oxford handook of clinical specialities 9th ed

OXFORD
HANDBOOK
OF CLINICAL
SPECIALTIES
NINTH EDITION
JUDITH COLLIER
MURRAY LONGMORE
KEITH AMARAKONE
3
3 Great Clarendon Street, Oxford OX2 6DP
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education by
publishing worldwide. Oxford is a registered trade mark of Oxford University Press
in the
UK and certain other countries.
Published in the United States by Oxford University Press Inc., New York
© Oxford University Press,
2013
The moral rights of the authors have been asserted
First published
1987
Fifth edition
1999
Translations:
Greek
Second edition
1989
Sixth edition

2003
Spanish Romanian
Third edition
1991
Seventh edition
2006
German Russian Polish
Fourth edition
1995
Eighth edition
2008
Hungarian Portuguese
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by licence or under terms agreed with the appropriate reprographics
rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.
You must not circulate this book in any other form and
you must impose the same condition on any acquirer.
British Library Cataloguing in Publication Data
Data available
Library of Congress Cataloging in Publication Data
Data available
Typeset by GreenGate Publishing Services, Tonbridge,
UK; printed
in China on acid-free paper through CC O set Printing Co. Ltd
ISBN 978-0-19-959118-3
Drugs

Except where otherwise stated, recommendations are for the non-pregnant
adult who is not breastfeeding. To avoid excessive doses in obese patients it may
be best to calculate doses on the basis of ideal body weight (
IBW): see p
621
.
We have made every e ort to check this text, but it is still possible that drug or
other errors have been missed.
OUP makes no representation, express or implied,
that doses are correct. Readers are urged to check with the most up-to-date
product information, codes of conduct, and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text, or for the misuse or misapplication of material in this work.

For updates/corrections, see oup.co.uk/academic/medicine/handbooks/updates.
Contents
Front cover
Back cover
Drugs ii
Preface to the ninth edition iv
Preface to the fi rst edition v
Confl icts of interest: none declared v
Understanding our patients vi
What happens when ward rounds collide? vii
Dedication viii
Acknowledgments ix
How to use this book x
A note on the use of pronouns x
Symbols and abbreviations xi
1 Obstetrics 1

2
Paediatrics 98
3 Gynaecology 240
4 Psychiatry 312
5 Ophthalmology 410
6 Primary care 466
7 Ear, nose and throat diseases 534
8 Dermatology 582
9 Anaesthesia 612
10 Unusual eponymous syndromes 638
11 Orthopaedics and trauma 656
12 Pre-hospital immediate care 790
Index 817
The content of each chapter is detailed on each chapter’s fi rst page.
iv
Preface
T
his is the fi rst medical textbook to take the health of its readers serious-
ly on the grounds that the health of one person (a patient) must not be
bought at the expense of another (their doctor). It is an unsettling paradox
that when we study medicine our own health goes out of the window (fi g 1),
with long hours of coal-face working often without joy or sustenance as our
health is shattered by the weight of an over-full curriculum (no doubt because
there are too many organs and we know far too much about them).
What can a book do about this defenestration (fi g 1)? First of all the ideal
book can (must!) be brief with a
clear distinction between work and
play. Secondly, such a book must
furnish the mind: as we drill down
into the minute structure of dis-

ease, there must be a correspond-
ing search for the macroscopic, the
human, and the universal. This book
intends to make plain the idea that
for every such spiral of down-drill-
ing, there is a corresponding upward
spiral (the swarf,
fi g 2) towards the
infi nite
—
and we aim the help the reader fi nd the jumping-o point where these
spirals intersect, so that the movement down (reductionism) is complemented
by a movement up (integrative medicine). Can this infl uence the heath of our
readers? The answer lies in a single
word: enlightenment.
The spiral illuminations at the be-
ginning of each chapter (and scat-
tered throughout the book) remind
us to follow the movement up as
well as the movement down. Fol-
low the swarf! We should do this in
our consultations, as well as in our
reading. Never pass over an oppor-
tunity to widen the horizons of your
patients, or to have your own hori-
zons widened by your patient: what
better way is there of reducing the
size of their (and our) insoluble prob-
lems? Here, it is enough to point out
that the well-furnished mind confers

resilience to the body. We all know
that stress brings on physical disease—and from this premise it is a short
step to accept that a resilient mind is central to maintaining heath. We aim to
fi nd magnetic correspondences in the jumping-o points between the down-
ward-drilling helix and the upward-spinning swarf-spirals using philosophy,
literature, humour, and tinctures of hope. Ultimately we would like readers
to develop their own methods, thereby converting passive acceptance of an
overfull curriculum into wealth, life, and beauty.

JABC, KM & JML—Preface to the
9
th
edition—Cape Clear
Fig 1. Defenestration
Fig 2. Swarf
“The way up is the way down…
Whether on the shores of Asia, or in the Edg-
ware Road.”
The dry salvages
TS Eliot; 1941
v
Preface to the 1
st
Edition
W
hen someone says that he is ‘doing obstetrics’—or whatever, this
should not hide the fact that much more is being done besides, not just
a little of each of medicine, psychiatry, gynaecology and paediatrics, but also
a good deal of work to elicit and act upon the patient’s unspoken hopes and
fears. At the operating table he must concentrate minutely on the problem in

hand; but later he must operate on other planes too, in social and psychologi-
cal dimensions so as to understand how the patient came to need to be on the
operating table, and how this might have been prevented. All the best special-
ists practise a holistic art, and our aim is to show how specialism and holism
may be successfully interwoven, if not into a fully watertight garment, then
at least into one which keeps out much of the criticism rained upon us by the
proponents of alternative medicine.
We hope that by compiling this little volume we may make the arduous task
of learning medicine a little less exhausting, so allowing more energy to be
spent at the bedside, and on the wards. For a medical student coming fresh
to a specialty the great tomes which mark the road to knowledge can numb
the mind after a while, and what started out fresh is in danger of becoming
exhausted by its own too much. It is not that we are against the great tomes
themselves—we are simply against reading them too much and too soon. One
starts o strong on ‘care’ and weak on knowledge, and the danger is that this
state of a airs becomes reversed. It is easier to learn from books than from
patients, yet what our patients teach us may be of more abiding signifi cance:
the value of sympathy, the uses of compassion and the limits of our human
world. It is at the bedside that we learn how to be of practical help to peo-
ple who are numbed by the mysterious disasters of womb or tomb, for which
they are totally unprepared. If this small book enables those starting to ex-
plore the major specialties to learn all they can from their patients, it will have
served its purpose—and can then be discarded.
Because of the page-a-subject format, the balance of topics in the follow-
ing pages may at fi rst strike the reader as being odd in places. However, it
has been our intention to provide a maximally useful text rather than one
which is perfectly balanced in apportioning space according to how common
a particular topic is—just as the great Terrestrial Globes made by George Phil-
lips in the
1960

