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2 American College of Obstetricians and Gynecologists with LEAD AUTHORS Robert Casanova, MD, MHPE, FACOG Adjunct Professor, Department of Medical Education, Assistant Dean for Clinical Sciences Curriculum, Assistant Vice Dean Medical Education Covenant Branch Campus, Texas Tech University Health Sciences Center, Lubbock, Texas Alice Chuang, MD, MEd, FACOG Professor, Department of Obstetrics and Gynecology, Clerkship Director, University of North Carolina School of Medicine, Chapel Hill, North Carolina Alice R. Goepfert, MD, FACOG Professor, Department of Obstetrics and Gynecology, Associate Dean for Graduate Medical Education and Designated Institutional Official, University of Alabama School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama Nancy A. Hueppchen, MD, MSc, FACOG Associate Professor, Department of Gynecology and Obstetrics, Associate Dean for Undergraduate Medical Education, Johns Hopkins University School of Medicine, Baltimore, Maryland Patrice M. Weiss, MD, FACOG Professor, Department of Obstetrics and Gynecology, Virginia Tech Carilion School of Medicine, Executive Vice President and Chief Medical Officer, Carilion Clinic, Roanoke, Virginia ORIGINAL AUTHORS Charles R. B. Beckmann, MD, MHPE, FACOG Former Professor of Obstetrics and Gynecology, Thomas Jefferson University College of Medicine, Former Director, Offices of Ambulatory Care and of OB-GYN Academic Affairs, Department of Obstetrics and Gynecology, Albert Einstein Medical Center, Philadelphia, Pennsylvania Frank W. Ling, MD, FACOG Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine and Meharry Medical College, Nashville, Tennessee; Partner, Women’s Health Specialists, PLLC, Germantown, Tennessee William N.P. Herbert, MD, FACOG Former William Norman Thornton Professor and Chair, Professor Emeritus, Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, Virginia 3 Douglas W. Laube, MD, MEd, FACOG Professor and former Chair, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Past President (2006–2007), American College of Obstetricians and Gynecologists Roger P. Smith, MD, FACOG The Robert A. Munsick Professor of Clinical Obstetrics and Gynecology, Director, Medical Student Education, Director, Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana 4 Acquisitions Editor: Matt Hauber Development Editor: Laura Horowitz/Andrea Vosburgh Editorial Coordinator: Laura Horowitz/Annette Ferran Editorial Assistant: Brooks Phelps Marketing Manager: Mike McMahon Production Project Manager: Bridgett Dougherty Design Coordinator: Steve Druding Manufacturing Coordinator: Margie Orzech Prepress Vendor: Newgen Knowledge Works Pvt. Ltd., Chennai, India 8th edition Copyright © 2019 Wolters Kluwer. Copyright © 2014, 2010, 2006, 2002, 1998, 1995, 1992 by Lippincott Williams & Wilkins, a Wolters Kluwer business. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China 9781496353092 Library of Congress Cataloging-in-Publication Data available upon request This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all 5 medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. LWW.com 6 The new lead authors would like to dedicate the eighth edition to the original authors who paved the way with the first six editions and invited us to collaborate on the seventh. We hope to continue the long tradition with this edition. In addition, we would like to dedicate this edition to the medical students who have inspired us and to the women who, as patients, have entrusted us with their care. Finally, we want to thank our families who supported us through the edits and rewrites. 7 About the Authors Drs. Beckmann and Ling embarked on the project that would become this textbook as a response to the conventional wisdom of the day that medical students should “know all of Williams.” They decided that this was unreasonable and opted to write a “core” textbook based on the APGO Learning Objectives instead. The rules were simple: fully address the objectives but only with essential information, not all that the author knows (i.e., the task was to decide what NOT to include, a much more difficult task than writing all you know). They also noted a lot of "here at ... we do…" kind of text, also useless, and agreed not to do that. In addition, they noted that many of the figures and some tables really added nothing, hence the rule that a figure or table must be able to "stand alone" and teach. If it could not pass that test, it was not worthy of the book. The first two editions were well received, but it was only when they added information they knew students were being asked on rounds (despite the first two rules) that the book gained its present popularity. Thus, from the earliest planning meetings for the first edition of Obstetrics and Gynecology, the authors have remained focused on the needs of the primary audience, medical students rotating through their clerkship in this specialty. Having medical education as a primary focus of their respective academic careers has made this team of authors uniquely positioned to create an effective learning tool. In this eighth edition, the “second generation” of leading ob/gyn clinician– educators took over as lead authors for each chapter. They, too, have dedicated their careers to enhancing the quality of women’s health through medical education. As evidence of their collective involvement and success in ob/gyn education, the author team 8 features the following current and past achievements: University Educational and Administrative Appointments Department Chair 4 Department Vice-Chairs 5 Fellowship Directors 1 Residency Directors 8 Student Clerkship Directors 11 Assistant/Associate Deans 7 Department Director of Undergraduate Medical Education 2 President Academy of Educators 1 Designated Institution Official 1 Chief Medical Officer 1 National Organizations American College of Obstetricians and Gynecologists (College) President 1 Committee Chair 3 District Chair 1 SASGOG Board 1 Association of Professors of Gynecology and Obstetrics (APGO) President 3 Council Member 7 Undergraduate Medical Education Committee Chair 2 Undergraduate Medical Education Committee Member 7 Academic Scholars and Leaders, Scholar 4 Academic Scholars and Leaders, Faculty 2 Academic Scholars and Leaders, Advisors 6 American Board of Obstetrics and Gynecology (ABOG) President 1 Vice President 1 Board Examiner 8 9 Chairman of the Board 1 Council on Resident Education in Obstetrics and Gynecology (CREOG) Chairman 1 Vice Chair 1 Education Committee Chair 3 Council Member 4 Program Chair 3 InTraining Exam 2 Other National Educational Activities and Honor National Test Committee Member 5 National Test Committee Reviewer 4 Peer-Reviewed Educational Research Publications 214 Medical Student Teaching Award 57 Resident Teaching Award 12 Resident Review Committee Member 5 District IV Mentor Award 2 The authors remain committed to not only including the most up-to- date evidence-based information but also presenting it in a fashion that meets the needs of the ever-evolving adult learner. This eighth edition of Beckmann and Ling’s Obstetrics and Gynecology is the latest step in our collective journey in the field of women’s health education. 10