Current Obstetrics and Gynaecology

Published by Elsevier
Print ISSN: 0957-5847
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PIP This article reviews the incidence of abortion and some of the factors that contribute to differences in the use of abortion between countries and between different population groups within the same country. Liberalization of abortion started in Europe in the 1930s and continues today. Currently, some 63% of the world's people live in countries where abortion is available on request or where social factors can be taken into consideration when evaluating a woman's request for pregnancy termination. However, governments that have legalized pregnancy termination have yet to provide adequate services to meet the demand. Every year up to 53 million women seek termination of an unwanted pregnancy; between 150,000 and 200,000 women die in the process and countless more are injured for life. Factors that affect abortion rate include the concept of liberalization of abortion, sex education, and accessible family planning services and emergency contraception. Although the Netherlands permits abortion, it has the lowest reported abortion rate in the world. In the US and in Scandinavia, young unmarried women make up the largest proportion of those who obtain abortion. In most other developed countries, married women with children constitute the largest group of abortion users.
 
Gene therapy has become a clinical reality due to scientific progress in isolating human genes and elucidating their function in health and disease. The first such treatment (gene supplementation for adenosine deaminase deficiency) was administered in 1990, and subsequently numerous protocols for gene therapy have been approved by the regulatory authorities. These early proposals can be broadly divided into gene supplementation for single gene disorders and therapeutic strategies in cancer. Amongst the single gene disorders, attention has particularly focussed on adenosine deaminase deficiency, cystic fibrosis, familial hypercholesterolaemia and haemophilia B. In cancer, gene therapy is being explored for tumour marking for residual disease, for tumour cell destruction (by immune stimulation or by targetted drug delivery) and with anti-sense strategies. However, gene therapy with administration of exogenous genes and manipulation of function of endogenous genes promises to have much wider applications. Strategies to treat a wide range of cardiovascular and neurological disorders and to curtail HIV infection have already been proposed and as the remaining human genes are cloned and their function elucidated, the list of potential therapies is bound to grow. These developments will be guided by the level of success achieved in the early trials in progress and there will need to be close regulation of this early work and prolonged follow-up of treated patients to ensure that the promise is realised.
 
The new emerging techniques for endometrial ablation are all attempts to improve upon Transcervical Resection of the Endometrium (TCRE), the gold standard against which ablative techniques tend to be judged in terms of efficacy. TCRE has some drawbacks, particularly the difficulty of safely mastering the technique and the problems associated with cutting tissue and exposing the vascular system — fluid overload and haemorrhage. Other difficulties of endometrial ablation that need to be overcome are the quite surprising regenerative ability of the endometrium and the very significant protective effect of the uterine blood supply. The thermal exchange effect of the uterine blood flow is even more marked in the presence of uterine fibroids due to the increased vascularity. The techniques currently emerging in this field are balloon systems (Cavaterm, thermal balloon, vestablate), cryotherapy and microwave.
 
Hysteroscopic metroplasty has largely replaced the need for abdominal metroplasty in patients with a septate or subseptate uterine abnormality. Advantages of the transcervical procedure include less morbidity, shorter operative duration, shorter post-operative convalescence and the possibility of vaginal delivery in subsequent pregnancies.
 
Spontaneous abortion is common in early pregnancy, whilst recurrent miscarriage is relatively rare. Empirical studies of psychological sequellae of spontaneous abortions are limited, but strongly suggest that a significant number of women who miscarry, experience grief and various degrees of clinically-significant depression and anxiety. Depression is more common amongst women with recurrent abortions. Contributory factors for the development of psychological distress in women range from obstetric history, personality, past history of psychiatric illness, attitude towards pregnancy and social support.There is evidence that clinicians are poor at the psychological management of miscarriage. If detected early, successful intervention can be made in cases of grief and other clinical disorders. Sensitivity, support and appropriate psychopharmacological intervention can significantly reduce distress.
 
