenorrhoea

Asherman’s syndrome

Atrophic vaginitis

Bartholin’s cyst/abscess

Benign ovarian mass

Carcinoma of the cervix

Carcinoma of the endometrium

Carcinoma of the ovary

Carcinoma of the vulva

Cervical intraepithelial neoplasia

Detrusor overactivity

Dysfunctional uterine bleeding

Dysmenorrhoea

Dyspareunia

Ectopic pregnancy

Endometriosis

Endometritis

Fibroids

Gestational trophoblastic malignancy

Gestational trophoblastic disease (hydatidiform mole)

Gynaecological infections – bacterial vaginosis

Gynaecological infections – Candida albicans

Gynaecological infections – Chlamydia

Gynaecological infections – gonorrhoea

Gynaecological infections – human papilloma virus

Gynaecological infections – syphilis

Gynaecological infections – toxic shock syndrome

Gynaecological infections – Trichomonas vaginalis

Hyperemesis gravidarum

Infertility

Intermenstrual bleeding

Intersex disorders

Menopause

Menorrhagia

Miscarriage

Pelvic inflammatory disease

Polycystic ovarian syndrome (PCOS)

Postcoital bleeding

Postmenopausal bleeding

Premenstrual syndrome

Urodynamic stress incontinence

Uterovaginal prolapse

Procedures

Caesarean section

Colposcopy

Epidural

Episiotomy

Evacuation of retained products of conception (ERPC)

External cephalic version

Fetal blood sampling

Gynaecological laparoscopy

Hysterectomy

Hysteroscopy

Induction of labour

Instrumental delivery

Prenatal diagnosis

Sterilisation (female)

Termination of pregnancy

Urodynamics

Appendices

Obstetric examination

Gynaecological examination

Menstrual cycle

Physiological changes in pregnancy

Normal mechanism of labour

Antenatal care

Intrapartum care

Postnatal care

Contraception

Cardiotocography (CTG)

Neonatal resuscitation

This edition first published 2010, © 2010 by Misha Moore, Sarah-Jane Lam and Adam R KayPrevious edition published 2004

Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been merged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell.

Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial offices:

9600 Garsington Road, Oxford, OX4 2DQ, UKThe Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK111 River Street, Hoboken, NJ 07030-5774, USA

For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell

The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

Library of Congress Cataloging-in-Publication Data

Rapid obstetrics & gynaecology / Misha Moore, Sarah Jane Lam, Adam R. Kay. – 2nd ed.p. ; cm. – (Rapid series)

Other title: Rapid obstetrics and gynaecology

ISBN 978-1-4051-9450-1

1. Obstetrics–Handbooks, manuals, etc. 2. Gynecology–Handbooks, manuals, etc. I. Moore, Misha. II. Lam, Sarah Jane. III. Kay, Adam R. IV. Title: Rapid obstetrics and gynaecology. V. Series: Rapid series. [DNLM: 1. Genital Diseases, Female–Handbooks. 2. Gynecology–Handbooks. 3. Obstetrics–Handbooks. 4. Pregnancy Complications–Handbooks. WQ 39 R218 2010]

RG110.R37 2010

618–dc22

2010010782

ISBN: 9781405194501

A catalogue record for this book is available from the British Library.

Preface

Obstetrics and Gynaecology can be a bewildering new world for both undergraduates and new trainees. Despite your wealth of clinical exposure you can find yourself back to square one, surrounded by brand new diseases and the mystifying territory of the Labour Ward.

The simple and structured nature of Rapid Obstetrics and Gynaecology lends itself extremely well to tackling the subject. By identifying the key topics, and distilling from these the key facts, this book will provide you with firm foundations and we hope to encourage some of you into this most rewarding of specialties.

