CONTEMPORARY OBSTETRICS AND GYNECOLOGY FOR DEVELOPING COUNTRIES

Description

Foreword Preface Reviewers Acknowledgements Contents About the Editors Contributors Part I: Women’s Reproductive Health 1: Sexual and Reproductive Health and Rights: An Overview 1.1 What Is Reproductive Health? 1.2 Sexual Health 1.3 Components of Sexual and Reproductive Health 1.4 What Is New About the Concept of Sexual and Reproductive Health? 1.5 The Role of Men in Sexual and Reproductive Health 1.6 The Concept of Sexual and Reproductive Health and Rights: A Paradigm Shift in Population Activities 1.7 Why Is Sexual and Reproductive Health Important? References 2: Clinical Diagnosis in Obstetrics and Gynaecology 2.1 Gynaecological History Taking 2.1.1 Introduction 2.1.2 History of Presenting Complaint 2.1.3 Menstrual History 2.1.4 Past Gynaecological History 2.1.5 Past Obstetric History 2.1.6 Past Medical and Surgical History 2.2 The Gynaecological Examination 2.2.1 General Physical Examination 2.2.2 Examination of the Abdomen 2.2.3 Pelvic Examination 2.3 Investigations in Gynaecology 2.3.1 Urethral, Vaginal and Endocervical Swabs 2.3.2 Papanicolaou Test or Pap Smear 2.3.3 Uterine Aspiration Cytology 2.3.4 Cold Cone Biopsy 2.3.5 Culdocentesis 2.3.6 Hormone Assay 2.3.7 Imaging Techniques 2.3.8 Diagnostic Endoscopy 2.4 Obstetric History Taking 2.4.1 Biodata 2.4.2 History of Current Pregnancy 2.4.3 Past Obstetric History 2.4.4 Gynaecological History 2.4.5 Past Medical and Surgical History 2.4.6 Drug History and Allergy 2.4.7 Family and Social History 2.4.8 Systemic Review 2.5 Obstetric Examination 2.5.1 General Examination 2.5.2 Abdominal Examination 2.6 Conclusion References 3: Maternal Mortality in Developing Countries 3.1 Definitions and Measurements of Maternal Deaths 3.2 Global Trends in Maternal Mortality Rates 3.3 Medical and Direct Causes of Maternal Mortality 3.4 Social Context of Maternal Mortality 3.5 Risk Factors for Maternal Mortality 3.6 Prevention of Maternal Mortality 3.6.1 Primary Prevention of Maternal Mortality 3.6.2 Secondary Prevention of Maternal Mortality 3.6.3 Tertiary Prevention of Maternal Mortality 3.7 Recommendations and Conclusion References 4: Preventing Perinatal Mortality in the Developing Countries 4.1 Introduction 4.2 Definitions 4.3 Incidence of Perinatal Mortality 4.4 Epidemiology of Perinatal Deaths 4.5 Factors Predisposing to Perinatal Mortality 4.5.1 Environmental Factors 4.5.2 Biosocial Factors 4.5.3 Obstetric and Gynaecological Factors 4.6 Causes of Perinatal Mortality 4.6.1 Direct Causes 4.6.1.1 Prolonged Obstructed Labour 4.6.1.2 Anaemia and Malnutrition 4.6.1.3 Hypertensive Diseases of Pregnancy 4.6.1.4 Antepartum Haemorrhage 4.6.1.5 Diabetes Mellitus in Pregnancy 4.6.1.6 Birth Trauma 4.6.1.7 Infections 4.6.1.8 Prematurity 4.6.1.9 Intrauterine Growth Restriction 4.6.1.10 Malpresentation 4.6.1.11 Perinatal Asphyxia 4.6.1.12 Post Maturity 4.6.2 Indirect Causes 4.7 Prevention 4.7.1 Primary Prevention 4.7.2 Secondary Prevention 4.7.3 Tertiary Prevention 4.8 Conclusion References 5: Abortion 5.1 Introduction 5.2 Spontaneous Abortion 5.2.1 Aetiology 5.2.2 Risk Factors for Spontaneous Abortion 5.2.3 Clinical Presentation 5.2.4 Differential Diagnosis 5.2.5 Management 5.2.6 Prevention of Spontaneous Abortion 5.3 Induced Abortion 5.3.1 Prevalence 5.3.2 Legal and Policy Context 5.3.3 Risk Factors 5.3.4 Consequences of Induced Abortion 5.3.5 Prevention 5.3.6 Human Rights and Gender Implications 5.4 Conclusion References 6: Female Circumcision/Mutilation/Cutting 6.1 Introduction 6.2 Operational Definitions 6.3 Epidemiology of Female Genital Cutting 6.3.1 Risk Factors for Female Genital Cutting 6.3.2 Practice of Female Genital Cutting 6.4 Health Consequences of Female Genital Cutting 6.5 Medical Management of Female Genital Cutting 6.5.1 Primary Prevention of Female Genital Cutting 6.6 Management of Female Genital Cutting Complications (Secondary Prevention) 6.6.1 Management of Short-Term Complications 6.6.2 Management of Long-Term Complications 6.6.3 Management of Female Genital Cutting in Pregnancy 6.7 Tertiary Prevention (the Rehabilitation of Victims of Female Genital Cutting) 6.7.1 Health Workers Training 6.8 Gaps in Applied Research Relating to Female Genital Cutting 6.9 Summary References 7: Reproductive Epidemiology, Health Status and Burden of Disability 7.1 Introduction 7.2 Operational Definitions 7.3 Reproductive Epidemiology in Africa 7.4 The Health Status of African Women 7.5 The Burden of Disability Among African Women 7.6 Conclusion References Part II: Obstetrics 8: Preconception Counselling and Prenatal Care 8.1 Preconception Care 8.1.1 Introduction 8.1.2 Definition of Preconception Care 8.1.3 The Rationale for Advocating for Preconception Care 8.1.4 Informal Versus Formal Pre-pregnancy Counselling 8.1.5 Components of Preconception Care 8.1.6 Maternal Assessment 8.1.7 Vaccination 8.1.7.1 Screening Tests 8.1.8 Preconception Interventions of Proven Benefits [1] 8.1.9 Organisation of Preconception Care Service 8.2 Prenatal Care 8.2.1 Definition of Prenatal Care 8.2.2 Aims of Prenatal Care [27] 8.2.3 The Core Components of Prenatal Care [28] 8.2.4 Classification of Prenatal Care [27] 8.2.5 Schedule of Prenatal Clinic Visits [28] 8.2.5.1 Booking Visit Booking History Examination Booking Investigations Prophylactic Drugs in Pregnancy [28] 8.2.5.2 Subsequent Prenatal Visits 8.2.5.3 At Every Visit General Examination for Pallor, Pedal Oedema Prenatal Advice Minor Ailments in Pregnancy [29] Prenatal Immunisation [28] Focused Antenatal Care (FANC) Traditional Versus Modified Form of Prenatal Care Pitfalls of Prenatal Care in West African Sub-region [28] 8.3 Conclusion 8.4 Summary References 9: Ultrasound in Labour and Delivery 9.1 Introduction 9.2 Basic Considerations – Equipment and Safety 9.3 Indications for Ultrasound Use on Labour and Delivery 9.3.1 Antepartum 9.3.1.1 Maternal Conditions 9.3.1.2 Prediction and Diagnosis of Preterm Labour 9.3.1.3 Assessing Gestational Age 9.3.1.4 Novel Late Pregnancy Dating Markers 9.3.1.5 Fetal Epiphyseal Ossification Centres 9.3.1.6 Trans Cerebellar Diameter (TCD) 9.3.1.7 Foot Length 9.3.1.8 Placental Localisation 9.3.2 Intrapartum 9.3.2.1 Prediction of Successful Induction of Labour 9.3.2.2 Prediction of Dystocia, Difficult or Prolonged Labour and Delivery 9.3.2.3 Assessment of Progress in Labour, Diagnosis of Protracted or Arrested Labour Cervical Dilatation Head Engagement or Head Progression Distance Head Station Head Direction Angle of Progression, Angle of Descent Head Perineum (Head Progression) Distance 9.3.2.4 Clinical and Ultrasound Pelvimetry, Sub-Pubic Arch Angle, Midline Angle 9.4 Summary 9.5 Recommendations References 10: Evidence-Based Antenatal Care 10.1 Introduction 10.2 Preconception Care 10.3 Organisation and Standardisation of Antenatal Care 10.4 Education, Counselling and Support 10.5 Antenatal Care Plans 10.6 The Initial (Booking) Visit (Up to 16-Weeks Gestation) 10.7 World Health Organization [22] 10.8 Risk Scoring 10.9 Second Visit (24–28 weeks) 10.10 Third Visit (32 weeks) 10.11 Fourth Visit (36 weeks) 10.12 Foetal Surveillance 10.13 Unbooked Patients (With no Antenatal Care) 10.14 Effectiveness of Different Antenatal Care Models 10.15 Barriers and Enablers to Utilisation of Antenatal Care 10.16 Summary References 11: Fetal Growth Abnormalities: Intrauterine Growth Restriction and Macrosomia 11.1 