bluuebunny/crossref_metadata_2025 huggingface dataset:
Diffuse parenchymal lung disease: An introduction
Authors: Teo F. , Wells A.U.
Published: February 2020

The nomenclature of diffuse parenchymal lung disease (also known as interstitial lung disease) has caused a great deal of confusion, with use of complicated histopathological terms not always corresponding to clinico-radiological entities. Five major groupings are now recognized: idiopathic interstitial pneumonias; diseases associated with systemic conditions, including rheumatological disorders; diseases caused by environmental triggers or drugs; granulomatous diseases; and other diffuse lung diseases. Classification is based on recognition of clinical, radiological, and histopathological patterns, as opposed to the purely histopathological terminology. Diagnosis is complicated by the large number of disorders grouped within the diffuse parenchymal lung diseases. A systematic diagnostic algorithm, based upon careful clinical evaluation and a logical sequence of tests, is essential. Clinical history, clinical examination, chest radiography, pulmonary function tests, and selective blood tests should be followed by high-resolution CT, bronchoalveolar lavage (in some cases), and lung biopsy (in a few cases).
The lung in autoimmune rheumatic disorders
Authors: Kokosi M.A. , Wells A.U.
Published: February 2020

Lung complications occur in all rheumatological disorders, but their frequency and type vary strikingly between different systemic diseases. Interstitial lung disease and pulmonary vascular disease are now increasingly recognized, although the detection of limited abnormalities poses difficulties for clinicians who must now distinguish between subclinical involvement and clinically significant disease. The presence or absence of exertional dyspnoea is often misleading as musculoskeletal limitation may mask respiratory symptoms or, alternatively, may cause exercise intolerance without lung pathology, due to the increased work associated with inefficient locomotion. Furthermore, interstitial lung disease precedes the onset of systemic disease in some cases, although typical autoantibody profiles are often diagnostic.
Lipoid (lipid) pneumonia
Authors: Bourke S. J.
Published: February 2020

Lipoid pneumonia is an unusual form of lung disease resulting from the accumulation of lipids in the alveoli, where they provoke a foreign body reaction with associated inflammation and sometimes local fibrosis. The lipids may be endogenous or exogenous in origin, and the clinical mechanisms and circumstances differ accordingly. Exogenous lipoid pneumonia occurs when animal, vegetable, or mineral oils are aspirated or inhaled into the lungs, provoking a foreign body reaction with chronic inflammation. Typical symptoms are cough and breathlessness. The chest radiograph and CT may show interstitial thickening, with areas of consolidation that may coalesce into a mass (paraffinoma) which simulates carcinoma. Bronchoalveolar lavage and biopsy show lipid-laden macrophages. In endogenous lipoid pneumonia the lipids are derived from surfactant and cholesterol released from decaying cells distal to bronchial obstruction.
Pulmonary alveolar microlithiasis
Authors: Bourke S. J.
Published: February 2020

Pulmonary alveolar microlithiasis is characterized by the deposition of calcium phosphate in the alveolar air spaces as a result of mutations of the SLC34A2 gene. The diagnosis is often made before symptoms have developed when a chest radiograph is performed for other reasons, and shows a dramatic typical ‘sandstorm’ pattern of diffuse bilateral calcified micronodules. The patient is often symptom-free when the diagnosis is made after a chest radiograph is taken incidentally and reveals calcified micronodules, but typically the disease progresses to respiratory failure over about 10–20 years. Etidronate has led to improvement in some cases that have been detected early. Lung transplantation is the main option in advanced disease. The severity of the disease and prognosis are variable, and this may be influenced by the specific type of gene mutation. Survival of 10–20 years from the onset of symptoms is typical.
Radiation pneumonitis
Authors: Bourke S. J.
Published: February 2020

The lungs can be injured by radiation used in the treatment of cancer, with the rapidly dividing endothelial cells and type II pneumocytes most affected. Immediate injury is followed by an inflammatory response and at a later stage by fibrosis. Chest radiography detects asymptomatic changes in about 50% of patients after radiotherapy. Acute radiation pneumonitis presents with cough, breathlessness, and fever about 2 months after exposure; corticosteroids are usually effective in relieving symptoms but do not prevent the subsequent development of fibrosis. Fibrosis typically develops about 6 months later, may progress for 6–24 months, but has usually stabilized by 2 years. Prevention depends on refining techniques for giving radiotherapy.
Mediastinal tumours and cysts
Authors: Lee Y.C. Gary , Davies Helen E.
Published: February 2020

Mediastinal masses are most conveniently categorized by their anatomical site in the anterior, middle, or posterior mediastinum. Most present as a radiographic abnormality alone, or in association with symptoms arising from compression of other mediastinal structures. Systemic symptoms such as fever or weight loss are more likely with malignant tumours such as lymphomas or thymomas. Detailed knowledge of normal mediastinal anatomy is a prerequisite to the interpretation of both normal and abnormal chest radiographs. Lymph nodes are present in all three compartments thereby knowledge of their anatomical relationships, together with sites of drainage, is important when interpreting radiographic mediastinal enlargement. The most important group of visceral nodes lie in the middle mediastinum and are predominantly subcarinal and paratracheal. Bronchopulmonary and hilar nodes are numerous but not visible radiographically unless pathologically enlarged.
ANCA-associated vasculitis
Authors: Jayne David
Published: February 2020

