Obstetrics and Gynecology: An Illustrated Colour Text

174 Pages·2003·35.12 MB·English

by  Joan Pitkin Alison Peattie Brian A. Magowan

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ELSEVIER
SCIENCE
Obstetrics and
Gynaecology
AN ILLUSTRATED COLOUR TEXT
Commissioning Editor: Ellen Green
Project Development Manager: Jim Killgore/Helen Leng
Project Manager: Nancy Arnott
Designer: Sarah Russell
Obstetrics and
Gynaecology
AN ILLUSTRATED COLOURTBtt
Joan Pitkin BSCFRCSFRCOG
Consultant Obstetrician and Gynaecologist
Northwick Park & St Mark's Hospital
NW London Hospitals NHS Trust
Harrow
Honorary Senior Lecturer, Faculty of Medicine
Imperial College
London
UK
Alison B. Peattie FRCOG
Consultant Obstetrician and Gynaecologist
The Countess of Chester Hospital
Chester
UK
Brian A. Magowan MRCOG
Consultant Obstetrician and Gynaecologist
Borders General Hospital
Melrose
UK
Illustrated by Ian Ramsden
CHURCHILL
LIVINGSTONE
EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2003
IV
CHURCHILL LIVINGSTONE
An imprint of Elsevier Science Limited
© 2003, Elsevier Science Limited. All rights reserved.
The right of Joan Pitkin, Alison Peattie and Brian Magowan to be identified
as authors of this work has been asserted by them in accordance with the
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First published 2003
ISBN 044305035X
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
Note
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recommended dose, the method and duration of administration,
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Cover image
Infertility: false-colour hysterosalpingogram of the abdomen of a woman
suffering from blocked fallopian tubes.
Credit
Science Photo Library
The
publisher's
policy is to use
paper manufactured
from sustainable forests
Printed in China
V
Preface
Obstetrics and gynaecology is a dynamic women-centred and to provide similar in the clinician by the woman is a
and rapidly changing speciality. Great standards of care worldwide. Nowhere privilege to be valued and respected.
advances have been made in prenatal else in medicine are we faced with the This book aims to encompass the
diagnosis, the management of infertility exhilaration of the arrival of new life; breadth and depth of our speciality in a
and contraceptive techniques. The equally, our speciality remains the vivid, easy-to-use fashion. Based on a
introduction of minimally invasive highest area for litigation - an added double-spread format for each topic, the
surgical procedures has reduced bed burden for clinicians - so that audit, subject comes alive through the
occupancy and analgesic requirements clinical governance and an evidence- generous use of illustrations but retains
allowing women to return home more based approach are especially pertinent. considerable up-to-date detail and covers
rapidly. Service delivery development, There continues to be areas of great some topics overlooked in other texts.
required to meet improving NHS controversy surrounding the speciality, The use of tables and 'key-point' boxes
standards, has seen the introduction of a especially assisted conception, facilitates easy reference. We hope it will
new multidisciplinary approach, new termination of pregnancy and hormone be instructive and enjoyable to read.
roles for midwives and the emergence of replacement therapy. In no other branch
the gynaecological nurse practitioner. of medicine are such private and
Obstetrics and gynaecology is both intimate details discussed regarding London Joan Pitkin
rewarding and demanding. Maternity dysparunia, vaginal discharge and 2003 Alison Peattie
care challenges all of us to be more psychosexual problems. The trust placed Brian Magowan
VI
Acknowledgements
We would like to acknowledge all those
who have lent material, the secretarial
support received and the patience of the
publishers and our long-suffering
partners.
London Joan Pitkin
2003 Alison Peattie
Brian Magowan
VII
Contents
Normal pregnancy - physiological Diabetes in pregnancy II 30 Postpartum haemorrhage and
signs and symptoms 2 abnormalities of the third stage of
Anaemia in pregnancy 32
labour 60
Antenatal care 4
Haemoglobinopathies in pregnancy 34
Obstetric emergencies 62
Pre-conceptual counselling 6
Antepartum haemorrhage 36
The normal puerperium 64
Fetal chromosomal abnormality 8
Multiple pregnancy 38
The abnormal puerperium 66
Fetal abnormality 10
Breech presentation 40
Alternative approaches to delivery 68
Infections in pregnancy 14
Venous thromboembolic disease 42
Analgesia in labour 70
Human immunodeficiency virus
Psychosocial problems in antenatal
(HIV) 16 The changing face of maternity care 72
care 44
Preterm labour and preterm premature Drug misuse and physical abuse 74
Mechanisms of normal labour 46
rupture of the membranes
Common problems in pregnancy 76
(PPROM) 18 Induction of labour and prolonged
