Current obstetrics & gynaecology最新文献

This article discusses some important and commonly used drugs in reproductive medicine, concentrating on the management of subfertility. Clomifene citrate is an effective first-line therapy in anovulation, resulting in 80% ovulation rates and 50–60% pregnancy rates. Gonadotrophins are effective ovulation-induction agents in cases of clomifene resistance or for superovulation protocols necessary for in vitro fertilisation. Metformin and aromatase inhibitors show promise, but further evidence is needed to support their routine use. Both gonadotrophin-releasing hormone agonists and antagonists are effective at preventing a premature surge of luteinising hormone, but it is unclear whether the antagonists, with their patient-friendly shorter cycle, will become the approach of choice. Concerns about the carcinogenic effects of infertility drugs do not seem to be supported by epidemiological evidence, but because of a possible time-lag effect, this area merits surveillance. Future developments include more patient-friendly drug-delivery systems.

The development of highly active antiretroviral therapy has transformed the prognosis of patients infected with human immunodeficiency virus type 1 (HIV) living in the developed world and increased the demand for reproductive care for these patients. The primary aim is to ensure that infected individuals do not put their uninfected partner or unborn child at risk. Centres offering assisted-conception treatment to HIV couples need to provide risk-reduction options such as sperm-washing, and reproductive counselling, and ensure the safety of uninfected patients and healthcare workers in the centre. Where the man is HIV-1 positive and the women HIV-1 negative, sperm-washing is a well-established, effective means of reducing HIV transmission risk compared with timed, unprotected intercourse. If a couple have additional fertility issues, sperm-washing can be combined with ovulation induction, in vitro fertilization or intracytoplasmic sperm injection. In HIV-positive women trying to conceive, reducing risk lies primarily after conception in preventing mother-to-child transmission, achieved through the use of antiretroviral medication during pregnancy and delivery, caesarean or managed vaginal delivery and an avoidance of breast-feeding.

Malpresentations of the fetus can arise by chance but can also be associated with maternal or foetal pathology. Excluding pathology is an important preliminary in their management, but even then they are associated with increased risks to both mother and fetus, including prolonged labour, cord prolapse, traumatic delivery and caesarean section. Early diagnosis and expert timely management are the cornerstones of good obstetric care generally, but they are crucial when malpresentations are first recognised in labour. The increasingly liberal use of caesarean section combined with the reduction in junior doctor working hours is decreasing clinical exposure and experience to these relatively rare obstetric complications. They will continue to occur, however, and therefore training to acquire and maintain skills in clinical assessment, decision making and obstetric manoeuvres is receiving increasing attention.

Dyspareunia is a form of sexual dysfunction that can significantly affect quality of life and cause relationship difficulties. It is a symptom of a variety of disease states with components of both physical and organic dysfunction. Obtaining a good sexual history in an outpatient setting requires high level of professionalism. A systematic examination of the lower genital tract is necessary to rule out any obvious cause, although further investigations such as ultrasound do not often offer additional information. Diagnostic laparoscopy is an invasive procedure that is of limited use in the management of dyspareunia but might help detect pelvic adhesions or endometriosis in those where this condition is suspected. Before embarking on a laparoscopy it is important for the patient to be aware of a management plan if the laparoscopy does not show any obvious cause. There are data to suggest that empirical medical treatment after clinical diagnosis of endometriosis is effective and has the advantage of avoiding any invasive procedures. Psychosexual causes are important to consider during the assessment of the patient experiencing dyspareunia.