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Controversies in Obstetrics, Gynaecology and Infertility
Alka Kriplani, Roya Rozati
PART 1: OBSTETRICS
1:
Pregnancy with Previous Caesarean Section
INTRODUCTION
Safety Issues: Vaginal Versus Repeat Caesarean Delivery
Management of Pregnancy with Previous Caesarean Section
Decision About the Mode of Delivery
Intrapartum Management
CONCLUSION
2:
Management of Hypertensive Disorders in Pregnancy
CONCLUSION
3:
Multiple Gestation
FOETAL DISORDERS
Intrauterine Growth Restriction
Discordant Twins
Twin to Twin Transfusion Syndrome (TTTS)
Monoamnionic Twins
Conjoined Twins
Acardiac Twin
INTRAPARTUM MANAGEMENT
Timing
Labour and Delivery
Route of Delivery
Interval Between Deliveries
Postpartum Management
SUMMARY
4:
Controversies in the Management of Preterm Labour and PPROM
DIAGNOSIS OF PRETERM LABOUR AND PPROM
CAN PRETERM LABOUR BE PREDICTED?
ARE PREVENTIVE MEASURES USEFUL?
DOES ROUTINE SCREENING FOR INFECTIONS HELP? (TABLE 4.4)
PHARMACOLOGIC PREVENTIVE INTERVENTION
Betamethasone vs Dexamethasone
Repeat Courses of Antenatal Steroids
TOCOLYSIS–TO STOP OR NOT TO STOP?
Tocolysis in Specific Conditions
Dual Tocolysis
MANAGEMENT OF PPROM
MATERNAL AND FOETAL SURVEILLANCE
Home Care vs Hospital Care
Antibiotics
Tocolysis in PPROM—to Give or Not to Give?
Amnioinfusion
Specific Treatment
Cervical Cerclage and PPROM; Should the Stitch be Removed?
PTB: PTL and PROM
At what Gestation should Delivery be Practical?
Induction of Labour in PPROM
Summary of Recommendations
CONCLUSION
5:
Birth Control and Termination of Pregnancy—Medical Means
COMBINED ORAL CONTRACEPTIVE “COC” PILLS
Other Newer COCs
Contraindications
Choice of Pill
Pill Taking
Missed Pills
PROGESTIN ONLY PILLS (POP)
INJECTABLE CONTRACEPTION
IMPLANTABLE CONTRACEPTIVE
VAGINAL CONTRACEPTIVE RINGS
Skin Patches—‘Ortho Evra’
Hormonal Contraception for Men
Fertility Awareness Based Methods
Calender Rhythm Method
Cervical Mucus Method
Advantages
Disadvantages
Withdrawal Method
Lactational Amenorrhoea Method (LAM)
Time to Stop LAM
Emergency Contraception
Mechanism of Action
Efficacy
Advantages
Follow-up
MEDICAL TERMINATION OF PREGNANCY—MEDICAL MEANS
For Early First Trimester
Contraindications
Pre-abortion Work-up
Role of Ultrasound
Counselling
Dosage and Schedule
Protocols and Follow-up Visits
Indications of Curettage
Side Effects
Onset of Next Menstruation
Late First Trimester
Second Trimester Termination
6:
Dystocia Due to Foetal Anomalies
OVERVIEW
NATURE OF DYSTOCIA
Management
LOCALISED ENLARGEMENT DUE TO MALFORMATIONS
Hydrocephaly
Diagnosis
Clinical Examination Findings
Treatment
Technique of Cephalocentesis
Craniotomy
Craniotomy of the Fore-coming Head
Craniotomy of the After-coming Head
Meningocele and Encephalocele
Foetal Abdomen as Cause of Dystocia
Ultrasound Diagnosis of Foetal Ascites
Tumours of the Foetal Pelvis
Ultrasound in Diagnosis of Sacrococcygeal Teratoma
Conjoined Twins
Ultrasound Diagnosis
Dystocia Prognosis
Problems During Caesarean Section
Maternal Effects of Dystocia
Ultrasound in the Diagnosis of Foetal Anomalies
CONCLUSION
PART 2: GYNAECOLOGY
7:
Current Advances in the Management of Abnormal Uterine Bleeding
INTRODUCTION
DIAGNOSIS OF AUB
History Taking