Introduction 11.2 Intrauterine Growth Restriction 11.2.1 Pathology of IUGR 11.3 Risk Factors and Causes of IUGR [7, 11, 12] 11.3.1 Foetal causes of IUGR 11.3.1.1 Genetic/Chromosomal Anomalies 11.3.1.2 Foetal Structural Abnormalities 11.3.1.3 Congenital Infections 11.3.1.4 Placental/Umbilical Cord Disorders 11.3.1.5 Multiple Gestation 11.3.1.6 Foetal Sex 11.3.2 Cautionary Tale 11.3.2.1 Maternal Causes of IUGR 11.3.2.2 Maternal Lifestyle/Habits 11.3.2.3 Maternal Prescription Drugs 11.3.2.4 Maternal Malnutrition and Malabsorption 11.3.2.5 Maternal Anaemia 11.3.2.6 Vascular Disorders 11.3.2.7 Maternal Infections 11.3.2.8 Uterine Abnormalities 11.3.2.9 Constitutionally Small Mother 11.3.2.10 Maternal Parity 11.3.2.11 Maternal Hypoxic Conditions 11.3.2.12 Clinical presentation and Antenatal Diagnosis of the Intrauterine Growth Restricted Foetus 11.3.2.13 Complications of IUGR 11.3.2.14 Maternal Complications Foetal Complications Immediate/Short-Term Neonatal Complications Long-Term Complications The Management of the pregnancy with IUGR Prognosis/Expected Outcome of IUGR Pregnancies 11.3.2.15 Prevention of IUGR 11.4 Large For Gestational Age (LGA) Foetuses/Foetal Macrosomia 11.4.1 Pathology of LGA/Macrosomia 11.5 Risk Factors and Causes of LGA/Macrosomia 11.5.1 Foetal Factors of LGA/Macrosomia 11.5.2 Maternal Factors for LGA/Macrosomia 11.5.3 Foetal Factors of LGA/Macrosomia 11.5.3.1 Postdate Pregnancy 11.5.3.2 Genetic and Congenital Disorders 11.5.3.3 Constitutional Large Foetus 11.5.3.4 Male Gender 11.5.3.5 Racial 11.5.3.6 Maternal Factors for LGA/Macrosomia 11.5.3.7 Maternal Obesity and Large Stature 11.5.3.8 Previous LGA/Macrosomic Newborn 11.5.3.9 ‘Postdatism’ 11.5.3.10 Advanced Maternal Age and Multiparity Cautionary Tale 11.5.3.11 Complications of LGA/Macrosomia 11.5.3.12 Maternal complications of Foetal Macrosomia 11.5.3.13 Foetal Complications 11.5.3.14 Neonatal Complications 11.5.3.15 Long-Term Complications 11.5.3.16 Treatment 11.5.3.17 Prognosis of Macrosomia/LGA Pregnancies 11.5.3.18 Prevention of LGA/Macromia 11.6 Summary References 12: Management of Normal and Abnormal Labour 12.1 Introduction 12.2 Partograph 12.3 Plotting the Modified WHO Partograph 12.4 Abnormal Labour 12.4.1 Abnormalities of the First Stage of Labour 12.4.2 Problems of the Latent Phase of Labour 12.4.3 Problems of the Active Phase of Labour 12.4.4 Problems of the Second Stage of Labour 12.4.5 Abnormalities of the Third Stage of Labour References 13: Premature Rupture of Membranes (PROM) 13.1 Introduction 13.2 Pathogenesis 13.3 Risk Factors 13.4 Expectant Management 13.5 Prelabour Rupture of Foetal Membranes at Limits of Viability 13.6 Pregnancy Complications and Outcome 13.7 Paediatric Outcomes References 14: Induction of Labour 14.1 Introduction 14.2 Indications for Induction of Labour 14.2.1 High Priority 14.2.2 Other Indications 14.2.3 Unacceptable Indications 14.2.4 Contraindications 14.2.5 Induction at 39 Weeks or More 14.3 Procedure 14.4 Pharmacological Methods of IOL 14.5 Gel Versus Tablets or Pessary 14.6 Regimen for Oxytocin (Syntocinon®) Infusion via a Volumetric Pump 14.6.1 Standardised Dilutions and Dose Regimes 14.6.2 Regimen for Oxytocin (Syntocinon®) Infusion via a Syringe Driver 14.6.3 Evidence 14.7 Special Situations 14.7.1 Previous CS 14.8 Intra-Uterine Foetal Death (IUFD) 14.9 Setting and Timing of Induction References 15: Electronic Fetal Monitoring 15.1 Introduction 15.2 History 15.3 Basic Fetal Physiology Relating to Oxygen Consumption 15.3.1 Delivery of Oxygen to Reach the Foetus 15.3.2 Oxygen Saturation Across the Placenta 15.4 Clinical Implications of Hypoxia 15.5 Determinants of Severity of Fetal Damage From Fetal Hypoxia 15.6 Fetal Coping Mechanisms to Avoid Fetal Hypoxia 15.7 Regulation of Fetal Heart Rate and Rhythm in Pregnancy 15.8 Factors That Could Affect Fetal Heart Rate Pattern Include 15.9 Indications for Electronic Fetal Monitoring 15.10 Cardiotocography (CTG) 15.10.1 The CTG Procedure 15.10.2 Basic Features of the CTG 15.11 Types of CTG Evaluation 15.11.1 Antenatal CTG 15.11.2 Intrapartum CTG 15.11.3 Interpretation of a CTG Trace 15.11.4 Clinical Implication 15.12 Controversies Surrounding the Use of EFM 15.13 Relevance of EFM in Low- and Medium-Income Countries (LMIC) 15.14 Challenges with EFM in Low- and Medium-Income Countries 15.15 Recommended Practical Approach for the Deployment and Use of EFM in LMIC 15.16 Setting Up a CTG Unit 15.17 The Antenatal Unit: Recommendations Here Include 15.18 The Intrapartum Unit: Recommendations Here Include 15.19 Summary References Further Reading 16: Operative Vaginal Delivery 16.1 Introduction 16.1.1 Incidence of Operative Vaginal Deliveries 16.2 Forceps Delivery 16.2.1 History of the Procedure 16.2.2 The Instrument [5] 16.2.3 Operative Classification 16.2.4 Indications for Forceps Delivery 16.2.5 Prerequisites for Forceps Delivery 16.2.6 Contraindication to Forceps Delivery 16.2.7 Patient Preparation for Forceps Delivery 16.2.8 Technique of Forceps Delivery (Fig. 16.3) [10] 16.2.9 Failed Forceps Delivery 16.2.10 Trial of Forceps Delivery 16.2.11 Complications of Forceps Delivery [5, 9, 10] 16.2.12 Post-operative Care 16.3 Vacuum Extractor (Ventouse) 16.3.1 History of the Vacuum Extractor 16.3.2 Types of Vacuum Extractors 16.3.3 Indications for Vacuum Assisted Delivery 16.3.4 Conditions That Must Be Fulfilled Before Embarking on Vacuum Extraction 16.3.5 Contraindication for Vacuum Extraction 16.3.6 Technique of Vacuum Extraction 16.3.7 Failed Vacuum Delivery 16.3.8 Complications of Vacuum Delivery 16.3.9 Medico Legal Concerns in Operative Vaginal Delivery 16.3.10 Advantages of the Forceps Over the Vacuum Delivery 16.3.11 Advantages of Vacuum Extraction Over Forceps Delivery 16.3.12 Controversies in Operative Vaginal Deliveries [5] 16.4 Destructive Operations 16.4.1 Prerequisites for Destructive Operations [23] 16.4.2 Contraindications to Destructive Operations [23] 16.4.3 Types of Destructive Operations 16.4.4 Post-operative Management After a Destructive Operation 16.4.5 Complications of Destructive Operations 16.5 Symphysiotomy 16.5.1 Technique 16.5.2 Indications for Symphysiotomy 16.5.3 Management Protocol [24, 35, 36, 37] 16.5.4 Maternal Mortality and Morbidity 16.6 Episiotomy 16.6.1 Types of Episiotomy 16.6.2 Benefits of an Episiotomy 16.6.3 Indications for Episiotomy 16.6.4 Technique of Episiotomy 16.6.5 Repair of an Episiotomy (Fig. 16.10) 16.6.6 After Care of an Episiotomy 16.6.7 Complications of Episiotomy 16.7 Conclusion References 17: Breech Presentation and Delivery 17.1 Introduction 17.2 Prevalence 17.3 Types of Breech Presentation 17.3.1 Frank Breech (50–70%) 17.3.2 Complete Breech (5–10%) 17.3.3 Incomplete (Footling) Breech (10–40%) 17.4 Antenatal Risk Categorisation 17.5 Clinical Assessment 17.6 Ultrasound Diagnosis of Breech Presentation 17.7 Significance of Type of Breech in Planning Delivery 17.8 Antenatal Management of Breech Presentation 17.8.1 External Cephalic Version 17.8.2 Risks Associated with ECV 17.8.3 Contraindications to ECV 17.8.4 Timing of ECV 17.9 Performing ECV 17.9.1 Adequate Counselling and Obtaining Informed Consent 17.9.2 Technique of ECV 17.10 Antenatal Management After ECV 17.10.1 Fetal Heart Rate Monitoring 17.10.2 Anti D Immune Globulin 17.11 Management After Unsuccessful ECV 17.12 Management After Successful ECV 17.13 Alternatives to ECV 17.13.1 Expectant Management 17.13.2 