BOOK
BMJ Clinical Review: Obstestrics and Gynaecology
Doctor Babita Jyoti | Mrs Eleftheria Kleidi
(2016)
Additional Information
Book Details
Abstract
Translating genomics into improved healthcare
Pre-implantation genetic testing
Cell-free fetal DNA and RNA in maternal blood: implications for safer antenatal testing
Preventing transmission of maternally inherited mitochondrial DNA diseases
Contraception for women: an evidence based overview
Pre-pregnancy care
Abortion
Diagnosis and management of ectopic pregnancy
Diagnosis and management of first trimester miscarriage
Gestational trophoblastic disease: current management of hydatidiform mole
The management of teenage pregnancy
Management of nausea and vomiting in pregnancy
Advising on travel during pregnancy
Skin disease in pregnancy
Obstetric anal sphincter injury
Managing perineal trauma after childbirth
Postpartum management of hypertension
Diagnosis and management of premenstrual disorders
Managing unscheduled bleeding in non-pregnant premenopausal women
Screening and treatment of Chlamydia trachomatis infections
Endometriosis
Developing role of HPV in cervical cancer prevention
Endometrial cancer
Assessment and management of vulval pain
Chronic pelvic pain in women
Dr Babita Jyoti is a Radiation Oncologist with a special interest in Paediatric Proton Therapy. She graduated in Medicine in India followed by training in UK and obtained MRCP (UK) & FRCR (UK).
She trained as a Clinical Oncologist at Clatterbridge Cancer Centre. She is currently working at the University of Florida Health Proton Therapy Institute in Paediatric Proton Therapy. She has been a PBL tutor and an OSCE examiner at Manchester Medical School.
Mrs Eleftheria Kleidi is a Specialty Registrar in Upper Gastrointestinal Surgery at Leighton Hospital, Crewe. She qualified from the Medical School of the University of Crete in 2004. After her foundation years, she started her training in general surgery in Athens and obtained her CCT in 2013. Since then, she has been specialising in UGI surgery and Bariatrics and was awarded the scholarship of the College of Surgeons of Greece for training in the UK. She completed her PhD in Bariatrics at the University of Athens in 2015.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Book Cover | C | ||
| Title | i | ||
| Copyright | ii | ||
| About the publisher | iii | ||
| About The BMJ | iii | ||
| Contents | iv | ||
| About the editors | vi | ||
| Introduction to Obsetrics and Gynaecology | vii | ||
| Prepregnancy care | 1 | ||
| Why should prepregnancy advice become an integral part of healthcare services? | 1 | ||
| What lifestyle changes should a woman planning pregnancy consider? | 1 | ||
| Which infections can harm the fetus? | 1 | ||
| Which drugs should be avoided and which are safe to continue? | 3 | ||
| What advice should be given to a woman with a chronic medical condition? | 3 | ||
| Why is prepregnancy advice important to women with mental health disorders? | 4 | ||
| When should women with a pre-existing medical condition conceive? | 5 | ||
| Should prepregnancy genetic screening be carried out? | 5 | ||
| What is the best way to get pregnant? | 5 | ||
| What is the evidence that prepregnancy health promotion works? | 5 | ||
| Related links | 7 | ||
| Abortion | 8 | ||
| Who can perform abortions? | 8 | ||
| What is the role of counselling before abortion? | 8 | ||
| What medical assessment is required? | 8 | ||
| What methods are available? | 9 | ||
| Surgical abortion | 9 | ||
| Medical abortion | 9 | ||
| Which method of abortion is preferable? | 10 | ||
| How is pain managed during abortion? | 10 | ||
| What are the risks associated with abortion? | 10 | ||
| Ongoing pregnancy | 10 | ||
| Incomplete abortion | 11 | ||
| Haemorrhage | 11 | ||
| Uterine perforation and cervical laceration | 11 | ||
| Infection | 11 | ||
| Long term sequelae | 11 | ||
| What follow-up is needed? | 11 | ||
| What contraceptive methods can be started after an abortion? | 12 | ||