Examination
Diagnostic Tests
Endometrial Aspiration
Ultrasound
Hysteroscopy
Other Investigations
MANAGEMENT OF AUB
Medical Management
Non-hormonal Medical Treatment
Antifibrinolytics—Tranexaemic Acid (TA)
Mode of Action (MOA) of Tranexaemic Acid
Side Effects
Antiprostaglandins
Hormonal Management
Control of Acute Heavy Bleeding
Control of Chronic Prolonged Bleeding
Combined Contraceptive Pill
Progesterone
Danazol
GnRH Analogues
Main Indication
Ovulation-inducing Agents
Hormone Replacement Therapy (HRT)
Intrauterine Progesterones
Surgical Management
First-generation Endometrial Ablation Techniques
Second-generation Endometrial Ablation Techniques
8:
Uterine Fibroids and their Management
INTRODUCTION
SYMPTOMS OF FIBROIDS
DIAGNOSIS OF FIBROIDS
MANAGEMENT OF FIBROIDS
Preoperative Preparation
Prerequisites for Laparoscopic Myomectomy
Laparoscopic Myomectomy
Principles of the Technique
Primary Procedure
Removal of the Myoma
RISKS OF LAPAROSCOPIC MYOMECTOMY
OTHER RISKS
Myomectomy by Laparotomy
Indications
Place of Laparoscopic-assisted Myomectomy
Alternative Minimally Invasive Methods
Uterine Artery Embolization
Complications
Laparoscopic Myolysis
Review of Results and Fertility Outcome
CONCLUSION
Leiomyomas and Polyps
Hysteroscopic Resection of Myomas
Complications of Hysteroscopic Surgery
Operative Complications
Postoperative Complications
LEIOMYOSARCOMAS
Clinical Features
Prognosis
Variants of Leiomyosarcoma
Intravenous Leiomyosarcoma
Benign Metastasizing Leiomyoma
Leiomyoblastoma
Leiomyomatosis Peritonealis Disseminata
9:
Interesting Images in Hysteroscopy
10:
Recent Trend in the Management of Ectopic Pregnancy
INTRODUCTION
PREVALENCE AND TRENDS
AETIOLOGY
CLINICAL PRESENTATION
DIAGNOSTIC MODALITIES
Pregnancy Kits
Serum β-hCG Level in Normal Pregnancy
Discriminatory hCG Level and Sonographic Co-relation
Prognostic Evaluation of Serial β-hCG Assay
Pelvic Scan by Transvaginal Sonography (TVS) and Transabdominal Sonography (TAS)
Transvaginal Colour Doppler Sonography (TVCDI)
Diagnostic Laparoscopy
Current Therapeutic Approach
Surgical Treatment
SURGICALLY ADMINISTERED MEDICAL TREATMENT (SAMT)
Expectant Management
Criteria for Expectant Management
MEDICAL MANAGEMENT
SUMMARY
11:
Disease of the Urinary System
ANATOMIC CHANGES
PHYSIOLOGIC CHANGES
ASSESSMENT OF RENAL DISEASE DURING PREGNANCY
URINARY TRACT INFECTION
Asymptomatic Bacteriuria
Urine Collection and Examination
Source of Infection
Importance of Diagnosis
Choice of Drug
Duration of Therapy
Acute Symptomatic Urinary Tract Infection
Acute Cystitis
Acute Pyelonephritis
ACUTE RENAL FAILURE
CHRONIC RENAL INSUFFICIENCY
Management Options
CHRONIC HAEMODIALYSIS PATIENTS AND PREGNANCY
Management Options
NEPHROLITHIASIS
Management Options
Haematuria During Pregnancy
PREGNANCY IN RENAL TRANSPLANT PATIENTS
Management Options
Antenatal Care
Dietary Counselling
Hypertension and Pre-eclampsia
Infections
Gastrointestinal Disorders
Parathyroid Dysfunction
Prednisone
Azathioprine
Cyclosporine
Decisions Regarding Delivery
Role of Caesarean Section
Breastfeeding
12:
Hormone Therapy in Gynaecology
PROGESTERONE AND PROGESTOGENS
GONADOTROPHINS
Gonadotrophin-releasing Hormone (gnRH) and its Analogues
ANDROGENS
ANTIHORMONES