Other Alternatives 17.14 Delivery of Persistent Breech Presentation at Term 17.14.1 Choosing the Route of Delivery 17.14.2 Scheduled Caesarean Section for Breech Presentation at Term 17.14.3 Planned Vaginal Breech Delivery for Persistent Breech Presentation at Term 17.14.3.1 Intrapartum Management of the Breech Birth 17.15 Postpartum Care 17.15.1 Neonatal Examination and Care 17.16 Documentation 17.17 Conclusion References 18: Caesarean Delivery and Peripartum Hysterectomy 18.1 History of Caesarean Section 18.2 The Incidence of Caesarean Section 18.3 The Indications of Caesarean Section 18.4 Cephalopelvic Disproportion (CPD) 18.5 Foetal Distress in Labour 18.6 Breech Presentation 18.7 Multiple Pregnancy 18.8 Very Low Birth Weight Babies (500–1499 g) 18.9 Prevention of Mother-to-Child Transmission of Maternal Infections 18.10 Maternal Request 18.11 Classification of Caesarean Section 18.12 Elective Caesarean Section 18.13 Caesarean Section in Labour 18.14 Surgical Technique of Caesarean Section 18.15 Peritoneal Closure 18.16 Anaesthesia for Caesarean Section 18.17 Complications of Caesarean Section 18.18 Maternal Death 18.19 Haemorrhage 18.20 Deep Venous Thrombosis and Pulmonary Thrombosis 18.21 Prophylaxis Against Thromboembolic Disease in Patients Undergoing a Caesarean Section 18.22 Caesarean Section and Chorioamnionitis 18.23 Peripartum (Caesarean/Postpartum) Hysterectomy 18.24 Indications 18.25 Infections 18.26 Urinary Tract Infection 18.27 Chest Infection 18.28 Endometritis 18.29 Wound Infection 18.30 Urinary Complications 18.31 Impact on Future Fertility 18.32 Management of a Previous Caesarean Section Scar 18.33 The Role of Pelvimetry 18.34 Management of a Trial of Scar 18.35 Risks of Scar Rupture 18.36 Recognition of the Ruptured Uterus 18.37 Alternatives to Caesarean Section 18.38 Court-Ordered Caesarean Section 18.39 Risk Management Issues in Caesarean Section 18.39.1 Timing of Elective Caesarean Section 18.39.2 Safety Practices 18.39.3 Perimortem Caesarean Section (PMCS) 18.40 Conclusion 18.41 Summary References 19: Obstetrical Analgesia and Anaesthesia 19.1 Introduction 19.2 Physiological Changes in Pregnancy and Their Implications 19.3 Hormonal Changes 19.4 Respiratory System 19.5 Cardiovascular System 19.6 Gastrointestinal System 19.7 Haematological Changes 19.8 Pain Pathway in Labour and Caesarean Section 19.9 Pain Relief in Labour 19.10 Why Pain Relief in Labour? 19.11 Methods of Pain Relief in Labour 19.11.1 Parenteral Analgesia 19.11.2 Inhaled Analgesia 19.12 Regional Analgesia for Labour 19.12.1 Spinal Analgesia 19.13 Labour Epidural Analgesia 19.14 Choice of Local Anaesthetic and Initiation of Labour Epidural Analgesia 19.15 Other Adjuvants 19.16 Maintenance of Lumbar Epidural Analgesia (Box 19.2) 19.16.1 Combined Spinal Epidural Analgesia 19.17 Epidural Analgesia: Progress and Outcome of Labour 19.17.1 Anaesthesia for Caesarean Section 19.18 General Anaesthesia for Caesarean Section 19.19 Regional Anaesthesia for Caesarean Section 19.19.1 Spinal Anaesthesia 19.20 Epidural Anaesthesia 19.21 Combined Spinal Epidural 19.22 Local Anaesthesia 19.23 Conclusion 19.24 Summary 20: Aetiology and Management of Obstetric Haemorrhage 20.1 Introduction 20.2 Causes of Obstetric Haemorrhage 20.3 Antepartum Haemorrhage 20.3.1 Placenta Praevia 20.3.1.1 Clinical Features and Diagnosis 20.3.1.2 Diagnosis Is Clinical but Confirmed by Placental Localisation 20.3.1.3 Clinical Management of Placenta Praevia 20.3.1.4 Expectant Management 20.3.1.5 Examination Under Anaesthesia (EUA) 20.3.1.6 Caesarean Section for Placenta Praevia 20.3.2 Abruptio Placentae 20.3.2.1 Aetiology 20.3.2.2 Pathology and Mechanism of Abruptio Placentae 20.3.2.3 Clinical Presentation 20.3.2.4 Complications of Abruptio Placentae 20.3.2.5 Management of Abruptio Placentae 20.3.3 Incidental Causes of Antepartum Haemorrhage 20.3.3.1 Uterine Rupture 20.3.3.2 Marginal Haemorrhage 20.3.3.3 Vasa Praevia 20.4 Postpartum Haemorrhage 20.4.1 Incidence 20.4.2 Causes of Primary Postpartum Haemorrhage 20.4.2.1 Uterine Atony 20.4.2.2 Methods of Prevention of Postpartum Haemorrhage Due to Uterine Atony 20.4.2.3 Vulval Haematomas 20.4.2.4 Third-Stage Abnormalities Retained Placenta Morbid Adhesion of the Placenta Acute Uterine Inversion 20.4.3 Treatment of Primary Postpartum Haemorrhage 20.4.4 Secondary Postpartum Haemorrhage 20.4.4.1 Coagulation Failure Haemostatic Changes in Pregnancy Disseminated Intravascular Coagulation (DIC) Management Drugs for the Treatment of Disseminate Intravascular Coagulation (DIC) 20.4.5 Evaluation of the Bleeding Patient 20.4.6 Resuscitation of the Bleeding Patient 20.5 Control of Obstetric Haemorrhage 20.5.1 The NASG Suit 20.5.2 Angiographic Embolisation of Bleeding Vessels 20.5.3 Obstetric Hysterectomy 20.5.4 Internal Iliac Artery Ligation 20.6 Conclusion References 21: Preterm Birth 21.1 Introduction 21.2 Epidemiology and Impact of PTB 21.3 Causes and Risk Factors 21.3.1 Maternal 21.3.1.1 Previous Spontaneous Preterm Birth (sPTB) 21.3.1.2 History of Miscarriage 21.3.1.3 Short Interbirth Interval 21.3.1.4 Genetic Factors 21.3.1.5 Race 21.3.1.6 Age 21.3.1.7 Cervical Injury and Surgery 21.3.1.8 Uterine Malformation 21.3.1.9 Smoking 21.3.1.10 Infection 21.3.2 Foetal 21.3.2.1 Multiple Pregnancy 21.3.2.2 Vaginal Bleeding in Early Pregnancy 21.3.2.3 Prediction of Preterm Birth 21.4 Diagnosis 21.5 Triage 21.6 Transabdominal Obstetrics USS (TAUSS) 21.7 Transvaginal Ultrasound (TVS) 21.8 Other Investigations 21.9 Treatment of Threatened and Diagnosed PTL 21.10 Maternal Corticosteroids 21.11 Tocolysis 21.12 Magnesium Sulphate for Neuroprotection 21.13 Progesterone 21.14 Antibiotics 21.15 Antimalarial Therapy 21.16 Neonatology Review 21.17 Management of Established Preterm Labour 21.17.1 Delivery 21.17.2 Foetal Monitoring 21.17.3 Foetal Scalp Electrode 21.17.4 Foetal Blood Sampling (FBS) 21.17.5 Analgesia 21.17.6 Mode of Delivery 21.17.7 Timing of Umbilical Cord Clamping 21.17.8 Post-Delivery Follow-Up and Preconception Clinic 21.17.9 Prevention 21.18 Conclusion References 22: The Puerperium 22.1 Introduction 22.2 Anatomical and Physiological Changes 22.2.1 The Uterus 22.2.2 The Cervix 22.2.3 The Vagina 22.2.4 Urinary System 22.2.5 Abdominal Wall 22.2.6 Cardiovascular System 22.2.7 Breast and Lactation 22.2.8 Colostrum and Milk 22.3 Management of the Puerperium 22.3.1 Immediate Postpartum Care 22.3.2 Postnatal Ward 22.3.3 Postnatal Clinic 22.4 Postpartum Complications 22.4.1 Puerperal Pyrexia 22.4.1.1 Causative Organisms Aerobic Gram-Positive Organisms Aerobic Gram-Negative Organisms Anaerobic Gram-Positive Organisms Anaerobic Gram-Negative Organisms 22.4.1.2 Mode of Infection 22.4.1.3 Predisposing Factors 22.4.1.4 Features of puerperal sepsis 22.4.1.5 Investigations 22.4.1.6 Recommendation Practices to Prevent and Treat Maternal Peripartum Infections 22.4.2 Hypertensive Disorders of Pregnancy 22.4.3 Postpartum Anaemia 22.5 Conclusion References Part III: Medical and Surgical Disorders in Pregnancy 23: Intensive Care Management of Trauma During Pregnancy 23.1 Introduction 23.2 Types of Trauma 23.3 Evaluation and Management 23.4 Conclusion Further Reading 24: Cardiovascular Diseases in Pregnancy 24.1 Introduction 24.2 Epidemiology 24.2.1 Physiological Changes in Pregnancy 24.2.1.1 Cardiovascular Physiology of Pregnancy 24.2.1.2 Hemodynamic Changes in Normal Pregnancy 24.2.2 Critical Periods 