s may seem at fi rst to provide an odd balance of place names,
with Alice Springs appearing more prominently than Amsterdam. To chart a
whole continent, and omit to name a single central location out of respect for
‘balance’ is to miss a good opportunity to be useful. George Phillips did not
miss this opportunity, and neither we hope, have we. It is inevitable that some
readers will be disappointed that we have left out their favoured subjects (the
Phillips’ Globe does not even mention Oxford!). To these readers we o er over
300
blank pages by way of apology.
JABC & JML—Preface to the 1
st
edition—Ferring,
1987
Confl icts of interest: none declared
Because of numerous and well-publicized occasions where writers of guide-
lines recommending certain drugs turn out to have undisclosed fi nancial
contacts with the pharmaceutical industries concerned,1 we wish to place on
record that we have no contacts with any pharmaceutical company, and no
pharmaceutical company employs us in any capacity, and neither have we re-
ceived any fi nancial input bearing upon our research for this publication. We
have a policy of not seeing representatives from the pharmaceutical industry,
or receiving their gifts or hospitality. We assert that the drugs recommended
in this book have been selected on the basis of the best available evidence.
DRs LONGMORE, COLLIER, and AMARAKONE,
2012
vi
Understanding our patients
Most of the time we treat our patients quite well, without ever really under-
standing them. The idea that we should strive to understand and empathize
with all our patients is unreasonable. Out-patient clinics and surgeries would

grind to a halt, and urgent visits would never get done. It is also possible that
to do so would be counter-productive from the patient’s point of view. For
two human beings to understand each other’s inner life is a rare event, and if
we o ered this understanding to all our patients they might become addict-
ed to us, and be unable to get on with the rest of their lives. Nevertheless, it is
good practice to try to understand some patients. Doing so may entail swal-
lowing an alien world and digesting it rather slowly. Paradoxically, to achieve
this, we very often need to keep our mouths shut, particularly with those in
whom we have reached a therapeutic impasse—for example if the illness is
untreatable, or the patient has rejected our treatment, or if the patient seems
to be asking or appealing for something more. Eye contact is important here.
One of the authors (
JML) recalls forever his very fi rst patient—found on a sur-
gical ward recovering from the repair of a perforated duodenal ulcer: a nice
simple surgical patient, ideal for beginners. I asked all the questions in the
book, and knew all his answers and his physical features, even the colour of
his eyes. Luckily, the house o cer who was really looking after him did not
ask so many questions, and knew how to interpret the appeal for help behind
those eyes, and in his busy day found space to receive the vital clue beyond
my grasp—that my patient was a drug addict and under great stress as he
could no longer fi nance his activity.
So, the fi rst step in trying to understand a patient is to sit back and listen.
Next, if possible, it is very helpful to see your patient often, to establish rap-
port and mutual respect. If the relationship is all one way, with the doctor
fi nding out all about the patient, but revealing nothing of him or herself, this
mutual respect can take a very long time to grow. But beware of sharing too
much of your own inner life with your patients: you may overburden them, or
put them o . Di erent patients respond to di erent approaches. Understand-
ing patients inevitably takes time, and it may be hard in a series of short ap-
pointments. A visit to the patient’s home may be very revealing, but for many

doctors trapped in hospital wards or clinics, this is impossible. But it is usual-
ly possible to have a longish private interview, and take whatever opportunity
arises. We once worked with a consultant who infuriated his junior sta on
busy ward rounds by repeatedly selecting what seemed to us the most bor-
ing and commonplace medical ‘cases’ (such as someone with a stroke) and
proceeding to draw the curtain around the patient’s bed to exclude us, and
engage in what seemed like a long chat with the patient, all in very hushed
voices, so that we never knew what he said—until Sister told us that he
never said anything much, and simply received anything that was on the pa-
tient’s mind. For the most part, he was swallowing their world in silence. We
came to realize that there was nothing that these patients, robbed as they
were of health and wholeness, appreciated more in their entire hospital stay.
vii
What happens when two ward rounds collide?
We once worked with a splendid consultant, Dr B—, who, among other ec-
centric but lovable traits, believed that data such as an
ECG should be inter-
preted according to the mood of the day and in the light of bedside nuances.
He would not let us label old
ECGs with the diagnosis accorded at the time
of their recording, in case this confl icted with later nuances. So during ward
rounds old
ECGs would be unearthed and reinterpreted by the great man,
as if he were a conductor wringing new meaning from a well-known score.
Ward rounds tended to be rather slow and it so happened that faster, newer
consultants would start overtaking us on ward rounds. But we noticed that
some of their entourage would take this moment of impact to hive o from
the fast ward round, and attach themselves to ours. The faster ward round
moved on to some trite destination leaving us to tussle with the great ques-
tions of medicine.

Let us consider further this moment of instability and choice when the two
ward rounds collide. As Paul Verlaine wrote, “There is nothing more precious
than a song which is cloudy from the joining of the indistinct with the precise”.
We tend to over-value the precise and undervalue the indistinct. Like Dr B—,
we need to re-interpret patients’ exact words as if they were a musical score. All
too often, though, we rely on summaries of our patients’ stories, massacred by
eloquent, but treacherous, medical jargon. Paul Verlaine knew what to do: “Take
eloquence, and wring its neck” is his advice, if it’s truth we are after. In its place
he recommends systematic ambiguity and giving nuance free rein
C
ar nous voulons la Nuance encor, For we want nuance,
Pas la couleur, rien que la Nuance! Not colour, nothing but nuance!
Oh! la nuance seule fi ance Only nuance joins
Le rêve au rêve et la fl ûte au cor! Dream to dream and fl utes to horns!
Paul Verlaine, Art poétique
So what are the facts? Give me hard facts and I will give you a diagnosis.
That was the alluring but dangerous message from the fast ward round. And
we all have to make our choice of when to hive o from this ward round and
join Dr B—. If we can accord some ambiguity to the facts we may start to
be of real use to our patients. After all, they have to live with the facts, so we
may as well let the facts breathe and have a complicated life of their own.
There is something undefi ned in every fact. Find what it is, and use the
undefi ned as a vehicle to explore your patient’s subtleties and contradictions.
So, in memory of Dr B—, we propose a new section in the Medical Notes
called Nuances, to be placed before the Functional Enquiry and after the
History of the Presenting Complaint. “The patient pointed to his ear when
he said this” or “He was obviously frightened reliving this moment ” or “The
patient ran out of language at this point ”
Running out of language is a sure sign that you are getting somewhere
with our patient. Too much eloquence is fatal: this is Paul Verlaine’s worthless

jewel (“ce bijou d’un sou”) that sounds hollow and fake when put to the test.
We have to accept that language is not very good at dealing with pain—or
any internal state.
viii
Dedication
ix
Acknowledgements
We thank those who have contributed their time and wisdom to previous edi-
tions: Dr Steven Emmet for detailed help in reading proofs; Professor Tor Chiu
for his help with the
ENT chapter; Natalie Langdown for help with autism; Pro-
fessor Mark Lowenthal for his indefatigable help with Paediatrics and other
chapters. We thank all the authors who have joined us for previous editions: Ju-
dith Harvey, Tim Hodgetts, Duncan Brown, Peter Scally, Mark Brinsden, Ahmad
R. Mafi , and Tom Turmezei.
Specialist Readers We are hugely indebted to our Specialist Readers for their
advice, encouragement, and constructive criticism. Each chapter in this book
has benefi tted from their trustworthy oversight. They are thanked individually
at the beginning of each chapter.
Junior Readers It was our great pleasure to welcome a new team of Read-
ers to the ninth edition of this book. Our Junior Readers showed commitment,
intelligence, and ingenuity in their contributions to the referencing and cross-
referencing of this edition. We have a better book for it. Thank you to Mathura-
nayagham Niroshan, Shahzad Arain, Rashmi Singh, Josh Hurn, Konstantinos
Kritikos, Mark Cassar, William Hunt, David Lee, Aaron Lai, Winnie Chen, Yong
De Jun, Pooja Sarkar, Xuebin Dong, Roland Bensted, and Fandy Wang.
Reader participation We have been very fortunate to receive so many well-
considered suggestions and corrections to the book from readers . Their con-
tributions have enhanced the book and we are grateful. Over the years the list
has grown too large to accommodate in the book, so we now have a dedicated