The ANCA-associated vasculitides (AAV) are a grouping of three syndromes of acute and chronic inflammation characterized by their clinical and histological phenotypes, which are associated with circulating antineutrophil cytoplasm autoantibodies (ANCA). They comprise: granulomatosis with polyangiitis (GPA, formerly Wegener’s granulomatosis); microscopic polyangiitis (MPA); and eosinophilic granulomatosis with polyangiitis (EGPA, formerly Churg-Strauss syndrome). The defining histological lesion is a microscopic vasculitis affecting arterioles, capillaries, or venules associated with few or no deposits of immunoglobulin or complement. Granulomata, involving or close by blood vessels, are commonly present in GPA. These diseases involve multiple organ systems with considerable heterogeneity in extent and severity of organ involvement between patients, and overlapping clinical and histological features between syndromes.
Osteonecrosis, osteochondrosis, and osteochondritis dissecans
Authors: Clunie Gavin
Published: February 2020

This chapter examines the bone conditions of osteonecrosis, osteochondrosis, and osteochondritis dissecans. Osteonecrosis is ischaemia of bone caused by a range of conditions, including trauma, which cause intravascular or extravascular obstruction of blood flow to bone. Many cases are associated with pro-thrombotic conditions. Osteonecrosis can be asymptomatic, but if progressive often leads to secondary (adjacent) joint destruction. Diagnosis is made by magnetic resonance imaging. Aside from treatment of any underlying cause, treatment options include analgesics, vasodilators, and surgery. The osteochondritides are trauma-induced focal disturbances of cartilage, either in joints (articular) or at a periarticular epiphyseal plate or at a tendon or ligament insertion (apophysis/enthesis). Lesions typically occur in active children and adolescents and respond to biomechanical modifications and pain relief.
Clinical investigation of renal disease
Authors: Davenport Andrew
Published: February 2020

An accurate history and careful examination will determine the sequence and spectrum of clinical investigations required to make a diagnosis or decide on prognosis or treatment for renal disease. Midstream urine (MSU) sample—this standard investigation requires consideration of (1) macroscopic appearance, (2) stick testing, and (3) microscopy. Quantification of proteinuria—this is important because the risk for progression of underlying kidney disease to endstage renal failure is related to the amount of protein in the urine. Low molecular weight proteinuria is caused by proximal tubular injury and can be detected with markers. Knowledge of the glomerular filtration rate (GFR) is of crucial importance in the management of patients, not only for detecting the presence of renal impairment, but also in the monitoring of all patients with or at risk of renal impairment, and in determining appropriate dosing of those drugs cleared by the kidney. Measurement of plasma creatinine remains the standard biochemical test used to assess renal function. The simplified Modification of Diet in Renal Disease (sMDRD) formula is explained, along with a revised version (CKD-EPI). Investigations of tubular function, including the proximal tubule, distal tubule, and renal-induced electrolyte and acid–base imbalances are discussed in this chapter. Renal imaging covered in this chapter includes ultrasonography, ultrafast multislice CT scanning, magnetic resonance imaging, nuclear medicine scanning, and fluorodeoxyglucose positron emission tomography. Invasive techniques including antegrade or retrograde ureteropyelography and angiography are discussed. A renal biopsy should be considered in any patient with disease affecting the kidney when the clinical information and other laboratory investigations have failed to establish a definitive diagnosis or prognosis, or when there is doubt as to the optimal therapy.
Renal transplantation
Authors: Torpey Nicholas , Firth John D.
Published: February 2020

Renal transplantation is the preferred option for the treatment of endstage chronic renal failure in patients for whom there are no major medical contraindications. In well-selected recipients, both life expectancy and quality of life are superior to treatment with long-term dialysis. However, as the dialysis population continues to grow, the gap between supply and demand for renal transplantation is widening. Immunosuppression—excepting for transplants between HLA-identical twins, immunosuppression is required to prevent rejection, but there is no clear consensus on the best immunosuppressive regimen. Most centres use an induction antibody directed against CD25 or a T-lymphocyte-depleting antibody (thymoglobulin or alemtuzumab), followed by what is now called standard triple therapy—comprising a calcineurin inhibitor (almost always tacrolimus), combined with either mycophenolate mofetil or azathioprine, and steroids. Steroids are not infrequently tailed off rapidly in the early post-transplant period. Transplant rejection can be classified into four main categories: (1) hyperacute, (2) accelerated, (3) acute cellular, and (4) humoral. Complications of renal transplantation—this chapter discusses specific and nonspecific side effects of immunosuppressive agents, infective complications (including viral, bacterial, fungal, and parasitic infections), malignant complications, and other complications (including hypertension, accelerated atherosclerosis, and electrolyte, musculoskeletal, haematological, gastrointestinal, and cosmetic disorders) in detail. Prognosis—first-year transplant losses from rejection have been dramatically reduced from about 40% in the 1970s to 5%. However, the rate of chronic graft loss remains at about 4% per year. The commonest cause of insidious late graft failure is probably chronic antibody-mediated rejection, frequently associated with poor adherence to immunosuppression. Calcineurin toxicity may also contribute. A major focus of research is to identify non-nephrotoxic immunosuppressive agents able to suppress antibody-mediated rejection.
Minimal-change nephropathy and focal segmental glomerulosclerosis
Authors: Saleem Moin , Willcocks Lisa
Published: February 2020

