Current obstetrics & gynaecology最新文献

Female urinary incontinence is a common but underreported condition. Initial investigation and treatment can in most cases be undertaken without urodynamic or other detailed tests. History by the use of validated symptom and quality of life questionnaires is key to the initial investigation. Initial treatment includes pelvic floor muscle training (PFMT) regardless of the type of incontinence; lifestyle interventions and bladder retraining, anticholinergics and serotonin/noradrenaline reuptake inhibitors (e.g. duloxetine) are also included depending on the type of symptoms. In mixed incontinence the predominant symptom should be treated first. When this initial treatment is ineffective, further investigation should be offered prior to specialised treatment. Urodynamics should be considered for all patients prior to surgery. Imaging and cystoscopy to exclude pathology, for example in elderly patients with an overactive bladder, are also necessary. Newer surgical interventions should be offered after careful consideration of the risk:benefit ratio for each individual woman and the amount of evidence that is currently available to support their use.

Well-organised cervical screening programmes have reduced the mortality from cervical cancer by up to 50% in the developed world. Despite the successful development of human papilloma virus vaccines, there is likely to remain a need for cervical screening for the foreseeable future. In contrast, the value of mass screening for ovarian cancer remains unproven, although current screening methods can detect early-stage disease in asymptomatic individuals. Breast screening does appear to be associated with a reduction in mortality in the long term but paradoxically may increase death rates in young women in the short term. Testing for sexually transmitted infections is effective in reducing morbidity but tends to be selective at present because of concerns over the cost and psychosocial implications of general population screening.

Venous thromboembolism (VTE) is one of the leading causes of maternal mortality worldwide and is also the cause of significant maternal morbidity. This article discusses the risk factors for VTE in pregnancy, the management of the pregnant woman at risk both antenatally and post-partum, and the acute management of VTE when it occurs during pregnancy.

The thrombophilias, both heritable and acquired, are becoming increasingly recognised as a cause of morbidity and mortality both within and outside pregnancy. There has been a recent increased interest in the thrombophilias and their link with recurrent miscarriage, preeclampsia, abruption and intrauterine growth restriction. The relationship between the thrombophilias and adverse pregnancy outcome is addressed in detail, with reference to the current literature available on this evolving subject.

Polycystic ovarian syndrome (PCOS) is one of the most common hormonal disorders affecting women, although the true incidence and pathophysiology have yet to be determined. A diagnosis of PCOS is likely to be associated with an increased long-term risk of developing cardiovascular disease and type 2 diabetes, especially in obese women. The evidence base for a causal relationship between cancer risk and PCOS is weak. Lifestyle changes leading to weight loss is the most effective treatment in these patients. There is insufficient evidence for the use of metformin or surgical interventions such as ovarian drilling in preventing the long-term effects of PCOS.

Although we now have many contraceptives, couples still have a negative perception of their personal choices. Many know little about methods other than the combined pill and the condom, and in particular, knowledge of long-acting methods is very poor. Methods that are very safe, such as barriers and natural family planning, are unfortunately not very effective. Meanwhile, the very effective methods—the hormonal contraceptives and intrauterine devices (IUDs)—raise more concerns about health risks and side effects. A woman's choice of contraceptive will be influenced by many factors, and her requirements will change with time. As prescribers, it is our responsibility to ensure that couples are given sufficient and appropriate information to enable them to make decisions.

Hypertension is a common complication of pregnancy. Maternal and foetal outcomes depend upon the nature of the hypertension affecting the pregnancy, which can range from mild gestational hypertension to severe preeclampsia with its associated multisystemic complications. Preeclampsia is a leading cause of maternal mortality. The World Health Organization estimates that, worldwide, over 100 000 women die from preeclampsia each year, and the condition has remained one of the leading causes of maternal death in the UK over recent decades. Features of substandard care were shown in 46% of the 14 deaths associated with preeclampsia or eclampsia in the last report on Confidential Enquiries into Maternal Deaths in the UK. Intracranial haemorrhage was the single largest cause of death, reflecting a failure of effective antihypertensive therapy and in particular ineffectual treatment of the raised systolic blood pressure. Although recent research has clarified the underlying aetiology of this condition, this has disappointingly not yet translated into a clinical useful prevention strategy. There is a clear need for greater awareness of the causes and optimal management of this common condition.

With advances in management, many women with sickle cell disease now survive to have children. The high risk of fetal and maternal sequelae mandates multidisciplinary management involving an obstetrician, a haematologist, an anaesthetist and a haemoglobinopathy specialist nurse. Hydroxyurea, a new treatment for sickle cell disease, is contraindicated in pregnancy. Exchange transfusion may be indicated in women with a serious obstetric or haematological complications. In those with sickle cell disease, the entire pregnancy is a high-risk period that warrants close monitoring. It is thus important for every obstetrician to be familiar with the condition.