webpage for the purpose: www.oup.com/uk/ohcs9acknowledgements.
If you would like to give us feedback, correct a mistake, or make a suggestion,
you can do so by fi lling in the comment card enclosed in this volume and posting
it to us, or by going to our website: www.oup.com/uk/ohcs9efeedback
.
x
How to use this book
This book has some useful features to help you get the most out of the informa-
tion inside.
Quick chapter look-ups Index on the back cover refers to and aligns with the
coloured tabs on the sides of the pages.
References (1) Every reference has an individual identifi cation indicated by a
pink superscript number. The full details of every reference are held online at

www.oup.com/ohcs9refs.
Cross references There are cross references to other chapters within the book,
to the Oxford Handbook of Clinical Medicine (
OHCM), and to other titles in the
Oxford Medical Handbooks series.
Reference intervals Included inside the back cover. Conversion factors to and
from
SI units are given on the bookmark.
Right-hand vertical comments At the side of some tables and topics, an alter-
native opinion of the content inside.
Symbols and abbreviations See opposite.
Corrections and suggestions Found a mistake? Have a suggestion for the next
edition? Let us know at www.oup.com/uk/ohcs9efeedback. Major changes
are announced online at www.oup.co.uk/academic/series/oxhmed/updates.
A note on the use of pronouns
For brevity, the pronoun ‘he’ or ‘she’ has been used in places where ‘he or she’

would have been appropriate. Such circumlocutions do not aid the reader in
forming a vivid visual impression, which is one of the leading aims of good au-
thorship. Therefore, for balance and fairness, and where sense allows, we have
tried alternating he with she.

don’t dawdle! Prompt action
saves lives

this phrase is important
more (or less) vital topic; a rough

(
†
)
guide for
1
st
-time readers

an opportunity for holistic/non-
reductionist thinking
confl ict (controversial topic)
1
,
2
,
3
references at oup.co.uk/ohcs9refs
1
,

2
,
3
drug dose not in BNF, see
oup.co.uk/ohcs9refs
# fracture
 di erential diagnosis
 :  male to female ratio
 decreased
 normal (eg plasma level)
 increased
~ about
≈
approximately equal
–ve negative
+ve positive
 on account of/because of
 therefore
A&E emergency department
A2A angiotensin 2 receptor (blockers)
ABC air, breathing, circulation
A(P)LS advanced (paediatric) life support
manuals
ABR audiological brainstem responses
AC ante cibum (before food)
ACE(i) angiotensin-converting enzyme
(inhibitor)
ACLS advanced cardiac life support
ACTH adrenocorticotrophic hormone
ADD attention defi cit disorder

ADH antidiuretic hormone
AFP -fetoprotein (=alpha)
AIDS acquired immunodefi ciency syn.
Alk alkaline (phos=phosphatase)
ALL acute lymphoblastic leukaemia
ALT alanine aminotransferase
ANA antinuclear antibody
ANF antinuclear factor
ANS autonomic nervous system
AP anteroposterior
APH antepartum haemorrhage
APLS advanced paediatric life support
APM auto-premotor syndrome
ARF acute renal failure
ARM artifi cial rupture of membranes
ASD atrioseptal defect
ASO antistreptolysin O (titre)
ASW approved social worker
ATLS Advanced Trauma Life Support
manual; see
www.trauma.org
ATN acute tubular necrosis
AV atrioventricular
AVM arteriovenous malformation
HCG -human chorionic gonadotrophin
BJGP British Journal of General Practice
BMJ British Medical Journal
BNA borderline nuclear abnormality
BNF British National Formulary
BNF

C
children’s BNF
BP
blood pressure
© courtesy of the copyright holder
C3 complement
Ca carcinoma
CBRN chemical, biological, radiological,
nuclear
CBT cognitive-behaviour therapy
CCDC consultant in communicable
disease control
CCF combined (right & left sided)
cardiac failure
CHC combined hormonal
contraception
ChVS chorionic villus sampling
CI contraindications
CIN cervical intra-epithelial neoplasia
CMV cytomegalovirus; controlled
mandatory ventilation
CNS central nervous system
CoC combined oral contraceptive
COM chronic otitis media
CPA care programme approach
CPAP continuous +ve airways pressure
CPR cardiopulmonary resuscitation
CRP c-reactive protein
CRPS complex regional pain syndrome
CSF cerebrospinal fl uid

CT computer tomography
CVP central venous pressure
CVS cardiovascular system
CXR chest x-ray
D dimension (or dioptre)
D&C dilatation (cervix) & curettage
D&V diarrhoea and vomiting
dB decibel
DHS dynamic hip screw
DIC disseminated intravascular
coagulation
DIP distal interphalangeal
DKA diabetic ketoacidosis
dL decilitre
DM diabetes mellitus
DMSA dimercaptosuccinic acid
DNA deoxyribonucleic acid
DOH Department of Health (NHS)
DPL diagnostic peritoneal lavage
DRG dorsal root ganglion
DSM-IV Diagnostic & Statistical Manual,
4
e
DUB dysfunctional uterine bleeding
DVT deep venous thrombosis
E-BM evidence-based medicine
EBV Epstein–Barr virus
ECG electrocardiogram
ECT electroconvulsive therapy
EEG electroencephalogram

EIA enzyme immunoassay
ENT ear, nose and throat
ERPC evacuation of retained products
of conception
ESR erythrocyte sedimentation rate
ET endotracheal
FB foreign body
FBC full blood count
FCR fl exor carpi radialis
FDP fl exor digitorum profundus
FDS fl exor digitorum sublimis
FH family history
FNA fi ne needle aspiration
Symbols and abbreviations
x
i
x
i
x
i
x
i
xii
FNT fetal nuchal translucency
FSH follicle-stimulating hormone
G gauge
g gram
G()GT . gamma()glutamyl trans-
peptidase
G6PD glucose-

6
-phosphate
dehydrogenase
GA general anaesthesia
GCS Glasgow coma scale
GFR glomerular fi ltration rate
GH growth hormone
GI gastrointestinal
GP general practitioner
h hour
Hb haemoglobin
HBsAg hepatitis B surface antigen
HBV hepatitis B virus
HCG human chorionic gonadotrophin
HDL high-density lipoprotein
HFOV high-frequency oscillatory
ventilation
HIV human immunodefi ciency virus
HLA human leucocyte alleles
HPA Health Protection Agency
HPO hypothalamic–pituitary–ovarian
HPV human papilloma virus
HRT hormone replacement therapy
HVS high vaginal swab
ibid ibidem (Latin, in the same place)
IBW ideal body weight
ICP intracranial pressure
IE infective endocarditis
Ig immunoglobulin
IHD ischaemic heart disease