| Diagnosis and management of ectopic pregnancy | 15 | ||
| What is ectopic pregnancy? | 15 | ||
| What causes ectopic pregnancy and who is at risk? | 15 | ||
| How is ectopic pregnancy diagnosed? | 15 | ||
| Clinical findings | 15 | ||
| Ultrasound | 16 | ||
| Serum biochemistry | 16 | ||
| Surgery and histopathology | 16 | ||
| How is ectopic pregnancy treated? | 16 | ||
| Referral | 16 | ||
| Surgery | 17 | ||
| Medical treatment | 17 | ||
| Expectant management | 17 | ||
| Does ectopic pregnancy affect future fertility? | 17 | ||
| What are the recommendations from clinical guidelines? | 17 | ||
| Psychological support | 18 | ||
| Diagnosis and management of first trimester miscarriage | 20 | ||
| What is miscarriage? | 20 | ||
| What causes miscarriage? | 20 | ||
| How is miscarriage diagnosed? | 20 | ||
| Clinical findings | 20 | ||
| How can ultrasound help diagnose miscarriage? | 21 | ||
| Early fetal demise | 21 | ||
| Incomplete miscarriage | 21 | ||
| Complete miscarriage | 21 | ||
| What is the role of biochemical markers? | 21 | ||
| What is the role of surgery and histology? | 22 | ||
| Is it possible to prevent miscarriage? | 22 | ||
| How is miscarriage managed? | 22 | ||
| When to refer? | 22 | ||
| Expectant management | 22 | ||
| Medical management | 22 | ||
| Surgical treatment | 22 | ||
| Choice of treatment | 23 | ||
| What to expect during the recovery period? | 23 | ||
| What are the psychological needs of women who miscarry? | 23 | ||
| What do clinical guidelines recommend? | 23 | ||
| Gestational trophoblastic disease: current management of hydatidiform mole | 26 | ||
| How common is gestational trophoblastic disease? | 26 | ||
| What is hydatidiform mole and who gets it? | 26 | ||
| How does gestational trophoblastic disease present clinically? | 26 | ||
| How is a diagnosis of gestational trophoblastic disease made? | 26 | ||
| How are hydatidiform moles initially managed? | 26 | ||
| What is the risk of malignancy and should women be screened? | 27 | ||
| What factors increase the risk of malignant progression of hydatidiform mole? | 28 | ||
| Who needs chemotherapy after hydatidiform mole? | 28 | ||
| What happens to patients referred for specialist treatment? | 28 | ||
| Follow-up after chemotherapy | 29 | ||
| Are cases of hydatidiform mole missed in the UK and should we worry? | 29 | ||
| How should gestational trophoblastic disease be screening for and treated in developing countries? | 29 | ||
| The management of teenage pregnancy | 32 | ||
| How common is teenage pregnancy? | 32 | ||
| Who is more likely to be a teenage mother? | 32 | ||
| What are the medical considerations in teenage pregnancies? | 32 | ||
| What are the social considerations of teenage pregnancy? | 33 | ||
| Can teenage pregnancy be prevented? | 33 | ||
| Who is involved in caring for teenage mothers? | 33 | ||
| How should teenage mothers be cared for during pregnancy? | 34 | ||
| Dietary considerations | 34 | ||
| Avoidance of smoking, alcohol, and drugs | 34 | ||
| Screening for sexually transmitted infections | 34 | ||
| Family involvement | 34 | ||
| What are the needs of teenage mothers in the postnatal period? | 34 | ||
| Management of nausea and vomiting in pregnancy | 37 | ||
| Who gets hyperemesis gravidarum? | 37 | ||
| What is the underlying pathophysiology of nausea and vomiting in pregnancy? | 37 | ||
| How is hyperemesis gravidarum diagnosed? | 38 | ||
| What are the treatment options? | 38 | ||
| Diet and supplements | 38 | ||
| Intravenous fluids, vitamin supplements, and thromboprophylaxis | 38 | ||
| Antiemetics | 39 | ||
| Corticosteroids | 39 | ||
| Summary of antiemetic use | 40 | ||
| Clinical model of care in nausea and vomiting in pregnancy | 40 | ||
| Conclusion | 40 | ||
| Advising on travel during pregnancy | 43 | ||
| What are usual restrictions on travel in pregnancy? | 43 | ||
| Who is at increased risk of adverse outcome and when? | 43 | ||
| First trimester | 43 | ||
| Second trimester | 43 | ||
| Third trimester | 43 | ||
