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Current Obstetrics and Gynecology
Gita Ganguly Mukherjee, Basab Mukherjee, Sudip Chakravarty, Bhaskar Pal
ONE:
Periconceptional Care: A Multidisciplinary Team Approach
INTRODUCTION
OPTIMAL TIME
WHO ARE PERICONCEPTIONAL COUNSELORS?
COMPONENTS
SCOPE
Chronic Medical Disorders
Diabetes Mellitus
Epilepsy
Heart Disease
Hypertension
Renal Disease
Hypothyroidism
PSYCHIATRIC ILLNESS
INFECTIONS AND VACCINATIONS
GENETIC DISEASE AND CONGENITAL MALFORMATIONS
TWO:
Evidence Based Obstetric Practice
DIABETES IN PREGNANCY
MULTIPLE PREGNANCIES
Beneficial form of Care in Pregnant Women
Forms of Care Likely to be Beneficial
Forms of Care of Unknown Effectiveness
Forms of Care Unlikely to be Beneficial
CONCLUSION
THREE:
EmOC: Its Role in Reducing Maternal Mortality
MATERNAL MORTALITY–A BURNING ISSUE WORLDWIDE
INDIAN SCENARIO
CAUSES OF MATERNAL DEATHS
Direct Causes
Other Problems that Contribute to Increased Maternal Mortality in India
Key Strategies to Save Lives of Pregnant Women are
Why Focus on Emergency Obstetric Care?
Defining Emergency Obstetric Care
Basic EmOC
Comprehensive EmOC
Challenges in Addressing Emergency Obstetric Care in Low Resource Settings
Federation of Obstetric and Gynecological Societies of India and EmOC
FOUR:
Critical Care in Obstetric Practice
PHYSIOLOGICAL CHANGES IN VARIOUS SYSTEMS
CRITICAL CARE UNIT
Prevalence and Prognosis of Pregnant Women Requiring ICU Admission
Conditions Requiring Critical Care in Obstetrics
Hypovolemic Shock
Septic Shock
Disseminated Intravascular Coagulation
Pathophysiology
Causes
Treatment
Amniotic Fluid Embolism (AFE)
Pathophysiology
Clinical Presentation
Hypoxia
Hypotension/Shock
Coagulopathy/DIC
Management
Pulmonary Embolism
Management
Unstable Pulmonary Embolism
Acute Respiratory Distress Syndrome (ARDS)
Management
Mechanical Ventilation
Perimortem Caesarean Section in the Critically Ill Patient
FIVE:
Prescribing in Pregnancy
PHYSIOLOGICAL CONSIDERATIONS IN PREGNANCY
FOOD AND DRUG ADMINISTRATION (FDA) PREGNANCY RISK CLASSIFICATION
TERATOGENICTY AND THE FETUS
DRUGS, GENETICS AND PHYSIOLOGICAL BASIS OF TERATOGENICITY
PRESCRIBING DRUGS IN PREGNANCY
PRESCRIBING WHILE BREAST FEEDING
PREFERRED DRUGS AND MEDICAL CONDITIONS IN PREGNANCY
Anti Microbials
Analgesics
Anticoagulants
Anticonvulsants
Antiemetics
Antihypertensives
Diuretics
PSYCHOTROPIC DRUGS
COUNSELING AND MANAGEMENT OF A PREGNANT WOMAN WITH MEDICATION EXPOSURE
SIX:
Traveling During Pregnancy
INTRODUCTION
AIR TRAVEL
Risks of Air Travel During Pregnancy
Risks of Hypoxia
Ozone
Risks of Radiation
Solar Proton Events
Risk of Immobility, Circulatory Problems and Deep Vein Thrombosis (DVT)
Risk of Communicable Diseases
Malaria
Aircraft Disinsection
Risk of Traveler's Diarrhea during Pregnancy
Jet lag
Cabin Humidity and Dehydration
Contraindications to Air Travel
Safest Time to Fly
Safety of Airport Screening Machines
Staying Comfortable While Flying
Medical Assistance on Board
TRAVELING BY CAR
Guidelines for Traveling by Car13
TRAVELING BY BUS OR TRAIN
Guidelines for Traveling by Bus or Train
Motor Vehicle Accidents
TRAVELING BY SHIP
Under What Circumstances is Travel Inadvisable?