IM intramuscular
INR international normalized ratio of
prothrombin time
IOP intraocular pressure
IP interphalangeal
IPPV intermittent positive pressure
ventilation
IPT interpersonal therapy
IQ intelligence quotient
ISQ in status quo (Latin, no change)
ISS injury severity score
ITP idiopathic thrombocytopenic
purpura
ITU intensive therapy unit
IU/iu international unit
IUCD intrauterine contraceptive device
IUI intrauterine insemination
IV intravenous
IVF in vitro fertilization
IVI intravenous infusion
IVU intravenous urography
JVP jugular venous pressure
K
+
potassium
kg kilogram
kpa kilopascal
L litre
LA local anaesthesia
LBC liquid-based cytology

LCR ligase chain reaction
LDH lactate dehydrogenase
LFT liver function test
LH luteinizing hormone
LHRH luteinizing hormone-releasing
hormone
LMP day
1
of last menstrual period
LMWH low molecular weight heparin
LP lumbar puncture
LVH left ventricular hypertrophy
μ(g) micro(gram)
MAOI monoamine oxidase inhibitor
MCP metacarpophalangeal
MCV mean cell volume
MEA microwave endometrial ablation
MET meta-analysis
mg milligrams (
μg=microgram=mcg)
MHA Mental Health Act
MI myocardial infarction
ML millilitre
mmHg millimetres of mercury
MRI magnetic resonance imaging
MSU midstream urine culture
MTP metatarsophalangeal
mU milliunit(s)
MVA motor vehicle accident
N=

20
* reference to a randomized trial
of
20
patients (* or what ever
number follows
N)
n
=
63
* reference to a non-randomized
trial of
63
patients (* or what
ever number follows n)
N
2
O nitrous oxide
NaCl sodium chloride
NAI non-accidental injury
NBM nil by mouth (no solids or fl uids)
NEJM New England Journal of Medicine
NEPE non-epileptic paroxysmal events
NGT nasogastric tube
NHS National Health Service
NICE National Institute for Health and
Clinical Excellence
NICU neonatal intensive care unit
NMJ neuromuscular junction
NOF neck of femur

NSAID non-steroidal anti-infl ammatory
drug(s)
OAE otoacoustic emissions
OED Oxford English Dictionary, OUP
OHCM
Oxford Handbook of Clinical
Medicine
8
e
, OUP
OM
otitis media
OME otitis media with e usion
OMV open mouth view
ON omni nocte (take at night)
ORh–ve . blood group O, Rh negative
ORIF open reduction and internal fi xation
OT occupational therapist
PA posteroanterior
P
a
CO
2
partial pressure of CO
2
in arterial
blood
PAN polyarteritis nodosa
pANCA . perinuclear antineutrophil
cytoplasmic antibody

P
a
O
2
partial pressure of oxygen in
arterial blood
PC post cibum (after food)
PCA patient-controlled anaesthesia
PCOS polycystic ovarian syndrome
PCR polymerase chain reaction
PCV packed cell volume
x
i
x
i
x
i
x
i
x
i
x
i
xiii
PDA patent ductus arteriosus
PE pulmonary embolus
PET pre-eclamptic toxaemia
PG pemphigoid gestations
PGD preimplantation genetic diagnosis
PICU paediatric intensive care unit

PID pelvic infl ammatory disease
PIP proximal interphalangeal
PKU phenylketonuria
PMB postmenopausal bleeding
PMS premenstrual syndrome
PO per os (Latin for by mouth)
PoP progesterone-only pill
POP plaster of Paris
PPH postpartum haemorrhage
PR per rectum
PTR prothrombin ratio
PUO pyrexia of unknown origin
PUVA psoralen-ultraviolet A
PV
per vaginam (via the vagina)
QOF quality & outcomes framework
 treatment (prescribing drugs)
RA rheumatoid arthritis; regional
anaesthesia
RBC red blood cell
RCGP Royal College of General
Practitioners
RCOG Royal College of Obstetricians
and Gynaecologists
RCT randomized controlled trial
REM rapid eye movement
RMO registered medical o cer
RSD refl ex sympathetic dystrophy
RSI repetitive strain injury; rapid
sequence induction

RTA road tra c accident(s)
RTS revised trauma score
RUQ right upper quadrant
RVH right ventricular hypertrophy
S
1
S
2

1
st
and
2
nd
heart sounds
SAD seasonal a ective disorder
SALT speech and language therapist
SAO
2
arterial blood O
2
saturation,
≈

SpO
2
(allows for carboxyhaemoglobin)
SBE subacute bacterial endocarditis
SC subcutaneous
SCBU special care baby unit

SE side-e ects
sec second(s)
SFH symphysis fundal height
SERM selective oestrogen receptor
modulator
SGA small-for-gestational age
SLE systemic lupus erythematosus
SNHL sensorineural hearing loss
SpO
2
pulse oximetry estimated
S
a
O
2
; no allowance for
carboxyhaemoglobin
SSRI selective serotonin reuptake
inhibitor(s)
stat statim (Latin for once); single dose
STD sexually transmitted disease
STI Sexually transmitted infection
SUFE slipped upper femoral epiphysis
SVC superior vena cava
SVP saturation vapour pressure
syn syndrome
T° temperature, degrees Centigrade
t½ half life
T3 triiodothyronine
T4 thyroxine

TB tuberculosis
TBW tension band wiring
TCRE transcervical resection of
endometrium
TED transverse elastic graduated
TENS transcutaneous electrical nerve
stimulation
TFT thyroid function tests
TIA transient ischaemic attack
ToP termination of pregnancy
TPH transplacental haemorrhage
TPR temperature, pulse, and
respirations
TRTS triage revised trauma score
TSH thyroid-stimulating hormone
TSOH transient synovitis of the hip
U unit(s)
U&E urea and electrolytes
UK United Kingdom
URTI upper respiratory tract infection
US(S) ultrasound (scan)
UTI urinary tract infection
UV ultraviolet
VLBW very low birthweight infant
VSD ventriculoseptal defect
VTE venous thromboembolism
VUR vesico-ureteric refl ux
WCC white blood cell count
wt weight
WR Wasserman reaction

yrs, y years
ZN Ziehl–Neelsen (stain for TB)
Fig 1. This plan is rendered almost unintelligible by over-use of abbreviations. It might mean:
If in status quo (
ISQ=no change in state) in 2 days’ time (/7 in this context means days; /52
would mean weeks), refer to the Sexually Transmitted Infections clinic for treatment (
)—
if it turns out he does not arrive (
DNA), follow-up at the out-patient department.2
x
i
x
i
x
i
x
i
x
i
1 Obstetrics
Pre-pregnancy counselling
2

Hypertension & eclampsia
1

48
Care plans
3
Prematurity

50
Booking criteria
4
Small for gestational age
52
Physiological changes in Large for gestational age
53
pregnancy
6
Postmaturity
54
Obesity
7