Minimal-change nephrotic syndrome (MCNS) is an immune-mediated condition, usually of unknown cause. On light microscopy the glomeruli appear normal, and on electron microscopy there is effacement of epithelial cell foot processes over the outer surface of the glomerular basement membrane. MCNS is the cause of about 75% of cases of nephrotic syndrome in children and 17% in adults.

Management and prognosis—treatment in adults is with prednisolone at an initial dose of 80 mg/day, then tapering. This leads to complete remission in 90 to 95% of patients, but 50 to 75% of glucocorticoid-responsive adults will have a relapse. Progression to renal failure is not expected and would call the diagnosis of MCNS into question. Focal segmental glomerulosclerosis (FSGS) is not a specific disease entity but a histological lesion, often of unknown aetiology, which is characterized by segmental areas of glomerular sclerosis. It may be (1) primary—either due to genetic mutation, or associated with an unknown circulating protein factor that causes an increase in glomerular permeability; or (2) secondary—the end product of a variety of pathological processes including glomerular hyperfiltration, healed glomerulonephritis, viral (including HIV) infection, or parasitic infection. Management and prognosis—corticosteroid and immunosuppressive therapy should be considered only in patients with primary FSGS and nephrotic syndrome. The steroid regimen is as used for MCNS, but with lesser success. Steroid-resistant cases are treated with ciclosporin (for which there is most published evidence), mycophenolate mofetil, or cyclophosphamide. Prognosis depends on histology and response to treatment.
Membranous nephropathy
Authors: De Vriese An S. , Fervenza Fernando C.
Published: February 2020

Membranous nephropathy (MN) is the most common cause of nephrotic syndrome in Caucasians adults. It may also present with asymptomatic proteinuria. Its defining feature is the presence of subepithelial immune deposits, localized between the podocyte and the glomerular basement membrane. Aetiology—primary MN (80% of cases) is caused in most cases by antibodies against the M-type phospholipase A2 receptor (PLA2R). Secondary MN occurs as a consequence of drugs, malignancy, or autoimmune disease. Prognosis—the clinical course of primary MN is variable: spontaneous complete remission of proteinuria occurs in 20 to 30% and progressive kidney failure develops in 20 to 40% over 5 to 15 years. Patients with gross proteinuria (>8 g/day) are at high risk of progression, as are those with a high and rising anti-PLA2R antibody level. Management—patients at low risk of progression have an excellent long-term prognosis and should be treated conservatively without immunosuppression. Patients at medium and high risk for progression benefit from immunosuppression in addition to conservative treatment. Corticosteroid monotherapy is ineffective in primary MN and should not be used. Standard treatment regimens include corticosteroids with alkylating agents (chlorambucil, cyclophosphamide), corticosteroids with mycophenolate mofetil, and calcineurin inhibitors (ciclosporin, tacrolimus). Early experience with rituximab has given some promising results.
The renal tubular acidoses
Authors: Sayer John A. , Karet Fiona E.
Published: February 2020

Renal tubular acidosis (RTA) arises when the kidneys either fail to excrete sufficient acid, or are unable to conserve bicarbonate, with both circumstances leading to metabolic acidosis of varying severity with altered serum potassium. Proximal and distal types of RTA can be differentiated according to which nephron segment is malfunctioning. Proximal RTA: aetiology and diagnosis—the condition may be (1) secondary to generalized proximal tubular dysfunction (part of the renal Fanconi’s syndrome), or rarely (2) due to an inherited mutation of a single transporter (NBC1) located at the basolateral surface of the proximal tubular epithelium. The combination of normal anion gap acidosis with other features of proximal tubular dysfunction such as renal phosphate wasting (and hypophosphataemia), renal glycosuria, hypouricaemia (due to uricosuria), aminoaciduria, microalbuminuria, and other low molecular weight proteinuria suggests the diagnosis. Management—this requires large quantities of oral alkali with (in most cases) potassium supplements to prevent severe hypokalaemia. Distal RTA: aetiology/diagnosis—two main classes are differentiated by whether (1) the acid-handling cells in the collecting ducts are themselves functioning inadequately, in which case there is associated hypokalaemia (this is ‘classic’ distal RTA); or (2) the main abnormality is of the salt-handling principal cells in the same nephron segment, in which case hyperkalaemia occurs and the acidosis is a secondary phenomenon—this is hyperkalaemic distal RTA. The combination of normal anion gap acidosis with a urine pH higher than 5.5 suggests classic distal RTA. Management—(1) classic distal RTA—1 to 3 mg/kg per day of oral alkali; (2) hyperkalaemic distal RTA—treatment is with sodium bicarbonate, but fludrocortisone and/or potassium-lowering measures may also be necessary. Precipitating drugs should be stopped.
Thrombocytosis and essential thrombocythaemia
Authors: Aruch Daniel , Hoffman Ronald
Published: February 2020