Every day some 150 000 unwanted pregnancies, close to 53 million in a year, are terminated by induced abortion. One third of these abortions are performed under unsafe conditions, resulting in about 500 deaths every day — or approximately 180 000 in 1 year. The majority of these deaths occur in countries in the developing part of the world, where access to abortion is restricted either by law or because existing services are inadequate. The trend towards liberalisation of abortion started in Europe in the 1930s and continues today. Currently, some 63% of the world's people live in countries where abortion is available on request or where social factors can be taken into consideration when evaluating a woman's request for pregnancy termination. Liberalisation of abortion does not inevitably lead to an increase in the number of abortions, as illustrated by the example of the Netherlands which has the lowest reported abortion rate in the world despite its liberal law. Other factors such as universal sex education in schools and easily accessible family planning services, including services for adolescents and the provision of emergency contraception, influence a country's abortion rate to a much greater extent than the degree of liberalness of its law. This is also reflected by the demographic characteristics of the women who most often utilise abortion. In English-speaking countries, especially the USA, and in Scandinavia, young unmarried women make up the largest proportion of those who obtain abortion and the major challenge in these countries, therefore, is to improve sexual education and contraceptive use and hence reduce unintended pregnancy amongst this group. In most other developed countries, including those in Central and Eastern Europe, that have reliable abortion statistics, and probably also in most of the developing world, married women with children constitute the largest group of abortion users and thus the greatest need here is to provide contraceptive services and supplies and encourage their use. But neither the family planning methods currently available nor the people who use them are perfect, and it would be unrealistic to believe, therefore, that unplanned pregnancy and induced abortion are totally preventable.
 
Over the last decade a series of new gonadal proteins have been discovered. Inhibins and activins belong to this ever-growing family of proteins, which includes Müllerian inhibiting substance, epidermal growth factor (EGF), transforming growth factor (TGF), and insulin-like growth factors (IGF). It has become evident that the regulation of gametogenesis can no longer be explained solely by the effects of the sex-steroids and the two gonadotrophins, follicle-stimulating hormone (FSH) and luteinizing (LH).This review will focus on the inhibin-related proteins. The structure of these proteins, their production and actions will be discussed as well as their clinical importance.
 
This case report describes the onset of an acute psychiatric illness in pregnancy in a patient known to suffer porphyria. The diagnostic dilemma this raised is discussed.
 
A case of primary adenocarcinoma of the stomach presenting as postmenopausal bleeding from a cervical polyp is described to highlight the need to pay attention to even innocent-looking cervical polyps.
 
Advanced extrauterine pregnancies, although uncommon, are associated with significant morbidity and even mortality. Early diagnosis is, therefore, essential. A high index of suspicion is necessary and ultrasound examination is the best investigative tool to date. Conservative management with the aim of fetal viability in pregnancies greater than 24 weeks' gestation is an appropriate form of management and does not adversely effect maternal morbidity and mortality.
 
Trophoblastic disease results from an inappropriate and excessive proliferation of the trophoblast. Most cases result from an antecedent pregnancy where abnormal fertilisation has occurred. These abnormal fertilisations result in hydatidiform moles. Most, but not all cases of gestational trophoblastic disease (GTD) follow hydatidiform moles. Only maternal age, a previous molar pregnancy in the woman and race (with the co-variate of geography) have consistently been identified as epidemiological risk factors. Whilst the genetic pathogenesis of hydatidiform moles is well understood, the aetiological factors that result in these abnormal fertilisations remain unclear. It is not possible to examine the epidemiology or aetiology of non gestational trophoblastic disease adequately because of its rarity.
 
Endometrial hyperplasias and many endometrial carcinomas are the result of over-stimulation of the endometrium by oestrogens. Hyperplasias are classified as simple, complex or atypical, the terms ‘simple’ and ‘complex’ referring to the glandular architectural pattern as assessed under low magnification and ‘atypical’ taking account of nuclear features under high power. Atypical hyperplasia may be difficult to distinguish from well-differentiated adenocarcinoma. The commonest type of adenocarcinoma, the typical endometrioid carcinoma, needs to be distinguished from the less frequently encountered serous and clear cell carcinomas because of the much worse prognosis associated with the latter two types of tumour. Squamous elements may be found in endometrial carcinomas; the importance of this finding and the value of assessing the malignancy of the squamous component is controversial.
 