Symptoms That Need Immediate Medical Attention
CONCLUSION
SEVEN:
Trauma in Obstetrics
INTRODUCTION
GENERAL PRINCIPLES OF TRAUMA RESUSCITATION
Primary Survey
Vasopressor Drugs
Antidysrhythmics
Open Heart Massage
Defibrillation
Fluid Replacement
Peri-mortem CS
Resuscitation
Secondary Survey
Diagnostic Studies and Laboratory Tests
Definitive Treatment
DIFFERENT TYPES OF TRAUMA
Blunt Trauma
General Management of Blunt Trauma during Pregnancy
Management of Specific Complications with Blunt Trauma
Abruptio Placenta
Preterm Labor
Uterine Rupture
Fetomaternal Hemorrhage
Penetrating Trauma
Burns
EIGHT:
Day Care Obstetric Unit
CONCEPT OF A DAY CARE UNIT
Day Care Unit
Maternal Conditions
Pregnancy-related Conditions
Investigations in a Day Care Unit
Ultrasound
Fetal Cardiotocography (CTG)
General Issues
Advantages in Day Care Unit
Disadvantages of a “Day Care Obstetric Unit”
CONCLUSION
NINE:
Antenatal Evaluation of Fetal Health
FIRST AND SECOND TRIMESTER
THIRD TRIMESTER
Fetal Movement Chart
Symphysis-Fundal Height Measurement
Third Trimester Ultrasonography
GROWTH ASSESSMENT
AMNIOTIC FLUID INDEX (AFI)
DOPPLER STUDIES
Middle Cerebral Artery (MCA)
Descending Thoracic Aorta (DTA)
Venous Dopplers
Biophysical Profile (BPP)
Antepartum Cardiotocography (CTG)
TIMING OF DELIVERY
CONCLUSION
TEN:
Doppler Ultrasonography in Modern Obstetrics
INTERPRETATION OF DOPPLER SIGNALS
SAFETY OF DOPPLER ULTRASOUND
UMBILICAL ARTERY (UA) (Fig. 10.1)
ROLE OF UA DOPPLERS IN IUGR
UMBILICAL ARTERY DOPPLER IN UNSELECTED PATIENTS
UA Dopplers in Multiple Gestation
Multivessel Doppler and its role in IUGR
Fetal Descending Aorta (FDA) (Fig. 10.3)
Middle Cerebral Artery (MCA) (Fig. 10.4)
FETAL VENOUS CIRCULATION
UMBILICAL VEIN (UV)
DUCTUS VENOSUS (DV) (Fig. 10.5)
INFERIOR VENA CAVA (Fig. 10.6)
UTEROPLACENTAL PERFUSION
ELEVEN:
Deficiency Anemia in Pregnancy— Current Scenario
INTRODUCTION
DEFICIENCY ANEMIA
Developmental Stages of Iron Deficiency
Folic Acid and Vit B12 Deficiency
Other Factors
Magnitude of the Problem and Effect on Pregnancy
Maternal Risks
Fetal and Neonatal Risks
Clinical Presentation
Investigations
Management
Treatment of Deficiency Anemia
DISCUSSION
CONCLUSION
TWELVE:
Hemoglobinopathies in Pregnancy
TYPES OF HB AND STRUCTURE 1,2
TYPES OF HEMOGLOBINOPATHIES
Alpha Chain Defects
Beta Chain Defects
Screening
Thalassemia Screening4,5
Beta Thalassemias
Sickle Cell Hemoglobinopathies in Pregnancy
EFFECT OF SICKLE CELL DISEASE ON PREGNANCY
Management During Pregnancy
For Sickling Crisis
Labor Management
Postpartum
Contraception
THIRTEEN:
Gestational Diabetes Mellitus
INTRODUCTION
DEFINITION
MAGNITUDE OF THE PROBLEM
International
Indian Scenario
SCREENING
HOW TO SCREEN3,5
SCREENING FOR GDM
Random Plasma Glucose
DIAGNOSIS OF GDM
CLINICAL MANIFESTATIONS
Effects of Diabetes on Pregnancy
Effects on Mother
Effect of Diabetes on the Fetus
Fetal Macrosomia (30–40%) Results From
Congenital Anomalies (6–10%)
Effects of Pregnancy on Diabetes
MANAGEMENT OF GDM
General Management
Medical Nutritional Therapy (MNT)
EXERCISE
Contraindications to Exercise
MEDICAL MANAGEMENT
Insulin Therapy
Precautions to be taken while on Insulin
Factors to be taken into Consideration While Changing Dose of Insulin
Oral Hypoglycemics are not used since
SELF MONITORING OF BLOOD GLUCOSE (SMBG)
Steps to Achieve a smooth Pregnancy are
OBSTETRIC MANAGEMENT
TESTS FOR FETAL WELL BEING
MANAGEMENT DURING LABOR
Time of Delivery
Mode of Delivery
Anesthesia
POSTPARTUM CARE
NEONATAL RISKS
Antenatal Corticosteroids and GDM
LONG-TERM THERAPEUTIC CONSIDERATIONS
CONTRACEPTION
FOURTEEN:
Hepatitis in Pregnancy
INTRODUCTION
Effect of Pregnancy on Hepatitis
Effect of Hepatitis on Pregnancy
VIRAL HEPATITIS