The term thrombocytosis refers to a platelet count elevated above 450 × 109/litre, which can be (1) primary—including essential thrombocythaemia, chronic myeloid leukaemia, polycythaemia vera, and myelodysplastic syndromes; or (2) secondary—including iron deficiency, infection, blood loss, and malignancy. Essential thrombocythaemia: aetiology—the JAK2 V617F missense mutation typical of polycythaemia vera is found in about 50% of cases. In addition, 10% of patients have a mutation in the thrombopoietin receptor gene, MPL, and 30% have a mutation in calreticulin (CALR). Approximately 10% of patients have none of these mutations and are referred to as ‘triple negative’ essential thrombocythaemia. Diagnosis requires all of the following four major criteria: (1) platelet count greater than 450 × 109/litre; (2) bone marrow biopsy showing proliferation mainly of the megakaryocyte lineage with increased numbers of enlarged, mature megakaryocytes with hyperlobulated nuclei without a significant increase or left shift in neutrophil granulopoiesis or erythropoiesis and very rarely minor (grade 1) increase in reticulin fibres; (3) failure to meet the criteria for other myeloproliferative neoplasms; and (4) presence of JAK2, CALR, or MPL mutations. Alternatively, diagnosis can be met when the first three major criteria are present and the one minor criterion, namely the presence of another clonal marker or absence of evidence for reactive thrombocytosis. Treatment requires risk stratification based on the age of the patient and any prior history of thrombosis, with treatment being reserved for those at a high risk of developing complications and not introduced simply on the basis of platelet counts alone unless there is extreme thrombocytosis (>1500 × 109/litre). Therapies include low-dose aspirin and cytoreduction.
Non-Hodgkin lymphoma
Authors: Bhatt Vijaya Raj , Armitage James O.
Published: February 2020

Non-Hodgkin’s lymphomas comprise precursor lymphoid neoplasms, mature B-cell neoplasms, and mature T-cell neoplasms. The aetiology of most cases is unknown, but increased risk is associated with immune deficiencies, agricultural chemicals, autoimmune disorders, treated Hodgkin’s disease, and some infectious agents. Incidence varies from 10 to 22 cases per 100 000 per year in different populations. Patients with non-Hodgkin’s lymphoma most commonly present with lymphadenopathy, but other presentations include systemic symptoms or those attributable to mediastinal or retroperitoneal masses or involvement. Diagnosis is typically based on expert evaluation of an adequate lymph node biopsy. Staging depends largely on determining the anatomical extent of disease, with FDG positron emission tomography/CT scanning generally the preferable imaging modality. For most patients, the goal of therapy is to achieve a complete remission. Patients with definitely curable lymphomas, such as diffuse large B-cell lymphoma and Burkitt’s lymphoma, are almost always treated promptly with intensive regimens, for example, chemotherapy with CHOP (cyclophosphamide, doxorubicin, vincristine (Oncovin), and prednisone) plus the anti-CD20 monoclonal antibody rituximab. By contrast, follicular lymphoma is often not curable and the best treatment is not clear, with many physicians favouring no initial therapy in an asymptomatic patient. Patients who are not cured with initial therapy are candidates for what has been termed ‘salvage therapy’. For most patients, the only curative approach in this setting is haematopoietic stem cell transplantation, the toxicity of which means that it is only sensibly offered to carefully selected patients. Various new agents, such as small molecule kinase and BCL-2 inhibitors, and immune checkpoint inhibitors, offer hope for the future.
Haemopoietic stem cell transplantation
Authors: Gordon-Smith E.C. , Morris Emma C.
Published: February 2020

Haemopoietic stem cells (HSCs) give rise to the blood cell lineages and the cells of the immune system, and their transplantation may be an appropriate part of the management of conditions including (1) malignant haematological disorders (e.g. leukaemia, lymphoma, myeloma); (2) bone marrow failure syndromes (e.g. aplastic anaemia); and (3) congenital disorders—(a) haematological (e.g. Fanconi’s anaemia); (b) immunological—inherited immunodeficiency syndromes; and (c) metabolic (e.g. lysosomal storage diseases). Transplantation of HSCs uses either autologous HSCs (patient’s own stem cells) or allogeneic HSCs (harvested from an appropriately matched sibling or unrelated healthy donor). Successful engraftment of allogeneic HSCs depends upon (1) overcoming immune rejection by the recipient; (2) preventing or suppressing graft-versus-host disease (GVHD), in which donor cells mount an immune attack against recipient tissues; and (3) supporting the patient through periods of profound cytopenias and immune deficiency with susceptibility to infection. Identification and sources of HSCs—HSCs are principally identified by expression of the surface antigen CD34. Sources include (1) bone marrow; (2) peripheral blood—following stimulation by cytokines (e.g. granulocyte colony-stimulating factor); and (3) umbilical cord blood.
Clinical approach to the diagnosis of skin disease
Authors: Venning Vanessa
Published: February 2020

