LECTURE NOTES Obstetrics And Gynaecology
LECTURE NOTESObstetrics andGynaecologyDIANA HAMILTON-FAIRLEY2nd edition
Lecture Notes: Obstetrics and Gynaecology
Lecture NotesObstetrics andGynaecologyDiana Hamilton-FairleyMD, FRCOGConsultant Obstetrician and GynaecologistGuy’s and St Thomas’s Hospital NHS Trust, LondonSecond Edition
2004 D. Hamilton-Fairley 1999 Blackwell Science LtdPublished by Blackwell Publishing LtdBlackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USABlackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UKBlackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, AustraliaThe right of the Author to be identified as the Author of this Work has been asserted in accordance with theCopyright, Designs and Patents Act 1988.All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in anyform or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UKCopyright, Designs and Patents Act 1988, without the prior permission of the publisher.First published 1999Reprinted 2000, 2001Second edition 2004Library of Congress Cataloging-in-Publication DataHamilton-Fairley, Diana.Lecture notes on obstetrics and gynaecology / Diana Hamilton-Fairley. — 2nd ed.p. ; cm.Rev. ed. of: Lecture notes on obstetrics and gynaecology / Geoffrey Chamberlain,Diana Hamilton-Fairley.Includes index.ISBN 1-4051-2066-51. Obstetrics. 2. Gynecology.[DNLM: 1. Obstetrics. 2. Gynecology. WQ 100 H217L 2004] I. Title: Obstetrics andgynaecology. II. Chamberlain, Geoffrey, 1930 — Lecture notes on obstetrics and gynaecology. III. Title.RG526.C43 2004618 — dc222004007260ISBN 1-4051-2066-5A catalogue record for this title is available from the British LibrarySet in 8/12 Stone Serif by SNP Best-set Typesetter Ltd., Hong KongPrinted and bound in India by Replika Press Pvt. Ltd.Commissioning Editor: Vicki NoyesEditorial Assistant: Nic UlyattProduction Editor: Helen Harvey and Karen MooreProduction Controller: Kate CharmanFor further information on Blackwell Publishing, visit our website:http://www.blackwellpublishing.comThe publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which hasbeen manufactured from pulp processed using acid-free and elementary chlorine-free practices. Furthermore, thepublisher ensures that the text paper and cover board used have met acceptable environmental accreditation standards.
ContentsPreface, viiAcknowledgements, viii1 Basic science, 1Part 1 The woman2 The woman as a patient, 19Part 2 The young woman3 Puberty and menstrual problems of youngwomen, 294 Subfertility, 385 Pregnancy prevention, 466 Benign diseases, genital tract infections andsexual problems, 62Part 3 The reproductive years7891011The mother and fetus in pregnancy, 83Bleeding in pregnancy, 95The antenatal period, 105Diseases of pregnancy, 122Diseases in pregnancy, 13812131415Normal labour, 157Abnormal labour, 174Puerperium, 203The newborn, 211Part 4 The mature woman16171819Abnormal vaginal blood loss, 219Pelvic pain, 228Breast disease, 247Screening for gynaecological cancer, 258Part 5 The older woman20 Malignant gynaecological conditions, 26721 The menopause, 27822 Pelvic floor disorders, 284Part 6 Audit of obstetrics and gynaecology23 Statistics of reproductive medicine, 297Answers to self-assessment questions, 306Index, 323v
PrefaceWelcome to the second edition of Lecture Notes:Obstetrics and Gynaecology. Professor GeoffreyChamberlain asked me to assist him with the combining of the original well-established separateLecture Notes on Obstetrics and Lecture Notes onGynaecology by joining him as editor of this textbook aimed at undergraduate medical, midwiferyand nursing students, junior doctors, nurses andmidwives. He told me then that he intended to retire from the editorship for the second edition. Iowe him an enormous debt as a teacher, mentorand guide through my career and into the complexarea of editing a book with an illustrious list of eminent obstetricians and gynaecologists as its previous editors. He graciously agreed to proof read thisedition and I thank him for his helpful contribution to the final version. He continues to work asthe Emeritus Professor of History of Medicine atthe University of Wales.In this edition I have asked two of my colleaguesat Guy’s, King’s and St Thomas’s MedicalSchool/Guy’s and St Thomas’s Hospital NHS Trustto expand the sections on Sexually TransmittedDiseases and Breast Disease to reflect the changesin the undergraduate medical curriculum whichcombines Obstetrics and Gynaecology, BreastDisease and Sexual Health in several UK universities. I would like to thank them both: Dr DavidLewis FRCP, MD from Sexual Health and MrNicholas Beechey Newman FRCS, MS who wrotethe chapter on Breast Disease. I think their twochapters (6 and 18) are a valuable addition to thebook and I hope you, the reader, will agree.Feedback from students, Senior