CONTEMPORARY OBSTETRICS AND GYNECOLOGY FOR DEVELOPING COUNTRIES

• Publisher: SPRINGER NATURE
• Year: 2021
• Tongue: English
• Leaves: 784
• Edition: 2
• Category: Library

✦ Table of Contents

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