MM, SJL, ARK

2010

List of abbreviations

ABCairway, breathing, circulationABGarterial blood gasACEangiotensin-converting enzymeACTHadrenocorticotrophic hormoneAFPalphafetoproteinAIDSacquired immune deficiency syndromeAISandrogen insensitivity syndromeAMAanti-mitochondrial antibodiesAPHantepartum haemorrhageARDSacute respiratory distress syndromeARMartificial rupture of membranesASMAanti-smooth muscle antibodiesASDatrial septal defectBMIbody mass indexBPblood pressure bpm beats per minuteBSObilateral salpingo-oophorectomyBVbacterial vaginosisCAHcongenital adrenal hyperplasiaCBTcognitive behavioural therapyCEAcarcinoembryonic antigenCMVcytomegalovirusCNScentral nervous systemCOCPcombined oral contraceptive pillCPDcephalopelvic disproportionCTcomputerised tomographyCTPAcomputerised tomography pulmonary angiogramCTGcardiotocographCVAcerebrovascular accidentCVPcentral venous pressureCVSchorionic villous samplingCXRchest x-rayD&Edilatation and evacuationDICdisseminated intravascular coagulationDVTdeep vein thrombosisEBVEpstein–Barr virusECGelectrocardiogram echo echocardiogramECTelectroconvulsive therapyECVexternal cephalic versionERPCevacuation of retained products of conceptionFBCfull blood countFBSfetal blood samplingFEVforced expiratory volumeFFPfresh frozen plasmaFHfetal heartFHRfetal heart rateFSEfetal scalp electrodeFSHfollicle stimulating hormoneFTA-ABSfluorescent treponemal antibody absorptionGBSgroup B StreptococcusGDMgestational diabetes mellitusGFRglomerular filtration rateGGTgamma glutamyl transferaseGnRHgonadotrophin-releasing hormoneGTTglucose tolerance testG&Sgroup and saveHAARThighly active antiretroviral therapyHbA1cglycosylated haemoglobinHBsAghepatitis B surface antigenHCGhuman chorionic gonadotrophinHGhyperemesis gravidarumHNPCChereditary non-polyposis colon cancerHELLPhaemolysis, elevated liver enzymes, low plateletsHIVhuman immunodeficiency virusHPLhuman placental lactogenHPVhuman papilloma virusHRheart rateHRThormone replacement therapyHSGhysterosalpingogramHSVherpes simplex virusHVShigh vaginal swabICSIintracytoplasmic sperm injectionIMintramuscularIOLinduction of labourIMBintermenstrual bleedingIPPVintermittent positive-pressure ventilationITPidiopathic thrombocytopenic purpuraITUintensive treatment unitIUCDintrauterine contraceptive deviceIUDintrauterine deathIUGRintrauterine growth restrictionIUSintrauterine system (contains levonorgestrel)IUIintrauterine inseminationIVintravenousIVFin-vitro infertilisationJVPjugular venous pressureLFDlarge for datesLFTliver function testsLHluteinising hormoneLLETZlarge loop excision of the transformation zoneLMPlast menstrual periodLMWHlow molecular weight heparinLVEFleft ventricular ejection fractionLVFleft ventricular failureLVSlow vaginal swabMC&Smicroscopy culture and sensitivityMCVmean corpuscular volumeMgSO4magnesium sulphateMMRmeasles, mumps, rubella vaccineMRImagnetic resonance imagingMSmultiple sclerosisMSUmid-stream urineNSAIDSnon-steroidal anti-inflammatory drugsNTnuchal translucencyOAoccipitoanteriorOHSSovarian hyperstimulation syndromeOToccipitotransverseOPoccipitoposteriorPAPP-Apregnancy-associated plasma protein APCBpostcoital bleedingPCOSpolycystic ovarian syndromePCRpolymerase chain reactionPDApatent ductus arteriosusPEpulmonary embolismPEFRpeak expiratory flow ratePETpre-eclamptic toxaemiaPIDpelvic inflammatory diseasePMBpostmenopausal bleedingPOby mouthPOPprogesterone-only pillPPHpostpartum haemorrhagePPROMpre-term premature rupture of membranesPRper rectumPROMprelabour rupture of membranesPTLpreterm labourPVper vaginaRhDRhesus D antigenRMCrecurrent miscarriageRPOCretained products of conceptionRPRrapid plasma reaginSCsubcuticularSERMsselective (o)estrogen receptor modulatorsSFDsmall for datesSHBGsex-hormone binding globulinSLEsystemic lupus erythematosusSROMspontaneous rupture of membranesSSRIselective serotonin reuptake inhibitorSTIsexually transmitted infectionTAHtotal abdominal hysterectomyTFTthyroid function testsTOPtermination of pregnancyTORCHtoxoplasma rubella cytomegalovirus herpes simplexTPHATreponema pallidum haemagglutination assayTSHthyroid stimulating hormoneTTTStwin-to-twin transfusion syndromeTVStransvaginal scanTVTtension-free vaginal tapeU&Eurea and electrolytesUSSultrasound scanUTIurinary tract infectionVDRLVenereal Disease Research LaboratoryVINvaginal intraepithelial neoplasiaV/Qventilation perfusion (scan)VSDventricular septal defectVTEvenous thromoboembolismVZIGvaricella zoster immunoglobulinX-matchcrossmatch

Obstetrics

Acute fatty liver of pregnancy

DEFINITION

Rare pregnancy-associated disorder characterised by fatty infiltration of the liver.