Causative Agents
Type of the Disease
Acute Viral Hepatitis
Fulminant Hepatic Failure (FHF)
HEPATITIS A
HEPATITIS B
HEPATITIS C
HEPATITIS D
HEPATITIS E
MANAGEMENT OF THE PREGNANT WOMEN WITH HEPATITIS
Acute Viral Hepatitis
Fulminant Hepatic Failure
NONVIRAL CAUSES OF HEPATITIS IN PREGNANCY
Drug Induced
Autoimmune Hepatitis (AIH)
FIFTEEN:
Thromboembolism in Pregnancy
HERITABLE THROMBOPHILIAS
ANTIPHOSPHOLIPIDS
RISK ASSESSMENT AND SCORING: WHO SHOULD BE OFFERED THROMBOPHILIA SCREENING ?6, 7
THROMBOPHILIA SCREENING
Diagnosis
DIAGNOSIS OF DVT DURING PREGNANCY
THROMBOEMBOLISM IN PREGNANCY
General
Heparin
Warfarin (Coumarins)
Mechanical Measures
UNFRACTIONATED HEPARIN
LOW MOLECULAR WEIGHT HEPARIN (LMWH)
Management Options: Thromboprophylaxis in Pregnancy (Table 15.5)
CONCLUSION: TAKE HOME MESSAGE
SIXTEEN:
Current Concepts in Pregnancy Induced Hypertension
INTRODUCTION
PREDICTION OF PRE-ECLAMPSIA
Thrombophilia and Pre-eclampsia— The Evidence so Far
Screening for Pre-eclampsia
Prevention of Pre-eclampsia
SECONDARY PREVENTION
Aspirin and Other Antiplatelet Drugs
Role of Calcium in Prevention of Pre-eclampsia
Role of Antioxidants in Prevention of Pre-eclampsia
Tertiary Prevention
Novel Techniques for Cerebral Evaluation in Pre-eclampsia
MANAGEMENT OF PRE-ECLAMPSIA
Admission to Hospital vs Day Care Unit
Role of Antihypertensives
Prophylactic MgSO4 Therapy in Pre-eclampsia
Role of Plasma Volume Expansion in Pre-eclampsia
Expectant Management of Severe Pre-eclampsia
Mode of Delivery
HELLP Syndrome
Long Term Prognosis After Pre-eclampsia
Renal Disease and Pre-eclampsia
Hepatic Disease and Pre-eclampsia
Recurrence Risk
Psychological Consequences
Counseling
Conclusion
SEVENTEEN:
HIV in Pregnancy
INTRODUCTION
PREVALENCE OF HIV INFECTION IN WOMEN
VERTICAL TRANSMISSION OF INFECTION
Intrauterine Infections
Intrapartum Vertical Transmission
Postpartum Transmission
FACTORS AFFECTING VERTICAL TRANSMISSION
Anti-HIV Immunity
PREVENTION OF VERTICAL TRANSMISSION OF HIV15–17
Antiviral Therapy
ACTG Protocol 07615
Therapeutic Regimen
Thai Study16
Regimen
HIV NET 012
Obstetric Precautions
Delivery by Caesarean Section
Breastfeeding22,23
LABORATORY EVALUATION
Pretest Counseling
Informed Consent
Post Test Counseling
CDC Guidelines for HIV Testing in Pregnancy
ELISA (Enzyme-Linked Immuno-Sorbent Assay)
Western Blot
CD4 Lymphocyte Count
Quantitative Viral Load Assay
Other Tests that are Routinely Performed
MATERNAL THERAPY FOR HIV IN PREGNANCY24
PRINCIPLES OF THERAPY HIGHLY ACTIVE ANTI-RETROVIRAL THERAPY – HAART
ANTI-RETROVIRALS
Nucleoside Reverse Transcriptase Inhibitors
Non-nucleoside Reverse Transcriptase Inhibitors
Protease inhibitors
STRONGLY RECOMMENDED REGIMENS27
POTENTIAL BENEFITS OF EARLY THERAPY
CONTRACEPTION
CONCLUSION
EIGHTEEN:
Management of Preterm Labor
DEFINITION
CLINICAL CONTEXT
Asymptomatic Women
Prevention
Role of Progesterone
Bacterial Vaginosis
Symptomatic Women
Causes
DIAGNOSIS OF PRETERM LABOR
Clinical Evaluation
Investigations
Fetal Fibronectin in Women with Preterm Labor
Role of Amniocentesis in Suspected Preterm Labor
Therapies to Improve Outcome and Delay Delivery
TREATMENT OF PRETERM LABOR
TOCOLYTIC AGENTS
Mechanism of Action
A. Betamimetics (β-adrenergic Agonists)
Efficacy
Dose and Administration
MONITORING
B. Magnesium sulfate
Mechanism of Action
Efficacy
Dose and Administration
CALCIUM CHANNEL BLOCKERS
Mechanism of Action
Dose
PROSTAGLANDIN SYNTHETASE INHIBITORS (INDOMETHACIN)
Indomethacin
Mechanism of Action
Dosage and Administration
Contraindications
OXYTOCIN ANTAGONISTS
Mechanism of Action
NITRIC OXIDE (NO) DONORS
PROGESTERONE
Maintenance Therapy of Tocolytics
Antibiotics
Corticosteroids