Lecturers andProfessors has led to many smaller changes in thebook including an expansion on the history takingand examination sections. At the end of each chapter there are five self-assessment questions with theanswers/marking schemes given in Answers to selfassessment questions (p. 306). The questions coverthe full range that may be found within the examination system in the United Kingdom, both atundergraduate and postgraduate levels, includingextended matched questions, scenarios for practicing history taking as in Objective Structured Clinical Examination (OSCE) as well as the moretraditional Multiple Choice Questions. I trustthey will be of help in the learning and revisionprocess.Over the decades this series has been translatedinto many languages, thus reaching an international audience. I hope those using this book allover the world and those who are not doctors intraining will find the changes made to this bookan addition to their learning even though manyof them are based on the changes that haveoccurred in the British Medical Undergraduatecurriculum.As the editor, I would like this book to aid itsreaders’ understanding of this very important areaof health care and that some of you will turn tocaring for women and their families as your longterm career. If this book contributes to either orboth of these then I am pleased.Diana Hamilton-Fairley, 2004vii
AcknowledgementsI would like to thank the following for their invaluable contribution to this book: Dr David LewisFRCP, MD Consultant, Department of Genitourinary Medicine, Guy’s and St Thomas’s HospitalNHS Trust; Mr Nicholas Beechey Newman FRCS,MS Senior Lecturer, Department of EndocrineviiiSurgery, Guy’s, King’s and St Thomas’s HospitalMedical School, King’s College London; ProfessorGeoffrey Chamberlain Emeritus Professor ofHistory of Medicine, University of Wales; andthe editorial and publishing staff of BlackwellPublishing.
Chapter 1Basic scienceFemale anatomyThe woman’s body is built in a different way fromthat of the male; it is less muscular and thereforehas a slighter skeleton to support the muscles. Inthe abdomen, the non-pelvic organs are similarand subject to the same diseases. Readers are therefore referred to books on general anatomy and thischapter is concerned with female pelvic anatomy.Since much changes in pregnancy we will introduce the pregnancy aspects in this section andChapter 7.Uterus (Box 1.1)A hollow, muscle-walled organ in the pelvis communicating with each fallopian tube and, throughits cervix, the vagina.Pre-pregnancy: 7 5 3 cm; weight, 40 g.Full term: 30 25 20 cm; weight, 1000 g.StructureMuscle in three layers with vascular anastomosisbetween them.1 Outer: thin, longitudinal, merging with ligaments.2 Middle: very thick, spiral muscle fibres withblood vessels between.3 Inner: thin, oblique with condensation at eachcornu and at the upper and lower end of the cervical canal — the internal and external os.Increase in size during pregnancy is mostlydue to hypertrophy of existing cells rather thanincrease in number. Changes are stimulated byoestrogen and gradual stretch (maximumeffective stretch about term).Blood supply (Fig. 1.1)From the uterine and ovarian arteries, mostly theformer. The uterine artery is a branch of the internal iliac artery. It runs in the lower edge of thebroad ligament to the junction of the uterine bodyand cervix before running up the side of the uterusgiving off several branches into the myometrium.The ureter lies immediately beneath the uterineartery.Cervix (Box 1.2)Barrel-shaped canal at the bottom of the uterus.(Fig. 1.2) Mostly connective tissue with muscle atupper and lower end (internal and external os). Inlate pregnancy the ground substance of connectivetissue becomes softer with a greater water contentand the cervix becomes softer clinically.LigamentsUterus is supported by ligaments (Fig. 1.3). Theprincipal supports of the uterus are the transversecervical ligaments (cardinal ligaments), the1
Chapter 1 Basic rvixUreterrunningforwardUterineartery(a)SacrumBody ofuterusCervixBladderPubisUrethraVulvaPouch ofDouglasRectumVaginaAnusFigure 1.1 Relations of the uterus. (a)Anteroposterior view. (b) Lateral view.See also Box 1.1.(b)Box 1.1 Relations of the uterusPeritoneum2The body and fundus arecovered with peritoneumIn front, this is reflected to theupper surface of the bladderOver the rest of the uterus, theattachment is dense and itcannot be stripped off theuterine muscleAnteriorThe uterovesical pouch andbladderLateralThe broad ligaments withtheir contentsPosteriorThe pouch of DouglasThe rectumBox 1.2 Relations of the cervix above theattachment to the vaginaAnteriorLoose connective tissueBladderPubocervical ligamentsLateralThe ureter 1 cm lateral to the cervixThe uterine arteryUterine veinsParametrial lymph glandsNerve gangliaThe transverse cervical ligamentPosteriorPeritoneum of the pouch of DouglasThe uterosacral ligaments
