Obstetrics and Gynaecology

374 Pages·2008·11.06 MB·English

by  Maryam Pariseai

Second Edition
Obstetrics
and
Gynaecology
First edition authors:
Nick Panay, Ruma Dutta,
Audrey Ryan and
J A Mark Broadbent
Second Edition
Obstetrics Series editor
Daniel Horton-Szar,
BSc(Hons), MBBS(Hons), MRCGP
Northgate Medical Practice,
Canterbury, Kent, UK
and
Gynaecology
Maryam Parisaei,
DFFP MRCOG
Specialist Registrar in Obstetrics & Gynaecology,
Barnet Hospital, London, UK
Archana Shailendra,
MBBS DGO
Senior House Officer, Obstetrics & Gynaecology,
Darent Valley Hospital, Dartford, Kent, UK
Ruma Dutta,

BSc MBBS MRCOG
Consultant Obstetrician & Gynaecologist, Hillingdon Hospital
NHS Trust, Uxbridge, Middlesex, UK
J A Mark Broadbent,

BSc FRCOG MFFP
Consultant Obstetrician & Gynaecologist, Barnet and Chase
Farm NHS Trust, Hertfordshire, UK
Edinburgh • London • New York • Oxford • Philadelphia • St Louis • Sydney • Toronto 2008
Commissioning Editor: Alison Taylor
Development Editor: Lulu Stader
Project Manager: Andrew Palfreyman
Page design: Sarah Russell
Icon illustrations: Geo Parkin
Cover design: Stewart Larking
Illustration management: Merlyn Harvey
© 2004, Elsevier Limited.
© 2008, Elsevier Limited. All rights reserved.
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First edition 2004
Second edition 2008
ISBN: 978-0-7234-3472-6
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Notice
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or
appropriate. Readers are advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to verify the recommended
dose or formula, the method and duration of administration, and contraindications. It is the
responsibility of the practitioner, relying on their own experience and knowledge of the patient, to
make diagnoses, to determine dosages and the best treatment for each individual patient, and to
take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor
the/Authors assumes any liability for any injury and/or damage to persons or property arising out
or related to any use of the material contained in this book.
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Preface
It can be difficult for the contemporary medical student to gain a true insight into the 
careers of Obstetricians and Gynaecologists when some Foundation Schools proide as 
little as eight weeks’ training in Obstetrics and Gynaecology. With an eer increasing 
and oerwhelming body of medical knowledge, it is difficult enough to grasp a basic 
academic knowledge let alone be expected to gain important clinical experience in 
such a short period of time. This is compounded by the fact that O&G has medical, 
surgical and obstetric components all requiring different skills and thought processes. 
Learning from reference texts may allow the student to memorise the facts but not 
necessarily how to assimilate these facts in a clinical setting.
This book presents the theory of O&G in a more clinically orientated manner, as the 
patient would present in the real life situation, that is, by symptoms. This should 
focus the student to help deelop an insight into the thought processes that will be 
necessary when they start seeing and managing patients. A good clinical history will 
focus on releant posities and negaties and proide a differential diagnosis on which 
to base releant inestigations and Part one is written with this in mind. Part two is 
presented with a focus on disease processes and proides insight into the diagnosis 
and management of common disorders. The use of algorithms, diagrams, ‘Hints 
and Tips’ boxes and the newly introduced ‘Communication’ boxes gies a clearer 
understanding of the processes inoled in managing patients as well as some of the 
more common pitfalls. The text is written not only by consultants but also by registrars 
so combining the wisdom of experience with the latest changes in modern practice.
To reflect the latest assessment methods the self-assessment section has been altered 
for the second edition. More extended matching questions (EMQ’s) hae been added. 
These hae been shown to better assess the ability of the student to assimilate the 
information proided rather than just rely on a good memory, skills that will hopefully 
produce a better quality of doctor. Many students see the final MBBS examination 
as a huge hurdle. The Crash Course philosophy is to proide the student with the 
releant clinical knowledge and assessment techniques to be better able to oercome 
this hurdle with less fear and more confidence.
J A Mark Broadbent BSc FRCOG MFFP
More than a decade has now passed since work began on the Crash Course series. 
Medicine neer stands still, and the work of keeping this series releant for today’s 
students is an ongoing process. This second edition builds upon the success of the 
preceding books and incorporates a great deal of new and reised material, keeping 
the series up to date with the latest medical research and deelopments in pharma-
cology and current best practice.
As always, we listen to feedback from the thousands of students who use Crash 
Course and hae made further improements to the layout and structure of the books. 
Each chapter now starts with a set of learning objecties, and the self-assessment 
sections hae been enhanced and brought up to date with modern exam formats. We 
hae also worked to integrate material on communication skills and gems of clinical 