Antiprogestogen
Drugs Affecting Gonadotrophins
Dopaminergic Drugs
13:
Genital Tuberculosis in Women
INTRODUCTION
Epidemiology, Pathogenesis and Spread
SITES
Ovaries
Fallopian Tubes
Endometrium
Cervix
Vagina and Vulva
CLINICAL PRESENTATION
Age
SYMPTOMS
Infertility
Menstrual Abnormalities
Ectopic Pregnancy
Congenital Tuberculosis
Unusual Symptoms
SIGNS
DIAGNOSIS
Clinical
Lab
Trends
TREATMENT
Medical Therapy
Short-term Vs Long-term Chemotherapy
Side Effects
Role of Surgical Treatment
Tuboplasty
Pregnancy After Genital TB
FUTURE PROSPECTS
ACKNOWLEDGEMENTS
SUMMARY
INVESTIGATIONS
14:
Endometrial Cancer
INTRODUCTION
Epidemiology and Aetiology
Pathology
Clinical Symptoms and Signs
Screening for Endometrial Cancer
Diagnosis
Staging
Prognostic Factors
Treatment for Endometrial Cancer
Surgical Management
Radiotherapy
Chemotherapy
Hormonal Therapy
Hormone Replacement Therapy
Recurrent Disease
Prognosis: Overall Survival and Treatment Outcome
Follow-up After Treatment
15:
Disorders of Ovary: Malignant Ovarian Tumours
INTRODUCTION
CLASSIFICATION OF OVARIAN TUMOURS
Screening Procedures
Management
Surgical Staging
Radiotherapy
Chemotherapy
Follow-up
Second Look Laparotomy
Metastatic Tumours
16:
Controversies in Classification and Management of Premalignant Lesions of Cervix
INTRODUCTION
CLASSIFICATION OF CYTOLOGICAL ABNORMALITIES OF THE CERVIX
Which is the Best Method of Cervical Screening?
Collection Techniques
HPV Testing
How Often should Cervical Screening be done?
What are the Options for Low Resource Communities?
What is the Role of Newer Technologies?
What should be the Management of Precancerous Cervical Lesions?
Controversies in Managing Abnormal Smears
17:
Controversies in the Management of Squamous Intraepithelial Lesion (SIL)
INTRODUCTION
CONTROVERSY BASED ON THE CYTOLOGY REPORT
CONTROVERSY IN DECISION MAKING IN THE MANAGEMENT
Controversial Role of HPV Testing
CONTROVERSIAL ROLE OF COLPOSCOPY
Management of High-Grade Lesions
CONTROVERSY IN THE ROLE OF HYSTERECTOMY
CONCLUSION
PART 3: INFERTILITY
18:
Transvaginal Sonography for Ovulation Monitoring
INTRODUCTION
ROLE OF ULTRASOUND
Follicle Monitoring
Spontaneous Cycle
Ultrasound Signs of Imminent Ovulation
Signs of Ovulation
Corpus Luteum
Stimulated Ovarian Cycle
How to Measure a Follicle
Applications of Ultrasound in Ovulation Monitoring
Role of Colour Doppler
Aberrant Follicular Growth
CONCLUSION
19:
Polycystic Ovarian Syndrome and Ovulation Induction
INTRODUCTION
OPTIONS FOR OVULATION INDUCTION IN PCOS
WEIGHT LOSS
CLOMIPHENE CITRATE (CC)
Clomiphene Citrate Alone
Mechanism of Action
Dosage
Contraindications to the Use of Clomiphene Citrate
Adverse Effects
Pregnancy and Long-term Considerations
Additional Intervention with CC Therapy
GONADOTROPIN THERAPY
Gondotropin Therapy Alone
Additional Interventions with Gonadotropins
Gonadotropins with GnRH Agonists (GnRHa)
Gonadotropins with Gonadotropin-releasing Hormone Antagonists
METFORMIN
OVARIAN DRILLING
CONCLUSION
20:
Controversies in Drug Administration for Controlled Ovarian Hyperstimulation in Assisted Reproductive Technologies
INTRODUCTION
FOLLICULAR STIMULATION IN IVF
ROLE OF LUTEINIZING HORMONE (LH) IN ART
Human Menopausal Godadotropin: Should We Bid Them Goodbye!!
