Current obstetrics & gynaecology最新文献

Vaginal discharge is a common symptom in women of reproductive age. The causes can be divided into those that are infective or non-infective, the most common being the infective agents. Initial assessment of a patient with vaginal discharge requires a thorough history, including sexual history, examination, and testing for these common infections.

The non-sexually transmitted infections (STIs)—bacterial vaginosis and candidiasis—are the most frequently encountered and these can often be diagnosed immediately by the clinical findings and simple bedside tests. Persistence or recurrence of these infections is also seen and might require repeated or prolonged courses of treatment.

The STIs—chlamydia, gonorrhoea and trichomoniasis—can also cause vaginal discharge and diagnosis requires appropriate laboratory tests to be performed. Partner notification and treatment is an essential part of the management.

In the absence of any infections, physiological discharge should be considered as a possible cause.

The incidence of obesity (body mass index (BMI)>30 in the first trimester) is increasing in the UK pregnant population and with it the risks such patients present in their obstetric care. Clinical assessment of fetal growth can be difficult and associated problems of increased risks of pregnancy complications are found: diabetes, hypertension, venous thromboembolism. Caesarean section rates are increased as are complications during and following operative procedures. Greater efforts need to be made to encourage weight loss to within normal BMI ranges to endeavour to reduce these risks in subsequent pregnancies in all obese pregnant women.

In the recent white paper ‘Choosing Health: making healthy choices easier’, the UK Government outlined the actions required to prioritise sexual health care in the NHS. This is in response to an unprecedented rise in sexually transmitted infections (STIs) in recent years. There has been an increase in high-risk sexual activity, ignorance regarding consequences and higher incidence of infection resulting from migration from developing countries. Acquisition abroad via so-called ‘sex tourism’ is also a factor in prevalence, as is the development of drug-resistant infections.

Early identification of infection is crucial to prevent or ameliorate sequelae. Obstetricians and gynaecologists will often be patients’ first point of contact; thereafter, liaison with genitourinary medicine colleagues is vital. Special consideration of safe treatments and prevention of vertical transmission in pregnant patients present obstetricians with extra challenges.

Sadly, intrauterine fetal death is a common occurrence and one that all labour ward personnel should be trained to manage. Recent advances have improved the likelihood of identifying a cause. The key to this is a logical and methodical approach to investigation. Postmortem examination remains a critical aspect of investigation and labour ward teams require a clear understanding of the legal aspects of this. Sympathetic and supportive care of parents should respect parental wishes and allow choice wherever possible. However, maternal safety should also be a central aspect of this care.

Obstetrics is a specialty that is widely perceived to be associated with a high risk of litigation. In the UK, it accounts for about 60–70% of the total (malpractice) sum paid by the NHS Litigation Authority (NHSLA) each year. Professionals involved in malpractice claims can become demoralized and the fear of litigation might be deterring young medical graduates from entering the specialty, leading to a recruitment crisis. Patients, and their families, who are involved in a litigation process often experience physical and emotional trauma, which might not be alleviated by financial compensation. During the antenatal period, missing structural abnormalities during obstetric ultrasound and failure to inform the patients of such abnormalities can result malpractice claims. Intrapartum fetal distress, shoulder dystocia and complications of vaginal birth after caesarean section account for the majority of obstetric litigation. Effective communication, team working, documentation, training and education as well as robust risk management strategies can help improve patient care and reduce medico-legal claims.

The global pandemic of human immunodeficiency virus (HIV) infection has had significant impact on women of reproductive age. Mother-to-child transmission (MTCT) is an important route by which children are being infected worldwide. With early diagnosis and effective antenatal strategies, maternal health can be optimised and MTCT rates significantly reduced. These strategies include the use of antiretroviral therapy (ART) in pregnancy (either for reasons of maternal health or as prophylaxis to prevent MTCT), as well as delivery by pre-labour caesarean section in those with a detectable viral load, combined with avoidance of breastfeeding and administration of ART to the newborn in the first month of life.

Survival and later morbidity after extremely preterm birth are key issues to factor into the care of women and their children at borderline viability. Whereas we have robustly collected information on survival that shows some increases at 24–25 weeks of gestation, few data suggest any change in morbidity. Of babies born before 26 weeks of gestation around one quarter grow up with serious disability. Mild disabilities are common amongst the remainder. Overwhelmingly the major adverse outcome following extremely preterm birth is cognitive impairment, something that may not be apparent until school age, when we make increasing demands on children to perform. Despite these problems studies of very preterm/very low birthweight children as adults seem to indicate good adaptation and integration into society.

Parturition is a multifactorial, physiological process involving numerous interrelated maternal and fetal pathways, which may be both positive feed-forward and negative feedback. The mechanisms that initiate human parturition are not yet fully understood, despite decades of clinical, physiological and biochemical research by many investigators. However, it has been proposed that there are a number of stages that promote the myometrium to a contractile state, including the upregulation of receptors, prostaglandin production, and increased formation of intracellular contraction-associated proteins. The exact trigger for uterine contractions and which pathway is pre-eminent is yet to become clear. Cervical ripening is independent of the initiation of uterine contractions, although the pathways are not yet fully known, it does involve the release of proinflammatory cytokines, leukocyte infiltration into the cervix, the release and activation of extracellular matrix metalloproteinases, other proteins and glycoproteins. Drugs that act upon the pregnant uterus can be thought of as modifiers of these endogenous physiological pathways controlling normal myometrial contractility and cervical ripening. They may be characterized by their sites of action into agents acting upon prostaglandin pathways, progesterone receptors, $\beta$-adrenergic receptors, calcium channels, the oxytocin receptor and via nitric oxide. Drugs may also be functionally classified into agents used for the induction and augmentation of labour, for the termination of pregnancy, to treat postpartum haemorrhage, and to treat threatened preterm labour. This review aims to discuss the therapeutic drugs that act on the pregnant uterus.