24.2.3 Cardiac Findings in Normal Pregnancy 24.2.4 Cardiovascular Diagnosis in Pregnancy 24.2.5 Pregnancy and Heart Murmurs 24.3 Pathological Conditions and Pregnancy 24.3.1 Hypertensive Disorders 24.3.1.1 Objective 24.3.2 Valvular Heart Disease 24.3.3 Valvular Heart Disease 24.3.3.1 Aortic Stenosis 24.3.3.2 Aortic Artery Disease and Pregnancy 24.3.3.3 Prosthetic Cardiac Valves 24.3.3.4 Congestive Cardiac Failure 24.3.4 Cardiomyopathy 24.3.4.1 Hypertrophic Cardiomyopathy: (HCM) 24.3.5 Congenital Heart Disease 24.3.5.1 Cyanotic Congenital Heart Disease Tetralogy of Fallot (TOF) Ebstein’s Anomaly Transposition of the Great Arteries Congenitally Corrected Transposition of Great Artery Pulmonary Hypertension and Eisenmenger 24.3.5.2 Management of Cyanotic Mothers Medical Aortic Diseases Previous Aortic Dissection Arrhythmia Coronary Artery Disease 24.3.5.3 Venous Thromboembolism Learning Objective Treatment Effect of Pregnancy on Heart Disease Effect of Heart Disease on Pregnancy Risk Stratification General Management Preventive Concepts in Managing Cardiovascular Diseases in Pregnancy General Preventive Measures Preconceptional Counseling Pregnancy Onset Medical Termination of Pregnancy Antenatal Care 24.4 Future Prospects References 25: Respiratory Disorders in Pregnancy 25.1 Introduction 25.2 Anatomic Changes in Normal Pregnancy 25.3 Respiratory Physiology and Pregnancy 25.4 Dyspnoea of Pregnancy 25.5 Effect of Respiratory Diseases on the Respiratory System During Pregnancy 25.5.1 Bronchial Asthma 25.6 Pneumonias 25.6.1 Pathogens 25.7 Tuberculosis 25.7.1 Diagnosing Tuberculosis in Pregnancy 25.7.1.1 Anti-Tuberculous Therapy 25.7.1.2 Breast Feeding and TB 25.7.1.3 Contraception 25.8 Pulmonary Venous Thromboembolism 25.9 Pulmonary Hypertension 25.9.1 Pulmonary Oedema 25.9.2 Pleural Effusion 25.9.3 Sleep-Disordered Breathing 25.10 Nitric Oxide (NO) in Pregnancy and Disease References 26: Hypertension in Pregnancy 26.1 Introduction 26.2 Definition 26.3 Proteinuria 26.4 Classification 26.5 Chronic Hypertension 26.6 White-Coat Hypertension 26.7 Masked Hypertension 26.8 Transient Gestational Hypertension 26.9 Gestational Hypertension 26.10 Preeclampsia-Eclampsia 26.11 Risk Factors 26.12 Theories of Preeclampsia 26.12.1 Increased Response to Pressor Agents 26.12.2 Abnormal Invasion of the Trophoblast 26.12.3 Prostaglandins 26.12.4 Vascular Endothelial Injury 26.12.5 Genetic and Immunological Factors 26.12.6 Coagulation Abnormalities 26.13 Clinical Features and Multisystem Involvement in Preeclampsia 26.13.1 Cardiovascular Findings 26.13.2 Gastrointestinal Findings 26.13.3 Renal Findings 26.13.4 Haematologic Findings 26.13.5 Central Nervous System 26.14 Prevention of Preeclampsia 26.15 Management of Preeclampsia 26.16 Eclampsia 26.17 Conclusion References 27: Critical Care Management of Severe Preeclampsia-Eclampsia and Obstetric Hypertensive Crisis 27.1 Introduction 27.2 Aetiology of Preeclampsia: Abnormal Placentation 27.2.1 Mechanism of Seizures Complicating Preeclampsia 27.3 Principles of Management of Severe Preeclampsia and Eclampsia 27.4 Team Approach 27.5 Management of Seizures [29] 27.5.1 Management of Seizures: The +MAGPIE Study 27.5.2 Mechanisms of Magnesium Sulphate for Seizure Prevention [18] 27.5.3 Management of Seizures 27.6 Use of Magnesium Sulphate: Maternal, Perinatal, Infant and Late Childhood Effects [37–41] 27.7 Management of Hypertension 27.8 Hydralazine 27.8.1 Obstetric Side Effects of Hydralazine 27.9 Adalat (Nifedipine) 27.10 Labetalol (Fig. 27.4) 27.10.1 Labetalol: Clinical Pharmacology 27.11 Intravenous Use of Labetalol for Hypertensive Crisis 27.11.1 Side Effects 27.11.2 Precautions [29, 50] 27.12 Treatment of Resistant Hypertension [29] 27.13 Fluid Balance Management 27.14 Obstetric Management 27.15 Eclampsia: Mode of Delivery 27.16 Post-partum SP-OHC [61] 27.17 SP-EOHC: Later-Life Medical Diseases 27.18 Summary and Recommendation References 28: Haemoglobinopathies in Pregnancy 28.1 Introduction 28.2 Prevalence 28.3 The Pathophysiology of Sickle Cell Disease 28.4 Effect of Pregnancy on Sickle Cell Disease 28.5 Effect of Sickle Cell Disease on Pregnancy 28.6 Management of Sickle Cell Disease in Pregnancy 28.6.1 Clinical Presentations 28.6.2 Laboratory Investigations 28.7 Treatment 28.7.1 Preconception Care 28.7.2 Prenatal Diagnosis 28.7.3 Antenatal Care 28.7.4 Drug Use in SCD Women in Pregnancy 28.7.5 Sickle Cell Disease Crises in Pregnancy 28.7.6 Acute Chest Syndrome (ACS) in Pregnancy 28.7.7 Acute Stroke in Pregnancy 28.7.8 Pulmonary Embolism in Pregnancy 28.7.9 Acute Anaemia in Pregnancy 28.7.10 Intrapartum Care 28.7.11 Postpartum Care 28.8 Challenges of Managing Sickle Cell Disease in Pregnancy in Low and Middle Income Countries (LMICs) 28.9 Prevention 28.9.1 Health Education 28.9.2 Vaccinations 28.9.3 Genetic Counselling 28.9.4 Newborn Screening 28.10 Summary References 29: Anaemia in Pregnancy 29.1 Introduction and Definition 29.2 Environmental Factors and Pattern of Anaemia 29.3 Physiological and Other Considerations 29.4 Main Types of Anaemia 29.5 Management of Anaemia in Pregnancy 29.6 Diagnosis 29.7 Clinical Examination 29.8 Investigations 29.9 Clinical Approach to the Management of Anaemia in Pregnancy 29.10 Treatment 29.10.1 Correction of Anaemia 29.10.2 Choice of Method for Correcting Anaemia 29.10.3 Mild Anaemia 29.10.4 Moderate Anaemia 29.10.5 Severe Anaemia 29.11 Exchange Blood Transfusion 29.12 Parenteral Iron Therapy 29.12.1 Malaria Chemoprophylaxis 29.12.2 What Drug(s) to Give as Malaria Chemoprophylaxis? 29.13 Adverse Effects of Anaemia in Pregnancy 29.14 Prevention of Anaemia 29.15 Summary References 30: Diabetes in Pregnancy 30.1 Introduction 30.2 Definitions and Classification of Hyperglycaemia in Pregnancy 30.3 Epidemiology of Hyperglycaemia in Pregnancy 30.4 Risk Factors for Hyperglycaemia in Pregnancy 30.5 Pathophysiology and Clinical Presentation 30.6 Clinical Presentation 30.7 Consequences of Hyperglycaemia in Pregnancy 30.8 Diagnosing Hyperglycaemia in Pregnancy 30.9 Management 30.9.1 Prenatal Care 30.9.2 Counselling/Health Promotion 30.10 Blood Glucose Monitoring 30.11 Lifestyle Management 30.12 Pharmacological Therapy 30.12.1 Monitoring Maternal Well-Being 30.12.2 Monitoring Fetal Well-Being 30.13 Intrapartum Care 30.13.1 Timing and Mode of Delivery 30.14 Postpartum Care and Long-Term Follow-Up 30.14.1 Immediate Postpartum Period 30.14.2 Contraception 30.14.3 Postpartum Glucose Testing 30.14.4 Reducing Long-Term Risk of T2DM and Cardiovascular Disease 30.15 Controversies 30.15.1 GDM Screening: Selective Versus Universal Testing 30.15.2 Timing of Testing: Early Pregnancy Testing or Testing at 24 to 28 Weeks of Gestation? 