Betamethasone (BTM) Versus Dexamethasone (DTM)
Single versus Multiple Course of Corticosteroids
Intrapartum Monitoring of the Preterm Fetus
Delivery of the Preterm Fetus
CONCLUSION
NINETEEN:
Preterm Prelabor Rupture of Membranes
INTRODUCTION
FETAL MEMBRANES AND MECHANISM OF PPROM
CLINICAL RISK FACTORS
MATERNAL RISKS OF PPROM
FETAL RISKS OF PPROM
NEONATAL RISKS OF PPROM
PREDICTION OF PPROM
PREVENTION OF PPROM
DIAGNOSIS OF PPROM
Clinical Course
DETERMINANTS OF MANAGEMENT OF PPROM
Pre-treatment Evaluation
Place of Conservative Management of PPROM
Place of Antibiotics
GBS Prophylaxis
Place of Antenatal Corticosteroids
Place of Tocolytics
SPECIAL SITUATIONS
PPROM IN CERCLAGE PATIENTS
Timing of Delivery
CONCLUSION
TWENTY:
Managing the Rh Negative Mother
INTRODUCTION
INCIDENCE
PATHOPHYSIOLOGY
FACTORS AFFECTING RH–VE ISOIMMUNZATION
MANAGEMENT OPTIONS FOR DETECTION OF ALLOIMMUNIZATION
MANAGEMENT OPTIONS FOR NON SENSITIZED RH–VE WOMAN
Antepartum Prophylaxis
MANAGEMENT OPTIONS FOR RH NEGATIVE SENSITIZED WOMEN
Noninvasive Evaluation
Invasive Evaluation
TREATMENT OPTIONS FOR GROSSLY SENSITIZED WOMEN
TIMING OF DELIVERY
POSTNATAL CARE
MEDICOLEGAL ASPECTS
COST EFFECTIVENESS OF TREATMENT
CONCLUSION
TWENTY ONE:
Multifetal Pregnancy— Current Issues
INTRODUCTION
CLASSIFICATIONS (Table 21.1)
MANAGEMENT OPTIONS
Pre Pregnancy
Prenatal
Diagnosis of Chorionicity by Early Ultrasound
Pregnancy Reduction
Fetal Anomaly Scanning
Conjoined Twins (Fig. 21.1)
Maternal Weight Gain Pattern
Hypertensive Disease in Twin Pregnancies
Preterm Labor
Antepartum Surveillance
Triplet Pregnancy and Its Outcome
Fetal Problems Specific to Multiple Pregnancy
Intrapartum Management
Clinical Decisions
Perinatal Mortality Rate (PNMR)
CONCLUSION
TWENTY TWO:
External Cephalic Version and Rebirth of Vaginal Delivery in Breech Presentation
INTRODUCTION
REDUCING THE INCIDENCE OF BREECH PRESENTATION
Knee Chest Position
EXTERNAL CEPHALIC VERSION (ECV)
Effect of ECV on the Caesarean Section Rate
Indications of ECV
Contraindications of ECV
Success Rate of ECV and Influencing Factors
Role of Tocolysis in ECV
Role of Regional Anesthesia in ECV
Safety of ECV
Future of ECV
Alternatives to ECV
MODE OF DELIVERY
Elective Caesarean Section Versus Planned Vaginal Delivery At Term
MANAGEMENT OF PRETERM BREECH PRESENTATION
MANAGEMENT OF TWIN BREECH
CONCLUSION
TWENTY THREE:
Pregnancy with a Pelvic Mass
INTRODUCTION
CLINICAL PRESENTATION
DIAGNOSIS
COMMON PELVIC MASSES
Fibroid with Pregnancy
Effects on Pregnancy
Management
Pelvic Mass of Ovarian Origin (Table 23.1)
Malignant Ovarian Tumor
Management
TWENTY FOUR:
Unexplained Stillbirth
INTRODUCTION
DEFINITION
INCIDENCE
Effect of the Classification System Used on the Incidence
RISK FACTORS
Risk Estimates
Previous Caesarean Section and Unexplained Stillbirth
Other Factors
WHAT HAPPENS NEXT?
Communication
Investigations: Why, What, When?
The Role of Autopsy
PREVENTION
A COMMONLY FACED PROBLEM
TWENTY FIVE:
Domiciliary Delivery in the 21 Century
INTRODUCTION
REVIEW OF THE SCOPE OF DOMICILIARY DELIVERY
WHY RETHINK ON HOME BIRTH IN 21ST CENTURY
Deciding Factors for Planned Home Birth
Planned Home Birth – How Far is it Possible in India?
CONCLUSION
TWENTY SIX:
Intrapartum Assessment of Fetal Health
TESTS USED TO ASSESS INTRAPARTUM FETAL WELL BEING
INTERMITTENT AUSCULTATION (IA)
ELECTRONIC FETAL MONITORING (EFM)
PATHOPHYSIOLOGY OF AN ABNORMAL CTG TRACE
Baseline FHR
Baseline Variability
Accelerations
Decelerations
Early Decelerations (Fig. 26.2)
Late Decelerations (Fig. 26.3)
Variable Decelerations (Fig. 26.4)
Fetal Scalp Blood Sampling (FBS)
pH
Base Excess
Blood Lactate
Fetal Pulse Oximetry (FSpO2)
ECG Waveform Analysis (ST Analyzer-STAN)
CONCLUSION
TWENTY SEVEN:
Postpartum Hemorrhage
INTRODUCTION
CONSEQUENCES OF POSTPARTUM HEMORRHAGE
Prediction and Prevention of Postpartum Hemorrhage
Principles of Management of Postpartum Hemorrhage
TWENTY EIGHT:
Amniotic Fluid Embolism
BACKGROUND
INCIDENCE
PREDISPOSING FACTORS
PATHOPHYSIOLOGY
CLINICAL PRESENTATION
Mortality and Morbidity
Diagnosis
Management
CONCLUSION
TWENTY NINE:
Ultrasonography in Pregnancy
NORMAL SONOGRAPHIC APPEARANCE (Table 29.1)
Gestational Sac
Yolk Sac
Embryo and Amnion
ECTOPIC PREGNANCY
Specific Sonographic Findings
Live Embryo in the Adnexa
Nonspecific Findings
Adnexal Mass (Fig. 29.16)
Tubal Ring (Fig. 29.17)
Free Fluid
Transvaginal Color Flow Doppler
Normal Sonogram
EARLY PREGNANCY FAILURE
ULTRASOUND DIAGNOSIS
Embryonic Cardiac Activity (Fig. 29.18)
Gestational Sac Characteristics
Amnion and Yolk Sac Characteristics
Embryonic Bradycardia (Fig. 29.19)
Mean gestational sac diameter in relation to the CRL
Yolk sac size and shape
Relation of β-HCG to mean gestational sac diameter
Subchorionic hemorrhage
TVCFD predictors of pregnancy failure
FETAL ANOMALIES (Figs 29.21 to 29. 27)
FIRST TRIMESTER MASSES
Ovarian Masses (Fig. 29.28)
Uterine Masses
Fetal Number
Gender of the Twins
Number of Placenta
Estimation of Gestational Age
Placental Sonography
Thrombi and hematomas (Fig. 29.36)
Placenta Previa (Fig. 29.37)
Umbilical Cord (Fig. 29.38)
Nuchal Cord (Fig. 29.39)
Ultrasound and Amniotic Fluid (Fig. 29.40)
Evaluation of the Cervix
Fetal Biophysical Profile
Ultrasound in Congenital Malformations
DOPPLER ULTRASONOGRAPHY IN OBSTETRICS
Indian Law (PCPNDT Act) and Obstetric Ultrasound
CONCLUSION
ACKNOWLEDGEMENT
THIRTY:
Preimplantation Genetic Diagnosis
BLASTOMERE BIOPSY
BLASTOCYST BIOPSY
POLAR BODY BIOPSY (PBB) (OOCYTE BIOPSY)
PGD FOR GROUP ONE DISEASES (ANEUPLOIDY)
Following Conditions can be Diagnosed by FISH Technique
Use of PGD in IVF Treatment
PGD FOR GROUP 2 DISEASES
The Technique of PCR in PGD
Amplification Failure (AF)
Allele Dropout (ADO)
Contamination
COMMON DISEASES REFERRED FOR PCR
Autosomal Recessive Disorders (PCR)
Autosomal Dominant Disorders (PCR)
X-linked Disorders (FISH)
Experiences Obtained from Case Collections by ESHRE PGD Consortium Steering Committee12
Group I (Aneuploidy for FISH Technique)
Group II (Inherited Monogenic Recessive and Dominant Disorders) (ESHRE PGD 2000)
FURTHER ADVANCES IN PGD
Multiplex PCR
Fluorescent PCR
PCR for Embryo Selection in IVF
THIRTY ONE:
Common Problems in Pediatric Gynecology
INTRODUCTION
NEONATAL ENDOCRINOLOGICAL PROBLEMS
SEXUAL AMBIGUITY
VULVOVAGINITIS
LABIAL ADHESIONS
ENTEROBIASIS
VAGINAL BLEEDING
BREAST ASYMMETRY
PRECOCIOUS PUBERTY
IMPERFORATE HYMEN
NEOPLASMS
CONCLUSION
THIRTY TWO:
Recurrent Pregnancy Loss
CAUSES AND RISK FACTORS
Epidemiological Factors
Age
Parity
Genetic Factors
Structural Defects
Müllierian Duct Defects
Acquired Uterine Factors
Immunological Factors
Autoimmune Diseases
Alloimmune Factors
Endocrine Causes
Diabetes Mellitus
Thyroid Dysfunction
Luteal Phase Defect
Hypersecretion of LH
High Androgen Levels
Hyperprolactinemia
Thrombophilias
Infection
Social and Environmental Factors
INVESTIGATIONS
MANAGEMENT
Counseling
Genetic Factors
Anatomic Factors
Immunological
APS
Alloimmunity
Endocrine Causes
Supportive Treatment
THIRTY THREE:
Ectopic Pregnancy: Current Management Trends
INTRODUCTION
EPIDEMIOLOGY
RISK FACTORS
DIAGNOSIS
CLINICAL FEATURES
Transvaginal Sonography (TVS)
Serum β-hCG Quantitative Assay
Combining β-hCG Level and USG Findings to Improve Diagnostic Accuracy
Serum Progesterone Assay
Dilatation and Curettage
Laparoscopy
Culdocentesis
Laparotomy
Other Tests of Limited Use
MANAGEMENT
Surgical Management
Laparoscopy or Laparotomy?