| What are the specific risks associated with air travel? | 43 | ||
| Miscarriage and preterm birth | 43 | ||
| Venous thromboembolism (box 2) | 44 | ||
| Exposure to radiation | 44 | ||
| Low oxygen saturation | 44 | ||
| What are the risks from communicable diseases? | 44 | ||
| Travellers’ diarrhoea (box 3) | 44 | ||
| Malaria in pregnancy | 45 | ||
| Other infections | 45 | ||
| What pre-travel advice should you give after assessing risk? | 45 | ||
| Women considering air travel | 45 | ||
| Women consulting early in pregnancy | 45 | ||
| Women consulting after the first trimester | 45 | ||
| Extended travel abroad and advice on travel insurance | 46 | ||
| Travel to a malaria endemic country | 46 | ||
| Are travel vaccinations safe in pregnancy? | 46 | ||
| Considerations in the returning pregnant traveller | 46 | ||
| Skin disease in pregnancy | 48 | ||
| Why is skin disease common in pregnancy? | 48 | ||
| What are the specific dermatoses of pregnancy? | 48 | ||
| Pemphigoid gestationis | 48 | ||
| Polymorphic eruption of pregnancy | 48 | ||
| Atopic eruption of pregnancy | 49 | ||
| Algorithmic approach to the specific dermatoses of pregnancy | 49 | ||
| How are the specific dermatoses of pregnancy treated? | 49 | ||
| What are the other common skin diseases in pregnancy? | 50 | ||
| Inflammatory skin diseases | 50 | ||
| Psoriasis vulgaris | 50 | ||
| Acne vulgaris | 50 | ||
| Acne rosacea | 50 | ||
| Pityriasis rosea | 50 | ||
| Urticaria | 51 | ||
| Erythema nodosum | 51 | ||
| Skin infections and infestations | 51 | ||
| Herpes simplex virus | 51 | ||
| Varicella zoster virus | 51 | ||
| Scabies | 51 | ||
| Autoimmune skin diseases | 52 | ||
| Systemic lupus erythematosus | 52 | ||
| Pemphigus vulgaris | 52 | ||
| Skin tumours | 52 | ||
| Benign melanocytic naevi | 52 | ||
| Malignant melanoma | 52 | ||
| What drugs can be used systemically in pregnancy? | 53 | ||
| What are the recommendations for use of topical corticosteroids? | 53 | ||
| Diagnosis and management of subclinical hypothyroidism in pregnancy | 56 | ||
| Introduction | 56 | ||
| Definition of subclinical hypothyroidism | 56 | ||
| Thyrotropin and free thyroxine ranges in different trimesters | 56 | ||
| Thyrotropin and free thyroxine ranges in different countries | 56 | ||
| Measurement of free thyroxine | 57 | ||
| Causes of hypothyroidism | 57 | ||
| Prevalence of subclinical hypothyroidism | 58 | ||
| Iodine deficiency in pregnancy | 58 | ||
| Impact of subclinical hypothyroidism on pregnancy outcome and intellectual development of the fetus | 58 | ||
| Pregnancy complications excluding neuro-intellectual development | 58 | ||
| Neurologic and intellectual complications | 59 | ||
| Studies that included women with subclinical hypothyroidism or overt hypothyriodism | 60 | ||
| Treatment of subclinical hypothyroidism | 60 | ||
| Women without pre-existing hypothyroidism | 60 | ||
| Women with pre-existing hypothyroidism | 60 | ||
| Maintenance and monitoring of levothyroxine therapy | 61 | ||
| Recommendations | 61 | ||
| Application in clinical practice | 61 | ||
| Screening for thyroid disease in pregnancy | 61 | ||
| Geographic considerations | 62 | ||
| Future studies | 62 | ||
| Conclusion | 62 | ||
| Preterm birth and the role of neuroprotection | 66 | ||
| Introduction | 66 | ||
| Incidence | 66 | ||
| Preterm birth | 66 | ||
| Epidemiology | 66 | ||
| Survival of preterm neonates | 66 | ||
| Neurodevelopmental consequences of prematurity | 66 | ||
| Cerebral palsy | 66 | ||
| Definition and risk factors | 66 | ||
| Pathophysiology | 67 | ||
| Incidence | 67 | ||
| Other neurodevelopmental consequences of prematurity | 67 | ||
| Motor dysfunction | 67 | ||
| Sensorineural hearing loss and blindness | 68 | ||
| Cognitive and academic outcomes | 68 | ||
| Pathophysiology of preterm birth and perinatal brain injury | 68 | ||
| Prevention of preterm birth: progesterone | 69 | ||
| Neuroprotective effects of progesterone | 69 | ||