Hypertensive disorders of pregnancy continue to be an important cause of both maternal and perinatal mortality and morbidity, and are a significant drain on patient and health service resources. Blood pressure measurement is pivotal to the diagnosis and management of hypertensive disorders. However, current conventional methods of blood pressure assessment during pregnancy are associated with a high number of false positive and false negative diagnoses. Errors inherent in conventional sphygmomanometer measurements may lead to unreliable measurements of antenatal blood pressure. Automated ambulatory blood pressure monitoring addresses both the level of blood pressure and its variations and recognises that these can only be described adequately by taking a large number of measurements in the patient's everyday surroundings. Automated blood pressure measurement will be of value in this setting only if it improves current management by focusing resources on truly hypertensive pregnancies, and achieves equivalent outcomes with fewer resources and less disruption for patients. Ambulatory blood pressure monitoring may significantly reduce the total number of in-patient antenatal admissions, with obvious social and economic benefits. It may also provide a tool which will more appropriately direct clinical action to those designated at risk.
 
Expansion of amniotic fluid volume is usually achieved by instillation of sterile fluid into the amniotic cavity by either the transabdominal or transcervical route. However, it has recently been demonstrated that oral hydration of the mother can have the same effect. Amnioinfusion always has the same indication, which is expansion of reduced amniotic fluid volume, but has several different applications. Oligohydramnios hinders ultrasound diagnosis as the lack of acoustic window and degree of fetal flexion limit the view obtained. Diagnostic amnioinfusion circumvents these problems by restoring amniotic fluid volume. Midtrimester oligohydramnios is associated with a poor fetal prognosis, whatever the underlying aetiology. Part of this is attributable to the underlying pathology, but a significant proportion is mediated through the fetal effects of oligohydramnios. Thus, serial amnioinfusion has been proposed as a therapeutic technique to maintain amniotic fluid volume. Amnioinfusion can be used to introduce antibiotics into the uterine cavity either for infection prophylaxis or treatment. Intrapartum amnioinfusion has been used to dilute thick meconium to prevent meconium aspiration, and to alleviate fetal heart rate pattern abnormalities. This article will examine these different roles of expansion of amniotic fluid volume.
 
Different techniques now available to obstetric anaesthetists will be examined including spinal anaesthesia, spinal catheters, combined spinal epidurals and subarachnoid and epidural opiates. The article will also examine the influence regional anaesthesia has on obstetric management, the condition of the fetus and maternal wishes.
 
An anatomical view of pelvic support has a lineage in the specialty of almost a century22 and has been built upon by the work of several groups in the southern USA. [26], [3] and [4] Careful history and physical examination, with individualized surgical repair of each defect in the supporting network of endopelvic fasciae, are the hallmarks of this approach. There is much less emphasis on the muscular elements of the ‘pelvic floor’ and much more emphasis on the non-muscular components of the endopelvic fasciae. Traditional concepts of female continence based on theories of ‘pressure transmission to an intra-abdominal urethra’ are under increasing scrutiny, and a shift of emphasis from the ‘pressure-flow’ paradigm to an anatomical viewpoint will benefit many patients when translated into clinical practice. The present description is simplified, and interested readers are advised to consult the original accounts and the most complete description of this subject.26 It is a salutary lesson that we do not have objective evidence of the medium and long-term outcomes of such common operations as abdominal hysterectomy, while we persist in the widespread usage of unvalidated investigations such as cystometry. It is now important that objective studies of the varieties of USI and the anatomical consequences of common surgical operations are performed to improve patient outcomes and advance the emerging subspecialty of reconstructive pelvic surgery.
 
A single cause for the development of endometriosis is unknown. Of the historical hypotheses for the development of endometriosis, coelomic metaplasia and transplantation of retrograde endometrium have been the most widely accepted. Of the modern factors, which appear significant in the subsequent development of endometriosis, genetic predisposition and disturbed angiogenesis are the most intriguing. Active studies are in progress to attempt to identify genes relevant to the development of endometriosis. Active research is also studying the vascular supply to areas of endometriosis and the role of angiogenesis, or new blood vessel formation, in the pathogenesis of this disease. The availability of molecular biology probes, as well as medicines, which inhibit angiogenesis are direct consequences of the application of this basic research to this common clinical problem.
 
The recognition that multiple pregnancies contribute disproportionately to perinatal morbidity and mortality, coupled with the increasing numbers of twin and higher order births associated with assisted reproduction, has focused attention on those perinatal problems which are commoner in, or specific to, multiple pregnancy. This review will deal with antenatal management of multiple pregnancy with particular emphasis on those aspects which have been influenced by innovations in clinical practice.
 
