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OXFORD MEDICAL PUBLICATIONSOxford Handbook ofObstetrics andGynaecology

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Oxford Handbook ofObstetrics andGynaecologyThird EditionEdited bySally CollinsSpecialist Registrar in Obstetrics and Gynaecology,The John Radcliffe Hospital,Oxford, UKSabaratnam ArulkumaranProfessor of Obstetrics and Gynaecology,St George’s Hospital Medical School,University of London, UKKevin HayesSenior Lecturer/Honorary Consultant in Obstetricsand Gynaecology, and Medical Education,St George’s Hospital Medical School,University of London, UKSimon JacksonConsultant Gynaecologist,The John Radcliffe Hospital,Oxford, UKLawrence ImpeyConsultant in Obstetrics and Fetal Medicine,The John Radcliffe Hospital,Oxford, UK1

3Great Clarendon Street, Oxford, OX2 6DP,United KingdomOxford University Press is a department of the University of Oxford.It furthers the University’s objective of excellence in research, scholarship,and education by publishing worldwide. Oxford is a registered trade mark ofOxford University Press in the UK and in certain other countries Oxford University Press, 2013The moral rights of the authors have been assertedFirst edition published 2005Second edition published 2008Third edition published 2013All rights reserved. No part of this publication may be reproduced,stored in a retrieval system, or transmitted, in any form or by any means,without the prior permission in writing of Oxford University Press,or as expressly permitted by law, or under terms agreed with the appropriatereprographics rights organization. Enquiries concerning reproductionoutside the scope of the above should be sent to the Rights Department,Oxford University Press, at the address aboveYou must not circulate this book in any other binding or cover and you mustimpose the same condition on any acquirerBritish Library Cataloguing in Publication DataData availableISBN 978–0–19–969840–0Printed in China byC&C Offset Printing Co. Ltd.Oxford University Press makes no representation, express or implied, that thedrug dosages in this book are correct. Readers must therefore always check theproduct information and clinical procedures with the most up-to-date publishedproduct information and data sheets provided by the manufacturers and the mostrecent codes of conduct and safety regulations. The authors and the publishers donot accept responsibility or legal liability for any errors in the text or for the misuseor misapplication of material in this work. Except where otherwise stated, drugdosages and recommendations are for the non-pregnant adult who is notbreast-feeding.

vContentsPreface viAcknowledgements viiAbbreviations ixContributors xxiii123456789101112131415161718192021222324Normal pregnancyPregnancy complicationsFetal medicineInfectious diseases in pregnancyMedical disorders in pregnancyLabour and deliveryObstetric anaesthesiaNeonatal resuscitationPostnatal careObstetric emergenciesPerinatal and maternal mortalityBenign and malignant tumours in pregnancySubstance abuse and psychiatric disordersGynaecological anatomy and developmentNormal menstruation and its disordersEarly pregnancy problemsGenital tract infections and pelvic painSubfertility and reproductive medicineSexual assaultContraceptionMenopauseUrogynaecologyBenign and malignant gynaecological conditionsMiscellaneous gynaecologyIndex 9569613621635653685771

viPrefaceWelcome to the third edition of this Oxford Handbook. In obstetrics andgynaecology, as in all fields of medicine, the available evidence, technologyand guidelines can move forward at a rapid pace and often prove difficultto keep up with. As the majority of junior doctors are well aware, thegaps in our knowledge often become apparent at the most inopportunemoments; this book seeks to fill those gaps rapidly and effectively. It usesthe well-known Oxford Handbook format to facilitate easy navigationaround concise, clinically relevant, evidence-based information. It can bequickly dipped into for specific answers between seeing patients in clinic oron delivery suite, as well as providing a solid, general grounding for thosejust beginning in the specialty. It also has sufficient depth and detail to provide a good starting point in the preparation for postgraduate exams. Toensure the most up-to-date information is always available, emphasis hasbeen placed on providing relevant web addresses, especially for guidelinesand useful organizations. Text boxes have also been employed to helphighlight some of the more important pieces of information.Although this handbook is most likely to be used by trainees within thespecialty, we envisage it will be useful for all those involved in women’shealth, including GPs, midwives, and medical students. We hope you find ita helpful resource and that it proves to be a valuable companion and guidein your everyday practice of obstetrics and gynaecology.