pregnancy 48 Vital statistics 78
Hypertension 20
Intrapartum fetal monitoring 50 The newborn 80
Small for dates fetus 22
Abnormal labour 52 Problems in the first week of life 82
Medical disorders in pregnancy 24
Operative delivery 54 Bereavement in obstetrics and
Diabetes in pregnancy I 28
gynaecology 84
The perineum 58
Gynaecological assessment Non-hormonal methods Cervical carcinoma 136
of the patient 86 of contraception 110
Carcinoma of the uterus 138
Developmental and paediatric Amenorrhoea 112
Benign ovarian conditions 140
gynaecology 88
Polycystic ovarian syndrome 114
Ovarian carcinoma 142
Puberty and its abnormalities 90
Day care surgery 116
Benign vulval conditions 144
Miscarriage 92
Uterine fibroids 118
Vulval carcinoma 146
Induced abortion (termination
Physiology of menstruation 120
of pregnancy) 94 Menopause: physiological changes 148
Disorders of menstruation I 122
Trophoblastic disorders 96 Menopause: management 150
Disorders of menstruation II 124
Ectopic pregnancy 98 Uterovaginal prolapse 152
Acute and chronic pelvic pain 126
Pelvic inflammatory disease 100 Urinary incontinence 154
Endometriosis 128
Genital infections 102 Emotional disturbances
Investigation of infertility 130 in gynaecology 156
Oestrogen-dependent hormonal
contraception 106 Management of infertility 132 Psychosexual disorders 158
Progestogen-dependent hormonal Cervical intraepithelial neoplasia Postoperative care 160
contraception 108 (CIN) 134
Index 162
2 OBSTETRICS
Normal pregnancy - physiological signs and
symptoms
Changes to the maternal physiology in
Table 1 Changes in the cardiovascular system
pregnancy (Fig. 1) allow maximum
Change Results/requirements
efficiency of fetal growth and
Increased blood volume 2600 to 3800 ml Raised from early in pregnancy [8-9 weeks)
metabolism. As this is very different
Increased red cell mass 1400 to 1650-1800 ml Needs ready iron supply for optimal rise (see p. 3)
from the normal maternal physiology
Decreased haemoglobin (Hb) and haematocrit Proportional to the above two factors- termed the
it cannot be equally advantageous. physiological anaemia of pregnancy
Normally homeostatic mechanisms, Increased resting cardiac output 4.5 to 6 l/min Early rise maintained through pregnancy and labour.
after detecting a change, return the Declines in puerperium
organism to the resting state, but Raised heart rate 80 to 90 bpm Needs increased stroke volume
manipulation of the mother's Increased oxygen consumption by 30-50 ml/min Increased cardiac output needed to distribute this
homeostatic mechanisms is done by the Decrease in total peripheral resistance (TPR] to Vasodilatation - also allows dissipation of heat produced
parallel rise in cardiac output (CO) by the fetus
fetus in anticipation of its needs as it
Mid trimester fall in blood pressure due to Need to know blood pressure (BP) in first trimester when
grows. So, many changes are noted by
greater drop in TPR than rise in CO assessing a raised BP in pregnancy (see p. 20)
the mother in early pregnancy when the
Increased incidence of heart murmurs due to increased Need to distinguish pathology from functional murmurs -
actual needs of the fetus are minimal. flow across valves consider antibiotics in labour for structural heart disease
Changes to the energy balance and
respiratory control occur via the
hypothalamus and are typically functions such as blood volume, blood Cardiovascular system
mediated by progesterone, while constituents and coagulation, and total The main changes seen in the
changes to the more peripheral body water are mediated by oestrogen. cardiovascular system are shown in
Table 1. At term the distribution of the
raised cardiac output is:
« Uterus 400 ml/min extra
• Kidneys 300 ml/min extra
» Skin 500 ml/min extra
« Elsewhere 300 ml/min extra.
Urinary tract
The anatomy of the renal tract changes
in pregnancy. Cellular hypertrophy
causes a 1 cm increase in renal length.
The diameter of the ureters is
increased due to the relaxant effect of
progesterone on the smooth muscle
and in later pregnancy there may be
ureteric obstruction due to uterine
enlargement. Increased filtration of
glucose may lead to glycosuria as the
proximal tubular ability to reabsorb
glucose is overloaded. The patient is
aware of urinary frequency due to
increased renal blood flow and the
pressure of the pregnant uterus on her
bladder in early pregnancy. There is a
diuresis immediately following delivery
of the placenta as the vascular bed is
contracted down by nearly 500 ml.
Table 2 lists the changes in values seen
during pregnancy.
Gastrointestinal tract
Progesterone causes smooth muscle
relaxation and thus decreased gut
motility with adverse effects for the
mother. The resultant constipation can
be very uncomfortable and may be
exacerbated by treatment with oral
iron therapy. Straining at stool may
Fig. 1 Maternal systems changed by pregnancy.