As in most medical specialties, the diagnosis of skin disease relies on careful history taking, and a thorough examination, supported in some cases by appropriate investigation. Astute physicians will also be aware that management outcomes are improved by taking account of the impact of skin disease on patients’ lives, whether through discomfort, disfigurement, or disability. This section, however, is chiefly concerned with aspects of history taking and examination that inform the diagnostic process. There are certain key points in the history of skin disease that should be specifically elicited. These should include a description of the events surrounding the onset of skin disease: when and where it started, and how it progressed.
Lumbar puncture
Authors: Davies R. Rhys , Larner Andrew J.
Published: February 2020

Lumbar puncture for examination of the cerebrospinal fluid has been an integral part of neurological practice since the pioneering work of Quincke at the end of the 19th century. The proximity of nervous tissue and cerebrospinal fluid may afford insights into pathological processes within the nervous system through examination of the cerebrospinal fluid, which may not easily be accessed by other investigational modalities. Because of this importance, guidelines on routine cerebrospinal fluid analysis have been published. The related procedure of cervical or cisternal puncture may also be used to obtain cerebrospinal fluid, but is far less frequently performed. Cerebrospinal fluid samples should always be regarded as precious, and hence every effort made to ensure correct analysis and interpretation; suboptimal performance is not infrequently encountered in day-to-day clinical practice.
Demyelinating disorders of the central nervous system
Authors: Coles Alasdair , Chandran Siddharthan
Published: February 2020

The common feature of all of the demyelinating diseases is that, initially at least, the oligodendrocyte-myelin unit is the primary target, with the axon comparatively spared. There are a range of causes, both acquired and inherited, which this chapter explores. Multiple sclerosis, the prototypic demyelinating disorder of the central nervous system, is the leading causing of neurological disability among young adults in many industrialized nations. In the last two decades therapies have been licensed with increasing capacity to suppress the inflammation which underlies the condition, leading to durable benefits to patients. The next most prevalent demyelinating disease is neuromyelitis optica. Originally thought to be a variant of multiple sclerosis, it is now recognized to be a distinct disease whose treatment is radically different from multiple sclerosis.
Intracranial tumours
Authors: Rees Jeremy
Published: February 2020

Intracranial tumours represent about 2% of all cancers. There are no known risk factors apart from prior irradiation to the skull and brain and a few rare neurogenetic syndromes (e.g. neurofibromatosis, von Hippel–Lindau syndrome, Li–Fraumeni syndrome). They may be intrinsic or extrinsic, which determines potential resectability. Neuroepithelial tumours (predominantly gliomas) account for 50–60% of all primary tumours. Molecular analysis has now been added to the histological grade and subtype to provide an integrated diagnosis which provides more accurate information for treatment and prognosis. As systemic anti-cancer treatments evolve and produce long-term control of visceral and bone disease, brain metastases are becoming increasingly common and are best treated with feither stereotactic radiosurgery or neurosurgery to avoid the cognitive decline associated with whole brain radiotherapy.
Psychopharmacology in medical practice
Authors: Cowen Philip J.
Published: February 2020

Drugs intended to treat psychiatric disorders are referred to as psychotropic drugs. The main categories are antidepressants, mood stabilizing drugs, antipsychotic drugs, and antianxiety drugs. These drugs are widely used in medical practice and most clinicians are likely to have under their care several patients receiving treatment with them. Practitioners therefore need to have an understanding of both the uses and unwanted effects of psychotropic drugs, and particularly of (1) their interactions with drugs used to treat other medical conditions, (2) characteristic abstinence syndromes that can occur with sudden discontinuation of antidepressants (particularly selective serotonin reuptake inhibitors and venlafaxine) and anxiolytics.
Psychiatry, liaison psychiatry, and psychological medicine
Authors: Sharpe Michael
Published: February 2020

Psychiatry first developed as a separate medical specialty about 150 years ago when physicians were recruited to staff the new lunatic asylums. It later embraced psychotherapy and more recently has adopted community rather than hospital-based working. The fact that psychiatry remains largely separate from other areas of medicine, together with the increasing focus on technical procedures in medicine, has led to sometimes inadequate psychiatric care for medical patients. Measures to address this shortcoming began 50 years ago with the ad hoc development of liaison psychiatry teams, providing in-reach psychiatric services from mental hospitals to general hospitals. A more recent innovation is to reintegrate psychiatrists into medical teams as specialists in psychological medicine to provide joined up medical and psychiatric care.
Basic sciences in obstetrics and gynaecology
Authors: Doumouchtsis Stergios
Published: February 2020

This chapter provides up-to-date information on a series of subjects covering a wide spectrum of basic sciences and selected topics with relevance to various clinical practice areas in obstetrics and gynaecology. It is not possible to provide a completely comprehensive cover of all areas of basic sciences within a book chapter, but the subjects explored here include the structure and function of the genome ovulation and ovarian function, fertilization and implantation, embryology, pathology, microbiology, immunology, biochemistry, physiology, endocrinology, pharmacology, and physics (including imaging techniques). Some of these topics are discussed in more detail in other chapters in this textbook. Key knowledge is presented using simple and concise definitions for quick reference along with tables and diagrams.
Obesity in obstetric and gynaecological practice
Authors: Sahota Sukhwinder , Mahmood Tahir
Published: February 2020