Fetal distress
55
Antenatal care
8

Obstetric shock
55
Anti-D
9

Antepartum haemorrhage
56
Prenatal diagnosis
10
Normal labour
58

Tests for Down’s syndrome
12
Membrane rupture
60
Preimplatation tests
13
Induction of labour
62
Placenta
14
Active management of labour
64
Thromboprophylaxis
16
Pain relief in labour
66
Minor symptoms
17
Multiple pregnancy, IVF
68
–
9
Hyperemesis gravidarum
18
Breech
70
Pregnancy & medical conditions

Other malpresentations
71

– Sickle-cell disease
19


Prolapsed cord
72
– Cardiac disease
20

Impacted shoulders
72
– Psychopharmacology
21
Meconium-stained liquor
73
– Anaemia
22
Dystocia
74
– HIV
23
Forceps/ventouse
76
– Diabetes mellitus
24
Caesarean section
78
– Thyroid disease
25


Uterine rupture
80
– Jaundice
26

Mendelson’s syndrome
80
– Malaria
27
Stillbirth
82
– Renal disease
28

Postpartum haemorrhage
84
– Epilepsy
29
Retained placenta
86
– Connective tissue disease
30

Uterine inversion
86
– Hypertension
31

DIC and coagulation defects
88

– Thromboembolism
32

Amniotic fl uid embolism
89
– Thrombophilia
33
Birth injuries
90
,
Ante/perinatal infection
34
–
7
maternal
91
Abdominal pain
38
Episiotomy and tears
92
Abdominal palpation
40
Puerperium
94
Pelvis and head
42
Contraception after a baby
95
Fetal monitoring
44–5

Maternal mortality
96
Ultrasound
46
Perinatal mortality
97
Sources RCOG Green Top guidelines; Saving Mothers’ Lives (Confi dential En-
quiry). 1
Mat
mor
t

2011
Cochrane database (www.liv.ac.uk/lstm/ehcap/pc/nwc-pcl.html).
Relevant topics elsewhere: Neonatology, p
107
–
22
; breastfeeding, p
124
–
6
; rhe-
sus disease, p
116
; ectopic pregnancy, p
262
; miscarriage/termination, p
258
–

60
;
trophoblastic disease, p
264
; fi broids in pregnancy, p
277
; preterm/light-for-
dates babies, p
128
; chickenpox in pregnancy, p
144
; parvo virus B
19
, p
142
; post-
natal depression, p
408
.
1 The term pregnancy-induced hypertension with proteinuria is tending to replace the term
pre- eclampsia. We have not followed this trend as to do so obscures the vital fact about pre-
eclampsia: it may lead on to eclampsia. We favour pre-eclampsia because it is short and sends
the shadow of a shiver down our spines, being a reminder of how dangerous it can be.
We thank Ms Alison Peattie, our Specialist Reader, and Mathuranayagham
Niroshan, our Junior Reader, for their contribution to this chapter.
Obstetrics
1

The essence of reproductive health
Pregnancy is a risky a air for babies and mothers. The textbook causes of

maternal mortality in the
UK are pulmonary embolism, eclampsia, haemor-
rhage, infection, and cardiac diseases, with all the other causes being rare.
But if an obstetrician could be granted one wish, it would not be to abol-
ish these; rather it would be to make every pregnancy planned and desired
by the mother. Worldwide, a woman dies every minute from the e ects of
pregnancy, and most of these women never wanted to be pregnant in the
fi rst place—but either had no means of contraception, or were without the
skills, authority, and self-confi dence to negotiate with their partners. So the
real killers are poverty, ignorance, and the unwieldy desires of men, and the
real solutions entail literacy, economic growth, and an equality of dialogue
between the sexes. Any obstetric or governmental initiatives in reproductive
health which do not recognize these facts are doomed.
2
School-based sex education This can be e ective, if linked to easy access
to contraceptive services. This is the conclusion of a meta-analysis, taking
into account cohort studies (if meta-analyses confi ne themselves to the
15
or so randomized studies, no benefi t is shown). 3 It may be necessary to
foster a knowledge-sharing, skill-promoting environment that is part of a
continuing process, and not a ‘one-o ’ a air—for educational programmes
to work.
Adolescent pregnancy rates:
USA:
116/1000
; UK:
57/1000
; Canada:
50/1000
. In

2007
in England & Wales
160
pregnancy were terminated in
those
<14
years old (out of
~200,000
terminations and
~650,000
live births). 4
Defi nitions
Gravidity refers to the number of pregnancies that a woman has had (to
any stage). Parity refers to pregnancies that resulted in delivery beyond
28
weeks’ gestation. An example of the shorthand way of expressing
pregnancies before and after
28
weeks is: para
2+1
. This means that she
has had
2
pregnancies beyond
28
completed weeks’ gestation, and
1
which
terminated prior to
28

weeks. If she is not pregnant at the time of describing
her she is gravida
3
, but if she is pregnant now she is gravida
4
. Twins present
a problem as there is controversy as to whether they count as
1
for both
parity and gravidity or should count as
2
for parity.
It is unclear whether the cut-o point in these defi nitions should now be
24
weeks, to harmonize with the new defi nition of stillbirth (p
82
). In general,
aim to use proper English rather than the shorthand described above, which
is open to ambiguity. For example, when presenting a patient try something
like: ‘Mrs Cottard is a
32
-year-old lady who is
15
weeks into her
4
th
pregnancy;
the
3
rd

ended in a miscarriage at
17
weeks, and the others came to term with
normal deliveries of children who are now
2
&
8
.’ The bald statement ‘Para
2+1
’
is ambiguous, incomprehensible to the patient, and misses the point that the
patient is now approaching the time when she lost her last baby.
Length of pregnancy: Normal pregnancy is
40
weeks from the LMP. Nae-
gele’s rule: expected delivery date (
EDD)
≈
1
yr and
7
days after LMP minus
3

months (not if last period was a withdrawal bleed; for cycles shorter than
28
days, subtract the di erence from
28
; if longer, add the di erence). A
revised rule suggests the addition of

10
days rather than
7
is more accurate.
Obstetrics
2
Pre-pregnancy counselling
The aim is to help prospective parents embark upon pregnancy under
conditions most likely to ensure optimal fetal and maternal wellbeing. Babies
conceived
18
–
23
months after a live birth have lowest rate of perinatal
problems. 5 Reduce weight if obese (for risks of obesity see p
7
). Ensure the
woman is rubella (
±
chickenpox, p
144
) immune prior to pregnancy; assess need
for thromboprophylaxis in pregnancy (p
16
). Other areas include:
•Optimal control of chronic disease (eg diabetes) before conception. This is
also important for hypothyroidism as the fetus cannot make thyroxine until
12
weeks and under-replacement may a ect neurodevelopment. Strict diet is
essential peri-conceptually for women with phenylketonuria (

PKU).
•Stop teratogens or seek expert advice prior to conception (p
29,
p
31
). Parox-
etine is associated with fetal heart defects in
1
st
trimester use, as is lithium
(rate 
8
:
1000
to
60
:
1000
) with Ebstein’s anomaly  from
1
to
10
per
20 000
.