Urinary FSH Versus Recombinant FSH
ROUTE OF ADMINISTRATION
DOSAGE
COST EFFECTIVENESS OF rFSH VS uFSH
Use of Gonadotropin-Releasing Analogues in IVF Protocol
Three Regimens have been Described
Development of GnRH Antagonists
Regimens of GnRH Antagonists
THE POTENTIAL ADVANTAGES OF GNRH ANTAGONISTS
Clinical Application
Recombinant hCG
SUMMARY
21:
Unexplained Infertility
INTRODUCTION
THE ENIGMA OF DIAGNOSIS
THEORIES FOR UNEXPLAINED INFERTILITY
TREATMENT OPTIONS
SUMMARY
22:
Intrauterine Insemination Principles and Practice
INTRODUCTION
ARTIFICIAL INSEMINATION: THE PAST
INTRAUTERINE INSEMINATION: THE PRESENT
CONTROLLED OVARIAN HYPERSTIMULATION AND IUI
INDICATIONS FOR IUI AND RESULTS
CERVICAL FACTOR
MALE FACTOR
EJACULATORY FAILURE
IMMUNOLOGICAL FACTORS
ENDOMETRIOSIS
UNEXPLAINED INFERTILITY
RECENT CONTROVERSIES: IVF OR IUI?
IUI OR IVF? OUR RESULTS
MELBOURNE IVF MUMBAI RESULTS
PLANNING A TREATMENT CYCLE
ROLE OF THE LABORATORY
HOW MANY CYCLES?
HOW MANY IUIs PER CYCLE?
TECHNIQUES OF INTRAUTERINE INSEMINATION
POST-INSEMINATION: WHAT NEXT?
INVITING SUCCESS IN AN IUI PROGRAMME
CONCLUSION
23:
Andrology in Medically Assisted Reproductive Techniques
INTRODUCTION
CAUSES OF INFERTILITY IN MEN
Standardised Procedures for Investigating and Diagnosing
FACTORS AFFECTING MALE FERTILITY
Sperm Density
Environment
Lifestyle
GENETIC CAUSES OF MALE INFERTILITY
MANAGEMENT OF MALE INFERTILITY
Dietary Supplements (Comahaire and Mahmoud, 2003)
Intracytoplasmic Sperm Injection (ICSI)
CONCLUDING REMARKS
24:
In Vitro Fertilisation
INTRODUCTION
CAUSES OF INFERTILITY
INDICATIONS FOR IVF
STIMULATION PROTOCOL
Long Protocol
Short Protocol
Ultrashort Protocol
Induction of Ovulation
ADVANTAGES AND DISADVANTAGES OF GNRH AGONISTS AND ANTAGONISTS
Monitoring IVF Cycles
Introduction
Baseline Assessment
Ultrasound
Endocrinology
Ovarian Stimulation
Cycle Monitoring
Reasons for Monitoring the Cycle
Methods of Monitoring Follicular Maturation
Monitoring Cycles—GnRH Antagonists
Follicular Aspiration
Retrieval Techniques
Laparoscopic Oocyte Retrieval
Follicular Aspiration
Advantages
Disadvantages
Ultrasound-guided Retrieval
Advantages of Ultrasound-guided Transvaginal Follicular Aspiration
Disadvantages: Risks
Clinical Aspects of Oocyte Retrieval
Timing of Oocyte Retrieval
Anaesthesia
EGG PICK-UP TECHNIQUE: IMPORTANT POINTS
EGG PICK-UP DIFFICULTIES
Oocyte Treatment: From Egg Retrieval to Insemination
Culture Dish Preparation
Oocyte Search (As Aspiration Proceeds)
Method
Oocyte Grading
Sperm Collection and Preparation
Evaluation of Sperm
Semen Analysis
Care of the Specimen
Sperm Viability
Hypo-osmotic Swelling Test
Sperm Preparation Techniques
Percoll Gradient Technique
Method