AETIOLOGY

Likely to be due to a mitochondrial disorder affecting fatty acid oxidation.

ASSOCIATIONS/RISK FACTORS

Nulliparity, multiple pregnancy, obesity, male fetus, pre-eclampsia.

EPIDEMIOLOGY

UK prevalence estimated at 5 per 100 000.

HISTORY

Often non-specific, normally in third trimester: nausea, vomiting, abdominal pain, jaundice, bleeding.

EXAMINATION

Liver tenderness, jaundice, ascites, manifestations of coagulopathy. Fifty percent of women will have proteinuric hypertension.

PATHOLOGY/PATHOGENESIS

Accumulation of microvesicular fat in haepatocytes, periportal sparing, small yellow liver on gross examination.

INVESTIGATIONS

Bloods: FBC (assess Hb, haemoconcentration, thrombocytopenia), clotting (↓ synthesis + consumption of clotting factors), LFT (↑ transaminases, mild hyperbilirubinaemia), U&E, glucose (hypoglycaemia common).

MANAGEMENT

Delivery is necessary to halt deterioration. Treatment is supportive: fluid management; correction of hypoglycaemia; blood transfusion as appropriate; correction of coagulopathy with platelets/FFP/cryoprecipitate. Liver transplantation is rarely necessary.

COMPLICATIONS

Maternal: Death, haemorrhage (secondary to DIC), renal failure, hepatic encephalopathy, sepsis, pancreatitis.

Fetal: Death.

PROGNOSIS

Maternal mortality 10–20%; perinatal mortality 20–30%.

Amniotic fluid embolism

DEFINITION

Obstetric emergency in which amniotic fluid and fetal cells enter the maternal circulation causing cardiorespiratory collapse.

AETIOLOGY

Unclear. Entry of amniotic fluid or fetal debris to the maternal circulation provokes either an anaphylactoid reaction or activation of the complement cascade.

ASSOCIATIONS/RISK FACTORS

Often occurs in the absence of identifiable risk factors. Multiparity, ↑ maternal age, Caesarean section, uterine hyperstimulation, use of uterotonics, placental abruption, trauma, termination of pregnancy.

EPIDEMIOLOGY

UK prevalence is 1.8 per 100 000 maternities.

HISTORY

Sudden-onset dyspnoea ± chest pain, ?collapse.

EXAMINATION

Tachypneoa, cyanosis, hypotension, tachycardia, evidence of coagulopathy.

PATHOLOGY/PATHOGENESIS

The precipitating reaction causes pulmonary artery spasm, ↑ pulmonary arterial pressure and ↑ right ventricular pressure, resulting in hypoxia. Hypoxia leads to myocardial and pulmonary capillary damage and LVF. Post mortem reveals fetal squames and debris in the maternal pulmonary circulation.

INVESTIGATIONS

Bloods: ABG, FBC, clotting, U&E, X-match.

Imaging: CXR.

Other: ECG.

MANAGEMENT

Largely supportive; manage in ITU.

Airway: Maintain patency.

Breathing: High-flow oxygen ± intubation.

Circulation: Two large-bore IV cannulae, fluid resuscitation, consider pulmonary artery catheter and ionotropic support, correct coagulopathy with FFP/cryoprecipitate/platelets, blood transfusion if necessary.

Consider delivery.

COMPLICATIONS

Cardiac arrest, death, DIC, seizures, uterine atony and haemorrhage, pulmonary oedema, ARDS, renal failure.

PROGNOSIS

In the UK: 37% mortality, of which 25% occurs within the first hour.

Cardiac disease in pregnancy

DEFINITION

Cardiac disease in a pregnant woman.