Basic science Chapter 1are stretched and thickened. They soften becauseof the progesterone and relaxin effect on collagen.Internal osCervical canalExternal osFigure 1.2 A longitudinal section of the cervix.uterosacral ligaments and the round ligament. Theround ligament rises from the fundus of the uterusanterior to the fallopian tube and passes into theinguinal canal ending in the labia majora. Thebroad ligament is made of two layers of peritoneum that run over the fallopian tubes anteriorly to the uterovesical reflection and posteriorlyto the rectovaginal reflection. In pregnancy theseOvary (Box 1.3)The ovaries have twin functions; both steroid production and gametogenesis. They are a pair oforgans on each side of the uterus, in close relationto the fallopian tubes. Each ovary is attached to theback of the broad ligament by a peritoneal fold,the mesovarium, which carries the blood supply,lymphatic drainage and nerve supply of the ovary.The blood supply to the ovaries is principally fromthe ovarian arteries which arise from the aorta justbelow the renal arteries.The ovary is approximately 4 cm long, 3 cm wideand 2 cm thick and weighs about 10 g. A generalview of the organs in the pelvis is shown inFig. 1.1b.StructureThe ovary has an outer cortex and inner medulla(Fig. 1.4) and consists of large numbers of primordial oocytes supported by a connective tissuestroma. It is covered by a single layer of cubical,1Box 1.3 Relations of the ovary(a)3213(b)Figure 1.3 The ligamentous supports of the uterus. (a)Frontal view. (b) Lateral view. 1, transverse cervical ligament; 2, round ligaments; 3, uterosacral ligaments.The ovary lies free in the peritoneal cavityAnteriorThe broad ligamentPosteriorThe peritoneum of the posteriorwall of the pelvisThe common iliac artery and veinThe internal iliac (hypogastric)arteryThe ureterLateralPeritoneum over the obturatorinternus muscleThe obturator vessels and nerveFurther out, the acetabulum andhip jointAboveThe fallopian tube, which curlsover the ovaryLoops of bowelOn leftThe pelvic colon and its mesenteryOn rightThe appendix if it dips intothe pelvis3
Chapter 1 Basic scienceGerminal epitheliumCortexCorpus luteumMature follicleGrowingGraafian follicleHilumAtretic follicleTunica albugineaMedullaFigure 1.4 Maturation of the oocytes to follicles.germinal epithelium which is often missing inadult women. Beneath is the fibrous capsule of theovary, the tunica albuginea, a protective layerderived from fibrous connective tissue.The cortex of the ovary at menarche containsabout 500 000 primordial oocytes that may become follicles, cysts about 0.1 mm in diameter.They have a single layer of granulosa cells whichproduce oestradiol and specially differentiatedtheca cells which produce androgens.During each menstrual cycle many primordialfollicles are recruited, but usually only one develops fully to become a mature Graafian follicle andexpels its oocyte. The granulosa cells multiply andsecrete follicular fluid. The oocyte with its granulosa layer projects into the follicle (Fig. 1.4). Thestroma cells outside the granulosal cell layer differentiate into: the theca interna (a weak androgen secretor); the theca externa (no hormone secretingfunction).Shortly before ovulation, meiosis is completed inthe primary oocyte in response to the luteinizinghormone (LH) surge. The oocyte casts off the firstpolar body resulting in the number of chromosomes in the remaining nucleus being reducedfrom 46 to 23. Thus the primary oocyte and thefirst polar body each contain the haploid number(23) of the chromosomes.4At this stage, the ripe follicle is about 20 mm indiameter. At ovulation it ruptures, releasing theoocyte usually into the fimbriated end of the fallopian tube.The follicle in the ovary collapses, the granulosacells become luteal cells while the theca internaforms the theca lutein cells. A corpus luteum develops and projects from the surface of the ovary. Itcan be recognized by the naked eye by its crinkledoutline and yellow appearance. Its cells secreteoestrogen and progesterone. If the ovum is not fertilized, the corpus luteum degenerates in about 10days. A small amount of bleeding occurs into itscavity, the cells undergo hyaline degeneration anda corpus albicans is formed. If pregnancy doesoccur, the corpus luteum grows and may reach3 cm in diameter. It persists for 80–120 days andthen gradually degenerates.The fallopian tubeThe fallopian tube is the oviduct conveyingsperm from the uterus to the point of fertilizationand ova from the ovary to the uterine cavity. Fertilization usually takes place in the outer part ofthe tube.The tube has four parts: The intramural (cornual) part is 2 cm long and1 mm in diameter.
