Obstetrics, Gynaecology and Reproductive Medicine最新文献

With the rate of Caesarean sections rising globally, we are seeing an increase in associated complications. One of these complications is a Caesarean scar pregnancy (CSP). These are ectopic pregnancies that implant into the scar of the previous Caesarean section and are associated with severe maternal and fetal morbidity and mortality. An early diagnosis of CSP and prompt intervention can help to mitigate some of the risks. In this review article we go through the diagnosis and management of CSP. We also present two cases of CSP, both managed in the same way but with very different outcomes, illustrating the complexity of this condition. Finally we review the emerging evidence for prevention of scar niche formation.

An understanding of clinical governance and risk management is essential for a career in obstetrics and gynaecology. In a stressed and struggling system, knowing where and how to improve our maternity services is crucial in order to keep our patients safe. This article outlines the principles of clinical governance with a focus on risk management; it provides insight as to how this is managed and implemented within NHS trusts. We will look at how just culture and systems-based learning determine the effectiveness of both, and we will demonstrate how this is used by external governing bodies to judge the safety of maternity units. Only through robust clinical governance structures is the NHS able to ensure that it learns from mistakes and evolves to safeguard future patients and its workforce. Knowledge of the inner workings of these structures is important for examination preparation, any job interview, and for providing responsible and safe care to patients as a clinician.

Cancer treatments, including chemotherapy, surgery, and radiotherapy, present distinct challenges to reproductive health. Ovarian function might undergo various degrees of impairment, leading to a significantly diminished ovarian reserve, even without persistent amenorrhea. The return of menses post-chemotherapy might not mirror the full extend of follicular damage. Ovarian reserve testing is indicated in reproductive-aged cancer survivors. The magnitude of follicle depletion can be influenced by factors such as age, initial ovarian reserve, and specific treatment modalities. Radiotherapy, dependent on its target, can introduce risk to both ovarian and uterine health. Moreover, radiotherapy targeting the brain can disrupt the hypothalamic-pituitary-reproductive axis, adding another layer of reproductive complication. As cancer survival rates improve, addressing these multifaceted reproductive concerns has become essential.

Cervical cancer causes more than 300,000 deaths worldwide every year, affecting women from a young age. It has a well-understood natural history, caused by HPV, which is estimated to be responsible for 99.8% of cases. In order to decrease the number of UK cervical cancer cases, a national screening programme was launched in 1988. Women between the ages of 25 and 64 are invited for cervical screening. A primary high-risk HPV testing approach is used, whereby samples are only tested for cytology if they are positive for high-risk HPV. The national HPV vaccination programme was introduced in 2008 in the UK. The Gardasil 9 vaccine is offered at year 8 in UK schools (ages 12–13 years old) to boys and girls. These programmes have been a huge success in reducing the number of cervical cancer cases. However, still only 70% of eligible women attend their screening appointments. To further increase the proportion of women reached by the programme, further alternatives are currently tested, including home vaginal swab tests and urinary HPV testing.

Pre-Implantation genetic diagnosis is available to couples at risk of conceiving a pregnancy affected with a known genetic disorder. Assisted reproductive techniques are used in combination with micromolecular diagnostic technologies to recognise at-risk embryos with pathogenic genetic variants at the pre-implantation stage using polar body, blastomere or trophectoderm biopsy. This review will discuss the varying genetic disorders diagnosed by Pre-Implantation Genetic Diagnosis, as well as the ethical, legal and safety implications of the process. Pioneering advances in molecular biology and cytogenomics have been utilised to expand the spectrum of genetic disorders detected.

Birthweight has increased in the UK and abroad over the last 30 years, partly attributed to the increasing prevalence of maternal obesity and gestational diabetes. The aim of this review is to provide better understanding of definition, epidemiology, detection and management of the large fetus. Many definitions of large infants, or fetal overgrowth, have been described in the literature including macrosomia (weight above 4 kg) or large for gestational age (LGA, defined as weight above the 90th centile by population, customised or international growth charts). Errors in estimation of fetal weight by ultrasound reduce the accuracy of predicting the actual birthweight. Although no single definition is currently universally accepted, the terminology LGA has the advantage of identifying the large fetus even when macrosomia has not yet occurred. Irrespective of definition, fetal overgrowth is associated with an increased risk of adverse perinatal outcomes including need for caesarean delivery, postpartum haemorrhage, third and fourth perineal tears, shoulder dystocia, low Apgar score, admission to neonatal intensive care unit, and increased neonatal morbidity and perinatal mortality. Major risk factors for LGA are maternal obesity, diabetes and increased gestational weight gain but these are not highly predictive of LGA. Previous efforts to prevent fetal overgrowth have had limited success which explain the current focus on improving management once an LGA fetus is identified by ultrasound. Management of LGA has changed substantially in the last decade in response to the ruling Montgomery v Lanarkshire Health Board [2015], national reports from the Healthcare Safety Investigation Branch (HSIB), and international literature. Induction of labour for large for gestational age at early term seems to reduce the incidence of shoulder dystocia but may increase the rate of the third and fourth degree tears. Caesarean section seems to be associated with a reduced risk of LGA related adverse neonatal outcomes, mainly birth trauma, however the number needed to treat is high, being mostly recommended for estimated fetal weight above 4.5 kg in women with diabetes. NICE currently recommends that women with estimated fetal weight above the 95^th centile should have a comprehensive discussion regarding birth options including expectant management, induction of labour and elective caesarean; choice should be offered due to the lack of clear evidence of benefit of one strategy over another. Observational evidence suggests that an estimated fetal weight between the 90^th and the 95^th centile have a much weaker association with adverse neonatal outcomes and is not associated with increased perinatal mortality compared to an estimated fetal we