| Neuroprotection with corticosteroids | 69 | ||
| Definition of viability and changing use of steroids | 70 | ||
| Neuroprotection with magnesium sulfate | 70 | ||
| Concerns over the use of magnesium sulfate | 70 | ||
| Magnesium: mechanism of action | 71 | ||
| Evidence supporting the use of magnesium | 71 | ||
| Protocol development | 72 | ||
| Emerging treatments | 72 | ||
| N-acetylcysteine | 72 | ||
| Erythropoietin | 72 | ||
| Melatonin | 72 | ||
| Umbilical cord blood stem cells | 72 | ||
| Summary of emerging treatments | 73 | ||
| Conclusion | 73 | ||
| Obstetric anal sphincter injury | 76 | ||
| What is obstetric anal sphincter injury and how can it be recognised? | 76 | ||
| How many women get it? | 76 | ||
| Why might the incidence be underestimated clinically? | 76 | ||
| What are the risk factors for obstetric anal sphincter injury? | 76 | ||
| How is obstetric anal sphincter injury managed after childbirth? | 77 | ||
| Repair of the anal sphincter | 77 | ||
| What is the optimum method of repair? | 77 | ||
| Additional treatment: antibiotics and laxatives | 77 | ||
| How should third and fourth degree perineal tears be followed up? | 78 | ||
| Tools for assessing the problem | 78 | ||
| What problems are associated with obstetric anal sphincter injury? | 78 | ||
| What is the prognosis for these patients? | 78 | ||
| What influences the prognosis? | 79 | ||
| What is the advice for future deliveries? | 79 | ||
| What is the role of caesarean section? | 79 | ||
| Training | 79 | ||
| Managing perineal trauma after childbirth | 81 | ||
| What is perineal trauma? | 81 | ||
| How common is it? | 81 | ||
| What are the risk factors? | 81 | ||
| How should perineal trauma be managed in the immediate post-delivery period? | 81 | ||
| Recommended repair technique and material for perineal trauma | 81 | ||
| Perineal repair training | 82 | ||
| What is the approach to assessment and management in primary care? | 82 | ||
| What are the complications of childbirth related perineal trauma? | 83 | ||
| Infection | 83 | ||
| Wound dehiscence | 83 | ||
| Excessive granulation tissue formation | 84 | ||
| What is the impact of childbirth related perineal trauma on sexual function? | 84 | ||
| What is the role of pelvic floor muscle exercises for women with perineal trauma? | 85 | ||
| Postpartum management of hypertension | 87 | ||
| What are the normal blood pressure changes during pregnancy and postpartum? | 87 | ||
| How should blood pressure be measured? | 87 | ||
| What causes and known associations should be included when assessing early postpartum hypertension? | 87 | ||
| How quickly should pregnancy associated hypertension resolve? | 87 | ||
| How should new onset postpartum hypertension be identified? | 87 | ||
| Why should postpartum hypertension be identified? | 88 | ||
| How should women with early postpartum hypertension be managed? | 88 | ||
| How should women with postpartum hypertension be managed after discharge? | 88 | ||
| Which antihypertensives should be used? | 88 | ||
| Who should be investigated for secondary hypertension? | 89 | ||
| When should persistent proteinuria be investigated? | 89 | ||
| What are the implications of hypertension in pregnancy for future pregnancies? | 90 | ||
| How should long term health risk be assessed and managed? | 90 | ||
| Diagnosis and management of premenstrual disorders | 93 | ||
| How should symptoms be measured? | 93 | ||
| How are premenstrual disorders diagnosed? | 93 | ||
| How are premenstrual disorders managed? | 93 | ||
| The consultation and treatment planning | 93 | ||
| Which treatments can be effective without suppressing ovulation? | 94 | ||
| Non-drug based treatments | 94 | ||
| Diuretics | 94 | ||
| Psychotropic drugs | 94 | ||
| How can we treat premenstrual disorders using hormones? | 95 | ||
| Hormonal treatment that does not suppress ovulation | 95 | ||
| Treatment by suppression of ovulation | 95 | ||
| Oral contraception | 95 | ||
| GnRH agonist analogues | 95 | ||
| Danazol | 96 | ||