Antenatal care has been the subject of much interest, both medical and political, since its inception at the beginning of the 20th century. Only recently has this care come under scrutiny from a scientific perspective. Much of the content of antenatal care is now recognised as ritual rather than vital. This review assesses those aspects of antenatal management at the booking visit that are considered routine for every pregnant woman, identifying areas of proven benefit.
 
Antenatal care has been the subject of much interest, both medical and political, since it's inception at the turn of the century. Only relatively recently has the whole process of this care come under scrutiny from a scientific perspective. Much of what was previously thought of as a vital part of care is recognized as irrelevant ritual. This review assesses those aspects of antenatal management which are thought of as routine for every pregnant woman, identifying areas of proven benefit.
 
Routine antenatal care in later pregnancy is geared towards the detection of problems requiring specialist input. This review follows on from ‘routine antenatal management at the booking clinic’, and assesses the specific tasks and investigations that are routine for all women in later pregnancy.
 
Drugs should only be prescribed during pregnancy when there are clear indications; the risks of possible adverse side effects in the mother or fetus must be weighed against the likely benefits. Despite this concern, antibiotics are used during pregnancy, including 5% during the first trimester. There are few indications for the prophylactic use of antibiotics in pregnancy, but they are of value in a small number of conditions, such as Lancefield group B streptococcal carriage, recurrent bacteriuria, bacterial vaginosis, premature ruptured membranes, Caesarean section and in pregnant women with known cardiac lesions.In general, the full adult dose should be used when treating infections in pregnant women and for the prevention of infection prior to surgery. However, low-dose antibiotics for protracted periods of time can be used in the prevention of recurrent bacteriuria. Those antibiotics known to be associated with possible adverse events should be avoided and those antibiotics which have dose-related side effects should be monitored and the dose adjusted accordingly.
 
Antimicrobial prophylaxis in gynaecological surgery remained controversial for more than 30 years until properly designed, controlled studies revealed their value in defined situations. Although controversy may still exist concerning the benefits of one antibiotic versus another, the concept of using perioperative antibiotics to prevent postoperative infections should become commonplace in gynaecological surgery and the outcome should be audited. Surgical-site infection surveillance and risk-factor analysis will reveal opportunities for improvement.
 
The purpose of this article is to describe the clinical pharmacology of antimalarial drugs in pregnancy. It is not meant to be an overview of the management of malaria in pregnancy, but a few clinical observations will be made by way of introduction. Malaria during pregnancy carries great risks both for mother and baby, particularly when women have come from non endemic areas and are therefore not immune. Maternal complications can include hypoglycaemia, adult respiratory distress syndrome, disseminated intravascular coagulation and renal failure. Fetal outcome is compromised by pre-term labour and spontaneous abortion which are believed to result from extensive malarial involvement of the placenta. The standard advice given to pregnant women intending to travel to areas where malaria is endemic is: ‘don't’. However, they often do travel, in which case prophylaxis is necessary. This generally takes two forms: non pharmacological and pharmacological. The former includes fairly obvious recommendations such as wearing long sleeved shirts and trousers and sleeping under netting which has an appropriately small mesh size and which is treated with insect repellent. Mosquito coils may also be helpful. Insect repellents are widely used by travellers to endemic areas but the more effective preparations contain N,N-diethyl-m-toluamide (Deet). This agent is absorbed through the skin and its safety in pregnancy has not been established.Each of the drugs used in the prophylaxis or treatment of malaria will now be considered.
 
Surgical treatment of ectopic pregnancy remains the definitive and universal treatment of ectopic pregnancy and this can be safely done by laparoscopy. Expectant treatment should be reserved for those with serum β-hCG of < 200 mIU/ml and declining and tubal diameter of ≥ 2 cm. A selected group of patients with early and unruptured tubal pregnancy can be treated by systemic methotrexate injection. The treatment is especially effective in those with serum β-hCG of < 5000 mIU/ml and serum progesterone of < 10 ng/ml. Methotrexate has also found its place in the management of persistently elevated serum β-hCG after surgical treatment. Transvaginal administration of methotrexate precludes surgery and general anaesthesia, but about one third of the patients subsequently require further treatment. Expectant and medical treatments of ectopic pregnancy should be done with utmost care. Tubal rupture can still occur despite low and declining serum β-hCG levels.
 