Obesity is a complex multifactorial disorder, which has reached epidemic proportions worldwide. It affects all aspects of an individual’s life: physical, social, emotional, and psychological. Although it is largely preventable, obesity is now a major public health issue and has a significant impact on the health and well-being of an individual throughout their lifespan. Obesity is associated with multiple adverse outcomes not only during the reproductive phase of a woman’s life but during the post-reproductive era as well. Obesity also increases risks for non-obstetrical and gynaecological illnesses such as diabetes mellitus, hypertension, metabolic syndrome, cardiovascular disease, and non-gynaecological cancers. Obesity thus is a cause of major societal economic burden.
General and specific infections in pregnancy including immunization
Authors: Ugwumadu Austin
Published: February 2020

Until very recently, the discussion about infections in pregnancy was focused on specific microorganisms, how the pregnant mother acquired the organism and transmitted it to the fetus, the effects of the infection on fetal survival, fetal loss, fetal growth, and development, and on the long-term sequelae. The narrative applied to the ‘TORCHES’ group of infections namely toxoplasmosis, rubella, cytomegalovirus, herpes, and syphilis, dominated the scene before the emergence of newer perinatal infections such as parvovirus B19 and HIV in the later years of the twentieth century. Numerically, the TORCHES group of infections accounts for fewer perinatal complications and morbidity than the more common but less specific ascending subclinical infections encountered clinically as chorioamnionitis and its precursors such as bacterial vaginosis, intermediate vaginal flora, aerobic vaginitis, group B streptococci, and other variants of abnormal lower genital tract flora. The contribution of ascending subclinical infections to the incidence of preterm delivery, long-term neurological and respiratory morbidity, and exacerbation of intrapartum hypoxic ischaemic injury is grossly understated worldwide while disproportionate amounts of resources continue to be expended globally on screening for and the management of the TORCHES group and related infections. In this chapter, the authors aim to cover the common and important perinatal infections and attempt to redress the imbalance in emphasis by drawing attention to the role of ascending subclinical infections in the aetiology of major adverse perinatal outcomes such as brain injury in both the term and the preterm infant.
Psychiatric disorders in pregnancy and the postpartum
Authors: Di Florio Arianna , Jones Ian
Published: February 2020

Obstetricians will frequently look after women with the new onset or recurrence of a psychiatric illness. Perinatal psychiatric disorders, in fact, are common, affecting over 15% of women in pregnancy or in the months after delivery, and have an impact not only on the health of the mother, but also on the well-being of their offspring. Untreated, severe postpartum disorders are associated with an increased risk of both suicide and, in rare but tragic cases, infanticide. Despite their importance, maternal psychiatric disorders are underdiagnosed and undertreated. This chapter provides a concise introduction to perinatal psychiatric disorders and emphasizes the role of prevention, early detection, and collaborative care.
Fetal therapy
Authors: Monaghan Caitriona , Thilaganathan Basky
Published: February 2020

Fetal therapy is defined as any prenatal treatment administered to the mother or fetus with the primary indication to improve perinatal or long-term outcomes for the fetus or newborn. The practice of fetal therapy is a relatively new concept in the field of obstetrics. It originated over 55 years ago when Liley et al. first performed intraperitoneal transfusion for the treatment of fetal anaemia. Since then, the practice has evolved from open fetal surgery to minimally invasive techniques used to manage an array of complex conditions. The domain of fetal therapy is an ever-evolving specialty. This chapter discusses key principles and techniques of current fetal therapy. As well as providing background information on how these techniques have evolved, it also focuses on determining what information future developments may bring.
Respiratory diseases in pregnancy
Authors: Nelson-Piercy Catherine , Lapinsky Stephen
Published: February 2020

Respiratory diseases, particularly asthma, are common in women of childbearing age. Respiratory symptoms, particularly breathlessness, are also common in pregnancy. This chapter discusses the normal physiological changes that occur in the respiratory system during gestation and cover the common and less common respiratory diseases that predate pregnancy: asthma, sarcoidosis, cystic fibrosis, restrictive and interstitial lung disease, pulmonary arteriovenous malformations. lymphangioleiomyomatosis, and sleep-disordered breathing. It also covers intercurrent problems such as bacterial and viral pneumonia, as well as conditions that may arise due to complications of the pregnancy itself: adult respiratory distress syndrome, amniotic fluid embolism, gastric acid aspiration, transfusion-related acute lung injury, and pneumothorax.
The management of labour
Authors: Kanagalingam Devendra
Published: February 2020

