Current obstetrics & gynaecology最新文献

Problems in early pregnancy are common, and many women will encounter them at some time in their reproductive life. It is important that the clinician is able to assess the woman who presents in early pregnancy, know what investigations are required and offer an appropriate choice of treatment. Early pregnancy units are an ideal setting for this to take place. Although many women who attend these units will leave reassured that the pregnancy is viable, miscarriage and ectopic pregnancy will be diagnosed in others. The clinical situation at presentation, the results of investigation and the circumstances of the woman will determine the appropriate management in each case—expectant, medical or surgical.

Obesity complicating pregnancy continues to be a major clinical problem for the obstetrician and the obstetric anaesthetist. Studies suggest that the physiological changes of pregnancy, designed to increase maternal energetic efficiency and liberate fetal substrates, may contribute to a worsening of obesity in susceptible subjects. Adverse outcomes of pregnancy that are significantly more common in the obese include maternal death, thromboembolism, preeclampsia, gestational diabetes, emergency caesarean section, neonatal death and fetal overgrowth. Outside pregnancy, obesity in the mother and the newborn contribute to later disease patterns that can shorten life expectancy.

Clinical and epidemiological studies have begun to change the way in which we think about foetal growth restriction. Research worldwide has established that people who were small at birth and had poor infant growth have an increased risk of adult cardiovascular disease and type 2 diabetes, particularly if their restricted early growth is followed by increased childhood weight gain. These relations extend across the normal range of infant size in a graded manner. The observations have led to the ‘developmental origins of health and disease hypothesis’, which proposes that cardiovascular disease and type 2 diabetes originate through developmental plastic responses made by the foetus and infant; these responses increase the risk of adult disease if the environment in childhood and adult life differs from that predicted during early development. Evolutionary considerations and experimental findings in animals strongly support the existence of major developmental effects on health and disease in adulthood.

Intrauterine growth restriction (IUGR) is a common clinical diagnosis in obstetrics, although it is frequently not diagnosed until after delivery. There are many causes, and our understanding of the pathophysiology is limited. Individuals with a low birthweight have an increased risk of adult disease such as ischaemic heart disease, and the fetus and neonate have an increased risk of mortality and morbidity. Severe early-onset IUGR is uncommon and presents difficult management decisions. Delivery is the only practical treatment option, and the timing of delivery must be aimed to maximise gestation while minimising the risks of continued intrauterine life. The investigation of the fetal circulation using Doppler ultrasonography has become more sophisticated, with greater attention being played to the venous circulation, particularly that unique to the fetus: the umbilical vein and ductus venosus.

Polycystic ovarian syndrome (PCOS) is a common endocrine disorder affecting women in their reproductive years. It is frequently associated with reproductive dysfunction, including anovulatory infertility and early pregnancy loss. The underlying pathophysiology of PCOS is not fully understood, although there is considerable evidence to suggest that an excess of ovarian androgen production, either genetically determined or due to hyperinsulinaemia or hypersecretion of luteinising hormone (LH), remains central in the pathogenesis of PCOS. Chronic anovulation seems to be the result of abnormal folliculogenesis characterised by follicular arrest at the small antral phase with escape from atresia. Hypersecretion of LH, hyperandrogenaemia and/or hyperinsulinaemia has been postulated as the possible underlying mechanism of early pregnancy loss in women with PCOS. Anovulatory infertility in PCOS women can be treated with insulin-sensitising measures (such as weight reduction and metformin), clomifene citrate, laparoscopic ovarian diathermy (LOD) and ovarian stimulation with follicle-stimulating hormone. LOD and metformin may help to reduce the risk of miscarriage in women with PCOS, although the effectiveness of these measures remains to be established.

The past few years have seen rapid advances in the understanding and management of fetal disease. The development of high-resolution and 3D/4D ultrasound and the ability to analyse fetal DNA in the maternal blood have proved to be exciting innovations. In utero fetal therapy is, however, still limited by the complications of preterm labour and premature rupture of membranes, and the further development of endoscopic procedures is dependent on improvements in the management of these complications. In this article, we look at some of the recent advances in fetal medicine and speculate on the possible directions that future developments may take.

Cervical cerclage is a procedure in which sutures are inserted around the cervix in women suspected to have cervical weakness. This is thought to prevent cervical dilatation and membrane exposure, thus helping the uterus to retain the pregnancy in women who are prone to miscarrying, mostly in the mid-trimester. It was first described over 50 years ago by Shirodkar, followed by McDonald. It has been widely practised in different parts of the world with variable results. This procedure can be performed as either a planned or an emergency operation depending on the clinical situation. Based on the indication, the approach could be vaginal or abdominal. Despite having been practised widely, uncertainty still exists with regard to its indications, patient selection, effectiveness and adverse effects. Counselling patients of the possible outcome of the procedure in terms of success needs to be individualised. In this article, we revisit the basics of this condition, along with the available evidence for its practice.

Every gynaecologist should study the law applicable to his or her practice. This involves a knowledge of civil law, especially the tort of negligence, and criminal law, as well as the related acts. The application of legal principles has become a part of everyday practice, ranging from the signing of consent forms to risk management and incident reporting. There is a considerable overlap with medical ethics. This article gives an overview of the various aspects of law in gynaecological practice, ranging from the reasons for getting into trouble, statutory law and authority, new trends in consent, the provision of information, risk management, clinical incident reporting and complaints, the concept of safe practice, the legal position of guidelines, and professional and personal conduct. Forensic gynaecology also involves extensive legal and clinical knowledge. Specific problem areas such as abortion, female sterilisation, colposcopy, hysteroscopy, laparoscopy, hysterectomy, urogynaecology and assisted conception are discussed. The article concludes with some suggestions for training and education.