Medical Management
Criteria for Medical Management (Methotrexate Administration)33
Regimens of Methotrexate
Contraindications of Methotrexate17
Success of Methotrexate Therapy Depends on
Side Effects of Methotrexate
Counseling and Follow Up in Medical Management
Local Injection
Expectant Management
Criteria of Expectant Management37
Follow Up and Counseling of Expectant Management
REPRODUCTIVE OUTCOME FOLLOWING ECTOPIC PREGNANCY
CLINICAL PREDICTIVE TOOLS33
FUTURE DIRECTIONS
LEVEL OF EVIDENCES AND GRADE OF RECOMMENDATION
THIRTY FOUR:
Gestational Trophoblastic Disease
INTRODUCTION
CLASSIFICATION
INCIDENCE
PATHOLOGY
Epithelioid Trophoblastic Tumor (ETT)
Miscellaneous Trophoblastic Tumors (Benign Lesions)
Some Facts about hCG
Risk Factors for GTD
Hydatidiform Mole
Complications Associated with Evacuation
Surveillance after Evacuation
Current Recommendations for Pregnancy after HM14
Malignant Gestational Trophoblastic Neoplasia (Choriocarcinoma)
Current FIGO Criteria for Diagnosis of Post-molar GTN
Diagnostic Evaluation
CONCLUSION
THIRTY FIVE:
Hyperprolactinemia
INTRODUCTION
PROLACTIN
REGULATION OF PROLACTIN SECRETION
HYPERPROLACTINEMIA — DEFINITION
EPIDEMIOLOGY
ETIOLOGY
Physiological
Drug-induced Hyperprolactinemia
Hypothyroidism
Pituitary Tumors
Idiopathic Hyperprolactinemia
Macroprolactinemia
CLINICAL PRESENTATION
DIAGNOSIS
MANAGEMENT
BROMOCRIPTINE
CABERGOLINE
QUINAGOLIDE
SURGERY
MONITORING AND FOLLOW-UP
MANAGEMENT DURING PREGNANCY
CONCLUSION
THIRTY SIX:
Polycystic Ovary Syndrome— An Overview
DEFINITION
ETIOLOGY OF PCOS
PATHOPHYSIOLOGY
DIAGNOSIS
PCOS and Pregnancy
LONG-TERM CONSEQUENCES
MANAGEMENT OF POLYCYSTIC OVARY SYNDROME
Management of PCOS in Adolescents and in Women Not Desirous of Fertility
Lifestyle Modifications
Drugs are used as Supportive Therapy
Oral Contraceptives
Antiandrogens
Glucocorticoids
Physical Methods
Insulin Sensitizing Agents (ISA)
Important Agents
Complications
Management of Infertile PCOS
Ovulation Induction
Mechanism of Action of CC
Limitation of CC
Induction of Ovulation by Gonadotropins
Drawbacks of Gonadotropin
Role of Dexamethasone and Bromocriptine
Aromatase Inhibitors
Mechanism of Action
Wedge Resection
Ovarian Drilling
Mechanism of Action
In Vitro Fertilisation (IVF)
Immature Oocyte Collection and In Vitro Maturation
CONCLUSION
THIRTY SEVEN:
Unexplained Infertility: An Overview with Our Experience on Management
INTRODUCTION
INCIDENCE
MAGNITUDE OF THE PROBLEM
POSSIBLE ETIOLOGICAL FACTORS
OCCULT DEFECT OF OOCYTES
SPERM-OVUM CONTACT DEFECT
OCCULT SPERMATOZOAL DEFECT
IDENTIFYING DEFECT EITHER IN SPERMATOZOA OR IN OOCYTE
ROLE OF PREOVULATORY 64 KD UTERINE FLUID GLYCOPROTEIN IN UNEXPLAINED INFERTILITY
ROLE OF OXIDATIVE STRESS AND ANTIOXIDANTS ON SPERMATOZOAL FUNCTION IN APPARENTLY NORMAL SEMINOGRAM
LUTEINISED UNRUPTURED FOLLICLE (LUF) SYNDROME
OCCULT ENDOMETRIOSIS
LUTEAL PHASE DEFECT
UREAPLASMA INFECTIONS
MANAGEMENT
Superovulation with or without Adjuncts
Our Observation
Intrauterine Insemination
IVF in the Treatment of Unexplained Infertility
CONCLUSION
THIRTY EIGHT:
Male Infertility: Where Are We?
INTRODUCTION
PATHOPHYSIOLOGY
Frequency
CLINICAL ASSESSMENT
History
Physical Examination
CAUSES
Pretesticular causes of Infertility
Hypothalamus
Pituitary
Peripheral Organs
Primary testicular causes of infertility
Chromosomal Abnormalities
Nonchromosomal Testicular Failure
Varicocele
Post-testicular Causes of Infertility
LABORATORY INVESTIGATIONS
Semen Analysis
Antisperm Antibody Test
Hormone Analysis
Imaging Studies
Other Tests
Procedures
Testicular Biopsy
TREATMENT
Medical Treatment
Surgical Treatment
Other Measures
Assisted Reproduction Techniques (ART)
General Measures
THIRTY NINE:
Genital Tuberculosis: Anything New in Diagnosis?