Sperm Preparation Steps Using Percoll
Swim-up Technique
Method
Sperm Preparation using the Swim-up Technique
Further Sperm Preparation Methods
Mini-Swim-Up Technique
Procedure
Centrifugation
Procedure
Glass Wool Filtration
Procedure
Pentoxiphylline and 2-Desoxyadenosine
Insemination of Oocytes
Insemination Procedure
Assessment of the Fertilisation Cascade
Fertilisation
Procedure of PN Monitoring
Zygote Scoring
Pronuclei
Nucleoli
Polar Bodies
Evaluation of the Early Embryo
Development to the Blastocyst Stage
Blastocyst Transfer, Advantages and Disadvantages
Disadvantage
Embryo Transfer
VARIABLES AFFECTING EMBRYO TRANSFER SUCCESS
Trial Transfer
Problem of Cervical Mucus
CONCLUSION
Retained and Expelled Embryos
Procedure of Embryo Transfer
Difficult Embryo Transfers—Does it Matter?
Ultrasound Guidance
The Luteal Phase
Luteal Support Protocols
Special Problem of the Luteal Phase after Ovarian Stimulation
Elements of Luteal Support
Progesterone Supplementation
Oestradiol Supplementation
Route of Support
Oral Route
Intramuscular Route
Vaginal Route
Luteal Support Protocols
Support in Stimulated ART Cycles
Support in Recipient Cycles
Support in Thaw—Transfer Cycles
IVF Success Rates
Physiological Factors for Success
Positive Factors
Negative Factors
Implantation Rate/Clinical Pregnancy Rate
AGE OF THE WOMAN
QUALITY OF THE EMBRYOS
MHRI 2002 IVF Pregnancy Rates*
WHAT ARE THE COMPLICATIONS OF IVF?
25:
Intracytoplasmic Sperm Injection
INTRODUCTION
INDICATIONS FOR ICSI
SHOULD ICSI BE DONE IN ALL IVF CYCLES?
PROCEDURE OF ICSI
Ovarian Stimulation
Oocyte Retrieval
Oocyte Dissection
Sperm Preparation
Gamete Preparation
Injection
Fertilisation
Establishment and Follow-up of Pregnancy
SPERM RETRIEVAL TECHNIQUES
Obstructive Azoospermia
Causes
Non-Obstructive Azoospermia
Clinical Features of Obstructive and Non-obstructive Azoospermia
Obstructive
Non-obstructive
Sperm Retrieval Methods for the Treatment of Obstructive Azoospermia
Microsurgical Epididymal Sperm Aspiration
Percutaneous Epididymal Sperm Aspiration (PESA)
Testicular Sperm Aspiration (TESA)
Sperm Retrieval Methods for the Treatment of Non-obstructive Azoospermia
Sperm Cryopreservation within Evacuated Egg Zonae
ICSI Failures
Rescue ICSI
Spermatid Injection
Genetics of ICSI
Clinical Outcome of ICSI—Results
Clinical Results of ICSI
Perinatal Outcome of ICSI Pregnancies
Genetic and Malformation Risks
CONCLUSION
OUR EXPERIENCE
26:
Egg and Embryo Donation
INTRODUCTION
INDICATIONS FOR OOCYTE/EMBRYO DONATION
RECiPIENT SCREENING (TABLE 26.1)
SOURCES OF DONORS
Egg Sharing
Donor Screening
ENDOMETRIAL STIMULATION AND SYNCHRONISATION
POST-TRANSFER MANAGEMENT
OBSTETRICAL OUTCOME
EXPLORING THE FUTURE