The cervical screening programme in the UK has had a long and complicated gestation. It was unplanned and has been unloved, and, initially, not surprisingly, failed to thrive. It was then taken in hand, given firm guidance and began to improve. It continues to suffer from misunderstanding and the effects of the poor handling in the past, but with careful supervision and monitoring it is beginning to be recognized as one of the most successful medical screening programmes in the world.
 
Endometriosis is a significant gynaecological problem of wide spread prevalence. It is a dynamic disease with a range of symptoms and histological appearances which can change throughout the woman's lifetime. The pathogenesis of this essentially oestrogen dependent disease remains enigmatic, and no one theory can fully account for all the cases of endometriosis. The complexity and probable multifactorial nature of this disease has contributed to the difficulty in elucidating its true pathogenesis. It is proposed that in women who develop endometriosis, exfoliated endometrium survives and grows because of reduced immunosurveillance, and the presence of elevated growth and angiogenic factors in the peritoneal environment. These factors may originate from the increased population of activated peritoneal macrophages. Further work is needed to elucidate the role of theses cells and that of the local factors within the peritoneal environment in the pathogenesis of endometriosis, which may lead to the development of new alternative treatments.
 
This article outlines the main psychological issues involved in the management of chronic pelvic pain. It argues for an integrated process of care that acknowledges the role of psychological factors in all experiences of pain and attempts to help the patient to understand this from the inception of care. Issues at each level in the process of care, through seeking help and primary and secondary care, are systematically considered, and guidance is provided on when more specific psychological input may be needed. The emphasis is on psychological aspects of management by all staff throughout the process so that women do not feel that their distress is marginalised. The importance of pre-existing beliefs, women's need for an acknowledgement of the reality of their distress, how to provide information and effective reassurance are discussed. Issues to consider in terms of mood, the role of sexual abuse and the influence of chronic pelvic pain on relationships are included, together with ideas about specific psychological approaches that can be of benefit.
 
This review summarizes essential features of the functional morphology of human term placenta, concentrating on the processes of proliferation, growth, diffusive transport and microvascular permeability. It introduces the main structures that make up the ‘villous membrane’ interposed between the maternal and fetal bloods. It then presents an updated view of the proliferation of the principal functional compartment of the membrane, the trophoblast. This is a continuously renewing epithelium: cytotrophoblast cells divide mitotically throughout gestation and are recruited into the overlying syncytium. Contrary to previous dogma, cytotrophoblast is not depleted during gestation. The syncytium loses nuclei in large aggregates (syncytial knots), which detach into the maternal circulation. At least some nuclei are apoptotic and may be phagocytosed by macrophages at extraplacental sites. The villous stroma and fetal endothelium also grow by proliferation. These processes help to expand exchange surface areas and minimize diffusive distances, structural quantities that can be used to estimate placental-oxygen diffusive conductance. The fetal vascular compartment contributes substantially to overall transplacental resistance to solute transport. Fetal vessels are lined by a continuous endothelium with well-differentiated junctional complexes in the paracellular clefts. These complexes contain adhesion molecules that are vulnerable to exogenous agents, and whose expression and localization have been linked with junctional disruption and altered permeability, and altered placental efficiency and permeability. Changes in placental proliferation, growth, diffusive transport and vascular permeability may all play a role in pregnancy-related disorders such as pre-eclampsia and diabetes.
 
The need for large numbers of observations and many hours of testing time make it impossible to create a truly reliable examination of clinical competence. This paper argues that the traditional methods of assessment used by supervisors in ‘apprenticeship’ situations can be made reliable by the use of a number of observers making continuous observations during normal service contacts. The validity of the scale introduced in the college's log books is established by long usage in the real world. By providing a structure for trainees to keep track of these ‘de facto’ assessments, the new system can ensure that all practitioners reach the required standards of competence.
 
