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Benign Conditions and Congenital Anomalies of the Ovaries and Fallopian Tubes

Clinical Keys for This Chapter ▪ The adnexa are composed of the ovaries and fallopian tubes, along with the blood vessels, ligaments, and connective tissues located along both sides of the uterus. Benign ovarian masses may be classified as functional, inflammatory, metaplastic, or neoplastic. Functional cysts are the most common masses and almost always resolve spontaneously. Differentiating between benign and malignant ovarian masses is extremely important…

Benign Conditions and Congenital Anomalies of the Uterine Corpus and Cervix

Clinical Keys for This Chapter ▪ Uterine fibroids (also called leiomyomas) are benign smooth muscle tumors, and about 80% are asymptomatic. They are very common, with an estimated prevalence of 70% by the sixth decade of life. Uterine tumors presenting as fibroids are rarely malignant, with less than 1 in 1000 leiomyosarcomas found at the time of surgical removal. Fibroids may cause abnormal uterine bleeding, pelvic…

Benign Conditions and Congenital Anomalies of the Vulva and Vagina

Clinical Keys for This Chapter ▪ Benign vulvovaginal problems are among the ten leading disorders encountered by primary care clinicians in the United States. Women with these disorders commonly present with irritation and pruritus (itching), but many conditions are asymptomatic and just visually troubling. ▪ There is significant variation in the normal appearance of the female vulva, with clitoral and labial size differences. Epithelial lesions in…

Obstetric Procedures

Clinical Keys for This Chapter ▪ Real-time (two-dimensional [2D]) ultrasonic imaging of the uterus, placenta, fetus, and cervix has become important for assessment of almost all pregnancies in the United States. Early in pregnancy, ultrasonic imaging is important for pregnancy dating and for ruling out multiple pregnancies. During mid-gestation, measurement of the biparietal diameter of the fetal head, the abdominal circumference, and the femoral length can…

Common Medical and Surgical Conditions Complicating Pregnancy

Clinical Keys for This Chapter ▪ Diabetes and thyroid disorders are among the most common and consequential medical conditions that occur during pregnancy, labor, and the postpartum period. Diabetes may precede pregnancy or may occur because of pregnancy, with a return to the prepregnancy state after delivery. Gestational diabetes mellitus (GDM) is defined as glucose intolerance with onset or first recognition during pregnancy. Pregestational diabetes mellitus…

Rhesus Alloimmunization

Clinical Keys for this Chapter ▪ In this chapter, the term hydrops fetalis refers to immune (or rhesus [Rh] antibody-mediated) hydrops fetalis and is synonymous with the older term erythroblastosis fetalis. Hydrops fetalis is a form of in utero heart failure. In the setting of Rh alloimmunization, it is characterized by the presence of fetal ascites, pericardial effusion, pleural effusion, subcutaneous edema (best seen as scalp…

Hypertensive Disorders of Pregnancy

Clinical Keys for This Chapter ▪ Preeclampsia (sometimes called toxemia of pregnancy ) is a multisystem disorder that is thought to arise as a consequence of inadequate cytotrophoblastic invasion of the spiral uterine arteries and failure to establish the normal low resistance uteroplacental circulation. This leads to placental ischemia and the presumptive involvement of secondary mediators responsible for endothelial dysfunction, local and systemic vasospasm, and activation…

Multifetal Gestation and Malpresentation

Clinical Keys for This Chapter ▪ In the United States and other developed countries, multiple gestations have increased, and currently account for at least 3.5% of live births. The two major reasons for this increase have been the use of assisted reproductive technologies (ARTs) to treat infertility, and the increasing maternal age of women having children. Twins are twice as likely in women over the age…

Obstetric Complications: Preterm Labor and Delivery, PROM, IUGR, Postterm Pregnancy, and IUFD

Clinical Keys for This Chapter ▪ Prematurity is the leading cause of infant morbidity and mortality. Preterm birth (PTB) is defined as deliveries occurring from 20 weeks up to 37 weeks of gestational age. When preterm birth occurs either spontaneously or in the presence of premature rupture of the membranes (PROM), it must be appropriately managed to prevent early delivery. Premature labor and delivery is best…

Uterine Contractility and Dystocia

Clinical Keys for This Chapter ▪ Normal and effective spontaneous labor is dependent upon normal uterine physiology and careful watchful waiting without overly aggressive obstetric management. Dystocia is dysfunctional labor that often has complex origins, and may develop after the normal onset of labor or after the induction of labor for indicated reasons. Metabolic dysregulation before pregnancy or during pregnancy secondary to the mother's health are…