viiAcknowledgementsWe would like to thank all our second edition authors, especially thetrainees at the John Radcliffe and St George’s hospitals. Additionally, weare very grateful to those who have gone the extra mile to ensure thatour third edition chapters are up to date, especially Charlotte Bennett,Lucy MacKillop, and Jo Morrison who reviewed the highly specializedareas of neonatology, maternal medicine, and oncology to ensure thatthey contained the best available evidence. We would also like to thankthe doctors of all grades who anonymously reviewed some of the text,providing valuable feedback and further fine-tuning the finished manuscript. To conform to the Oxford Handbook style and to avoid overlapand repetition, some contributions have been considerably edited and wethank all our authors for their understanding. We are most grateful toProf. Basky Thilaganathan for providing many of the ultrasound imagesand Ms Penny Trotter for the colposcopy pictures. Last, but definitelynot least, we would like to thank our partners and families who continueto remain so patient and supportive throughout this project, especiallyBerni O’Connor ‘for doing all the real work on the home front’ and DavidReynard ‘for putting up with all this’.Sally Collins, Sabaratnam Arulkumaran,Kevin Hayes, Simon Jackson, and Lawrence ImpeyLondon and Oxford, October 2012

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ixAbbreviationspprimaryssecondary vepositive–venegativeA&EAccident and EmergencyAAAlcoholics AnonymousAATaspartate aminotransferaseABCairway, breathing, and circulationABGarterial blood gasesACabdominal circumferenceACEangiotensin converting enzymeACEIangiotensin-converting enzyme c hormoneADHantidiuretic hormoneAEDFabsent end diastolic flowAFatrial fibrillationAFEamniotic fluid embolismAFIamniotic fluid indexAFLPacute fatty liver of pregnancyAFPalpha-fetoproteinAINperi-anal intraepithelial neoplasiaAISandrogen insensitivity syndromeAJCCAmerican Joint Committee on CancerALPalkaline phosphataseALTalanine transaminaseAMHantimüllerian hormoneANantenatalANAantinuclear antibodyAPHantepartum haemorrhage

xABBREVIATIONSAPRAntiretroviral Pregnancy RegistryAPSantiphospholipid syndromeAPTTactivated partial thromboplastin timeARDSadult respiratory distress syndromeAREDFabsent/reversed end diastolic flowARMartificial rupture of membranesARTassisted reproductive technologiesASDatrial septal defectASISanterior superior iliac spinesASTaspartate amniotransferaseAVMarteriovenous malformationAWEaceto-white epitheliumAXRabdominal X-rayBCEBacillus Calmette–Guerinbdtwice dailyBEPbleomycin, etoposide, and cisplatinBFHIBaby-Friendly Hospital InitiativeBMblood sugar monitoringBMDbone mineral densityBMIbody mass indexBOTSBorderline Ovarian Tumour StudyBPblood pressureBPDbiparietal diameterBRCAbreast cancer geneBSObilateral salpingo-oophrectomyBVbacterial vaginosisCA125cancer antigen 125CAHcongenital adrenal hyperplasiaCAIScomplete androgen insensitivity syndromecARTcombination antiretroviral therapyCBAVDcongenital bilateral absence of the vas deferensCBTcognitive-behavioural therapyCCAMcongenital cystic adenomatoid malformationCCTcontrolled cord traction

ABBREVIATIONSCEAcarcinoembryonic antigenCEMACH Confidential Enquiry into Maternal and Child HealthCEMDConfidential Enquiry into Maternal DeathsCESDIConfidential Enquiry into Stillbirths and Deaths in InfancyCFcystic fibrosisCFTRcystic fibrosis transmembrane conductance regulationcGINcervical glandular intraepithelial neoplasiaCHDcongenital heart diseaseCINcervical intraepithelial neoplasiaCLcorpus luteumCMACECentre for Maternal and Child EnquiriesCMVcytomegalovirusCNScentral nervous sytemCNSTClinical Negligence Scheme for TrustsCOCPcombined oral contraceptive pillCPcerebral palsyCPPchronic pelvic painCPRcardiopulmonary resuscitationCrHDcoronary heart diseaseCRLcrown–rump lengthCRPC-reactive proteinCSCaesarean sectionCSEcombined spinal epiduralCSFcerebrospinal fluidCTcomputed tomographyCTGcardiotocographyCVcyclophosphamide and vincristineCVAcerebrovascular accidentCVDcardiovascular diseaseCVPcentral venous pressureCVSchorionic villus samplingCXRchest X-rayDCDAdichorionic, diamnioticDESdiethylstilbestrolxi