INTRODUCTION
PATHOGENESIS AND PATHOPHYSIOLOGY
DIAGNOSIS
Signs and Symptoms
Investigations
Chest X-ray
Mantoux Test (Tuberculin Test)
TB MPB 64 Patch Test
Endometrial Curettage
Endometrial Aspiration Cytology
Menstrual Blood
Polymerase Chain Reaction (PCR)
Transcription Mediate Amplification (TMA) and Nucleic Acid Amplification (NAA)
Imaging
Hysterosalpingography
Tubes
Uterus
Cervix
Ultrasonography
Computerised Tomography (CT)
Endoscopy
Hysteroscopy
Laparoscopy
CA-125
CONCLUSION
FORTY:
Reproductive Tract Infections (RTIs)
INTRODUCTION
INCIDENCE
ANATOMY AND PHYSIOLOGY
Clinical Features of PID
Symptoms
Signs
Differential Diagnosis
Laboratory Data for Diagnosis of RTIs6
COMPLICATIONS
Infertility
Ectopic Pregnancy
Chronic Pelvic Pain
HIV Infection
Cervical Cancer
Mortality
During Pregnancy
MANAGEMENT
Women with PID will require hospitalization under following conditions
Regimen A — Oral outpatient
Regimen B — Outpatient
Regimen A — Inpatient
Regimen B — Inpatient
Alternative Regimens — Outpatient/Inpatient
Concept of Syndromic Approach
Global Results
Surgical Treatment
VAGINAL DISCHARGE
Bacterial Vaginosis
Diagnosis16
Treatment
Candidiasis
Diagnosis
Treatment
Trichomonas vaginalis
Diagnosis
Treatment
Cervicitis
Diagnosis
Treatment for Chlamydia trachomatis Endocervitis
Treatment for Neisseria Gonorrhea Endocervicitis
Strategies to End RTIs
ACKNOWLEDGEMENT
FORTY ONE:
Adenomyosis: Dilemma in Diagnosis and Management
INTRODUCTION
Incidence
Pathophysiology
Symptoms
Diagnosis
Limitations of Other Investigations
USG
MRI
Diagnostic Pitfalls
Treatment Dilemma
Surgical Treatment
Results of Surgical Treatment
CONCLUSION
FORTY TWO:
Managing Infertility with Endometriosis
INTRODUCTION
CAUSES OF INFERTILITY DUE TO ENDOMETRIOSIS
PROBABLE CAUSES OF ENDOMETRIOSIS DUE TO INFERTILITY
MANAGEMENT OF INFERTILITY WITH ENDOMETRIOSIS
EARLY-STAGE ENDOMETRIOSIS
Surgical Treatment
Medical Treatment
MODERATE TO SEVERE ENDOMETRIOSIS
Surgical Treatment
Medical Treatment
Pre- and Postoperative Medical Treatment
ENDOMETRIOMA
ENDOMETRIOSIS AND IUI
ENDOMETRIOSIS AND IVF
RECENT ADVANCES AND RESEARCH
SUMMARY — KEY POINTS
Basic Management Protocol
TAKE HOME MESSAGE
FORTY THREE:
Chronic Pelvic Pain: Diagnosis and Management
PREVALENCE OF CPP
EVALUATION OF THE PATIENT
History Taking
Physical Examination
Laboratory Examination
Laparoscopy
MANAGEMENT
GYNECOLOGICAL CAUSES
Endometriosis
Adhesions
Pelvic Congestion
Pelvic Inflammatory Disease
UROLOGIC CAUSE
Chronic Urethral Syndrome
GASTROENTEROLOGICAL CONDITIONS
Irritable Bowel Syndrome (IBS)
Management
MUSCULOSKELETAL CAUSES
MYOFASCIAL PAIN
PSYCHOLOGICAL FACTORS
VULVODYNIA
MANAGEMENT OF CHRONIC PELVIC PAIN
SURGICAL TREATMENT
Laparoscopy
Presacral Neurectomy
Hysterectomy
CONCLUSION
FORTY FOUR:
Medical Management of Dysfunctional Uterine Bleeding
INTRODUCTION
MEDICAL MANAGEMENT
ACTIVE MEDICAL THERAPY
THE PLACE OF MEDICAL MANAGEMENT IN DUB
ACUTE DYSFUNCTIONAL UTERINE BLEEDING
CHRONIC DYSFUNCTIONAL UTERINE BLEEDING
Tranexamic Acid
PROSTAGLANDIN SYNTHETASE INHIBITORS
HORMONAL TREATMENTS
The Oral Contraceptive Pill (OCP)
Oral Progestogens
Intrauterine Progestogens
Other Agents
CONCLUSION
FORTY FIVE:
Conservative Management of Uterine Fibroids
INTRODUCTION
MEDICAL MANAGEMENT
SURGICAL TREATMENT
FORTY SIX:
Oophorectomy During Hysterectomy—An Appraisal
FORTY SEVEN:
Changing Trends in Management of Genital Prolapse
CHANGING TRENDS IN OPERATIVE TREATMENT
Group-A (Figs 47.1 and 47.2)
Group-B (Figs 47.3 to 47.7)
Group-C (Figs 47.8 to 47.14)
Group-D (Fig. 47.15)
Group-E: Recurrent Prolapse
FORTY EIGHT:
HRT: Post WHI
INTRODUCTION
THE WOMEN'S HEALTH INITIATIVE (WHI) TRIAL
CRITICISM OF THE WHI TRIAL
THE MILLION WOMEN STUDY (MWS)
OTHER STUDIES
BENEFITS OF HRT
Vasomotor Symptoms
Urogenital Symptoms
Osteoporosis
Colorectal Cancer
RISKS OF HRT
Breast Cancer
Venous Thromboembolism
Coronary Heart Disease
Stroke
Endometrial Cancer
Gallbladder Disease
Unresolved Issues
THE DIVERGENT DATA ON CARDIOVASCULAR DISEASE
WOMEN WITH PREMATURE MENOPAUSE
ALTERNATIVE THERAPY
CONCLUSION
FORTY NINE:
Ultrasound in Gynecological Tumors
INTRODUCTION
SCOPE OF ULTRASOUND IN GYNECOLOGICAL TUMORS