30.16 Summary References 31: Venous Thromboembolism in Pregnancy 31.1 Introduction 31.2 Epidemiology of VTE in Pregnancy 31.3 Pathophysiology of DVT in Pregnancy 31.4 Risk Factors for Venous Thromboembolism in Pregnancy 31.5 Clinical Features of VTE in Pregnancy 31.6 Diagnosis of VTE in Pregnancy 31.7 Diagnosis of PE 31.8 Screening for Thrombophilia 31.9 Management of Acute VTE 31.10 Treatment of VTE in Pregnancy 31.11 Management of the Limb in Acute DVT 31.12 Use of Inferior Vena Cava Filters 31.13 Treatment of Acute Massive PE in Pregnancy 31.14 Maintenance Therapy 31.15 Complications of Heparin Therapy 31.16 Management of Labour and Delivery 31.17 Induction of Labour 31.18 Postpartum Management 31.19 Prevention of Post-thrombotic Syndrome (PTS) 31.20 Summary References 32: Inherited Bleeding Disorders in Pregnancy 32.1 Introduction 32.2 Inherited Bleeding Disorders 32.2.1 von Willebrand Disease (VWD) 32.2.2 Epidemiology 32.2.3 Clinical Features 32.2.4 Diagnosis 32.2.5 Antenatal Management 32.2.6 Delivery 32.2.7 Tranexamic Acid 32.2.8 Management of the Neonate 32.2.9 Haemophilia 32.2.10 Management of Delivery in Pregnant Carriers (Table 32.3) 32.2.11 Prenatal Diagnosis 32.3 Acquired Bleeding Disorders in Pregnancy 32.3.1 Thrombocytopaenia in Pregnancy 32.3.2 Gestational Thrombocytopaenia (GT) 32.3.3 Clinical Presentation 32.3.4 Immune Thrombocytopaenia (Idiopathic Thrombocytopaenic Purpura (ITP)) 32.3.5 Clinical Features 32.3.6 Laboratory Investigations 32.3.7 Management of ITP During Pregnancy 32.3.8 Treatment of ITP During Pregnancy 32.3.8.1 Splenectomy 32.3.9 Disseminated Intravascular Coagulation (DIC) in Pregnancy 32.3.10 Clinical Features of DIC 32.3.11 Diagnosis 32.3.12 Treatment of DIC in Pregnancy 32.3.12.1 Platelet Transfusion 32.3.12.2 Fresh Frozen Plasma (FFP) 32.3.13 Haematological Management of Obstetric Haemorrhage (OH) 32.3.14 Red Cells 32.3.15 Fresh Frozen Plasma (FFP) 32.3.16 Cryoprecipitate 32.3.17 Platelets 32.3.18 Recombinant Factor VIIa (RVIIa) 32.3.19 Tranexamic Acid 32.3.20 Monitoring 32.3.21 Evaluation Post Haemorrhage References 33: Haematological Disorders in Pregnancy 33.1 Introduction 33.1.1 Anaemia in Pregnancy 33.1.2 Iron Deficiency 33.1.3 Epidemiology 33.1.4 Aetiology 33.1.5 Absorption and Iron Homeostasis 33.1.5.1 Iron Balance 33.1.6 Requirement in Pregnancy and Delivery [5, 9] 33.1.7 Clinical Features 33.1.8 Laboratory Features 33.1.9 Management 33.1.10 Folate, B12 and Megaloblastic Anaemia 33.1.11 Epidemiology 33.1.12 Absorption 33.1.13 Pathogenesis 33.1.14 Clinical Features 33.1.15 Diagnosis 33.1.16 Treatment 33.1.17 Prevention 33.1.18 Haemoglobinopathies 33.1.19 Antenatal/Neonatal Screening 33.1.20 Sickle Cell Disease and Pregnancy 33.1.21 Pathogenesis and Pathology of Pregnant Sickle Cell Anaemia (SCA) Clients 33.1.22 Maternal and Foetal Outcome 33.1.23 Management of Sickle Cell Disease in Pregnancy 33.1.24 Acute Chest Syndrome (ACS) 33.1.24.1 Labour 33.2 Thalassaemia 33.3 Other Causes of Anaemia in Pregnancy 33.3.1 Immune and Non-immune Haemolytic Anaemia 33.3.2 Foetomaternal Alloimmunisation Syndromes 33.3.3 Haemolytic Disease of Foetus/Newborn 33.3.3.1 Aetiopathogenesis 33.3.4 Management 33.3.5 Prevention 33.3.6 HELLP Syndrome 33.3.7 Other Haematological Abnormalities 33.4 Summary References 34: Mental Health Disorders in Pregnancy and Puerperium 34.1 Introduction 34.1.1 Depression 34.1.1.1 Incidence/Prevalence 34.1.1.2 Clinical Presentation [15] 34.1.1.3 Investigations 34.1.1.4 Diagnosis 34.1.1.5 Management 34.1.1.6 Follow Up 34.1.1.7 Prevention 34.1.1.8 Special Considerations in Limited-Resource Settings 34.1.2 Anxiety 34.1.2.1 Incidence/Prevalence 34.1.3 Clinical Presentation 34.1.3.1 Further References [14, 21] 34.1.3.2 Investigations/Diagnosis 34.1.3.3 Management 34.1.3.4 Follow-Up 34.1.3.5 Prevention 34.1.4 Psychotic Disorders 34.1.4.1 Incidence/Prevalence 34.1.4.2 Clinical Presentation 34.1.4.3 Investigations/Diagnosis 34.1.4.4 Management 34.1.4.5 Prevention 34.1.4.6 Follow-Up 34.1.5 Maternal Mental Health, Suicide and Maternal Mortality References 35: HIV in Pregnancy 35.1 Introduction 35.2 Disease Description: Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) 35.2.1 Epidemiology of HIV/AIDS 35.2.2 Risk Factors for HIV Transmission 35.2.3 HIV Management 35.2.4 HIV Prevention 35.2.5 HIV Infection and Pregnancy 35.3 Mother-to-Child Transmission (MTCT) of HIV 35.3.1 Factors That Influence Mother-to-Child Transmission (MTCT) of HIV 35.4 Comprehensive Approach to Prevention of Mother-to-Child Transmission (PMTCT) of HIV 35.4.1 Management of HIV in Pregnancy 35.5 Preconception Care 35.5.1 HIV Testing and Counselling in Pregnancy 35.5.2 Pre-test Information 35.5.3 HIV Test 35.5.4 Post-test Counselling 35.5.5 Follow-Up Counselling 35.5.6 Antiretroviral Treatment for HIV-Positive Pregnant Women 35.5.7 Classes of Antiretroviral Drugs 35.5.8 Antiretroviral Regimen in Pregnancy 35.5.9 When to Commence Antiretroviral in Pregnancy 35.5.10 Discontinuation of Antiretroviral Therapy in Pregnancy and Breastfeeding Period 35.5.11 Problems with Use of Antiretroviral Therapy in Pregnancy 35.6 Obstetrics Care 35.6.1 Antenatal Care 35.6.2 Intrapartum Care 35.6.3 Unbooked/Unknown HIV Status in Labour 35.6.4 Mode of Delivery 35.6.5 Postpartum Care 35.6.6 Contraception 35.6.7 Cervical Screening 35.6.8 Management of HIV-Exposed Infants 35.6.8.1 Immediate Care 35.6.8.2 Antiretroviral Prophylaxis 35.6.8.3 Prophylaxis for Opportunistic Infections 35.6.8.4 Infant Feeding 35.6.8.5 Early Infant Diagnosis 35.6.9 Summary and Conclusion References 36: Non-HIV Viral Infections in Pregnancy 36.1 Introduction 36.1.1 Epidemiology 36.1.2 Grading of the Prevalence of Hepatitis B Surface Antigen and Geographic Distribution of HBV Infection 36.1.3 Mother-to-Child Transmission of Hepatitis B Infection 36.1.4 Signs and Symptoms of HBV 36.1.5 Diagnosis and Evaluation of HBV-Infected Pregnant Women 36.1.6 Laboratory Diagnosis 36.1.7 Management of HBV-Infected Pregnant Women 36.1.8 Drug Treatment 36.1.9 Management of Hepatitis B-Exposed Babies 36.1.10 Vaccine Non-responders 36.1.11 Breastfeeding 36.2 Prevention 36.2.1 General Awareness 36.2.2 Vaccination 36.2.3 Antenatal and Partner screening for HBV 36.2.4 Course of Hepatitis B Virus (HBV) Infection on Pregnancy 36.3 Other Viruses in Pregnancy 36.4 Hepatitis C Viral Infection in Pregnancy 36.4.1 Epidemiology 36.4.2 Symptoms of Hepatitis C Infection 36.4.3 Risk Factors and Mode of Transmission of Hepatitis C Virus 36.4.4 Vertical Transmission of HCV 36.4.5 Diagnosis 36.4.6 Treatment of HCV in Pregnancy 36.4.7 Complications of HCV in Pregnancy 36.4.8 Course of HCV on Pregnancy and Pregnancy on the Course of HCV 36.5 Rubella in Pregnancy 36.5.1 Epidemiology 36.5.2 Symptoms of Rubella Infection 36.5.3 Diagnosis of Rubella 36.5.4 Treatment of Rubella Infection 36.5.5 Complication of Rubella Infection 36.5.6 Prevention of Rubella 36.5.6.1 Vaccination 36.6 COVID-19 References 37: Neoplastic Diseases in Pregnancy 37.1 Introduction 37.2 Breast Cancer 37.2.1 Epidemiology 37.2.2 Clinical Presentation 37.2.3 Diagnosis 37.2.4 Treatment 37.3 Cervical Cancer 37.3.1 Epidemiology 37.3.2 Clinical Presentation 37.3.3 Diagnosis 37.3.4 Treatment 37.4 Ovarian Cancer 37.4.1 Epidemiology 37.4.2 Clinical Presentation 37.4.3 Management 37.5 Conclusion 37.6 Summary References 38: Oral Health in Pregnancy 38.1 Definition of Oral Health 38.1.1 Importance of Oral Health 38.1.2 Oral Health Status in Pregnancy 38.1.3 Impact of Mother’s Health on the Unborn Baby 38.1.4 Recommendations for Oral Health Care in Pregnancy 38.1.5 Prenatal Counselling 38.1.6 Preventive Methods 38.1.7 Anticipatory Guidance 38.1.8 Screening and Prevention 38.1.9 Diagnosis 38.1.10 Medications Used During Dental Procedures 38.1.11 Periodontal Therapy 38.1.12 Restorative Dentistry 38.1.13 Dental Extraction 38.1.14 Management of Acute Dental Conditions Further Reading Part IV: General Gynaecology 39: Ectopic Pregnancy 39.1 Introduction 39.1.1 Sites and Pathophysiology of Ectopic Pregnancy 39.1.2 Epidemiology of Ectopic Pregnancy 39.1.3 Clinical Presentation of Ectopic Pregnancy 