AETIOLOGY

Congenital heart disease: PDA, ASD, VSD, coarctation of the aorta, Marfan’s, Fallot’s tetralogy, Eisenmenger’s syndrome.

Acquired heart disease: Valvular defects, ischaemic heart disease.

Cardomyopathies: Including peripartum cardiomyopathy (new-onset cardiomyopathy and heart failure usually within time period of last month of pregnancy and 5 months post-partum).

ASSOCIATIONS/RISK FACTORS

As for cardiac disease in general: family history, obesity, hypertension, smoking, ↑ age, diabetes.

EPIDEMIOLOGY

Increasing prevalence due to ↑ maternal age, ↑ life expectancy for patients with congenital heart disease, ↑ immigrant populations.

HISTORY

Assess new/deterioration of symptoms: SOB, palpitations, orthopnoea, paroxysmal nocturnal dyspnoea, decreased exercise tolerance, chest pain.

EXAMINATION

General: Pulse, BP, JVP, ?oedema, ?cyanosis.

Chest: Heart sounds, murmurs (note: ejection systolic common in pregnancy), basal crepitations.

Abdomen: Fundal height (associated with IUGR).

PATHOLOGY/PATHOGENESIS

Dependent on aetiologies noted above. There is 40% increase in blood volume during pregnancy, hence cardiac strain. Women with cardiac disease are unable to increase cardiac output (uterine hypoperfusion, ↑ risk of pulmonary oedema).

INVESTIGATIONS

Bloods: FBC, U&E, LFT.

Cardiac: ECG, echo.

Fetus: Serial USS for fetal growth, cardiac anomaly scan if there is maternal congenital heart disease.

MANAGEMENT

Dependent on the aetiology.

General: Combined obstetric/cardiology care (tertiary referral centre).

Preconceptual: Assess cardiac status, address risks and absolute contraindications to pregnancy.

Antenatal: Optimise treatment, monitor fetal wellbeing, consider thromboprophylaxis.

Delivery: Consider optimum mode and timing of delivery, consult with anaesthetists, correct positioning, fluid management, consider antibiotic prophylaxis (structural defects).

Post-partum: Increase surveillance (period of haemodynamic change).

COMPLICATIONS

Maternal: Progression of disease, VTE, pulmonary oedema, death.

Fetal: PTL, ↑ congenital heart disease (if maternal congenital heart disease), IUGR, effects of teratogenic drugs for anticoagulation, fetal death.

PROGNOSIS

High risk of maternal mortality if LVEF <40% or LVF. Pulmonary hypertension: 20–50% maternal mortality rate. Eisenmenger’s: 50% maternal mortality rate. Patients with Marfan’s syndrome with aortic root >4–4.5 cm are advised against pregnancy.

Chronic hypertension in pregnancy

DEFINITION

Hypertension that is either present prior to conception (detected before 20/40) or persists after pregnancy.

AETIOLOGY

Essential hypertension in >90–95% (cause unknown). Remainder are secondary to: endocrine (Cushing’s, phaeochromocytoma, CAH), renal (renal artery stenosis, chronic renal disease), vascular (e.g. coarctation of aorta).

ASSOCIATIONS/RISK FACTORS

Increasing age, ethnicity (Afro-Caribbean), obesity, smoking, diabetes, family history, pre-eclampsia.

EPIDEMIOLOGY

Affects 1–5% of pregnancies.

HISTORY

Largely asymptomatic.

EXAMINATION

Blood pressure may be normal in first trimester due to ↓ systemic vascular resistance. Secondary causes include renal bruits, radiofemoral delay.

PATHOLOGY/PATHOGENESIS

Chronic systemic inflammatory response increases susceptibility to pre-eclampsia. Placental pathology similar to pre-eclampsia (arterial occlusive changes, excess villous syncytial knots, infarction etc.) leads to hypoperfusion of the maternal space.

INVESTIGATIONS

Bloods: FBC, U&E, LFT, Urate.

Urinalysis: For proteinuria. If secondary causes are suspected: urinary catecholamines, renal artery USS and so on.

Fetus: Serial USS for fetal growth.

MANAGEMENT

Medication: Convert to non-teratogenic medications: methyldopa, nifedipine, labetalol (note: ACE inhibitors are teratogenic), aspirin 75 mg od (↓ risk of pre-eclampsia/IUGR).