Basic science Chapter 1Intramural (cornual)Round ligamentFallopian tubeIsthmusInfundibulumAmpullaOvaryInfundibular ligamentPeritoneal foldsFigure 1.5 Peritoneal folds to two layers of peritoneum. The isthmus is thick-walled and is 3 cm long and0.7 mm in diameter. The ampulla is wide, thin-walled, being about5 cm long and 20 mm in diameter (Fig. 1.5). The infundibulum is the lateral end of the tube. Itis trumpet shaped, crowned with the fimbriae thatsurround the outer opening of the tube. Thefimbriae stabilize the abdominal ostium over theripening follicle in the ovary.StructureThe tube has three coats. An outer serous layer of peritoneum whichcovers the tube except in its intramural part andover a small area of its attachment to the broadligament. A muscle layer with outer longitudinal and innercircular smooth muscle. The mucosa or endosalpinx which lines the tubethat is thrown into numerous longitudinal folds orrugae. The rugae have a core of connective tissuecovered with a tall columnar epithelium.Three types of cell are found in the mucosa. Ciliated cells, which beat a current usually in amedial direction. Secretory cells, which provide the secretion for therapidly developing blastocyst allowing exchangeof oxygen, nutrients and metabolites. Intercillary cells with long narrow nuclei,squeezed between the other cells. There are rhythmic changes in the epithelium during the menstrual cycle; in the proliferative phase the cellsincrease in height and activity with increasedsecretions just after ovulation.Vagina (Box 1.4)The vagina is a fibromuscular canal extendingfrom the vestibule of the vulva to the cervix,around which it is attached to form the fornices.StructureThe anterior vaginal wall is about 10 cm long andthe posterior wall 15 cm. It is capable of greatdistension, as in childbirth, after the prolongedBox 1.4 Relations of the vaginaAnteriorThe bladder and urethraPosteriorUpper — the pouch of DouglasLower — the rectum, separated by therectovaginal septum and perineal bodyLateralThe cardinal ligaments and the levatorani muscles5
Chapter 1 Basic sciencehormonal stimulation of pregnancy. Normally, theanterior and posterior walls are in contact so thecavity is represented by an H-shaped slit.The walls have: an outer connective tissue layer to which theligaments are attached — it contains blood vessels,lymphatics and nerves; a muscular layer consisting of an outer longitudinal layer and an inner circular layer of variablethickness and function; the epithelium of stratified squamous epithelium which in adult women contains glycogen andis composed of three layers:(a) a basal layer;(b) a functional layer;(c) a cornified layer.The epithelium undergoes cyclical changes during the menstrual cycle and characteristic changesduring pregnancy. After the menopause it atrophies so that smears taken from postmenopausalwomen contain a high proportion of basal cells.There are no glandular cells in the vaginal epithelium and so the term vaginal mucosa should not beused.Vaginal fluid is composed of cervical secretionand transudation through the vaginal epithelium.The vagina allows colonization of lactobacilliwhich produce lactic acid from the glycogen in theepithelial cells.VulvaThe vulva or external genitalia of the female includes the mons, the labia major, the clitoris, thelabia minor, the vestibule, the external urethrameatus, the glands of Bartholin and the hymen(Fig. 1.6)The mons is a pad of fat which lies over the pubicsymphysis. It is covered with skin in which hairgrows profusely from puberty to the menopause.The labia major are two folds of skin whichenclose the vaginal opening. They are made up offatty tissue very sensitive to oestrogen stimulation;the skin of the labia major is covered with hair afterpuberty.The clitoris contains erectile tissue and isattached to the pubic arch by its crura. Folds of skinrunning forwards from the labia minor form theprepuce of the clitoris.The labia minor are delicate folds of skin, containing fibrous tissue and numerous blood vesselsand erectile tissue. The skin contains sebaceousglands, but no hair follicles, and epithelium whichlines the vestibule and vagina.MonsClitorisLabia majorUrethral orificeLabia minorVestibuleBartholins glandPerineumAnusFigure 1.6 The vulva.6
