Basic Sciences for Obstetrics and Gynaecology

212 Pages·1990·7.258 MB·English

by  Tim Chard MD, FRCOG, Richard Lilford MB, BCh, MRCOG, MRCP, PhD (auth.)

Tim Chard · Richard Lilford
Basic Sciences
for Obstetrics
and Gynaecology
Third Edition
With 56 Figures
Springer-Verlag
London Berl in Heidelberg New York
Paris Tokyo Hong Kong
Tim Chard, MD, FRCOG
Professor of Obstetrics, Gynaecology and Reproductive
Physiology, Joint Academic Unit of Obstetrics, Gynaecology and
Reproductive Physiology, St Bartholomew's Hospital Medical
College and The London Hospital Medical College, Department of
Reproductive Physiology, St Bartholomew's Medical College, West
Smithfield, London ECIA 7BE
Richard Lilford, MB, BCh, MRCOG, MRCP, PhD
Professor of Obstetrics and Gynaecology, Department of Obstetrics
and Gynaecology, University of Leeds, St James' University
Hospital, Beckett Street, Leeds LS9 7TF, West Yorkshire
ISBN-13:978-3-540-19591-7 e-TSBN-13:978-1-4471-3340-7
DOl: 10. 1007/978-1-4471-3340-7
British Library Cataloguing in Publication Data
Chard, T. (Tim)
Basic sciences for obstetrics and gynaecology. - 3rd ed
I. Science
I. Title II. Lilford, Richard J.
500
ISBN 35-401959-12
Library of Congress Cataloging-in-Publication Data
Chard, T.
Basic sciences for obstetrics and gynecology/Tim Chard, Richard Lilford, - 3rd ed.
p. cm. Includes bibliographical references.
ISBN 0-387-19591-2 (U.S.: alk. paper)
I. Medical sciences. I. Lilford, Richard, 1950-II. Title
(DNLM: I. Gynecology. 2. Internal Medicine. 3. Obstetrics.
4. Physiology. 5. Reproduction. WQ 100 C47 I b)
R. 129.C44 1990 618-dc20 DNLM/DLC 90-9564
for Li brary of Congress CIP
Apart from any fair dealing for the purposes of research or private study, or
criticism or review, as permitted under the Copyright, Designs and Patents Act
1988, this publication may only be reproduced, stored or transmitted, in any form
or by any means, with the prior permission in writing of the publishers, or in the
case of reprographic reproduction in accordance with the terms of licences issued
by the Copyright Licensing Agency. Enquiries concerning reproduction outside
those terms should be sent to the publishers.
© Springer-Verlag London Limited 1983, 1986, 1990
First published 1983 Second edition 1986 Third edition 1990
The use of registered names, trademarks etc. in this publication does not imply,
even in the absence of a specific statement, that such names are exempt from the
relevant laws and regulations and therefore free for general use.
Product liability: The publisher can give no guarantee for information about drug
dosage and application thereof contained in this book. In every individual case the
respective user must check its accuracy by consulting other pharmaceutical
literature.
Typeset by MJS Publications Printed and bound by The Bath Press
2128/3916-543210 Printed on acid-free paper
Preface to the Third Edition
In the four years since the publication of the second edition this
book has been very well received by those for whom it was
intended - candidates for primary examinations in Obstetrics and
Gynaecology. In consequence, we make no excuse for repeating
the formula of addressing only those facts which are neither
speculative nor contentious. An attempt to widen this brief would
multiply the length of the book by three or four times and would
place it in an identical category with several much larger texts
which we recommend at the end of each chapter to those seeking a
deeper understanding of any particular subject.
As the underlying philosophy remains the same, the main
changes in the third edition are the addition of new material and
revision of existing material. Revision of existing material has
been extensive, with many detailed changes aimed at expanding
the factual base while retaining or improving the clarity of
explanation. In addition, the book is now associated with an MCQ
Tutor which has proved especially popular. Finally, and probably
most important, many of the changes are those which have been
suggested by readers and reviewers of the first and second
editions: this feedback has been invaluable to the authors and we
now hope will be equally valuable to readers of the new edition.
London and Leeds Tim Chard
August 1989 Richard Lilford
Preface to the First Edition
The aim of this book is to provide a straightforward summary of
the knowledge required for preliminary examinations in specialist
obstetrics and gynaecology; the first part of the examination for
Membership of the Royal College of Obstetricians and Gynaeco
logists would be a good example. Thus the field covered is that of
the basic sciences (anatomy, physiology, biochemistry, etc.) as
applied to human reproduction.
Most examinations of this type are based on multiple choice
questions (MCQ). No apology is made for the fact that the present
book addresses the sort of 'fact' which lends itself to testing by this
approach. There is no discussion of speculative or contentious
areas, no account of present or future research and no references.
Excellent books are available which treat the topic in a much fuller
and more discursive manner and the present volume does not seek
to emulate them.
Readers will be aware that even apparently immutable facts are
subject to occasional revision. We have attempted to present the
'state of the art': most of the material is generally if not universally
accepted. A particular problem arises with numerical information.