Preface
wisdom from practising doctors. This will not only add to the interest of the text but 
will reinforce the principles being described.
Despite fully reising the books, we hold fast to the principles on which we first 
deeloped the series: Crash Course will always bring you all the information you need 
to reise in compact, manageable olumes that integrate pathology and therapeutics 
with best clinical practice. The books still maintain the balance between clarity and 
conciseness, and proiding sufficient depth for those aiming at distinction. The authors 
are junior doctors who hae recent experience of the exams you are now facing, and 
the accuracy of the material is checked by senior clinicians and faculty members from 
across the UK.
I wish you all the best for your future careers!
Dr Dan Horton-Szar
Series Editor
i
Dedications
To my mum, dad, Golnaz and Behzad for their incredible love and support.
MP
To my teachers for training me in this wonderful speciality; to my parents and Shailu
for their encouragement and support.
AS
To my dad, who would have been proud to see my name in print, and to my mum,
who is. Also to Paul and Jack for all their patience and love.
RD
With thanks to Tim for all his support during the preparation of this second edition
MB
vii
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Contents
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v Examination for prolapse  . . . . . . . . . . . . .30
Dedications. . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii Investigation of prolapse  . . . . . . . . . . . . .31
Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv
.7 .. .The.menopause. . . . . . . . . . . . . . . . . . . . . .33
Part I The Patient Presents Presentation and differential  
with . . . . . . . . . . . . . . . . . . . . . . 1 diagnosis  . . . . . . . . . . . . . . . . . . . . . . . . .33
Bleeding disturbances  . . . . . . . . . . . . . . .33
.1 .. Abnormal.uterine.bleeding. . . . . . . . . . . . . . .3
Vasomotor symptoms  . . . . . . . . . . . . . . .33
Absent periods  . . . . . . . . . . . . . . . . . . . . . .3
Psychological symptoms  . . . . . . . . . . . . .34
Heavy periods  . . . . . . . . . . . . . . . . . . . . . .6
Intermediate menopause  
Intermenstrual and postcoital bleeding  . . . .7
symptoms  . . . . . . . . . . . . . . . . . . . . . . . .34
Painful periods  . . . . . . . . . . . . . . . . . . . . . .7
Long-term symptoms of the  
Examination  . . . . . . . . . . . . . . . . . . . . . . .8
menopause    . . . . . . . . . . . . . . . . . . . . . .35
Postmenopausal bleeding  . . . . . . . . . . . . .8
.8 .. Subfertility. . . . . . . . . . . . . . . . . . . . . . . . . .37
.2 .. .Pelvic.pain.and.dyspareunia. . . . . . . . . . . . .11
Taking the history  . . . . . . . . . . . . . . . . . .37
Differential diagnosis  . . . . . . . . . . . . . . . .11
Examination  . . . . . . . . . . . . . . . . . . . . . .39
History to focus on the differential  
Investigation of subfertility  . . . . . . . . . . . .39
diagnosis of pelvic pain and  
dyspareunia  . . . . . . . . . . . . . . . . . . . . . . .11
.9 .. .Bleeding.and/or.pain.in.early..
Examination of patients with pelvic  
pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . .43
pain and dyspareunia  . . . . . . . . . . . . . . . .13
History for bleeding/pain  
Investigations of patients who have  
in early pregnancy  . . . . . . . . . . . . . . . . . .43
pelvic pain and dyspareunia  . . . . . . . . . . .14
Examining women with pain and/ 
or bleeding in early pregnancy  . . . . . . . . .44
.3 .. Vaginal.discharge. . . . . . . . . . . . . . . . . . . . .17
Differential diagnosis  . . . . . . . . . . . . . . . .17 Investigation of bleeding and/ 
Examination of patients with   or pain in early pregnancy  . . . . . . . . . . . .45
vaginal discharge  . . . . . . . . . . . . . . . . . . .18 Recurrent miscarriage  . . . . . . . . . . . . . . .46
Investigation of patients with   Trophoblastic disease  . . . . . . . . . . . . . . . .47
vaginal discharge  . . . . . . . . . . . . . . . . . . .19
10 .. .Bleeding.in.the.second.and.third..
.4 .. Vulval.symptoms. . . . . . . . . . . . . . . . . . . . .21 trimesters.of.pregnancy. . . . . . . . . . . . . . . .49
History  . . . . . . . . . . . . . . . . . . . . . . . . . .21 Differential diagnosis of bleeding  . . . . . . .49
Examination  . . . . . . . . . . . . . . . . . . . . . .21 History to focus on the differential  
diagnosis of bleeding  . . . . . . . . . . . . . . . .49
.5 .. Urinary.incontinence. . . . . . . . . . . . . . . . . . .25 Examination of patients who have  
History  . . . . . . . . . . . . . . . . . . . . . . . . . .25 bleeding in the second and  
Examination  . . . . . . . . . . . . . . . . . . . . . .26 third trimesters  . . . . . . . . . . . . . . . . . . . .50
Investigations  . . . . . . . . . . . . . . . . . . . . .27 Investigation of patients who have  
bleeding in the second and  
.6 .. Prolapse. . . . . . . . . . . . . . . . . . . . . . . . . . . .29 third trimesters  . . . . . . . . . . . . . . . . . . . .50
Differential diagnosis  . . . . . . . . . . . . . . . .29 Management of patients who have  
History to focus on the differential   bleeding in the second and  
diagnosis of prolapse  . . . . . . . . . . . . . . . .29 third trimesters  . . . . . . . . . . . . . . . . . . . .51
ix