xiiABBREVIATIONSDHDepartment of HealthDHEASdehydroepiand osterone sulphateDICdisseminated intravascular coagulationDOdetrusor overactivityDOAdirect occipito-anteriorDOLdirect occipito-lateraldRVVTDilute Russell Viper Venom TestDSDdisorders of sex developmentDUBdysfunctional uterine bleedingDVTdeep vein thrombosisEASexternal anal sphincterEBRTexternal beam radiotherapyEBVEpstein–Barr virusECemergency contraceptionECGelectrocardiographECOGEastern Cooperative Oncology GroupECTelectroconvulsive therapyECVexternal cephalic versionEDerectile dysfunctionEDDexpected date of deliveryEFMelectronic fetal monitoringEFWestimated fetal weightEGFRepidermal growth factor receptorEIAenzyme immunoassayELelevated liver enzymesEMAetoposide, methotrexate, and dactinomycinEOCepithelial ovarian cancerEPectopic pregnancyEPAUearly pregnancy assessment unitEPDSEdinburgh Postnatal Depression ScaleEPUearly pregnancy unitERCPendoscopic reterograde cholangio-pancreatographyERPCevacuation of retained products of conception

ABBREVIATIONSESRerythrocyte sedimentation rateETendometrial thicknessETTendotracheal tubeEUAexamination under anaestheticFBCfull blood countFDAFood and Drug AdministrationFDPfibrin degradation productFETOfetoscopic tracheal occlusionFEV1forced expiratory volume in 1sFFNfetal fibronectinFFPfresh frozen plasmaFGMfemale genital mutilationFHfetal heartFHRfetal heart rateFIGOInternational Federation of Gynaecology and ObstetricsFISHfluorescent in situ hybridizationFLfemur lengthFMfetal movementFPRfalse positive rateFSDfemale sexual dysfunctionFSEfetal scalp electrodeFSHfollicle-stimulating hormoneFU5-FluorouracilFVSfetal varicella syndromeGAgeneral anaesthesiaGASgroup A streptococcusGBSgroup B streptococcusGCSFgranulocyte colony-stimulating factorGDMgestational diabetes mellitusGFRglomerular filtration rateGIgastrointestinalGMCGeneral Medical CouncilGnRHgonadotrophin-releasing hormonexiii

nal trophoblastic diseaseGTTglucose tolerance testGUMgenitourinary medicineHhaemolysisHAARThighly active antiretroviral therapyHbhaemoglobinHBeAghepatitis B E antigenHBsAghepatitis B surface antigenHBVhepatitis B virusHChead circumferencehCGhuman chorionic gonadotrophinhcthaematocritHCVhepatitis C virusHDLhigh density lipoproteinHDUhigh dependency unitHELLPhaemolysis, elevated liver enzymes, and low plateletsHFEAHuman Fertilization and Embryology AuthorityHHhypogonadotrophic hypogonadismHIVhuman immune deficiency virusHLAhuman leucocyte antigenHNIGhuman normal immunoglobulinHNPCChereditary non-polyposis colorectal cancerHOCMhypertrophic obstructive cardiomyopathyHPhypothalamo-pituitaryhPLhuman placental lactogenHPOhypothalamus-pituitary-ovaryHPUHealth Protection UnitHPVhuman papillomavirusHRThormone replacement therapyHSDDhypoactive sexual desire disorderHSGhysterosalpingographyHSVherpes simplex virus

ABBREVIATIONS5-HT5-hydroxytryptamineHTLVhuman lymphotropic virusHVShigh vaginal ermittent auscultationIASinternal anal sphincterIBDinflammatory bowel diseaseIBSirritable bowel syndromeICinterstitial cystitisICSInternational Continence SocietyICSIintracytoplasmic sperm injectionICUintensive care unitIDSinterval debulking surgeryIgGimmunoglobulin GIgMimmunoglobulin MIGTimpaired glucose rual bleedingINRinternational normalized ratioIOLinduction of labourIpintraperitonealITPidiopathic thrombocytopaenic purpuraIUCDintrauterine contraceptive deviceIUDintrauterine death (of the fetus)IUGRintrauterine growth restrictionIUIintrauterine inseminationIUPintrauterine pregnancyIUSintrauterine systemIVintravenousIVFin vitro fertilizationIVUintravenous urogramJVPjugular venous pressurexv

xviABBREVIATIONSLAlocal anaestheticLARClong-acting reversible contraceptiveLATSlong-acting thyroid stimulatorLAVHlaparoscopic-assisted vaginal hysterectomyLDHlactate dehydrogenaseLDLlow density lipoproteinLElupus-erythematosusLFTliver function testLHluteinizing hormoneLLETZlarge loop excision of the transformation zoneLMPlast menstrual periodLMWHlow-molecular-weight heparinLNlymph nodeLNGlevonorgestrelLNMPlast normal menstrual periodLPlow plateletsLRlikelihood ratioLSCSlower segment Caesarean sectionLSDlysergic acid diethylamideLUNAlaparoscopic uterine nerve ablationLVEFleft ventricular ejection fractionLVSlow vaginal swabMAmentoanteriorMAISmild androgen insensitivity syndromeMASmeconium aspiration syndromeMCAmiddle cerebral arteryMCDAmonochorionic, diamnioticMCHCmean corpuscular haemoglobin concentrationMCMAmonochorionic, monoamnioticMCVmean corpuscular volumeMDMA3, linary teamMEAmicrowave endometrial ablation

