Current obstetrics & gynaecology最新文献

This review will consider the non-oral hormonal contraceptive methods—combined injectables, intramuscular and subcutaneous progestogen-only injectables, progestogen implants, the Levonorgestrel intrauterine system, transdermal patches and the, as yet unavailable, vaginal Nuvaring. The long-acting methods used as implants, injectables or as part of an intrauterine system are highly effective forgettable contraceptive methods and are likely to have a significant impact on the reduction of unintended pregnancy rates. They avoid the hepatic first pass metabolism and gastrointestinal interference with absorption of hormonal components, thus allowing lower doses to be used, which may reduce the incidence of side effects and risks.

Male and female sterilisation is used in many countries worldwide as a permanent method of contraception. Failure rates for female sterilisation are affected by age at sterilisation and by the method of tubal occlusion. Laparoscopic sterilisation has low complication rates but is unavailable in parts of the developing world due to the lack of facilities, equipment and expertise. Less invasive techniques are being developed, such as hysteroscopic tubal occlusion and administration of intrauterine agents. Failure rates for vasectomy are 10 times lower than those for female sterilisation. Complications such as pain, haematoma and granuloma formation may occur. Nursing staff and doctors can provide counselling prior to sterilisation. Failure rates, irreversibility, complications and alternative methods of contraception should be discussed and documented. Counselling should allow men and women to provide informed consent for sterilisation and reduce the incidence of regret and requests for reversal.

We are still failing in the optimal management of massive obstetric haemorrhage, as it remains the third most common direct cause of maternal mortality in the UK. With difficulties in the diagnosis, a loss of over 1000 ml is sensibly an appropriate cut-off to prompt the initiation of emergency measures. The causes are due to abnormalities of one of four basic processes, with uterine atony being the most common. Although risk factors have been associated with postpartum haemorrhage (PPH), antenatal risk assessment predicts only 40% of those who will develop PPH. Delay in initiating appropriate management in severe PPH is the major factor resulting in adverse outcomes. As significant life-threatening bleeding can occur unpredictably, a clear and logical sequence of steps is essential in the management of PPH. We present an algorithm previously proposed using the mnemonic ‘HAEMOSTASIS’ that spells the actions suggested for the effective control of PPH.

Urinary incontinence is a common problem affecting up to 35% of the female population. Initial management involves a thorough history, examination and urinalysis, following which a presumptive diagnosis can be made and initial treatment commenced; these can all be performed by trained nurses, or general paractitioners (GPs), in primary care. If these measures fail, then the patient should be referred for specialist management in secondary care. Three cases are described; stress incontinence, overactive bladder and mixed urinary incontinence, which highlight the principles of this care pathway and introduce new surgical techniques and drug treatment.

von Willebrand disease (vWD) is the most common inherited bleeding disorder. It is found in approximately 1% of the general population. This article covers the classification and laboratory diagnosis of vWD and focuses on the bleeding complications experienced by women with vWD during pregnancy and the puerperium, the available treatments and the monitoring thereof.

Suicide is the leading cause of maternal death in the UK. Recognising risk factors for major postnatal mental illness and distinguishing between normal emotional changes and psychiatric disorder during pregnancy is critical in routine antenatal care. Changes in prescribing practices in psychiatry may have implications for childbearing women. Recent developments in screening and prevention and recommendations arising from the Confidential Enquiries into Maternal Deaths will help achieve best practice in caring for mentally ill women during pregnancy and in the early postnatal period. There is a need for such issues to be routinely included in the professional training of obstetric, midwifery, primary care and psychiatric staff.

Physiological changes of pregnancy and the presence of the second patient, the fetus, mean that the management of thyroid disease in pregnancy is not the same as outside pregnancy. These adaptations and differences in management will be discussed.