| Estradiol | 96 | ||
| Is surgery a reasonable option? | 97 | ||
| Managing premenstrual disorders in general practice | 97 | ||
| Managing unscheduled bleeding in non-pregnant premenopausal women | 100 | ||
| Who gets unscheduled bleeding? | 100 | ||
| What causes unscheduled bleeding? | 100 | ||
| Intermenstrual bleeding | 100 | ||
| Postcoital bleeding | 101 | ||
| Breakthrough bleeding with hormonal contraception | 102 | ||
| How should I evaluate a woman with unscheduled bleeding? | 102 | ||
| Examination | 103 | ||
| Investigations | 103 | ||
| What is the role of ultrasound? | 103 | ||
| When is endometrial biopsy indicated? | 103 | ||
| How should I investigate women aged 20-24 years not on hormonal contraception? | 104 | ||
| How should women with abnormal bleeding while using hormonal contraception be investigated? | 104 | ||
| What treatment will be required? | 104 | ||
| How do I treat bleeding associated with contraception? | 104 | ||
| Screening and treatment of Chlamydia trachomatis infections | 107 | ||
| How common is chlamydia infection and who gets it? | 107 | ||
| How common are the serious consequences of chlamydia infection? | 107 | ||
| Chlamydia infection in women | 107 | ||
| Chlamydia infection in men | 107 | ||
| Infection in pregnancy | 107 | ||
| Other sequelae | 107 | ||
| How effective is screening for chlamydia infection? | 107 | ||
| What strategies can help to control chlamydia? | 108 | ||
| An opportunistic screening approach | 108 | ||
| What does testing for chlamydia involve? | 109 | ||
| Samples | 109 | ||
| Tests | 109 | ||
| Potential effects of chlamydia screening | 109 | ||
| How to manage a positive test result | 109 | ||
| Treating the infected person | 109 | ||
| Treating partners | 109 | ||
| Notifying partners | 109 | ||
| What is the best way to screen for chlamydia infection in community settings? | 110 | ||
| General practice | 110 | ||
| Pharmacies | 110 | ||
| Community sexual reproductive health | 110 | ||
| Innovation within chlamydia screening programmes | 110 | ||
| Conclusion | 110 | ||
| Fibroids: diagnosis and management | 113 | ||
| What are fibroids and where are they found? | 113 | ||
| What controls the growth of fibroids? | 113 | ||
| What is the clinical course of uterine fibroids? | 113 | ||
| How do women with fibroids present? | 113 | ||
| When do fibroids need to be investigated? | 113 | ||
| When should women be referred to secondary care? | 113 | ||
| What imaging investigations are useful in the assessment of fibroids? | 113 | ||
| When do fibroids need to be treated and how do doctors and patients select the best treatment? | 114 | ||
| What treatments can be considered in general practice without referral to specialist care? | 114 | ||
| Which are the most effective medical treatments? | 114 | ||
| What treatments are undertaken in secondary care? | 114 | ||
| Radiological treatments | 114 | ||
| Uterine artery embolisation | 114 | ||
| Surgical treatments | 115 | ||
| Myomectomy | 115 | ||
| Hysterectomy | 117 | ||
| What happens to fibroids during pregnancy? | 117 | ||
| Is there a risk of malignant transformation? | 117 | ||
| Endometriosis | 119 | ||
| What is endometreiosis? | 119 | ||
| What are the causes of endometriosis? | 119 | ||
| What is the natural course of endometriosis? | 119 | ||
| Are any other conditions commonly associated with endometriosis? | 119 | ||
| When should a clinician suspect endometriosis? | 119 | ||
| Pain | 119 | ||
| Infertility | 120 | ||
| What clinical examination is helpful to diagnose endometriosis? | 120 | ||
| What is the role of imaging in the diagnosis of endometriosis? | 120 | ||
| Ultrasonography | 120 | ||
| Magnetic resonance imaging (MRI) | 120 | ||
| Are biomarkers useful in diagnosing endometriosis? | 120 | ||
| What are the indications for laparoscopy? | 120 | ||
| How can endometriosis be treated? | 121 | ||
| Medical treatments to improve pain by suppression of endometriosis | 121 | ||