Obstetric Hemorrhage: Antepartum, Intrapartum, and Postpartum

Clinical Keys for This Chapter ▪ Antepartum hemorrhage can be a very serious complication of pregnancy. Hemorrhage may be painless or painful, and the source of the bleeding is usually maternal, but it can rarely be from the fetus. The initial evaluation must be carefully performed to first stabilize the patient, assess the well-being of the fetus, and determine the cause while establishing a plan of…

Fetal Surveillance during Labor

Clinical Keys for this Chapter ▪ The most important principle of both fetal and maternal surveillance during labor is that childbirth is a normal process, and the majority of laboring women and their fetuses will have a safe journey. Obstetricians must be aware of each patient's past history and be prepared to monitor the journey based upon maternal and fetal needs during the labor process. ▪…

Normal Labor, Delivery, and Postpartum Care: Anatomic Considerations, Obstetric Analgesia and Anesthesia, and Resuscitation of the Newborn

Clinical Keys for This Chapter ▪ Knowledge of the characteristics of the fetal head and maternal pelvis is necessary to understand the dynamic relationship between these two anatomic structures during labor. The fetal head, through a process of molding and flexion followed by internal rotation, passes through the maternal pelvis during the first and second stages of labor. At delivery (expulsion), there is external rotation of…

Antepartum Care: Preconception and Prenatal Care, Genetic Evaluation and Teratology, and Antenatal Fetal Assessment

Clinical Keys for this Chapter ▪ Preconception counseling is an important component of preventive care for couples that are considering pregnancy. It can identify risks related to family history, maternal medical conditions, and fetal and maternal chromosomal/genetic disorders that may result in congenital abnormalities. A simple screening tool called Before Pregnancy is available electronically at StudentConsult.com to facilitate the process of preconception assessment and counseling. ▪…

Maternal Physiologic and Immunologic Adaptation to Pregnancy

Clinical Keys for this Chapter ▪ The hemodynamic changes associated with pregnancy begin at 6 weeks' gestation and are associated with sodium and water retention. The mechanisms for these changes are secondary to elevations in the production of aldosterone, prostaglandins, atrial natriuretic peptide, and nitric oxide that reduce arterial vascular tone. This is followed by formation of arterial-venous shunts, due to invasion of the trophoblasts into…

Endocrinology of Pregnancy and Parturition

Clincal Keys for This Chapter ▪ The hormonal and nonhormonal changes that occur during pregnancy and parturition are regulated through a physiological mechanism referred to as the fetoplacental unit. A series of hormones and transmitters are produced by each of the components of this unit, and they have multiple effects within and between the fetus, the placenta and the mother. ▪ The fetal component of the…

Female Reproductive Physiology

Clinical Keys for this Chapter ▪ The female reproductive cycle (menstrual cycle) may be viewed as four separate physiologic cycles (hypothalamic, pituitary, ovarian, and endometrial) but is actually a highly complex and integrated event. This 28 (±7) day cycle allows for the maturation and release of an oocyte (usually only one) that if fertilized may implant in a receptive endometrium. If fertilization and implantation do not…

Female Reproductive Anatomy and Embryology

Clinical Keys for This Chapter ▪ The upper vagina, cervix, uterus, and fallopian tubes are formed from the paramesonephric (müllerian) ducts. The absence of the Y chromosome leads to the development of the müllerian (female) system with virtual total regression of the mesonephric (wolffian) or male system. With the Y chromosome present, a testis is formed and müllerian-inhibiting substance is produced, creating the reverse situation. ▪…

Clinical Approach to the Patient

Clinical Keys for this Chapter ▪ The clinical approach to obstetric and gynecologic patients requires sensitivity and an understanding that medical issues related to birth and reproductive care require a trusting relationship between a woman and her obstetrician and gynecologist as well as all health care professionals that she may encounter. ▪ Recent changes in the acceptance of sexual roles in society mean that a nonjudgmental…

Contraception

Introduction Forty-five percent of pregnancies in the United States are unintended. The most widely used method is female permanent contraception. The use of modern contraceptives has contributed substantially to the reduction of maternal and infant morbidity and mortality and to the ability of females to contribute to society. However, there remain gaps in contraceptive options and utilization, as approximately 45% of all pregnancies in the United…