39.1.3.1 Diagnosis of Unruptured Ectopic Pregnancy 39.1.4 Management of Ectopic Pregnancy 39.1.4.1 Sub-acute (Slow-Leaking) Ectopic Pregnancy 39.1.5 Treatment of Unruptured Ectopic Pregnancy 39.1.6 Prevention of Ectopic Pregnancy 39.1.7 Needed Research in Ectopic Pregnancy 39.2 Conclusion References 40: Prevention and Management of Recurrent Miscarriage 40.1 Introduction 40.1.1 Clinical Presentation 40.1.2 Risk Factors for Recurrent Pregnancy Loss 40.1.2.1 Epidemiological Factors 40.1.2.2 Genetic Factors Parental Chromosomal Rearrangements Abnormal Embryonic (Foetal) Karyotypes 40.1.2.3 Anatomical Factors Congenital Uterine Malformations Cervical Incompetence Endocrine Disorders Infection Inherited Thrombophilias Immunology Unexplained Miscarriages 40.1.2.4 Clinical Assessment History Investigations 40.1.2.5 Blood Tests Imaging 40.1.2.6 Genetic Factors Parental Karyotyping Infection Management General Advice Thrombophilias Cervical Weakness Chromosomal Abnormalities Endocrine Abnormalities Medications (Table 40.4) Infection Progesterone Dysfunction Intra-uterine Foetal Demise Treatment in Low-Resource Countries 40.2 Conclusion References 41: Control of Sexually Transmitted Infections Through Integrated Reproductive Health Services 41.1 Introduction 41.1.1 Integrated Reproductive Health Services 41.1.2 STI Risk Assessment 41.1.3 Programme Linkage 41.1.4 International Agreements 41.1.5 Strategy 41.1.6 Prevention 41.1.6.1 Screening 41.1.6.2 Risk for HIV 41.1.6.3 Vaccines 41.1.7 Clinical Presentations 41.1.7.1 Vaginal Discharge 41.1.7.2 Bacterial Vaginosis 41.1.7.3 Candida albicans 41.1.7.4 Trichomoniasis 41.1.7.5 Gonorrhoea 41.1.7.6 Chlamydia Trachomatis 41.1.8 Genital Lesion 41.1.9 Lower Abdominal Pain 41.1.10 Pregnancy 41.1.11 Diagnostic Challenges 41.1.12 Drug Treatment 41.1.13 Coverage 41.1.14 Adapting Protocols 41.1.15 Service Standards 41.1.16 Contact Tracing 41.1.17 Surveillance 41.1.18 Implementing Integrated Reproductive Health Services 41.1.18.1 Contraception 41.1.18.2 Fertility 41.1.18.3 HIV Programmes 41.1.18.4 Maternal, Newborn and Child Health 41.1.18.5 Adolescent Health 41.1.19 Barriers to Integration and Opportunities for Change 41.1.20 Sector-Wide Approach 41.1.21 Programme Effectiveness 41.1.22 Conclusions and Recommendations References 42: Uterine Fibroid and Hysterectomy 42.1 Introduction 42.1.1 Pathophysiology of Uterine Fibroids 42.1.2 Epidemiology 42.1.3 Risk Factors 42.1.4 Clinical Features 42.1.5 Diagnosis of Fibroids 42.1.6 Management of Uterine Fibroids 42.1.7 Hysterectomy 42.1.8 Conservative Surgical Treatment 42.1.9 Conservative Medical Treatment 42.1.10 Prevention 42.1.11 Research Gaps 42.1.12 Summary References 43: Endometriosis 43.1 Introduction 43.1.1 Incidence and Prevalence 43.1.2 Clinical Presentation 43.2 Investigation 43.2.1 Physical Examination 43.2.2 Laboratory Tests 43.2.3 Imaging 43.3 Transvaginal Ultrasound 43.3.1 Performing an Endometriosis Scan 43.3.2 Ultrasound-Based Staging System for Endometriosis 43.4 Computed Tomography Colonoscopy 43.5 Magnetic Resonance Imaging 43.6 Diagnosis 43.7 Reducing Diagnostic Delays in Resource-Restricted Countries 43.8 Management 43.9 Medical Treatment 43.10 Surgical Treatment References 44: Chronic Pelvic Pain 44.1 Introduction 44.2 Differential Diagnosis of Chronic Pelvic Pain and Common Associations 44.3 Clinical Assessment 44.3.1 History Taking 44.3.2 Physical Examination 44.3.3 General Examination 44.3.4 Abdominal Examination 44.3.5 Pelvic Examination 44.4 Investigations 44.4.1 Urinalysis 44.4.2 Screening for Infection 44.4.3 Diagnostic Imaging 44.4.4 Diagnostic Laparoscopy 44.4.5 Empirical Treatment 44.4.6 Cystoscopy 44.4.7 Proctoscopy and Colonoscopy and Barium Enema 44.5 Management 44.5.1 Medical Treatment 44.5.2 Combined Oral Contraceptive Pill 44.5.3 Progestogens 44.5.4 GnRH Analogues 44.5.5 Surgical Treatment 44.5.6 Adjunctive Therapies 44.6 Summary References 45: Infertility 45.1 Introduction 45.2 Epidemiology of Infertility 45.3 Causes of Infertility 45.3.1 Tubal Infertility 45.3.2 Uterine Infertility 45.3.3 Endometriosis 45.3.4 Anovulatory Infertility 45.3.5 Male Infertility 45.4 Investigation of Infertility 45.5 Clinical Examination of the Infertile Couple 45.6 Laboratory Investigations, Imaging and Endoscopy 45.6.1 Tests of Ovulation and Ovarian Reserve 45.6.2 Tubal Patency and Uterine Assessment Tests 45.6.3 The Post-coital Test 45.6.4 Semen Analysis and Male Function Tests 45.7 Management of Infertility 45.7.1 Primary Prevention of Infertility 45.7.2 Secondary Prevention of Infertility 45.8 Conventional Methods of Infertility Treatment 45.8.1 Tubal Surgery 45.8.2 Treatment of Anovulation 45.8.3 Treatment of Infertility Due to Uterine Abnormalities 45.8.4 Conventional Treatment of Male Infertility 45.8.5 Treatment of Unexplained Infertility 45.9 Assisted Reproductive Techniques 45.10 Tertiary Prevention of Infertility 45.11 Conclusion References 46: Laparoscopy 46.1 Introduction 46.2 Relevant Anatomy 46.3 Patient Selection and Preoperative Assessment 46.4 Consenting 46.5 Theatre and Patient Setup 46.5.1 Patient Positioning and Preparation 46.5.2 Creation of Pneumoperitoneum 46.5.3 Insertion of the Primary Umbilical Trocar 46.5.4 Initial Inspection 46.5.5 Insertion of the Secondary Trocars 46.5.6 Exit Techniques and Closure 46.6 Energy Sources and Power 46.7 Intracorporal Instrument Handling 46.8 Post-Operative Care 46.9 Complications of Gynaecologic Laparoscopy 46.9.1 Complications Involving the Bowel 46.9.2 Complications Involving the Ureters 46.9.3 Complications Involving Abdominal Wall Vessels 46.9.4 Complications Involving Retroperitoneal Major Vessels 46.9.5 Complications Involving Nerves 46.10 Troubleshooting 46.11 Robotic Surgery 46.12 Summary References 47: Pelvic Organ Prolapse 47.1 Introduction 47.2 Prevalence 47.3 Aetiological Factors 47.4 Epidemiology 47.4.1 General Symptoms 47.4.2 Anterior Compartment 47.4.3 Posterior Compartment 47.4.4 Others 47.4.5 Examination 47.4.6 Pelvic Examination 47.4.7 Investigation 47.5 Management of POP 47.5.1 Preventive Measures 47.5.1.1 Eradicate Harmful Obstetric Practices: Fundal Pressure Limit Prolonged Second Stage Eradicate Prolonged Obstructed Labour Non-obstetric Factors Lifestyle Interventions 47.6 Pelvic Floor Exercise 47.6.1 Vaginal Pessaries 47.7 Surgical Management of Pelvic Organ Prolapse 47.7.1 Anterior Repair 47.7.2 Posterior Repair 47.8 Vaginal Hysterectomy 47.9 Vaginal Vault Prolapse Surgeries 47.10 Abdominal Approach to POP Surgery 47.11 Laparoscopic Approach 47.12 Controversies in Surgical Management of Pelvic Organ Prolapse 47.13 Use of Mesh in Surgical Repair of POP 47.14 Conclusions References 48: Urogynaecology 48.1 Urinary Incontinence 48.1.1 Functional Physiology of the Lower Urinary Tract 48.1.2 Pathophysiology of Urinary Incontinence 48.2 Clinical Presentation 48.3 Investigations 48.3.1 Management of Urinary Incontinence 48.3.2 General Measures 48.3.3 Temporary Causes 48.3.4 Urodynamic Stress Incontinence (USI) 48.4 Conservative Treatment 48.4.1 Surgery 48.4.2 Detrusor Overactivity (DO) 48.4.3 Conservative Treatment 48.4.4 Surgical Treatment 48.4.5 Mixed Incontinence 48.4.6 Overflow Incontinence 48.4.7 Urethral Diverticulum 48.4.8 Other Lower Urinary Tract Problems 48.4.8.1 Urethral Prolapse 48.4.8.2 Urethral Caruncle 48.4.8.3 Urethral Stricture 48.4.8.4 Carcinoma of the Urethra References 49: Amenorrhea and