Virtually every common parameter in physiology and biochemis
try has been the subject of numerous studies, each of which yields
somewhat different results. This applies even to widely used
clinical tests, where every laboratory may have its own normal
range. Thus, with a few exceptions, most of the numbers given in
this book have a 'correction interval' of plus or minus 50%. For
example, if a figure of 10 U per litre is given as the normal level of
substance X, it is likely that any figure between 5 and 15 would be
acceptable. Examiners would be unlikely to set a 'false' statement
which did not lie well outside these limits.
For most purposes we have assumed that the reader has a
background knowledge of the basic sciences equivalent to that of a
medical undergraduate. Thus, for instance, we do not describe the
basic physiology of the cardiovascular system but simply address
the variations associated with fetal development and the maternal
reaction to pregnancy. In dealing with anatomy, we do not attempt
to provide any coherent picture of the structure and contents of
viii Preface to the First Edition
the female pelvis but instead concentrate on those aspects of
morphology which can be described on a 'yes/no' basis. Full,
illustrated descriptions of this topic are widely available elsewhere.
No book of this type can possibly be both encyclopaedic and
practical, and we do not claim to identify every conceivable fact
which might be asked in an examination. Equally, we believe that
we have covered sufficient ground to enable someone of moder
ately retentive memory to obtain a pass mark.
Finally, we hope that the book will also provide an ongoing and
useful source of quick factual reference for all those involved in
human reproductive medicine.
London, March 1983 Tim Chard
Richard Lilford
Contents
Chapter 1 Cell Biology, Embryology and the Placenta ....... ]
The Cell ................................................................... 1
The Genetic Code ...................................................... 4
Chromosome Abnormalities ......................................... 11
Gen~!ics:-Single and Multiple Gene Defects .................... 14
FertIlIsation .............................................................. 17
Cleavage of the Embryo: the Morula and the Blastocyst ...... 18
Implantation of the Blastocyst and Early Development of the
Placenta and Embryo ............................................... 20
Multiple Pregnancy................................. ................ .... 23
Development of the Placenta ........................................ 23
Further Development of the Embryo .............................. 24
The Placenta ............................................................. 28
Placental Synthesis ..................................................... 31
Placental Transfer ...................................................... 32
The Membranes and Amniotic Fluid ............................... 36
Further Reading ........................................................ 38
Chapter 2 Anatomy.............................................. .... 39
The Vulva ................................................................ 39
The Vagina... .............. ............ .................................. 41
The Uterus ............................................................... 42
The Fallopian Tubes ................................................... 45
The Ovaries .............................................................. 45
The Female Urological System ...................................... 46
The Levator Ani Muscles (Pelvic Diaphragm) ................... 48
The Perineum............................................................ 49
Peritoneum and Ligaments of the Pelvis .......................... 50
Blood Supply to the Female Pelvis.................................. 52
Lymphatic Drainage of the Female Pelvis ........................ 53
Nerve Supply to the Female Pelvis.................................. 53
The Pelvic Skeleton .................................................... 54
The Fetal Skull .......................................................... 59
Microstructure and Function of the Non-pregnant
Reproductive Tract.................................................. 60
x Contents
Embryology of the Genital System ................................ . 62
The Anterior Abdominal Wall ..................................... . 66
Further Reading ....................................................... . 68
Chapter 3 General Physiology and Biochemistry ............. . 69
The Cardiovascular System .......................................... . 69
The Lung ................................................................ . 74
The Kidney .............................................................. . 79
The Nervous System .................................................. . 80
The Gut and Nutrition ............................ _ .................. . 80
Metabolism .............................................................. . 82
Immunology ............................................................ . 88
Further Reading ....................................................... . 93
Chapter 4 Endocrinology .......................................... . 94
Some Basic Concepts in Endocrinology .......................... . 94
The·.Hypothalamus .................................................... . 95
The Anterior Pituitary ................................................ . 98
The Posterior Pituitary ............................................... . 103
The Breast and Lactation ............................................ . 104
Sex Steroids ............................................................. . 106
The Ovary ............................................................... . 112
The Testis ................................................................ . 116
Thyroid Gland .......................................................... . 119
The Adrenal Cortex ................................................... . 123
The Adrenal Medulla ................................................. . 126
Hormones Involved in Calcium Homeostasis ...................' . 126
Puberty and Menopause ............................................. . 128
Initiation of Labour ................................................... . 129
The Pineal Gland ...................................................... . 130
Further Reading ....................................................... . 131
Chapter 5 Pathology ................................................. .. 132
Inflammation ........................................................... . 132
Wound Healing ........................................................ . 135
