Current obstetrics & gynaecology最新文献

Abdominal pain in pregnancy poses a diagnostic and management challenge to the attending physician. Many causes are specific to pregnancy, but conditions affecting the non-pregnant woman can also complicate pregnancy. Identifying the cause is influenced by the anatomical and physiological changes of pregnancy. When diagnosis and symptom control fail after 6–8 h a multidisciplinary approach should be considered. The safety and the possibility of a systematic cross-sectional evaluation of the entire abdomen have been important reasons for the use of magnetic resonance imaging in pregnancy with intractable pain. Laparoscopic surgery when appropriate is now proving to be as safe as open surgery in pregnancy. Updating knowledge and assessment skills is essential in the management of abdominal pain in obstetric triage settings.

Dysmenorrhoea is commonly divided into primary dysmenorrhoea, where pelvic anatomy and ovarian function are normal and there is no co-existent pathology, and secondary dysmenorrhoea where there is an identifiable pathological condition. The true incidence is difficult to establish due to an inconsistency in the definition used and the population studied, but dysmenorrhoea probably affects between 40% and 70% of women of reproductive age, and compromises daily activities in up to 10% of women. It is associated with significant psychological distress, including both anxiety and depression, which may be co-existent, and requires considered, empathetic management by healthcare practitioners. Although the exact pathophysiological mechanisms that underlie the disease are incompletely understood, the pain most likely reflects increased myometrial activity induced by an excessive production of prostaglandin. This is supported by the clearly beneficial effect of non-steroidal anti-inflammatory agents, although optimal management of dysmenorrhoea depends on an understanding of the underlying cause with treatment specifically directed at this. Patients with primary dysmenorrhoea may simply need reassurance and simple analgesics, whereas those with secondary dysmenorrhoea require investigation and treatment of the underlying organic problem. Treatment is generally supportive, however, with adequate symptomatic relief provided for the majority of patients through the single or combined use of non-steroidal anti-inflammatory agents and the combined oral contraceptive pill. Lack of response to these agents increases the likelihood of a secondary cause for dysmenorrhoea prompting further investigations and specifically directed treatment upon diagnosis.

The small-for-gestational age baby contributes to cases of perinatal morbidity and mortality. Establishing small-for-gestational age status on gestational ultrasound is difficult because further management is aimed at differentiating the constitutionally normal baby from the baby who has an intrinsic problem or placental insufficiency. Even when the small fetus at risk of in utero demise from uteroplacental insufficiency is accurately identified, the optimum timing and mode of delivery are ill understood and can be difficult. The risk of premature delivery has to be weighed against the risk of fetal demise from intrauterine hypoxia. This review outlines the fetal biometric indices by which the diagnosis of a fetus that is ‘small-for-gestational-age’ is made. The place of serial scans for fetal biometry and the range of functional studies for fetal surveillance are discussed. Factors that should influence the timing of delivery are mentioned, and some recent advances in fetal surveillance are highlighted.

In 2001, the National Institute for Health and Clinical Excellence commissioned the National Collaborating Centre for Women and Children's Health to produce clinical guidelines for clinically effective, cost-effective and appropriate infertility treatment. These guidelines were to build on the existing Royal College of Obstetricians and Gynaecologists’ guidelines on the management of infertility, incorporating any new published scientific evidence available, in order to produce a seamless guide to the management of the infertile couple. In addition, the guideline needed to address the clinical criteria that had to be met to qualify for National Health Service (NHS) treatment, as well as the cost implications of implementing the guideline for the NHS. Three versions of the guideline were published in March 2004. This article describes the process of developing the guideline, the major recommendations included in the report and their implications for the health service.

Approximately 50% of infertile couples will require treatment with some form of assisted conception in order to achieve a pregnancy. In vitro fertilisation (IVF) can be viewed as both a test of reproductive potential, allowing a detailed assessment of oocytes, oocyte sperm interaction and embryo quality, and an effective treatment for most forms of subfertility. The many improvements in IVF treatment since the first baby was born some 27 years ago have occurred as a result of close multidisciplinary collaboration and the practical application of scientific advances in embryology and pharmacology. There have been several important landmarks, including the introduction of drugs for pituitary downregulation and superovulation, the introduction of transvaginal ultrasound scanning for monitoring follicle growth and oocyte retrieval, developments in embryo culture, oocyte donation, and the introduction of intracytoplasmic sperm injection for the treatment of severe forms of male infertility. The pace of change has not slowed: within the past decade, new technologies, including preimplantation genetic diagnosis, the in vitro culture of immature oocytes to viability, and the cryopreservation of oocytes, have widened the scope of clinical problems that can be addressed by IVF-associated technologies. Despite this progress, the majority of IVF cycles still do not produce a viable pregnancy, and the psychological stresses imposed upon couples by assisted conception treatment need to be managed carefully and sympathetically. IVF practice continues to require support from appropriately trained and skilled counselors.

The methods used for the diagnosis and management of ectopic pregnancy have developed over the past 10 years. Improved ultrasound and rapid access to serum human chorionic gonadotrophin monitoring have increased the accuracy of diagnosis. Laparoscopic surgery, rather than open surgery, is now the main method of treatment. The medical treatment of ectopic pregnancy in the form of methotrexate therapy is popular in a number of centres. The effects on future fertility and the recurrence rate of ectopic pregnancies will alter patients’ preference for treatment.