Abnormal Uterine Bleeding 49.1 Amenorrhea 49.1.1 Background 49.1.2 Causes 49.1.3 Evaluation 49.1.4 Treatment 49.1.5 Amenorrhea and Public Health in the Developing World 49.2 Abnormal Uterine Bleeding 49.2.1 Background 49.2.2 Causes 49.2.3 Evaluation 49.2.4 Treatment 49.2.5 AUB and Public Health in the Developing World 49.3 Conclusion References 50: Menopause 50.1 Definition 50.1.1 Reproductive Ageing 50.1.2 Perimenopause 50.1.3 The Menopause 50.1.4 Symptoms of the Menopause 50.1.4.1 Vasomotor Symptoms 50.1.4.2 Depression 50.1.4.3 Vaginal Atrophy 50.1.4.4 Sexual Dysfunction 50.1.4.5 Coronary Heart Disease 50.1.4.6 Osteoporosis 50.1.4.7 Urinary Incontinence 50.1.4.8 Urinary Tract Infection (UTI) 50.1.4.9 Other Morbidities 50.1.5 Premature Ovarian Insufficiency (POI) 50.1.6 Diagnosis 50.1.7 Management of the Menopause 50.1.7.1 Diagnosis 50.1.7.2 Information and Advice 50.1.7.3 Psychotherapy 50.1.7.4 Non-hormonal Drug Treatment 50.1.7.5 Hormone Replacement Treatment (HRT) 50.1.7.6 Estrogens 50.1.7.7 Progestogens 50.1.7.8 Combination of Estrogens and Progestogens 50.1.7.9 Tibolone 50.1.8 Selective Estrogen Receptor Modulators (SERMs) 50.1.9 Testosterone 50.1.10 Regimens of HRT 50.1.11 Risks of HRT 50.1.11.1 Venous Thromboembolism (VTE) 50.1.11.2 Risk of Endometrial Cancer 50.1.11.3 Risk of Breast Cancer 50.1.11.4 Risk of Cerebrovascular Accidents (Stroke) 50.1.11.5 Risk of Ovarian Cancer 50.1.11.6 Risk of Coronary Heart Disease 50.2 Summary References 51: Physiotherapy in Obstetrics and Gynaecology 51.1 Introduction 51.2 Operational Definitions 51.3 The Obstetrics and Gynaecology Healthcare Team 51.4 Physiotherapy Modalities Used in Obstetrics and Gynaecology Practice 51.5 Reproductive Diseases and Associated Sequelae Amenable to Physiotherapy 51.5.1 Urinary and Faecal Incontinence 51.5.2 Chronic Pelvic and Abdomen Pain Syndromes 51.5.3 Chronic Pelvic Inflammatory Disease and Salpingo-Oophoritis 51.5.4 Vestibulodynia and Dyspareunia 51.5.5 Persistent Genital Arousal Disorder 51.5.6 Post-Mastectomy Complications 51.5.7 Prenatal and Postpartum Musculoskeletal Dysfunctions 51.5.8 Postpartum Depression and Lifestyle Chronic Disorders 51.5.9 Developmental and Neurological Disorders 51.5.10 Postoperative Complications 51.6 Conclusion References Part V: Gynaecological Malignancies 52: Rising Burden of Gynaecological Cancers in Developing Countries 52.1 Introduction References 53: Molecular Biology of Gynaecological Cancers 53.1 Ovarian Cancer 53.1.1 Origins of Epithelial Ovarian Cancer 53.1.2 Molecular Pathways to Ovarian Cancer 53.1.2.1 Inherited Syndromes of Ovarian Cancers 53.1.3 Angiogenesis 53.2 Role of Specific Immune Responses and Immunotherapy 53.2.1 Ovarian Cancer-Specific Antigens 53.3 Endometrial Cancer 53.3.1 Type I Cancers 53.3.1.1 Microsatellite Instability 53.3.1.2 PTEN 53.3.1.3 β-Catenin 53.3.2 Type II Endometrial Cancer 53.4 Cervix, Vaginal, and Vulvar Cancers 53.4.1 Role of Human Papillomavirus 53.4.2 Immune Evasion by Human Papillomavirus 53.4.3 Human Papillomavirus Vaccines References 54: Gestational Trophoblastic Disease 54.1 Introduction 54.2 Epidemiology 54.3 Cytogenetics of Complete and Partial Moles 54.4 Pathology 54.4.1 Hydatidiform Mole 54.4.2 Complete Hydatidiform Mole 54.4.3 Partial Hydatidiform Mole 54.4.4 Invasive Mole 54.4.5 Placenta Site Trophoblastic Tumor (PSTT) 54.4.6 Choriocarcinoma 54.5 Clinical Presentation 54.5.1 Hydatidiform Mole 54.5.1.1 Complete Hydatidiform Mole 54.5.1.2 Partial Mole 54.5.2 Gestational Trophoblastic Neoplasia (GTN) 54.6 Diagnosis 54.6.1 Ultrasonography 54.6.2 Human Chorionic Gonadotropin 54.7 Pathologic Diagnosis 54.8 Treatment 54.8.1 Hydatidiform Mole 54.8.2 Follow-Up After Molar Evacuation 54.8.3 Gestational Trophoblastic Neoplasia (GTN) 54.8.4 Staging and Risk Scoring 54.8.5 Nonmetastatic and Metastatic Low-Risk GTN 54.8.6 High-Risk GTN 54.8.6.1 Chemotherapy 54.8.6.2 Radiotherapy 54.8.6.3 Surgery 54.8.6.4 PSTT 54.8.7 Follow-Up of Patients with GTN 54.9 Challenges in Management of GTD in Sub-Saharan Africa 54.10 Conclusion 54.11 Summary References 55: Cancers of the Vagina and Vulva 55.1 Overview 55.2 Cancer of the Vagina 55.2.1 Aetiology of Vaginal Cancer 55.2.2 Screening for Vaginal Cancer 55.2.3 Symptoms and Signs of Vaginal Cancer 55.2.4 Pathology 55.2.4.1 Pathological Types of Vaginal Cancer 55.2.4.2 Histologic Grading of Vulvar Cancer 55.2.4.3 Patterns of Spread of Vaginal Cancer 55.2.5 Staging of Vaginal Cancer 55.2.6 Diagnosis of Vaginal Cancer 55.2.7 Treatment of Vaginal Cancer 55.2.7.1 Chemoradiation 55.2.7.2 Radiation Therapy 55.2.7.3 Surgery 55.2.8 Prognosis 55.3 Cancer of the Vulva 55.3.1 Aetiopathogenesis of Vulvar Cancer 55.3.2 Clinical Features 55.3.3 Pathology 55.3.3.1 Histological Types 55.3.3.2 Histopathologic Grades 55.3.3.3 Mode of Spread 55.3.4 Staging of Cancer of the Vulva 55.3.5 Diagnosis 55.3.6 Investigations 55.3.7 Management of Cancer of the Vulva 55.3.7.1 Management of Early Vulvar Cancer (FIGO I and II) 55.3.7.2 Management of Advanced Vulvar Cancer (FIGO III and IV) 55.3.7.3 Prognosis Vulvar Cancer 55.3.8 Other Histologic Types of Vulvar Cancer [4, 14, 42, 48] 55.4 Summary References 56: Cervical Cancer Screening and Prevention 56.1 Introduction 56.2 Predisposing Factors for Cervical Cancer 56.3 Staging of Cervical Cancer 56.4 Clinical Presentation 56.5 Investigation and Diagnosis 56.6 Management 56.7 Follow-Up Plans 56.8 Special Issues 56.9 Cervical Cancer Prevention 56.10 Vaccination Against HRHPV 56.10.1 Vaccine Development 56.11 Screening for Cervical Cancer as a Prevention Strategy 56.12 Conclusion 56.13 Summary References 57: Cancer of the Uterine Corpus 57.1 Introduction 57.2 Endometrial Cancer 57.2.1 Etiology and Risk Factors 57.2.2 Protective Factors 57.2.3 Pathology of Endometrial Cancer 57.2.4 Spread of Endometrial Cancer 57.2.5 Staging and Prognosis of Endometrial Cancer 57.2.6 Clinical Presentation 57.2.6.1 Physical Findings 57.2.7 Diagnosis 57.2.8 Treatment 57.2.9 Adjuvant Treatment for Endometrial Carcinoma 57.2.9.1 Management of Recurrent Disease 57.2.10 Pelvic Recurrence 57.2.10.1 Radiation Treatment 57.2.10.2 Surgery 57.2.11 Extra-Pelvic Recurrence 57.2.11.1 Irradiation 57.2.11.2 Endocrine Therapy 57.2.11.3 Chemothearpy 57.3 Summary 57.4 Uterine Sarcoma 57.4.1 Staging 57.4.1.1 Treatment of Uterine Sarcomas Uterine Leiomyosarcoma Endometrial Stromal Sarcoma Low-Grade Endometrial Stromal Sarcoma High-Grade Endometrial Stromal Sarcoma Undifferentiated Endometrial Stromal Sarcoma 57.4.2 Adenosarcoma 57.4.2.1 Carcinosarcoma References 58: Epithelial Ovarian Cancer 58.1 Introduction 58.2 Classification 58.3 Risk Factors 58.3.1 Family History 58.4 Use of Ovulation-Inducing Agents 58.4.1 Protective Factors 58.4.2 Hysterectomy Tubal Ligation and Oophorectomy 58.4.3 Clinical Presentations 58.5 Laboratory Investigations 58.6 2014 FIGO Staging for Ovarian Cancer 58.6.1 Adjuvant Chemotherapy 58.6.2 Intraperitoneal Chemotherapy 58.7 Prevention and Screening of EOC 58.7.1 Screening for Epithelial Ovarian Cancer 58.7.2 Imaging 58.7.3 Screening in High-Risk Group References 59: Germ Cell Tumours of the Ovary 59.1 Introduction 59.2 Classification, Epidemiology, and Risk Factors 59.3 Clinical Features and Presentation 59.4 Clinical Pathology: Benign Germ Cell Tumours 59.4.1 Mature Cystic Teratoma 59.4.2 Mature Solid Teratoma 59.4.3 Monodermal Teratoma 59.4.4 Struma Ovarii: 59.5 Clinical