Basic science Chapter 1The vestibule is the area between the labia minorinto which opens the vagina, with the externalmeatus of the urethra in front and the ducts of theBartholin glands behind.The external urethral meatus is the opening ofthe urethra covered with squamous epithelium. Skene’s ducts from the posterior urethralglands open on to the posterior margin of themeatus.The Bartholin glands are a pair of glands, theducts of which are lined by columnar epithelium.Each gland is the size of a pea and in structure resembles salivary glands. The secretion is colourlessand mucoid and is produced mainly on sexualexcitement.The hymen is a circular or crescentic fold ofsquamous epithelium and connective tissuewhich partly closes the vaginal entrance in youngwomen. Its shape and size varies. It is oftenruptured or stretched by tampon insertion or byintercourse — childbirth destroys it.PerineumThe perineum is the area between the vaginalopening and the anus
Disease and Sexual Health in several UK universi-ties. I would like to thank them both: Dr David Lewis FRCP, MD from Sexual Health and Mr Nicholas Beechey Newman FRCS, MS who wrote the chapter on Breast Disease. I think their two chapters (6 and 18) are a valuable addition to the book and I hope you, the reader, will agree.
Introduction of Chemical Reaction Engineering Introduction about Chemical Engineering 0:31:15 0:31:09. Lecture 14 Lecture 15 Lecture 16 Lecture 17 Lecture 18 Lecture 19 Lecture 20 Lecture 21 Lecture 22 Lecture 23 Lecture 24 Lecture 25 Lecture 26 Lecture 27 Lecture 28 Lecture
OBSTETRICS & GYNAECOLOGY CATALOGUE 2015 3 Howkins & Bourne Shaw's Textbook of Gynaecology, 16/e By V.G Padubidri has a rich clinical and teaching experience of more than three decades. She has been a teaching faculty at Maulana Azad Medical College and Lady Hardinge Medical College where she taught both undergraduate and postgraduate students.
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Community Health Clinical Nurse, Warinilla Clinic, Drug and Alcohol Services SA Dr Dale Hamilton Clinical Staff Specialist, Obstetrics and Gynaecology, King Edward Memorial Hospital WA Dr Ross Haslam Director of Neonatology, Women's and Children's Hospital Adelaide SA Dr Joanne Ludlow Senior Staff Specialist in Obstetrics and Gynaecology .
Obstetrics and Gynaecology, Newham University Hospital NHS Trust, Glen Rd, London, UK E13 8SL. Email: sanduni.abeysuriya@nhs.net Mobile No: 07719659607 Co-authors Samreen Wasif Obstetrics and Gynaecology, Newham University Hospital NHS Trust, Glen Rd, London, UK E13 8SL. Email: samreen.wasif@nhs.net Callum Counihan
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24. Dr. N. Giridhar Gopal Professor Department of Radio-Diagnosis 25. Dr. N. Bhaskara Rao Professor Department of Obstetrics & Gynaecology 26. Dr. I. Sai Samyukta Assistant Professor, Department of Obstetrics & Gynaecology 27. Dr. K. Madhavi Assistant Professor, Department of Paediatrics 28.
6. Medical Microbiology & Immunology 1. Obstetrics & Gynaecology 2. General Surgery 3. Orthopaedics & Traumatology 4. Otorhinolaryngology (Head & Neck Surgery) 5. Ophthalmology 6. Internal Medicine 7. Paediatrics 7. Parasitology & Medical Entomology 8. Tissue Engineering 9. Obstetrics & Gynaecology 10. Pathology 11. Internal Medicine 12 .