Depending upon the symptomatology, treatment of endometriosis can be complex and difficult. In the absence of a definitive knowledge of the aetiology of the disease, treatment remains symptomatic. The medical management of endometriosis involves hormonal manipulation abolishing ovulation and causing secondary atrophy of the endometriotic implants. The efficacy of progestogens, danazol, or gonadotropin-releasing hormone (GnRH) agonists are somewhat similar and the choice of individual treatment should be determined by the age and symptoms of the patient as well as the side effects of the drug. As anovulation is the principal mode of action, the use of these treatments in women desirous of pregnancy is inappropriate. The role of anti-progestogens and immunomodulating agents remains to be determined. Surgical treatment is primarily by the laparoscopic route and the aim is to excise or ablate the endometriotic implants, as well as to remove endometriomata and divide adhesions. Conservative laparoscopic treatment should be the treatment of choice for patients presenting with infertility or endometriomas. Bilateral oophorectomy and hysterectomy will usually result in a complete cure, but should be reserved for those with severe endometriosis and obviously when no more children are desired.
 
Much of the contemporary management of pelvic organ prolapse (POP) is based on knowledge and surgery developed over 100 years ago. There is a clearer picture emerging of the anatomical defects that result in prolapse, and the cause of those defects. The importance of assessing symptomatology is highlighted, with the use of validated prolapse-specific questionnaires. A simplified version of the POP quantification system is described, which should be used by all clinicians dealing with the condition in order to communicate examination findings more accurately. There is a brief discussion of conservative management, and a more detailed review of the current surgical management options for each compartment. The use of graft material in reconstructive procedures is considered, and emerging minimal access techniques are described to illustrate how improved anatomical understanding has led to site-specific procedures to address those defects.
 
The article starts by reviewing those physiological changes which may occur during pregnancy that may affect fluid balance.Overall, the pregnant woman gains 7–10 litres of water during gestation and this is distributed to many sites. Isotonicity is maintained by an enhanced uptake of sodium from the maternal kidneys. The influence of cardiovascular factors such as changing colloid osmotic pressure, serum osmolality and aortocaval compression are also important when considering fluid dynamics.The situations where fluid may be needed during labour are then discussed. It is seen that there are strong preferences for the route of administration as well as the nature of the fluid to be used: the misuse of dextrose, in particular, may have deleterious effects on both mother and baby.Whereas the normal mother usually copes very well with overenthusiastic fluid administration, the outcome may not be so good in the compromised patient. The relevance of cardiac disease to fluid balance, the problems associated with Ritodrine therapy and the special pathophysiology of pre-eclampsia which affects fluid therapy are also discussed.The underlying message is that as with any drug, care should be taken when prescribing fluid to a labouring mother.
 
Behaviour is defined as the interaction of an organism with its environment. Fetal behaviour can be studied in three ways: by passive observation of fetal activity1, by recording the reaction of a fetus to a stimulus2 or by documenting fetal habituation, that is, the cessation of a response to a repeated stimulus.3 This last response represents a simple form of learned behaviour and potentially is the most sophisticated method of assessment of the three.
 
D&C is the commonest operation performed in England and Wales and can be performed on only half the population. During the past 20 years, techniques have been developed to allow this diagnostic procedure to be performed on outpatients without the need for general anaesthesia. The indications for endometrial biopsy and the techniques are described, together with an assessment of their reliability and acceptability. An examination of the published literature indicates that some devices are more sensitive than others at diagnosing uterine malignancy but even D&C under general anaesthesia is fallible. A critical review of the indications for endometrial biopsy is still necessary to reduce the number of operations being performed for dubious reasons.
 
Water immersion in the first stage of labour in an uncomplicated pregnancy would appear to be safe, providing there are no signs of fetal compromise and the water temperature is not allowed to rise above 37° C. It is possible that it may reduce the need for other forms of analgesia, but this has yet to be proved by a randomised trial. Claims have been made for a more rapid progress in labour, but there is no good evidence for this. No study has demonstrated any benefit to the fetus for underwater birth, and on rare occasions it could lead to serious complications, such as fresh water drowning or neonatal sepsis and add to difficulties in obstetric emergencies such as shoulder dystocia.
 