Pathology: Malignant Germ Cell Tumours 59.5.1 Immature Teratoma 59.5.2 Dysgerminoma 59.5.3 Endodermal Sinus Tumour 59.5.4 Choriocarcinoma 59.5.5 Embryonal Carcinoma 59.5.6 Polyembryoma 59.5.7 Mixed Germ Cell Tumour 59.6 Treatment Modalities: Surgery 59.7 Treatment Modalities: Chemotherapy 59.8 Post-Treatment Surveillance 59.9 Summary Glossary of Terms References 60: Principle of Radiation Therapy for Gynaecologic Cancers 60.1 Cervical Cancer 60.1.1 Introduction 60.2 Endometrial Cancer References 61: Emerging Trends and Best Practices in Hospice and Palliative Care 61.1 Introduction 61.2 Operational Definitions 61.3 Differences Among Euthanasia, Hospice, and Palliative Care 61.4 Dynamics of Multidisciplinary and Interdisciplinary Teams in Hospice and Palliative Care 61.5 Roles and Responsibilities of the Interdisciplinary Hospice and Palliative Care Team 61.6 Genesis and Transmogrification of Hospice and Palliative Care 61.7 Evolution of Hospice and Palliative Care as a Medical Speciality 61.8 Global Demand and Utilisation of Hospice and Palliative Care Services 61.8.1 Hospice and Palliative Care Best Practices 61.8.2 Stage One: Planning for End-of-Life Care 61.8.3 Stage Two: Spiritual and Emotional Care 61.8.4 Stage Three: Transition of Care to a Natural Home Setting 61.8.5 Stage Four: Inpatient Care 61.9 Pharmacological Management of Pain in the Hospice and Palliative Care Setting 61.10 Global Epidemiology of Opioid-Related Deaths 61.11 Complementary and Alternative Treatment Approaches in Hospice and Palliative Care 61.12 Clinical Guidelines on High-Quality Hospice and Palliative Care 61.13 Status of Hospice and Palliative Care Education in Africa 61.14 Summary References Part VI: Health Systems Organisation, Research Methodology and Biostatistics 62: Leadership of Healthcare Teams, Organisations and Systems: Implications for Curriculum Revision in Medical Education 62.1 Introduction 62.2 Operational Definitions 62.3 Differences Between Management and Administration 62.4 Types of Healthcare Team Practice 62.5 Current Status of Healthcare Team Practice in Nigeria 62.6 Leadership of Healthcare Team 62.7 Leadership of Healthcare Organisations and Systems 62.8 Organisational Theories 62.9 Leadership Theories 62.10 Contemporary Leadership Styles in the Changing World 62.11 Studies on Leadership from Nigeria 62.12 Conflict Resolution Strategies 62.13 The Much-Needed Medical Education Reforms, Anticipated Benefits and Barriers 62.14 Non-clinical Related Curriculum Weaknesses 62.15 Summary References 63: Mobilising Human and Financial Resources for Maternal Health 63.1 Introduction 63.2 Operational Definitions 63.3 Human Resource Mobilisation and Training: Human Capacity Building 63.4 Recruitment and Retention of Healthcare Personnel 63.5 Financial Resource Mobilisation 63.6 Healthcare Financing 63.7 International Donors 63.8 Sustainability of Gains 63.9 Application of Technology in Human Resource Mobilisation 63.10 Monitoring Human Resources in Public Health Programmes 63.11 Health Equity and Access 63.12 Workforce Demand-Supply Analysis and Forecasting 63.13 Tailoring Resource Mobilisation to Patient’s Spatial Positioning 63.14 Emerging Technologies and Supply of Vaccines and Laboratory Chemical Agents 63.15 New Paradigms of Doing Business in Health Care 63.16 Political Feasibility and Consensus Building 63.17 Long-Term Sustainability of Human and Financial Resources 63.18 Summary References 64: The Role of Professional Associations in Obstetrics and Gynaecology 64.1 Introduction 64.2 Aims and Roles of the Obstetrics and Gynaecological Professional Body 64.3 The Society of Gynaecology and Obstetrics of Nigeria 64.4 Global Affiliation and Organisational Structure of SOGON 64.5 Leadership Roles of SOGON 64.6 Contributions of National Societies of Obstetricians and Gynaecologist in Other Developing Countries 64.7 Summary References 65: Ethics, Liability, and Risk Management in Obstetrics and Gynaecology 65.1 Introduction 65.2 Ethics in Women’s Health 65.2.1 Ethical Frameworks and Perspectives 65.2.2 Common Ethical Issues and Problems in Obstetrics and Gynaecology 65.3 The Obstetrician–Gynaecologist’s Role in Society 65.4 Informed Consent 65.5 Conflict of Interest 65.5.1 Making Ethical Decisions in Practice 65.5.1.1 Providing Counselling to Inform Ethical Decisions 65.6 Liability in Law and Ethics 65.7 Who Is Liable for Clinical Negligence? 65.8 Does Litigation for Liability Improve Patient Safety? 65.9 Clinical Governance and Risk Management 65.9.1 Error Classification 65.9.2 Understanding and Managing Adverse Events 65.9.3 Clinical Governance and Risk Management in Obstetrics and Gynaecology 65.9.4 Summary Remarks: Clinical Governance and Risk Management in Sub-Saharan Africa References 66: Human Rights and Legal Treaties Relevant to Obstetrics and Gynaecology 66.1 Introduction 66.2 Human Rights: Definitions, Scope, Nature and Classification 66.3 Classification of Rights 66.4 General Nature of Human Rights 66.5 Emergence of Women’s Reproductive Rights 66.6 Human Rights Provisions Relevant to Obstetrics and Gynaecology 66.7 Conclusion 66.8 Summary References 67: Evaluation of Clinical Significance in Intervention Research 67.1 Introduction 67.2 Intervention Research 67.3 Clinical and Statistically Significant Difference 67.4 Measures of Clinical Significance 67.5 Effect Size Indicators 67.6 Testing for Statistical Significance in an Independent T-Test Group Design 67.7 Manual Calculation of Cohen-d Estimate for an Independent T-Test Group Design 67.8 Interpretation of Cohen’s d and Eta Square Estimates 67.9 Calculation of Cohen-d Estimate for a Dependent (Repeated Measures) T-Test Design 67.10 Calculation of Eta Square (η2) Estimate for Three or More Independent Groups Design 67.11 Calculation of Eta Square Estimate for Repeated Measures Design 67.12 Effect Size Estimation by the Social Science Statistics® Calculator 67.13 Estimation of Effect Size with the Psychometrica® Calculator 67.13.1 Practical Meta-Analysis Effect Size Calculator 67.14 Summary References 68: The Common Statistical Faux Pas in Journal Publications 68.1 Introduction 68.2 Prevention of Statistical Faux Pas 68.3 Sample Size Imperfections 68.4 Selection of Wrong Statistical Tests 68.5 Evaluation of the Underlying Assumptions for Using Parametric Tests 68.6 Levels of Measurements 68.7 Parametric and Non-parametric Equivalent Tests 68.8 Presentation of Study Outcomes 68.9 Summary References 69: Survey Research Major Methodological Flaws: Caveat Lector 69.1 Introduction 69.2 Operational Definitions 69.3 Survey Research Process 69.4 Translation and Adaptation of Questionnaires Published in Languages Other than English 69.5 Readability Defined 69.6 Determination of the Readability of a Research Questionnaire 69.7 Interpretation of the Readability Indices 69.8 Manual Calculation of Sample Size 69.9 Estimation of Sample Size from a Standard Indicative Table 69.10 Calculation of Sample Size from Effect Size Estimates 69.11 Use of the Check Market ® Calculator for Computing Optimum Sample Size 69.12 Determination of Optimum Sample Size with the UCSF Calculator 69.13 Calculation of Sample Size for Correlational Study 69.14 Conversion of Survey Research Clinical Data 69.15 Application of Health Calculator in Clinical Diagnosis 69.16 Summary References Appendix Examples of Survey Research in Obstetrics and Gynaecology Index