| Analgesia for pain associated with endometriosis | 121 | ||
| Emerging medical treatments for endometriosis | 121 | ||
| Surgical treatments for pain associated with endometriosis | 121 | ||
| Is there any evidence for complementary therapies in treatment of endometriosis? | 122 | ||
| What is the treatment for infertility associated with endometriosis? | 122 | ||
| Summary of fertility treatment options | 122 | ||
| Potential future treatments for infertility associated with endometriosis | 122 | ||
| What happens if endometriosis recurs after treatment and can recurrence be prevented? | 123 | ||
| Developing role of HPV in cervical cancer prevention | 125 | ||
| Who is at risk of cervical cancer? | 125 | ||
| How effective is cervical screening? | 125 | ||
| What improvements can HPV testing offer? | 125 | ||
| Strategies for exploiting HPV testing in cervical screening programmes | 126 | ||
| Secondary HPV testing (triage) of low grade abnormalities identified by primary cytology, before referral to colposcopy | 126 | ||
| HPV as test of cure after treatment of CIN | 126 | ||
| Use of HPV test as the primary screening test | 126 | ||
| Should women younger than 25 years be screened? | 126 | ||
| What are the HPV vaccines and why are they important? | 127 | ||
| Will vaccination mean that screening becomes unnecessary? | 128 | ||
| How can HPV based strategies benefit women in the developing world? | 128 | ||
| Endometrial cancer | 131 | ||
| Who gets endometrial cancer and what causes it? | 131 | ||
| What types are there? | 131 | ||
| How does a patient with endometrial cancer present? | 131 | ||
| How is the diagnosis made? | 131 | ||
| Referral to a gynaecologic oncology specialist centre | 132 | ||
| FIGO stage I | 132 | ||
| FIGO stages II-IV | 133 | ||
| How is endometrial cancer staged? | 133 | ||
| How is treatment decided? | 133 | ||
| What is the preferred surgical approach? | 133 | ||
| What is the role of radiotherapy and chemotherapy? | 133 | ||
| How should patients be followed up? | 134 | ||
| Diagnosis of ovarian cancer | 136 | ||
| What are the types of ovarian cancer and why is this relevant? | 136 | ||
| What risk factors are associated with ovarian cancer? | 136 | ||
| Epidemiological risk factors | 136 | ||
| Genetic risk factors | 136 | ||
| How do women with ovarian cancer present? | 136 | ||
| When should ovarian cancer be suspected in primary care? | 137 | ||
| Are CA125 tests and ultrasonography reliable? | 137 | ||
| CA125 testing | 137 | ||
| Ultrasonography | 137 | ||
| How can ovarian cancer be detected in premenopausal women? | 137 | ||
| What is the role of screening and prevention strategies? | 138 | ||
| What is recommended for women with a known genetic predisposition? | 138 | ||
| Are there any tests on the horizon? | 138 | ||
| What treatments are available for ovarian cancer? | 138 | ||
| What are the survival statistics? | 139 | ||
| Assessment and management of vulval pain | 141 | ||
| Who get vulval pain and what causes it? | 141 | ||
| Acute vulval pain | 141 | ||
| Chronic vulval pain | 141 | ||
| How should patients with vulval pain be evaluated? | 141 | ||
| History: which questions are important to ask? | 141 | ||
| Examination of a woman with vulval pain | 142 | ||
| What other investigations may be needed? | 142 | ||
| How can vulval pain be managed? | 143 | ||
| Management options in primary care | 143 | ||
| Referral to secondary care | 143 | ||
| How is vulvodynia managed? | 143 | ||
| Drug based treatments | 143 | ||
| Psychological and psychosexual therapy | 144 | ||
| Surgery | 145 | ||
| Chronic pelvic pain in women | 146 | ||
| What is chronic pelvic pain and who gets it? | 146 | ||
| What are the personal and societal costs of chronic pelvic pain? | 146 | ||
| How is chronic pelvic pain diagnosed? | 146 | ||
| What is the initial therapeutic approach for chronic pelvic pain? | 147 | ||
| What are the recommendations from clinical guidelines? | 149 | ||
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