6
HIV drugs didanosine and efavirenz have teratogenic potential and avoidance
may be possible 7 in fi rst trimester (seek expert advice).
•Medication to protect the fetus from abnormality (eg folate supplements for

neural tube defects, see p
140
and below).
•Provide expert information for those at  risk of abnormality so pregnancy
or its avoidance is an informed choice, and any tests needed (eg chorionic
villus sampling, p
10
) are planned. Regional genetic services give detailed pre-
pregnancy counselling. See p
154
. In relevant ethnic populations, take blood
for thalassaemia and sickle-cell tests (p
22
). If ‘cut’ (p
247
) o er defi bulation.
•Avoidance of infection: eg sperm washing advised if HIV+ve male partner
and
HIV-ve woman
•If past/family history of thromboembolism, screen for thrombophilia.
Diet To prevent neural tube defects (
NTD) and cleft lip, all should have folate-
rich foods
+
folic acid
0
.
4
mg daily

>1
month pre-conception till
13
wks (
5
mg/day
if past
NTD, on anti epileptics, p
29
, obese (BMI

≥30),
HIV+ve on co-trimoxazole
prophylaxis,
8
diabetic 9

or sickle cell disease p
19
).

Foods with
>0
.
1
mg of folic
acid/serving: brussels sprouts, asparagus, spinach, blackeye beans, fortifi ed
cereals. Avoid liver
& vit. A (vit. A embryopathy) & ca eine.
Smoking decreases ovulations, causes abnormal sperm production (

±
less
penetrating capacity),  rates of miscarriage (
≈2
), and is associated with
preterm labour and lighter-for-dates babies (mean
is
3376
g in non-smoker; smoker:
3200
g), placenta
praevia and abruption.

10 Reduced reading ability in
smokers’ children up to
11
yrs old shows that long-
term e ects are important.
~17
% of smoking moth-
ers stop before or in pregnancy.
Alcohol consumption High levels of consump-
tion are known to cause the fetal alcohol syndrome
(p
138
). Mild drinking eg
1
–
2
U/wk has not been shown

to adversely a ect the fetus but alcohol does cross
the placenta and may a ect the fetal brain. Miscar-
riage rates are higher among drinkers of alcohol.
NICE
recommends
<1
U/
24
h. Binge drinking (
>5
U/session) is
especially harmful.

11 To cut consumption: see p
513
.
Spontaneous miscarriage (
SM) Risk of miscarriage
is
8
.
9
% in women aged
20
–
40
yrs, rising to
74
.
7

% for
women
≥45
yrs. After
3
miscarriages, risk of next preg-
nancy failure is
44
.
6
% for nullips aged
25
–
29
yrs, and
35
.
4
% for parous women. 12
Recurrent spontaneous miscarriage See p
261
.
Search for those who
need counselling most
•
Diabetes mellitus
• Tropical travellers
• Frequent miscarriage
• Hypothyroidism
• Epilepsy

• Rubella-susceptible
• Pet-owners (toxo-
plasmosis risk is )
• Phenylketonuria
• BP 
• SLE
• Genetic history, eg:
•spina bifi da etc.
•thalassemia
•Duchenne’s
•cystic fi brosis
et al
†
3
Obstetrics
Individualized care plans—eg for diabetes mellitus

9
For optimal care, when there are many features that need to be addressed
an individualized care plan can help. The example below is of a care plan
for diabetic women. The care plan is a chance for dialogue between the
mother and her carers: all must sign-up to it. Placed in her notes it should
be consulted throughout pregnancy when the woman is seen. In the case
of a diabetic pregnancy the woman should be seen in a joint clinic where
a multidisciplinary team is available comprising obstetrician, diabetes
physician, diabetic specialist nurse, diabetes midwife, and dietician.
The care plan should cover the antenatal period and up to
6
weeks
post-partum. It can be individualized, and generally includes advice about:

•Aspirin
75
mg/
24
h PO until delivery to reduce pre-eclampsia risk. 
13
•Targets for glycaemic control (p
24
for levels; pregnant mother to liaise every
2
weeks with diabetic team concerning blood readings).
•Retinal digital screening with mydriasis schedule (as soon as possible after
pregnancy confi rmed if not screened in previous
12
months; after
1
st
ante-
natal appointment and again at
16
–
20
weeks if retinopathy seen on initial
screen in pregnancy and at
28
weeks if none seen at initial screening). 
14
Up
to
20

% develop proliferative retinopathy.
•Renal screening schedule (for microalbuminuria as well as dipstix protein,
at
1
st
appointment if not screened in previous
12
months). Refer to
nephrologist if creatinine
≥120
μmol/L or protein excretion
>2
g/day. Give
thromboprophylaxis if protein excretion
>5
g/day.
•Fetal surveillance (eg
4
chamber and outfl ow tract echo at
20
weeks;
ultrasounds at
28
,
32
, and
36
weeks for fetal growth and amniotic fl uid
depth and cardiotocogram eg twice weekly from
38

weeks if she chooses to
await spontaneous labour rather than accepting induction/caesarean sec-
tion when o ered at
38
weeks) earlier if growth restriction seen.
•Plan for delivery. If co-morbidity such as neuropathy or obesity arrange
anaesthetic assessment at
36
weeks.
•Diabetes care after delivery.
If macrosomia is found on ultrasound the consultant obstetrician should
then write a clear plan to determine follow-up scans, fetal surveillance, and
mode and time of delivery.
For postnatal care the care plan should include, as a minimum:
•Plan for managing glycaemic control (eg return to pre-pregnancy regimen).
•Neonatal care: feed as soon as possible then
2
–
3
hrly to prevent hypoglycae-
mia. Check glucose level at
2
–
4
h after birth, and if signs of hypoglycaemia.
Give
IV glucose to baby if symptomatically hypoglycaemic. Tube feed or give
IV glucose if
2
consecutive readings

<2
mmol/L despite maximal feeding or
if unable to feed. Do not discharge to community until
>24
h old, feeding well
and able to maintain glucose levels.
•Contraception (currently mothers with the worst obstetric outcomes are
the least likely to receive contraceptive advice).
•Follow-up care after discharge from hospital (eg glucose tolerance test
6

weeks postpartum and annually to see if still diabetic in gestational dia-
betes).
•How to access pre-pregnancy review prior to subsequent pregnancies.

The advantage of care plans is that by documenting the plan, it ena-
bles members of the team (including the mother and father, for they
are frequently the most reliable at making sure things happen if they know
what is expected) to check that pregnancy is monitored as planned.
4
Obstetrics
Booking criteria and home delivery
Most women in the UK have ‘shared obstetric care’—ie most of their antenatal
care is from the community midwife (
±
GP), with limited (or no) visits (usually
2
) to the hospital to see the consultant under whose care they are delivered,
returning home (eg after
6

–
72
h) for postnatal care. A minority receive their
complete care from hospitals and the usual reasons for this are that the compli-
cations envisaged make full consultant care desirable. Some women are cared
for by community midwives and their
GP, but increasingly, low-risk women are
receiving all their care from midwives, with doctors involved only if complica-
tions arise. Delivery may be in hospital in consultant- or midwife-led units, or,
more rarely, at home.
There is quite good evidence that consultant input into
antenatal care of normal pregnancies achieves no added benefi ts (p
8
)—but risk
factors making specialist visits and booking desirable are generally agreed (see
MINIBOX).
Is it safe for low-risk mothers to deliver in high-
technology hospitals? Here interventions with their
complications are more common. In the
UK this
question is usually academic (unless a midwife-led
delivery unit is available) as most
GPs are reluctant
to conduct births—and
6
months’ training in obstet-
rics gives scant skill. The rising birth rate and service
pressures are putting these big hospitals under great
strain. In places (eg New Zealand, Holland) where
delivery outside of big hospitals is the norm, there is

fairly clear (but not uncontested
) evidence that on
all measures, and in all but the highest risk groups,
big hospitals come out less favourably. The few trials
seeming to favour high-technology are now recog-
nized to be seriously fl awed.
Home delivery (Rare in England:
2
.
8
% of births in
2007
at home,
2
% in freestanding midwifery units,
3
% in alongside midwifery units.) Data comparing
morbidity and mortality in home vs hospital delivery
is sparse but a
2008
–
10 (
N
=65,438)
study showed in-
creased morbidity and high rate of transfer in labour
for nullips. 15 But an important observation is that
rapid intervention is necessary to save life (maternal
or fetal) in
~5

