Current obstetrics & gynaecology最新文献

This paper discusses the RCOG guidelines on examinations with specific reference to two ethico-legal dilemmas, namely a) a patient's request that an examination be performed without a chaperone and b) concerns that a colleague is not practising in accordance with the guidelines. Each scenario is discussed in the context of the law and ethical concepts of autonomy, trust and accountability. It is argued that guidelines provide a starting point for clinicians, but ethical sensitivity, reflection and professional judgement remain essential to maintaining standards in clinical practice.

There is a multitude of tests available for the investigation of tubal disease. This review gives an overview of the use of hysterosalpingography (HSG), the laparoscopy and dye test, hystero-contrast-sonography (HyCoSy), falloposcopy and fertiloscopy in the evaluation of the fallopian tubes. The current sensible approach would be to offer HSG for women with a low risk of tubal disease as HSG is a valid and accurate test used to diagnose tubal patency in subfertile couples. In women with suspected underlying gynaecological pathology such as endometriosis or pelvic inflammatory disease, and/or in the presence of tubal blockage on HSG, one should proceed with the laparoscopy and dye test to confirm or refute the diagnosis. The National Institute for Clinical Excellence also recommends the use of HyCoSy where the service is available as this is as effective as HSG in diagnosing tubal disease in low-risk women.

Chronic pelvic pain (CPP) is defined as non-menstrual pain of at least 3 months’ duration or menstrual pain of at least 6 months’ duration. Approximately 15% of women of reproductive age will suffer from CPP. The pain can vary in terms of the degree of social and daily function it inhibits, from work-related impairment of concentration and altered sexual and recreational habits to complete impairment of function resulting in days confined to bed. The pathophysiology may be gynaecological, gastrointestinal, urinary, musculoskeletal or psychiatric. The management will depend upon the diagnosis: in gynaecological conditions this is often achieved and managed through laparoscopy.

This article outlines the main psychological issues involved in the management of chronic pelvic pain. It argues for an integrated process of care that acknowledges the role of psychological factors in all experiences of pain and attempts to help the patient to understand this from the inception of care. Issues at each level in the process of care, through seeking help and primary and secondary care, are systematically considered, and guidance is provided on when more specific psychological input may be needed. The emphasis is on psychological aspects of management by all staff throughout the process so that women do not feel that their distress is marginalised. The importance of pre-existing beliefs, women's need for an acknowledgement of the reality of their distress, how to provide information and effective reassurance are discussed. Issues to consider in terms of mood, the role of sexual abuse and the influence of chronic pelvic pain on relationships are included, together with ideas about specific psychological approaches that can be of benefit.

Chronic pelvic pain (CPP) forms a significant cause of morbidity, resulting in patients seeking help in the primary care and hospital setting. CPP is a poorly understood condition. It is defined as both cyclical and non-cyclical pain that has a duration of more than 6 months. The aetiology of CPP is not limited to the realms of the gynaecologist but encompasses the disciplines of gastroenterology, urology, psychiatry, physical therapy and genitourinary medicine. Given the numerous facets of this condition, it is best managed in a multidisciplinary setting. Investigations into the cause of CPP have a low yield, making treatment difficult. This review aims to provide an evidence-based medical management of the main causes of CPP.

Haemorrhage complicates approximately 3% of pregnancies. Of these, about one-third are caused by placenta praevia, one-third by placental abruption and the remainder by other causes. Both placenta praevia and abruption can cause sudden unexpected and significant haemorrhage. They are potentially dangerous to both mother and fetus. Both require resuscitation of the mother and possibly delivery of the fetus. Complications such as disseminated intravascular coagulation and postpartum haemorrhage may occur.

Numerous reports have emphasised the need for all obstetric units to have in place plans for the management of massive obstetric haemorrhage and for all units to practise these protocols regularly.

Many women use alternatives to hormone therapy believing them to be safer and ‘more natural’, especially following the current controversies regarding hormone replacement therapy. The choice of treatments is confusing, and unlike conventional medicines, not much is known about their active ingredients, safety or side-effects, or how they may interact with other therapies. They can interfere with warfarin, antidepressants and antiepileptics with potentially fatal consequences. Some herbal preparations may contain oestrogenic compounds, and this is of concern for women with hormone-dependent disease such as breast cancer. There is also concern about contaminants such as mercury, arsenic lead and pesticides. This paper examines the evidence underlying the commonly used options both in terms of efficacy and safety.

Placebo-controlled studies have shown that oestrogen is effective for post-menopausal vasomotor and urogenital symptoms. Unopposed oestrogen may cause endometrial cancer, and women with a uterus should receive oestrogen combined with a progestogen. Symptomatic women can use hormone replacement therapy (HRT) for up to 3–5 years, but those wanting longer-term treatment must be fully counselled about the risks. Regarding asymptomatic women, placebo-controlled studies have shown that HRT reduces post-menopausal bone loss and fracture rates, but the protective effect is lost after treatment is stopped. Randomised studies have shown that HRT increases the risk of stroke and venous thromboembolism. All forms of HRT, but particularly combined HRT, increase the risk of breast cancer: the excess risk increases with duration of use and disappears 5 years after stopping HRT. Randomised trials have shown no effect of HRT on cardiovascular disease but were stopped early because of adverse effects. Asymptomatic women should not use HRT for disease prevention.