OVARIAN TUMORS
ENDOMETERIAL CANCERS
CERVICAL CARCINOMA
GESTATIONAL TROPHOBLASTIC TUMORS
CONCLUSIONS
FIFTY:
Management of Abnormal Pap Smear—An Evidence Based Guideline
INTRODUCTION
INDICATIONS OF PAP SMEAR
CERVICAL PRE-CANCER: HISTOLOGICAL TERMINOLOGY
CYTOLOGICAL TERMINOLOGY
GUIDELINES FOR REFERRAL TO COLPOSCOPY
Inadequate Specimen
Atypical Squamous Cells (ASC)
Atypical Glandular Cells
Low Grade Squamous Intraepithelial Lesions
High Grade Squamous Intra-epithelial Lesions
Squamous Cell Carcinoma or Adenocarcinoma
MANAGEMENT ALGORITHMS FOLLOWING COLPOSCOPY
‘SEE AND TREAT’ POLICY
ABNORMAL PAP SMEAR IN PREGNANCY
FOLLOW-UP AFTER TREATMENT
FIFTY ONE:
Ovarian Cancer Screening— An Overview
INTRODUCTION
WHO CRITERIA FOR SCREENING
The Disease
The Treatment
The Tests
WHO CRITERIA AND OVARIAN CANCER
The Disease
The Treatment
The Tests
Pelvic Examination
Tumor Marker
Ultrasonography
Color Doppler Imaging (CDI)
Newer Modalities
Multimodal Screening
Availability and Acceptability of the Tests
Cost-effectiveness
WHOM TO SCREEN
CONCLUSION
FIFTY TWO:
Endometrial Carcinoma— Management and Prognostic Factors
TREATMENT
SURGERY
RADIOTHERAPY
SYSTEMIC TREATMENT
PROGNOSTIC FACTORS
FIFTY THREE:
Improving Outcome of Ovarian Malignancy
FIFTY FOUR:
Breast and the Gynecologist
INTRODUCTION
CONGENITAL AND DEVELOPMENTAL ANOMALIES OF THE BREAST
CONGENITAL ANOMALIES
PUBERTY DISORDERS
BENIGN BREAST CONDITIONS
Mastodynia
Management
FIBROCYSTIC DISEASE LEADING TO VARIOUS PATHOLOGICAL CHANGES IN THE BREAST
Investigations of Benign Breast Diseases
Management
BENIGN TUMORS OF THE BREAST
INFLAMMATORY DISEASES OF BREAST
DISEASES OF NIPPLE
ORAL HORMONAL CONTRACEPTIVE AND BENIGN BREAST DISEASES
HORMONE REPLACEMENT THERAPY AND BENIGN BREAST DISEASE
BREAST SELF EXAMINATION
Incidence
Breast Cancer Risk and Breast Maturity
Genetic Considerations
Strategies For Lowering Breast Cancer Risk
PROPHYLACTIC CHEMOTHERAPY
Prophylactic Surgery
Types of Breast Cancer
Diagnosis
Early Detection
Clinical Examination
Screening
Mammogram
Genetic Screening
Biopsy
Treatment
Estrogen and Progesterone Receptor Status of Breast Cancer Cells
Other Markers
FIFTY FIVE:
Contraception in the Current Century
INTRODUCTION
CURRENTLY AVAILABLE CONTRACEPTIVE METHODS
TEMPORARY METHODS
1. Fertility Awareness–based Methods
Calendar Rhythm Method
Cervical Mucus Method
Basal Body Temperature (Symptothermal Method)
2. Coitus Interruptus
3. Barrier Methods of Contraception
Condom
Female Condom (Vaginal Pouch)
Spermicides
Diaphragm and Cervical Cap
Sponge
4. Lactation Amenorrhea Method (LAM)
5. Intrauterine Device
6. Combined Oral Contraceptive (COC)
Instructions to the Patient in Case of Missed Pill
Newer Pills
Contraindications for Low Dose COC17
Absolute Contraindications
Relative Contraindications
COC-Risks
Cerebrovascular Accidents (CVA, Stroke)
Acute Myocardial Infarction (MI)18
Breast Cancer
Other Side Effects
HEALTH BENEFITS OF ORAL CONTRACEPTIVES
Protection against Cancer
Ovarian Cancer
Endometrial Cancer
Colorectal Cancer
Contraceptive Health Benefits
Non Contraceptive Benefits
7. Progestin-Only Pill (POP)
8. Injectable Contraception
9. The Norplant System
10. NEW DELIVERY SYSTEMS
Vaginal Contraceptive Ring
Transdermal Hormonal Contraception
11. EMERGENCY CONTRACEPTION
Indications for Emergency Contraception:
II. PERMANENT METHODS
1. Female Sterilization
2. Male Sterilization
Timings for performing Female Sterilization
Essure for Female Sterilization
Failure Rate of Contraception
WHO Medical Eligibility Criteria
Uses of Different Methods
SUMMARY
FIFTY SIX:
The Menace of Free Radicals and Antioxidants in Obstetrics and Gynecology
INTRODUCTION
FREE RADICALS (FRs)
REACTIVE OXYGEN SPECIES (ROs)
MECHANISM OF ACTION OF FRs
ANTIOXIDANTS (AOs)
OXIDATIVE STRESS
AO STATUS IN NORMAL PREGNANCY
AOs AND DIABETIC EMBRYOPATHY
AOs AND DOWNS SYNDROME
FRs AND AOS IN PRETERM DELIVERY
FRS AND AOS IN NEWBORN BABIES
CARCINOGENESIS
Basics of Cancer Formation
AOs in Cancer Prevention
FRs AND AOS IN INFERTILITY — MALE
FRs AND AOS IN INFERTILITY — FEMALE
CONCLUSION
INDEX
TOC
Index
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