The Metabolic Response to Injury ................................. . 137
Shock ..................................................................... . 138
Tumours ....... ; ......................................................... . 139
Thrombosis and Embolism .......................................... . 148
Deposition of Salts and Pigments .................................. . 151
Effects of Radiation ..................................................... 151
Further Reading ....................................................... . 153
Chapter 6 Microbiology ............................................ .. 154
Bacteria .................................................................. . 154
Viruses ................................................................... . 158
Contents xi
Rickettsial Organisms ................................................. 163
Mycoplasmas (Pleuropneumonia-like Organisms) .............. 163
Fungal Infections ....................................................... 163
Protozoal Infections .................................................... 164
Some Characteristics of Infections at Special Sites .............. 164
Further Reading ........................................................ 165
Chapter 7 Pharmacology... ......... ... . .. ........................... 166
Introduction........................... ........ ........................... 166
Sedative, Hypnotic and Anxiolytic Agents ....................... 166
Antipsychotic Agents .................................................. 166
Antidepressive Agents ................................................. 167
Analgesic Agents ....................................................... 168
Antacid Agents............... .......... ................... . ........ ... .. 168
Laxative Agents ......................................................... 169
Ant~-~meti~ Agents .................................................... 170
Antlhistammes .......................................................... 170
Diuretic Agents ......................................................... 170
Antihypertensive Agents ............................................. 170
Drugs Affecting Blood Coagulation ................................ 171
Chemotherapy of Infection ........................................... 174
Pharmacology of Sex Steroids ....................................... 178
Drugs Affecting Contraction of the Uterus ....................... 182
Anticancer Drugs (Cytotoxic Agents) ............................. 185
General Anaesthetic Agents ......................................... 187
Local Anaesthetic Agents ............................................ 188
Some General Aspects of Pharmacology in Pregnancy ........ 189
Some General Aspects of Pharmacology During Breast
Feeding................. ...... ..... . ... .. . . . . . . ............ ............. 191
Appendix A Statistics. . . . ................ ... . .. . . .... ....... ........... . 192
Further Reading.............. .... .. . . . .................. . ...... . . . . . .... 193
Appendix B Ultrasound ................................................ 194
Subject Index ............................................................ 196
Chapter 1
Cell Biology, Embryology and the Placenta
The Cell
A cell consists of a nucleus, cytoplasm and a cell membrane.
The Nucleus
The nucleus consists of DNA, proteins (histones and acidic proteins) and
one or more nucleoli (largely made up of RNA), and a surrounding bilayer
membrane which is similar in composition to the endoplasmic reticulum.
The Cytoplasm·
The cytoplasm contains a variety of organelles:
1. Mitochondria: These have inner and outer bilayer membranes. The
inner membrane has numerous folds (cristae) which contain the respiratory
enzymes and cytochromes of the Krebs cycle, principal energy source of the
cell (via adenosine triphosphate, ATP). Mitochondria also contain self
replicating DNA. This is arranged in circles, is inherited exclusively from
the mother, and codes for mitochondrial enzymes such as cytochrome
oxidase and ATP synthetase.
2. The cytoskeleton: A system of filaments which are responsible for
shape, motility and contact inhibition. Three kinds of filaments occur:
microtubules (2~27 nm in diameter; contain tubulin and are responsible
for migration of chromosomes and beating of cilia and flagella); inter
mediate filaments (which contain tissue-specific proteins, e.g. cytokeratin in
epithelial cells); and microfilaments (4-12 nm in diameter; contain actin).
3. Lysosomes: Packages of hydrolytic enzymes involved in phagocytosis
and other 'garbage' collection functions.
4. Ribosomes: Granules of RNA; aggregates of ribosomes are polysomes.
5. Endoplasmic reticulum: A system of membranes continuous with
the nuclear envelope and the cell membrane, and enclosing tubules and
2 Basic Sciences for Obstetrics and Gynaecology
cisternae. The wall of the endoplasmic reticulum may be 'smooth' or
'rough', the latter bearing the ribosomes which are responsible for most
protein synthesis within a cell.
6. Golgi complex: A group of smooth membranes enclosing cisternae. All
newly synthesised proteins are directed to the Golgi complex where they are
sorted for their correct intracellular destinations.
The Cell Membrane
The cell membrane is a bimolecular sheet of lipid molecules penetrated by
islands of glycoprotein molecules. Membranes of adjacent cells may fuse
(desmosomes) or communicate via channels (gap junctions) or be closely
apposed as 'tight junctions'. Gap junctions contain pores which allow
passage of molecules up to a molecular weight of 1500; this molecular
interchange is the key to the dev~lopment of the early embryo. Many
epithelial cells have a surface of microvilli (1 ~ in length) which increase
the effective surface area; each microvillus has a core of 40 actin filaments.
Transport Through the Cell Membrane
Differences between intra- and extracellular fluid are summarised in
Table 1.1.
Table 1.1. The chemical composition of extracellular
and intracellular fluids
Extracellular Intracellular
(mEqilitre) (mEqilitre)
Na+ 142 10
K+ 4 140
Ca2+ 5 <1
Mg2+ 3 58
CI- 103 4
HC03- 28 10
Protein 5 40
Glucose 9Omg% 0-30mg%
There are three methods by which molecules cross the cell membrane:
1. Diffusion. Substances which are both water and lipid soluble (02, CO2,
alcohol, fatty acids and certain drugs) diffuse directly across the lipid layer.
Certain small molecules (e.g. water, chloride) diffuse through membrane
pores (8 A) which are associated with the membrane proteins. In the
renal collecting tubules the size of these pores is under the control of
antidiuretic hormone (ADH). Many substances (e.g. glucose and galactose,
but not fructose) cross the membrane rapidly by the process of 'facilitated