Vaginal bleeding during pregnancy is always a cause for concern, for both the woman and her doctor. As the pregnancy advances, the clinical significance of the bleeding increases. It may, in addition to threatening the pregnancy, eventually also cause maternal morbidity and even mortality. The woman should be reassured about the well-being of the fetus or fully informed as to the possible complications. As soon as the fetus is viable or nearly viable, it is very important to pinpoint the optimal time of delivery. Valuable gestational age will be lost by doing an unnecessarily early delivery; on the other hand, a severe haemorrhage may cause fetal death if distress is not detected in time. All related factors have to be evaluated carefully, in order to make the best possible decision about the management of the pregnancy.
 
One-fifth of deliveries in England and Wales are undertaken by caesarean section. The procedure has changed very little over the years, although evidence-based refinements have resulted in reduced morbidity; research continues in adapting techniques to improve safety further. Preoperative preparation involving anaesthetists and radiologists if complications are anticipated has contributed to improved outcome. Good surgical training is paramount, particularly because trainee doctors undertake many of the emergency procedures. Surgical techniques (including manoeuvres that may help in difficult situations) and surgical complications are discussed. Guidance from the UK National Institute for Health and Clinical Excellence on caesarean section has allowed more accurate counselling on risks and benefits, although difficulties remain.
 
The incidence of cervical cancer is falling. As a result of changes in the case-mix of cervical cancer the surgical options for treatment of this disease are changing. A younger patient load and the associated desire to preserve fertility have led to consideration of conservative procedures such as large loop excision of the transformation zone, cone biopsy and ‘radical’ trachelectomy. Radical procedures now include radical vaginal or radical laparoscopic hysterectomy as well as the classical Wertheim's hysterectomy. In this article we review the historical development of surgery in the management of cervical cancer and then discuss the prognostic characteristics of this disease as they influence surgical choice. We detail the surgical procedures currently used in this disease and describe the choices available with respect to stage of disease. The role of lymphadenectomy and oophorectomy are also considered and the influence of pregnancy on cervical cancer is reviewed.
 
Cure rates for early vulvar cancers treated by the traditional approach of radical vulvectomy and bilateral inguinal-femoral lymphadenectomy may exceed 90%, but physical and psychological morbidity are often high. Recent advances in the understanding of the dissemination of vulvar cancer and the prognostic factors influencing survival have led the way for an increasingly conservative approach to both the primary vulvar tumour and the management of the regional lymph nodes. Such individualisation of treatment, in carefully selected patients, has substantially reduced morbidity whilst retaining function and appearance of the vulva, without compromising recurrence rates or survival. The surgical approach to advanced disease is also under reappraisal. The use of preoperative chemoradiation therapy in advanced vulvar tumours may improve local and regional control and allow less extensive surgical resections.
 
In the last three decades, there has been a substantial improvement in survival rates of childhood cancers. As a result, we are encountering long-term sequlae of both the primary illness and of the therapy employed in treatment. The challenges include management of disorders of gonadal function, such as pubertal delay or failure, impaired menstruation, premature menopause and compromised fertility. When female survivors achieve a pregnancy, there is an increased risk of pregnancy loss, pre-term labour and intra-uterine growth retardation. Caesarean section, if required, may be complicated if the patient has had previous abdominal or pelvic surgery or radiotherapy.A multidisciplinary approach is a vital component of the management of all long-term survivors of childhood cancer, particularly of pregnancies in female patients.
 
The concept of therapeutic interventions involving genetic manipulation adds another dimension to the treatment of malignant disorders. Targeting various oncogenes (proto and suppressor), inducing cell death through the intracellular activation of drugs, influencing immune activity and reducing toxicity with standard modalities are all amenable to genetic strategies. Gene therapy in gynaecological cancers, though still in its infancy, has developed to the stage where preliminary trials on humans have commenced. This article is by no means comprehensive, but presents some of the basic concepts of gene therapy and some recent studies which encompass many of the principles involved in the translation of the therapy to humans.
 
Heart disease continues to be an important cause of maternal morbidity and mortality. This is largely because of the extensive haemodynamic changes that occur during pregnancy, namely the increase in blood volume, fluctuations in cardiac output, fall in systemic vascular resistance and the hypercoagulable state. High-risk periods include the end of the second trimester, during labour and the immediate postpartum period. Prognosis depends on the specific cardiac condition, the patient's functional class, presence of cyanosis, history of cardiac events or arrhythmia and the degree of systolic dysfunction. Pregnancy is contraindicated in women with Eisenmenger's syndrome, pulmonary hypertension, complex cyanotic congenital heart disease, Marfan's syndrome with aortic root dilatation, and those with severe left ventricular dysfunction. Women with heart disease should be thoroughly evaluated and counselled before and during pregnancy. Multidisciplinary care is essential for successful maternal and fetal outcomes.
 