% of low-risk pregnancies. This pin-
points the need for any domiciliary service to have
good equipment available for home delivery and good
emergency back-up (eg by emergency obstetric am-
bulance units—ie specially trained ambulance per-
sonnel who, it is hoped, will liaise directly with senior
medical obstetric sta in hospital).
Birth centres o er homely birth in congenial sur-
roundings (eg with purpose-designed birthing
pools). Formerly, labour ward facilities were nearby,
if needed, and the mother was attended by her
GP and community midwife. A
randomized trial showed that mothers’ satisfaction is great, and nearly all re-
quested this type of delivery for future births. 16 Such centres may o er a com-
promise to adherents of home delivery, and go a long way towards celebrating
rather than medicalizing birth. But we note that new
UK birth centres may be en-
tirely run by midwives, so if an obstetrician is needed (or an epidural) a lengthy
and possibly risky journey is needed. 17
www.birthchoiceuk.com.
Risk factor—vis à vis:
The mother
•
>40
yrs old
•Nullip
<20
or
>34
yrs

•History of infertility
•

≥
5
past pregnancies
•Multip
<154
cm tall
•Primip
<158
cm tall
•Obese with
BMI
≥
35
•Social deprivation
•
HBSAg or HIV
+
ve p
34
Past deliveries
•
Preterm or small (
<37

weeks,
<2.5
kg)

•Deformity, still-birth, or
neonatal death
•Caesarean section
•Hysterotomy
•Retained placenta/
PPH
•Placental abruption
•Had pelvic fl oor repair
•Instrumental deliveries
•Poor fetal growth or
wellbeing
•Diabetes, 
BP, anaemia
•Malpresentations after
34
weeks
•Serum -fetoprotein 
This pregnancy
•Cardiac/thyroid disease
•Renal/liver disease
•Multiple pregnancy
•Rh antibodies (p
116
)
•Autoimmune disorders
•Asthma/epilepsy
5
Obstetrics
5
Issues surrounding home delivery

1
Remember that normal delivery is a retrospective diagnosis.
•In the UK, because of past hospital experience of many abnormal labours,
GPs are often very wary of home birth.
•Medico-legal aspects tend to dominate thoughts about worst-case
scenarios—so that few
GPs willingly take on intrapartum care.
•It’s not clear who is to do the doctor’s ordinary work when absent on a
home delivery, if a mother particularly wants their
GP present. Some small
surgeries have had to close during delivery as no locum was available—an
unacceptable consequence of o ering mothers extra choice.
NB: in the UK,
midwives, but not
GPs, have a statutory duty to help at home deliveries.
•It is not clear if there are enough doctors or midwives with the necessary
experience in suturing and neonatal resuscitation. Where there is a good
team, there is no doubt that home delivery can be a safe and rewarding
experience.
•Decisions about the place of labour are dynamic, and need revising (eg in
29
%) as events in pregnancy unfold.
•Necessary equipment is not readily available, eg Entonox.®
•The key factor in increasing choice about home delivery is a good working
relationship between the parents, the
GP, and the midwife. Where this ex-
ists,
~70
% of home delivery requests tend to come to fruition; where the
GP is rated as being unsupportive, in a UK context, this fi gure drops to

54
%.
•Everyone needs to know that transfer in labour is common in labours start-
ing o as planned home deliveries (
9
–
14
% if multip,
36
–
45
% if primip)—
and there is excess morbidity for primips, though levels are still low.
18
•It is salutary to note that
<20
% of pregnancies in England and Wales are
considered ‘normal’ and without antenatal or postnatal complications.
19 If
normal delivery is defi ned as delivery without use of general anaesthetic,
induction, epidural, instrumentation or surgical intervention, the normal
delivery rate in England in
2003
was
51
%. 20 In the
2008
–
2010
study it was

58
% for planned obstetric unit birth,
76
% alongside midwifery unit,
83
%
freestanding midwifery unit and
88
% for home birth. 18 However, over-
medicalization is a real problem too, eg in
≥20
% of labours (p
58
).
•Intrapartum perinatal mortality rate for intended home delivery (
1994
–
2003
) was
0
.
48
:
1000
births for intended home delivery,
1
.
42
:
1000

for un-
intended home delivery, and
6
.
05
:
1000
births for women transferred to
another place for delivery.
21 Average intrapartum mortality for England
and Wales for all births for this period was
0
.
79
:
1000
births.
Indications for intrapartum transfer
•Malpresentation or breech in labour
•Signifi cant meconium-stained liquor
•Fetal heart monitoring indication including heart rate abnormalities (p
44
)
•Delay in
1
st
or
2
nd
stage labour

•Epidural pain relief requested
•Maternal T
o
>38
, or twice T
o

>37
.
5,

2
h apart
•Retained placenta (p
86
)
•Maternal BP raised
+140
/ and/or
+
/
90
•Uncertainty if fetal heart heard
•Emergency: (ante/post-partum haemorrhage, cord presentation/prolapse,
maternal collapse or need for advanced neonatal resuscitation)
•
3
rd
or
4

th
degree vaginal tear or other complicated perineal repair needed.
When considering transfer bear in mind imminence of birth.
6
Obstetrics
Physiological changes in pregnancy
Hormonal changes Progesterone, synthesized by the corpus luteum until
35
post-conception days and by the placenta mainly thereafter, decreases
smooth muscle excitability (uterus, gut, ureters) and raises body temperature.
Oestrogens (
90
% oestriol) increase breast and nipple growth, water reten-
tion, and protein synthesis. The maternal thyroid often enlarges due to in-
creased colloid production. Thyroxine levels, see p
25
. Pituitary secretion of
prolactin rises throughout pregnancy. Maternal cortisol output is increased
but unbound levels remain constant.
Genital changes The
100
g non-pregnant uterus weighs
1100
g by term. Mus-
cle hypertrophy occurs up to
20
weeks, with stretching after that. The cervix
may develop ectropion (‘erosions’). Late in pregnancy cervical collagen reduc-
es. Vaginal discharge increases due to cervical ectopy, cell desquamation, and
 mucus production from a vasocongested vagina.