Normal labour is a process of spontaneous expulsion of the fetus, placenta, and membranes at term. This process is initiated by complex endocrine mechanisms that cause uterine contractions which lead to effacement and dilatation of the cervix and descent of the fetus, resulting in delivery. About 10% of women go into labour in the preterm period. The progress is dependent on uterine contractions (power), the size and presentation of the fetus (passenger), and the size of the pelvis (passage). For ease of management, the observed labour is artificially divided into three stages. The partogram is used to manage labour and is where maternal and fetal observations can be plotted in addition to cervical dilatation and descent of the presenting part. The value of active management is still debated but has been adapted in routine practice. More research is needed to decide the best management of labour to optimize the maternal and fetal outcomes.
Obstetric analgesia and anaesthesia
Authors: Bampoe Sohail , Addei Anthony
Published: February 2020

This chapter is based on the current core curriculum of the Royal College of Obstetricians and Gynaecologists training programme. It covers the relevant anaesthesia knowledge criteria in the management of labour and delivery. The chapter provides succinct and important pieces of information on the following: (1) types and methods of action of analgesia and sedation including narcotics, hypnotics, and non-steroidal anti-inflammatory drugs and their indications and contraindications; (2) types and methods of action of regional anaesthesia including epidural, spinal, and pudendal nerve block and their indications and contraindications; (3) complications of anaesthesia and analgesia including cardiac arrest, respiratory arrest, aspiration, and drug reactions; (4) anaesthesia agents—induction, inhalational, and prophylactic measures; and (5) advice on pain relief.
Obstetric emergencies
Authors: Ghag Kiren , Winter Cathy , Draycott Tim
Published: February 2020

Obstetric emergencies can be unpredictable and sudden, and may result in significant morbidity and mortality. Successful management requires a rapid coordinated response from multiprofessional maternity teams. In the recent Confidential Enquiry into Maternal Deaths in the United Kingdom, substandard care was identified in over 50% of cases and one-third of these could have been prevented with better care. Recurring problems were identified, including a lack of multiprofessional team working, poor communication, and late recognition of the severely unwell woman. Multiprofessional training for obstetric emergencies has been demonstrated to reduce intrapartum harm and improve maternal and neonatal outcomes. This chapter focuses on the immediate management of obstetric emergencies and is largely derived from the authors’ work with the PROMPT Maternity Foundation and the contents of the PROMPT.
Preterm birth
Authors: Care Angharad , Alfirevic Zarko
Published: February 2020

This chapter discusses the epidemiology, prediction, prevention, and management of spontaneous preterm birth. Preterm birth is usually defined as delivery at any gestation before 37 completed weeks of pregnancy (<37+0 weeks, <259 days). The lower limit of preterm birth and upper limit of late spontaneous miscarriage are blurred as the limit of viability varies with differences in healthcare settings. This condition remains one of the biggest challenges facing obstetricians globally as a result of continuing high rates of morbidity and mortality. Spontaneous preterm birth is caused by a complex collection of pathophysiology with overlapping environmental interactions and behavioural influences that contribute to individual risk. Much debate exists regarding best prevention therapies and there remains a huge need for novel therapies and interventions for both prediction and prevention
Prolonged pregnancy
Authors: Walker Kate F. , Thornton Jim G.
Published: February 2020

Prolongation of gestation beyond 42+0 weeks (or 294 days) affects about 6% of pregnancies. It is associated with an increased risk of perinatal morbidity and mortality; the overall risk of pregnancy loss (stillbirth plus death occurring up to the age of 1 year) increases eightfold between 37 weeks and 43 weeks. Since trials comparing induction of labour with expectant management suggest that induction does not increase the rate of caesarean section, many clinicians offer it for pregnancies beyond 41 weeks. Induction of labour is usually performed using prostaglandin ripening followed, if necessary, by amniotomy and oxytocin infusion.
Malpresentation, malposition, and cephalopelvic disproportion
Authors: Murphy Deirdre J.
Published: February 2020

Normal labour involves an appropriate-sized fetus in a vertex presentation with a well-flexed head that descends and rotates within the maternal pelvis in response to uterine contractions, delivering in an occipitoanterior position. Abnormal labour occurs when any one or a combination of these factors deviates from normal. It may involve a malpresentation (e.g. face, brow, or breech), a malposition (e.g. occipitoposterior), or cephalopelvic disproportion. The consequences include prolonged labour, obstructed labour, operative vaginal delivery, or caesarean section. Appropriate management requires expertise in clinical assessment, decision-making, and the technical and non-technical skills of operative delivery. A systematic approach is required including an awareness of risk factors for abnormal labour, early identification of deviations from normal, use of preventative strategies where possible, and appropriate intervention when necessary. Good teamwork and clear communication between midwives and obstetricians is essential within a labour ward setting. Timely transfer may be required in a homebirth setting. Particular skills are required in low-resource settings where obstructed labour may be advanced at the time of presentation.
Miscarriage and recurrent miscarriage
Authors: Talaulikar Vikram Sinai , Matjila Mushi
Published: February 2020