SUMMARY
SURROGACY
Indications
27:
Preimplantation Genetic Diagnosis
INTRODUCTION
PREIMPLANTATION GENETIC DIAGNOSIS: AN OVERVIEW
INDICATIONS FOR PREIMPLANTATION DIAGNOSIS
METHODS AND RESOURCES AVAILABLE FOR PGD
Biopsy Stages
POLAR BODY BIOPSY
Procedure
Examination of the Polar Body
BIOPSY AT THE 4-CELL TO 8-CELL STAGE
Procedure
BIOPSY AT THE BLASTOCYST STAGE
DIAGNOSTIC METHODS AVAILABLE
FLUORESCENT IN SITU HYBRIDIsATION
POLYMERASE CHAIN REACTION (PCR)
ADO AND PCR
STRATEGIC APPROACH OF A PCR REACTION
THE PRESENT SITUATION
FUTURE OF GENE THERAPY
CONCLUSION
RECOMMENDATIONS
28:
Embryonic Stem Cellsfor Organ Repair
INTRODUCTION
What are Stem Cells?
Adult Stem Cells
Embryonic Stem (ES) Cells
Embryonic Stem Cell-based Transplantation Therapy
Stem Cell Therapy in Disorders of Brain and Spinal Cord
Stem Cells and Diabetes
Haematopoietic Differentiation of ES Cells
Differentiation of ES Cells to Cardiomyocyte
Embryonic Stem Cells vs Adult Stem Cells: Ethical Controversy
CONCLUSION
29:
Pelviscopy and ART
CONCLUSION
Hysteroscopic Tubal Cannulation
Pathophysiology of Proximal Tubal Occlusion
Diagnosis of Proximal Tubal Occlusion
TUBAL CANNULATION
Hysteroscopic Cannulation
Technique
Complications
POLYCYSTIC OVARIAN DRILLING OR LAPAROSCOPIC OVARIAN PUNCTURE WITH ELECTROCAUTERY
Mechanism of Action
Technique
Advantages of Laparoscopic Ovarian Puncture with Electrocautery
Results of PCOD drilling in Polycystic ovarian disease
ROLE OF LAPAROSCOPIC MYOMECTOMY IN INFERTILITY PATIENTS
TECHNIQUE
Removal of Fibroid by Morcellation
REVIEW OF RESULTS AND FERTILITY OUTCOME
ENDOMETRIOSIS
OVARIAN ENDOMETRIOSIS
Superficial Ovarian Endometriosis
Small Endometriomas
Large Endometriomas
Peritoneal Implants
LAPAROSCOPY AND LAPAROTOMY
HYDROSALPINX
CONSERVATIVE SURGERY FOR HYDROSALPINX
LAPAROSCOPIC TUBAL RECANALISATION
Technical Difficulties
CONCLUSION
FERTILOSCOPY
CONCLUSION
30:
Challenges and Issues in Assisted Reproductive Technology
INTRODUCTION
Scientific Challenges
Shortage of Gametes
Improving Success Rates
Multiple Gestation
Health Service Challenges
Professional Challenges
Transparency
Self Regulations
Surveillance
Social Challenges
The Public Trusts in Science
Cultural and Ethical Concerns
Gender Issues
Indian Scenario
Salient Features of the Guidelines
CHAPTER-1
Introduction, Brief history of ART and Requirement of ART Clinics
CHAPTER-2
Screening of Patients for ART: Selection Criteria and Possible Complications
CHAPTER-3
Code of Practice, Ethical Considerations and Legal Issues
Code of Practice
Providing ART Services to the Economically Weaker Section of the Society
CONCLUSION
INDEX
TOC
Index
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