Reviews in Gynaecological and Perinatal Practice最新文献

Gynaecologists are frequently referred women with chronic pelvic pain. These women are often frustrated as they seek to understand their pain and how to manage it. The investigation of women with chronic pelvic pain hinges on taking a full history including social and psychological issues and usually involves laparoscopy and transvaginal ultrasound. Management is often complex and includes taking a multidisciplinary approach as well as using hormonal agents, surgery and psychological interventions.

It is well established that there is a strong relationship between fetal growth and the subsequent development of type 2 diabetes and other features of the metabolic syndrome. The importance of the fetal environment has been shown in both human and rodent studies. Twin studies suggest that the relationship can be independent of genotype, and studies of individuals in gestation during famine clearly indicate the importance of the fetal environment. However the mechanistic basis of the relationship is as yet unknown. To investigate the underlying mechanisms behind this relationship, a number of animal models have been developed. Nutritional insults administered maternally such as calorie restriction, iron restriction, high fat feeding and protein restriction have all been shown to lead to features of the metabolic syndrome in the offspring. Exposure to hormones, surgical interventions and gestational diabetes have also been shown to have detrimental effects on the offspring. These animal models provide strong evidence that alterations in the fetal environment can lead to metabolic diseases in adult life.

Obstetricians frequently need to decide whether to induce a woman who has previously been delivered by Caesarean section (LSCS). There is very little evidence from randomised controlled trials to aid their decision making. Observational studies, with their inherent flaws, suggest a 3.6% maternal complication rate in women undergoing repeat elective LSCS, and approximately 66% vaginal delivery rate and 1% uterine rupture rate in women who were induced. There is little evidence to guide the choice of induction agent. Various factors have been suggested to predict a successful vaginal delivery, but a previous vaginal delivery appears to be strongly predictive of a good outcome. Alternative strategies, such as stretching and sweeping the membranes or awaiting spontaneous labour, may reduce the need for induction. If labour is induced in a woman with a scarred uterus we should ensure that the high risk situation is not compounded by poor care in labour.

Approximately 10% of cancer deaths in women in Westernised countries are due to gynaecological malignancy. Cancer results from the accumulation of multiple genetic alterations. Some alterations occur in the germline and increase susceptibility to disease during an individual's lifetime. Such alterations often manifest themselves as a clustering of cancer cases within families. However, these are relatively rare. Most genetic changes are spontaneous, occurring in somatic cells, and are associated with a progressive tumour development. It is likely that the compliment of genetic changes that initiate and accumulate during tumour formation influence clinical features of disease including histopathological subtypes, response to therapy and, ultimately, patient survival. It is hoped that a greater understanding of the underlying genetic basis of tumourgenesis will lead to better risk prediction for individuals with susceptibility to cancer, an improved ability to detect cancer at an earlier, more treatable stage and to the identification of novel therapeutic targets. Many of these goals are dependent on the continuing progress of biotechnology to develop high throughput methods for the rapid analysis and characterisation of blood and tumour tissue specimens for implementation in routine clinical diagnostic procedures.

Female hirsutism is a distressing and embarrassing problem although there is rarely a sinister underlying pathology. It is characterised by excessive coarse terminal hairs in a male-like pattern and is due to increased androgen production or increased sensitivity of androgen receptors. Polycystic ovary syndrome (PCOS) is by far the commonest cause of hirsutism. A systematic evaluation of the patient will readily identify any serious underlying cause. Therapeutic options often include a combination of medical treatments targeting different sites of action, apart from mechanical ablation, cosmetic measures, or use of a new topical treatment to reduce the rate of hair growth. The combined oral contraceptive pill (OCP) is the most commonly used treatment and can supplement other medications but may not be ideal for obese patients. Finasteride and cyproterone acetate are effective treatments and new evidence suggests that low doses of these treatments can be just as effective. Spironolactone can be an effective treatment for hirsutism, although it is not as widely used in the UK as it is elsewhere in the world. Insulin sensitisers, particularly metformin, are being used increasingly with very promising results but more data are needed. Obesity can aggravate hirsutism and influence the choice of treatment. Weight reduction should be a crucial element of treatment in women who are overweight. Due to the long growth cycles of body hair, any objective benefit from a systemic treatment would not be expected before 6–12 months. Concomitant reliable contraception should be used to avoid the possible harm of antiandrogens on a male foetus. Vaniqa and Dianette are the only licensed treatments for hirsutism in the UK.

Cervical incompetence is an important factor in the aetiology of preterm birth and mid-trimester miscarriage. Its diagnosis usually relies on clinical history, but recent studies have investigated the role of transvaginal ultrasound scanning, with the finding of shortened cervical length being associated with an increased risk of preterm delivery.

Cervical incompetence can be treated using MacDonald and Shirodkar cervical sutures. The largest study to date found a significant reduction in preterm delivery in those women who had a suggestive clinical history. This finding has been supported by the insertion of sutures in women found to have a shortened cervix on ultrasound scan. These findings are inconsistent, with some studies failing to confirm benefit.

Transabdominal cervical sutures have a role in treating women with previously failed cervical cerclage (success rates reported as over 80% in most studies) although the numbers of women who have undergone this treatment is small.

Cervical sutures have been used in the management of multiple pregnancies, although to date there is no good evidence that cervical sutures have a significant role.

The use of emergency cervical sutures seems to have a role in a select population of women who present with painless cervical dilatation, in the absence of infection; in these women gestation has been prolonged by up to seven weeks.

Pelvic inflammatory disease and pelvic abscesses have been reported as a major complication following a wide variety of obstetrical, gynaecological and surgical procedures. The aim of this review article is to emphasize the need for a more aggressive approach to detect and to treat what can be a debilitating condition that if inadequately treated may result in mortality. The large numbers of options available are discussed under the headings of: conservative management, interventional radiological management and surgical treatment. Lastly, preventive strategies are discussed, as pelvic inflammatory disease may result in tubal factor infertility, ectopic pregnancies, chronic pelvic pain and tubo-ovarian/pelvic abscesses.

The early human embryo develops in a tightly controlled, relatively protected environment. During the first 8–12 weeks of human gestation, the delivery of maternal blood, and therefore the amount of oxygen to the developing embryo is limited and the embryo is supplied with essential nutrients in part via the decidual uterine glands, the placental trophoblast and the secondary yolk sac. Factors that interfere with this process may well result in spontaneous miscarriage or adverse outcome later in pregnancy. There is mounting evidence for the presence of transporter systems for many substances including drugs and toxins from the maternal to the fetal compartments in early pregnancy. The role of these substances in both the protection of early pregnancy development and possible teratogenicity are explored in this chapter. Clearly, the timing of exposure to potentially damaging substances is crucial with effects on conception, implantation, placental development and organogenesis dependent on the gestation at which exposure occurs.

The development of postpartum urinary symptoms such as incontinence and voiding dysfunction are not uncommon and often difficult to resolve. The urinary tract undergoes both structural and functional changes during pregnancy and after delivery. These changes may be specific in response to pregnancy and in some women may be compounded by pathological changes that persist after delivery. In labour, factors such as prolonged labour, assisted vaginal delivery, and perineal laceration have been associated with development of bladder dysfunction. Anatomical and functional changes to the pelvic floor may occur secondary to pelvic floor distension during descent of the fetal head and maternal expulsive efforts during the active second stage of labour. This chapter focuses on the effect of pregnancy and childbirth on the lower urinary tract and discusses the possible mechanisms by which pelvic floor damage may occur and their long-term sequelae and management.