Complications of early pregnancy, including pregnancy loss and threatened miscarriage, are common. Miscarriage affects almost one in five pregnancies and accounts for utilization of a significant proportion of healthcare resources. Women presenting with miscarriage should ideally be assessed, diagnosed, and managed in early pregnancy assessment units. They should be provided with comprehensive information about expectant, medical, and surgical management options, and helped to make informed decisions about their care. Early pregnancy loss can be a source of considerable distress to women and they should be provided with appropriate support and counselling. Recurrent miscarriage (RM) remains a challenge to patients and clinicians alike. Recognition of the psychosocial impact should prompt involvement of mental health specialists, counsellors, and social workers in patient management. Inconsistencies in definition (two or three consecutive miscarriages) confound research in RM. Although endocrinological, thrombotic, autoimmune, and uterine structural perturbations have been described in association with RM, antiphospholipid syndrome and embryonic karyotype abnormalities remain the two closest conditions for which a reasonable explanation can be offered to patients along with prognostication for future pregnancies. A diagnosis of RM has additional implications, not only for previable pregnancy loss, but an association with adverse obstetric and future maternal health outcomes. A global consensus on the definition of RM, along with phenotypic characterization of this heterogeneous condition would improve interpretation of available data and future research. A thorough understanding of the underlying molecular pathophysiological mechanisms in specific phenotypic categories of RM is the fundamental requisite for the advancement of this field.
The menstrual cycle
Authors: Whitaker Lucy H.R. , Skorupskaite Karolina , Maybin Jacqueline A. , Critchley Hilary O.D.
Published: February 2020

The female human reproductive system comprises the hypothalamic–pituitary–ovarian axis and the reproductive tract (fallopian tubes, uterus, cervix, and vagina). The principal functions of this system are to produce an ovum, enable its fertilization and implantation, and allow growth and safe expulsion of the fetus into the external world. The menstrual cycle is critical for facilitation of the initial steps of this raison d’etre of the female reproductive system. As a greater understanding of the menstrual cycle biology is garnered, therapies that directly target pathways underpinning the regulation of normal and heavy menstrual bleeding are likely to emerge. Such future targeted therapies have the potential to offer a more personalized approach to management with minimization of undesirable side effects.
Menstrual disorders, amenorrhea, and dysmenorrhoea
Authors: Fraser Ian S. , Berbic Marina
Published: February 2020

Symptoms related to menstruation are the commonest cause of gynaecological complaints during the reproductive years, and cause more work absences than any other disorders commonly seen in women. These disturbances of menstrual bleeding and menstruation-associated pain can have major impacts on quality of life, and can lead to the development of significant symptoms due to iron deficiency and anaemia. There is a range of common and rare underlying causes of abnormal uterine bleeding, which have been well classified using the PALM-COEIN system. Investigations should be targeted at defining the underlying causes and assessing the degree of iron deficiency. Treatment depends on the underlying cause, and a range of surgical and medical approaches can be considered—improved quality of life is the key aim. Effective treatment for heavy menstrual bleeding should be accompanied by effective treatment for iron deficiency. Amenorrhoea (absence of menstruation for a specified period of time) may be due to disturbances of almost any part of the hypothalamic–pituitary–ovarian–uterine system. Investigations should focus on the interplay of reproductive hormones and exclusion of structural pathology. Treatment is aimed at managing the underlying cause, taking into account the desires of the patient in relation to pregnancy. Menstrual pain may be caused by an imbalance of prostaglandin metabolism (primary dysmenorrhoea) or by structural pathologies, such as endometriosis (secondary dysmenorrhoea). Symptoms can vary greatly and a careful history can often distinguish realistically between primary and secondary dysmenorrhoea. Treatment is often medical, although structural pathologies may require surgical excision.
Polycystic ovary syndrome
Authors: Huang Zhongwei , Yong Eu Leong
Published: February 2020

Polycystic ovary syndrome (PCOS) is an enigmatic condition and its pathophysiology remains to be determined but it is likely to involve the androgen, insulin, and anti-Mullerian hormone pathways. PCOS is diagnosed in women in the reproductive age group based on the Rotterdam criteria. The spectrum of disease involves various phenotypes based on the current diagnostic criteria and this may have reproductive, metabolic, and endocrine consequences. Reproductive issues include that of irregular menstrual cycles and anovulation. Metabolic disorders such as insulin resistance, obesity, dyslipidaemia, and hypertension must be screened for in all women who are diagnosed with PCOS. Long-term risks of metabolic and endocrine disorders in women with PCOS still need further confirmation with more robust data. Reproductive ageing appears to be increased in women with PCOS and they seem to menopause at a later age. Thus far, PCOS appears to be associated with endometrial hyperplasia and cancer.
Benign disease of the vulva
Authors: Simpson Rosalind , Nunns David
Published: February 2020

This chapter aims to enhance knowledge and skills in patient assessment, vulval examination, and treatment of vulval disease, specifically dermatological conditions and vulval pain. The prompt identification and treatment of vulval conditions can reduce anxiety, alleviate symptoms, and preserve an acceptable level of functioning for patients. Often simple measures can benefit the patient (e.g. use of emollients), but many have complex disease and can present with more than one condition so careful assessment and individualized management is essential. Combining treatment strategies is sometimes needed. Vulvodynia is not a skin condition but a chronic pain syndrome and is also covered in this chapter. It is important that health professionals work within their own competencies. Patients with complicated, rare, and treatment-refractory disease should be referred on to a vulval service for a multidisciplinary opinion.