Other: Monitor for pre-eclampsia, serial USS for fetal growth, uterine artery Dopplers at 24/40 (predicts pre-eclampsia).

COMPLICATIONS

IUGR, superimposed pre-eclampsia (25%), placental abruption, prematurity.

PROGNOSIS

Raised maternal and perinatal morbidity is related to superimposed pre-eclampsia.

Cord prolapse

DEFINITION

Descent of the umbilical cord through the cervix past the presenting part in the presence of ruptured membranes: an obstetric emergency.

AETIOLOGY

Potential space (e.g. unengaged presenting part) allows descent of the cord past the presenting part.

ASSOCIATIONS/RISK FACTORS

Breech presentation, abnormal lie, multiple pregnancy (second twin), prematurity, low birthweight, unengaged presenting part, polyhydramnios, ARM.

EPIDEMIOLOGY

Affects 0.1–0.6% of pregnancies.

HISTORY

An abnormal FHR is detected, often after membrane rupture.

EXAMINATION

Cord is felt or seen through the cervix below the presenting part.

PATHOLOGY/PATHOGENESIS

Compression of the cord by the presenting part and arterial spasm prevents blood flow through the cord, causing asphyxia.

INVESTIGATIONS

Unnecessary.

MANAGEMENT

Place patient in Trendelenberg or knee–chest position. Manually elevate the presenting part (this may also be achieved through bladder filling). Emergency delivery is necessary, usually via Caesarean section. The neonatal team should be present at delivery.

COMPLICATIONS

Hypoxic–ischaemic encephalopathy, fetal death.

PROGNOSIS

Perinatal mortality rate is 91 per 1000, higher if it occurs outside hospital.

Diabetes in pregnancy

DEFINITION

Pre-existing or new-onset diabetes in pregnancy.

AETIOLOGY

Pre-existing: Type 1 – failure of pancreas to produce insulin; type 2 – relative insulin deficiency associated with increased peripheral insulin resistance.

Gestational diabetes (GDM): Altered glucose tolerance in pregnancy.

ASSOCIATIONS/RISK FACTORS

GDM: ↑ maternal age, ethnicity (South Asian, Middle Eastern, Afro-Caribbean), obesity, smoking, PCOS, family history, previous macrosomic baby.

EPIDEMIOLOGY

Prevalence is 2–5% but estimates vary. GDM accounts for 90% of diabetes in pregnancy.

HISTORY

Pre-existing: Usually known to mother.

GDM: Usually asymptomatic, detected on screening.

EXAMINATION

Abdomen: Fundal height (macrosomia/polyhydramnios).

PATHOLOGY/PATHOGENESIS

Type I: Autoimmune destruction of pancreatic islet cells.

Type II: Genetic component + influence of age and obesity on peripheral insulin resistance.

GDM: ↑ insulin resistance in pregnancy (↑ secretion of insulin antagonists, including HPL, glucagon and cortisol), altered carbohydrate metabolism, failure of normal pregnancy increase in insulin production.

Fetus: Hyperglycaemia in early pregnancy may affect development (congenital abnormalities); hyperglycaemia causes fetal hyperinsulinaemia and macrosomia.

Neonatal: Hypoglycaemia can occur (withdrawal of maternal glucose while fetal insulin levels remain high).

INVESTIGATIONS

Delivery: Aim for delivery after 38 completed weeks of pregnancy. Sliding scale in labour.

Pre-existing: Detailed anomaly scan, fetal cardiac scan, ophthalmic examination.

GDM: Screening (universal or selective) by GTT at 26–28/40.

MANAGEMENT

Pre-existing

Preconceptual: Optimisation of glucose control.

Medical: Optimise diet, consider converting oral hypoglycaemics to insulin. Likely to require increasing doses of insulin.

Pregnancy: Capillary blood glucose monitoring, monitor for pre-eclampsia, serial USS for fetal growth.

Delivery: Sliding scale in labour.

Postpartum: Return to pre-pregnancy doses of medications.

GDM

Medical: Diet control. Persistent hyperglycaemia may require insulin treatment.

Pregnancy/delivery: As for pre-existing.

Postpartum: Stop insulin after delivery, fasting blood glucose 6/52 postpartum.

COMPLICATIONS

Maternal: Progression of pre-existing nephropathy/neuropathy/retinopathy, miscarriage, pre-eclampsia, operative delivery.

Fetal/neonatal