ABBREVIATIONSMEOWmodified early obstetric warning systemMImyocardial infarctionMMMTmixed mesodermal Müllerian tumourMMPmatrix metalloproteinaseMMRmumps, measles, and rubellaMMtRmaternal mortality ratioMoMmultiples of medianMPmentoposteriorMPAmedroxyprogesterone Imagnetic resonance imagingMROPmanual removal of placentaMSmultiple sclerosisMSAFmeconium-stained amniotic fluidMSUmidstream urine (sample)MTCTmother-to-child transmissionMTHFRmethylenetetrahydrofolate reductaseMWSMillion Women StudyNAATnucleic acid amplification testNBMnil by mouthNCSPNational Chlamydia Screening ProgrammeNECnecrotizing enterocolitisNHSCSP National Health Service Cervical Screening ProgrammeNHSLANational Health Service Litigation AuthorityNKnatural killerNNMneonatal mortalityNNRTINon-nucleoside analogue reverse transcriptaseNPSANational Patient Safety AgencyNPVnegative predictive valueNSAIDnon-steroidal anti-inflammatory drugNSCNational Screening CommitteeNTnuchal translucencyNTDneural tube defectxvii

xviiiABBREVIATIONSNYHANew York Heart AssociationOAoccipito-anteriorOABoveractive bladderOATSoligoasthenoteratozoospermiaodonce dailyOGTToral glucose tolerance testOHSSovarian hyperstimulation Organization of Teratology Information SpecialistsPAISpartial androgen insensitivity syndromePAPP-Apregnancy-associated plasma protein-APCApatient-controlled analgesiaPCBpostcoital bleedingPCIpercutaneous coronary interventionPCO2partial pressure of carbon dioxidePCOSpolycystic ovary syndromePCPprimary pneumocystis pneumoniaPCRpolymerase chain reactionPDApatent ductus arteriosusPDSpolydioxanone suturePEpulmonary embolismPEFRpeak expiratory flow ratePEPpost-exposure prophylaxisPETpre-eclamptic toxaemiaPFMEpelvic floor muscle exercisesPGprostaglandinPGDpreimplantation genetic diagnosisPGSpreimplantation genetic screeningPIprotease inhibitorPIDpelvic inflammatory diseasePIGFplacental growth factorPIHpregnancy-induced hypertension

ABBREVIATIONSPLCOProstate, Lung, Colorectal, and OvarianPMBpostmenopausal bleedingPMSpremenstrual syndromePOper oral (by mouth)POCTpoint of care testPOFpremature ovarian failurePOPprogesterone-only pillPPplacenta praeviaPPHpost-partum haemorrhagePPROMpreterm prelabour rupture of membranesPPVpositive predictive valuePRprogesteronePROMprelabour rupture of membranesPSperformance statusPSVpeak systolic velocityPTprothrombin timePTTpartial thromboplastin timePTUpropylthiouracilPULpregnancy of unknown locationPVper vaginamQventilationqdsfour times dailyQOLquality of lifeRCOGRoyal College of Obstetricians and GynaecologistsRCTrandomized controlled trialRECISTresponse evaluation criteria in solid tumoursREDFreversed end diastolic flowRhrhesusRMIrisk of malignancy indexROMrupture of membraneRPRrapid plasma reaginRRrelative riskRUQright upper quadrant (of abdomen)xix

xxABBREVIATIONSSADSsudden adult/arrhythmic death syndromeSAHsubarachnoid haemorrhageSARCSexual Assault Referral CentreSBstillbirthSCsubcutaneousSCBUspecial care baby unitSERMselective oestrogen reuptake modulatorSFHsymphysis fundal heightSFLt-1soluble-like tyrosine kinaseSGAsmall for gestational ageSHBGsex hormone-binding globulinSHOsenior house officerSIDSsudden infant death syndromeSLEsystemic lupus erythematosusSNRIserotonin and norepinephrine reuptake inhibitorSOLspace-occupying lesionSPDsymphysis pubis dysfunctionSpRspecialist registrarSROMspontaneous rupture of membranesSSRIselective serotonin reuptake inhibitorSTANST waveform analysisSTIsexually transmitted infectionSUIstress urinary incontinenceSVTsupraventr

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