Current obstetrics & gynaecology最新文献

Antepartum haemorrhage is bleeding from the genital tract in the second half of pregnancy. It continues to be an important cause of maternal and fetal mortality and morbidity. In those cases where a cause is identified, placental abruption and placenta praevia are two common responsible conditions. In the remaining half, the cause remains unidentified even after investigations. Placental abruption is diagnosed clinically, and is unpredictable. The management has changed little over the recent past. Availability of ultrasound has radically changed screening, diagnosis and management of women with placenta praevia. The frequency of placenta accreta appears to be increasing, and ultrasound can be useful for antenatal identification. Prenatal diagnosis dramatically improves the perinatal mortality associated with vasa praevia. Massive haemorrhage is still responsible for maternal deaths. A clear protocol for massive haemorrhage should be available in all units, be regularly updated and rehearsed.

Gestational trophoblastic disease is a disease of the proliferative trophoblastic allograft and includes partial mole (PM), complete hydatidiform mole (CM), invasive and metastatic mole, choriocarcinoma, placental-site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT). Suction evacuation is recommended to terminate CM or PM. PM or CM should be monitored with serum human chorionic gonadotrophin, and effective contraception should be advised for at least 6 months. About 10–20% of patients with molar pregnancy may progress to gestational trophoblastic neoplasia (GTN) which requires chemotherapy. At the 2000 International Federation of Obstetrics and Gynecology (FIGO) meeting, recommendations were made on the criteria for diagnosing GTN and on methods of investigation. Staging was revised to include a modified World Health Organization risk score. The first-line chemotherapy for low-risk GTN is methotrexate and, for high-risk GTN, EMA-CO is recommended. In PSTT and ETT, surgery plays a more important role than chemotherapy. Referral of patients to a centre with experience in treating GTN is important to ensure a good outcome.

Postpartum collapse signifies an acute event involving the brain, heart or lungs and may ultimately result in death. Every effort should be made to prevent this possible catastrophic outcome. This can be achieved by understanding the causes of maternal collapse and by prompt appropriate resuscitation. Implementing guidelines and ensuring a multidisciplinary input will improve the chances of a good outcome. In addition, it is essential that high-risk women are identified in the antenatal period to allow care to be optimized to prevent postpartum collapse.

Palliative care focuses on maximal treatment of symptoms of disease when there is no curative therapy available. In gynaecology, the majority of palliative care is focused in oncology care. Key symptom areas are pain control and management of bowel and pulmonary dysfunction including maximal management of nausea. In addition, the unique issues of end-of-life care create special challenges for communication with patients and their families. The role of the health professional is often that of navigator and advocate, and is a key role in a multidisciplinary approach to managing these patients.

Radiotherapy and chemotherapy are both widely used in the management of gynaecological malignancy. The reasons why tumours are destroyed and normal tissues recover after radiotherapy are complex and poorly understood. Therapeutic effects depend on differences in intrinsic radiosensitivity and the ability to repair and repopulate between normal and malignant tissue. Some tumours contain hypoxic cells, which are a source of radioresistance. At present, most radiotherapy treatments are carried out using a linear accelerator, which produces ‘skin sparing’ radiation and can treat deep-seated tumours. Brachytherapy (short-distance treatment) with implanted or internal radiation sources can also be used, and is an essential part of the radical radiotherapy for cervical carcinoma. Chemotherapeutic agents currently in use are cytotoxic and affect both normal and malignant cells. Side-effects include bone marrow suppression, nausea and vomiting, epilation, renal, cardiac and neurotoxicity. Ideally, agents with different mechanisms of action should be given in combination to overcome potential drug resistance. Multiple drugs should have differing patterns of toxicity so the highest tolerable doses can be given. Chemotherapy can also be given concurrently with radiotherapy to enhance the therapeutic effect. As most gynaecological chemotherapy treatments are palliative, patients should be selected with great care; the possible benefits of the treatment must be balanced against the risk of side-effects.

Good preoperative preparation of patients, both physically and psychologically, is essential to provide optimum intra-operative conditions and to lay the basis for a smooth postoperative recovery. A well planned postoperative care regime leads to a reduction in morbidity, shorter hospital stay and greater patient satisfaction.

Postnatal care is often described as the ‘Cinderella’ of the maternity services. It is now becoming recognised that inadequate support, advice and treatment can impact quite considerably upon a woman's daily life, her relationships with family and friends and her parenting abilities. This review provides an overview of the management of postnatal care and breastfeeding, and the factors most likely to promote mothers’ health and well-being.

The outcome of diabetic pregnancy has not changed over the last 15 years despite St. Vincent declaration, in terms of perinatal mortality and congenital malformation. This applies to both Types 1 and 2 diabetes. Type 2 diabetes is emerging as an additional risk as its incidence is increasing. National initiatives have been set up by the professional bodies (CEMACH Diabetic Project) and the UK Department of Health (Diabetic National Service Framework) to explore the current status of diabetic pregnancy and the impact of various health care issues on its outcome with a view to establishing future care plans on a national basis. The challenge is how to establish an effective partnership between the patients and the health care professionals. The key areas should include preconception service, effective clinical service delivery, audit and patient education. Future research should be focussed to understand the biological and sociological reasons behind adverse outcome of diabetic pregnancy.