Provision of critical care for the pregnant patient is a key component of the contemporary obstetric role. Improving the outcome for the critically ill obstetric patient is a goal set in each confidential enquiry into maternal mortality. Specific changes have been recommended for the organisation of care of patients with severe hypertensive diseases of pregnancy. Obstetric intensive care has been successfully provided in the US, South Africa and Holland. The principles of critical care of severe pre-eclampsia rest on a good understanding of the pathophysiology of the condition. The characteristics of fulminant disease are largely those of ischaemia and the role of critical care has much to do with preventing organ damage. The aim of therapy is to improve perfusion by volume expansion and vasodilation. The principle risk of this management is pulmonary oedema, dictating the need for close monitoring of patients in this situation.
 
Thousands of pregnant and breast-feeding women take a prescribed or over-the-counter drug preparation daily. Few of these products have been specifically tested for safety and efficacy during normal pregnancy, and there is only scant information on the impact of common pregnancy complications on drug clearance and efficacy. The safety of a drug for fetuses and nursing infants often cannot be determined until it is widely used. Governmental safety categories do not inform on how either pregnancy or lactation may alter the patient's response to therapy compared with the non-pregnant state, nor do they indicate the impact of common medical diseases on a drug's efficacy. In the absence of information many women are inappropriately denied medically important agents. Funding agencies should address these knowledge deficits in a comprehensive fashion, and pharmaceutical houses should be offered incentives to perform clinically relevant studies of drugs that might be used in reproductive-age women before these drugs are marketed. Until the large gaps in the body of knowledge are filled, caregivers should seek and frequently utilise references that are updated regularly throughout the year.
 
This paper discusses the RCOG guidelines on examinations with specific reference to two ethico-legal dilemmas, namely a) a patient's request that an examination be performed without a chaperone and b) concerns that a colleague is not practising in accordance with the guidelines. Each scenario is discussed in the context of the law and ethical concepts of autonomy, trust and accountability. It is argued that guidelines provide a starting point for clinicians, but ethical sensitivity, reflection and professional judgement remain essential to maintaining standards in clinical practice.
 
Post partum mood disorder of all severities is a common complication of childbirth. In many cases it is predictable and perhaps avoidable. In all cases, awareness by the obstetrician of risk factors and the clinical syndromes will allow for early detection, prompt treatment and a reduction in morbidity with subsequent benefits to the woman, her infant and her family.
 
Although we now have many contraceptives, couples still have a negative perception of their personal choices. Many know little about methods other than the combined pill and the condom and, in particular, knowledge of long-acting methods is very poor. A woman's choice of contraceptive will be influenced by many factors and her requirements will change with time. New contraceptives have appeared in the past couple of years but women are not always aware of their characteristics. As prescribers, it is our responsibility to ensure that couples are given sufficient and appropriate information to enable them to make decisions.
 
Contraceptive choices are expanding and new methods are becoming more widely available. New delivery systems for hormones have been added and there have been refinements of older methods, improving reliability and user friendliness. More choices remain open to women than to men. This paper will look at the ‘menu’ for reversible methods and some of the criteria for selection. Male and female sterilisation are used extensively when families are complete, but will not be discussed here. This discussion will attempt to put the client or patient in the foreground.
 
Throughout history twins have been the subject of either wonder or condemnation by various religious and cultural groups. Indeed, in some parts of the world even today twins are believed to be non-human and are punished accordingly. There has long been scientific interest in twin pregnancies, from Hippocrates and Aristotle to Galton, who was the first to appreciate the unique value of twins in research.
 
Top-cited authors
Sabaratnam Arulkumaran
  • St George's, University of London
Julian Jenkins
  • Repromed Sàrl
Alan H Handyside
  • Vitrolife Sweden AB Gothenburg Sweden
Catherine Nelson-Piercy
  • King's College London
Joyce C Harper
  • University College London