Haemodynamic changes Blood: From
10
weeks the plasma volume rises un-
til
32
weeks when it is
3
.
8
litres (
50
%
>
non-pregnant). Red cell volume rises
from
1
.
4
litres when non-pregnant to
1
.
64
litres at term if iron supplements not
taken (
18
%), or
1
.
8
litres at term (

30
%) if supplements are taken—hence Hb
falls due to dilution (physiological ‘anaemia’).
WCC (mean
10
.
5

≈

10
9
/L), plate-
lets,
ESR (up
4
-fold), cholesterol, -globulin, and fi brinogen are raised. Albumin
and gamma-globulin fall. Urea and creatinine fall.
Cardiovascular: Cardiac output rises from
5
litres/min to
6
.
5
–
7
litres/min in
the fi rst
10
weeks by increasing stroke volume (

10
%) and pulse rate (by
~15

beats/min). Peripheral resistance falls (due to hormonal changes).
BP, particu-
larly diastolic, falls during the second trimester by
10
–
20
mmHg, then rises to
non-pregnant levels by term. With increased venous distensibility, and raised
venous pressure (as occurs with any pelvic mass), varicose veins may form.
Vasodilatation and hypotension stimulate renin and angiotensin release—an
important feature of
BP regulation in pregnancy.
Aorto-caval compression From
20
weeks the gravid uterus compresses the
inferior vena cava (and to a lesser extent the aorta) in supine women reducing
venous return. This reduces cardiac output by
30
–
40
% (so-called supine hypo-
tension). Placing the woman in left lateral position or wedging her tilting
15
°

to the left relieves the pressure and restores cardiac output.

Other changes Ventilation increases
40
% (tidal volume rises from
500
to
700
mL), the increased depth of breath being a progesterone e ect. O
2
con-
sumption increases only
20
%. Breathlessness is common as maternal P
a
CO
2
is
set lower to allow the fetus to o oad CO
2
. Gut motility is reduced, resulting
in constipation, delayed gastric emptying, and, with a lax cardiac sphincter,
heartburn. Renal size increases by
~1
cm in length during pregnancy.
Frequency of micturition emerges early (glomerular fi ltration rate  by
60
%),
later from bladder pressure by the fetal head. The bladder muscle is lax but
residual urine after micturition is not normally present. Skin pigmentation (eg
in linea nigra, nipples, or as chloasma—brown patches of pigmentation seen
especially on the face), palmar erythema, spider naevi, and striae are common.

Hair shedding from the head is reduced in pregnancy but the extra hairs are
shed in the puerperium.
Pregnancy tests Positive eg from
9
days post-conception (or from day
23

of a
28
-day cycle) until
~20
weeks of pregnancy; they remain positive for
~5

days after miscarriage or fetal death. Otherwise, the false
+
ve rate is low. They
detect the -subunit of human chorionic gonadotrophin in early morning urine,
so are positive in trophoblastic disease (p
264
).
†
7
Obstetrics
Maternal obesity a ects the fetus adversely,
casting a long fat shadow over the baby’s adult
life (with risk of heart disease, diabetes, the met-
abolic syndrome and some cancers, eg breast,
lung).
23 Epigenetic mechanisms (

p653
) mean that
the over- (and under)nutrition may infl uence not
just this baby, but subsequent generations down
the centuries.
24 There is also risk of macrosomia,
meconium aspiration. 25 Incidence is rising in the
UK and women with a BMI
>35
constitute
15
% of
mothers dying, and almost
50
% of those dying
from thromboembolism are obese.

As mothers may be more motivated to accept lifestyle modifi cations,
pregnancy is a period during which obesity can be more e ectively man-
aged. Control of body weight during this period is vital. Aim to encour-
age weight loss well before embarking on planned pregnancy.
NB: dieting
during pregnancy may not be wise as low weight gain during pregnancy
correlates with lighter babies more prone to postnatal problems.
26 Good
evidence is lacking. Lowest neonatal mortality is for birth weights of
3500
–
4500
g and maternal weight gain depending on BMI: 27

BMI
<19
.
8
recommended total weight gain (not twins):
12
.
5–18
kg
19
.
8–26 11
.
5–16kg
26
.
1–29
.
0 7–11
.
5kg
>29 2*–6kg
*Assuming personal coaching and using a food diary (“I didn’t eat the
cake as I knew I’d have to write it down, so I chose fruit instead ”). Some
may need no weight gain.
medicinenet.com/script/main/art.asp?articlekey
=
100897
2010

CMACE/RCOG guidelines recommend giving
5
mg folic acid from
1

month before conception and for the fi rst trimester if
BMI
≥30
to prevent
increased risk of neural tube defects. Obese women are more prone to
vitamin
D defi ciency so ensure they are taking
10
μg vitamin D supplemen-
tation while pregnant and breastfeeding. If
BMI
≥30
, screen for diabetes,
eg oral glucose tolerance test at
24
–
28
weeks and consider heparin throm-
boprophylaxis for
7
days postnatally if one additional thrombotic risk fac-
tor (p
16
), with addition of TED stockings if
2

risk factors. Mobilize all obese
women early. If women with
BMI
≥30
require caesarean section, give IV
prophylactic antibiotics and, if subcutaneous fat is
>2
cm thick, suture that
separately, to prevent infection.
Women with
BMI
≥40
should always receive
7
-day postnatal heparin
prophylaxis and
TED stockings whatever the mode of delivery. They should
have an antenatal consultation with an obstetric anaesthetist with an an-
aesthetic plan made for labour and delivery, and need
3
rd
trimester assess-
ment to plan manual handling requirements and provision of appropriate
TED stockings. When in labour inform anaesthetist. They should have con-
tinuous midwifery care and should have an
IV sited early in labour. If opera-
tive delivery is required the attending anaesthetic should be a consultant (or
signed o obese-competent) obstetric anaesthetist.
Pregnancy and obesity 22 (BMI >30 at booking, p530)
"Eating for 2 is the only nice thing about being pregnant"

For mothers, obesity in-
creases prevalence of:
•Miscarriage
•Pre-eclampsia
•Gestational diabetes
•Thromboembolism
•Cardiac disease
•Induced labour
•Caesarean section
•Infection (eg post-op)
•
PPH
•Maternal mortality
•Feeding by bottle
Obstetrics
8
The aims of antenatal care are to: • Detect any disease in the mother
• Ameliorate the discomforts of pregnancy • Monitor and promote fetal well-
being
• Prepare mothers for birth • Monitor trends to prevent or detect any
early complications of pregnancy:
BP is the most important variable (eclampsia,
p
48
). • Is thromboprophylaxis (p
16
) or aspirin (p
3
and p
31

) needed?
Who should give antenatal care? Midwives may manage care, calling in doc-
tors if risks (p
4
) or specifi c needs arise. Book by
12
weeks: see within
2
weeks if
already
≥12
weeks pregnant. Women with BMI
≥35
need consultant care.
The 1
st
antenatal visit is very comprehensive. Find a language interpreter if
she needs one. Avoid using relatives (confi dentiality issues). History:
•Usual cycle length; LMP (a normal period?); see Naegele’s rule (p
1
).
•Contraception; drugs; past history, eg surgery to abdomen or pelvis.
•Any fertility problems; outcome and complications of past pregnancies.
•Is there family history of diabetes, BP, fetal abnormality, or twins?
•Does she have concurrent illness (p
20
–
35
)? Has she been ‘cut’ (p
247

). If past
or family history of
DVT or embolism, screen for thrombophilia.
•Is gestational diabetes (GDM) a risk? Screen (
75
g glucose tolerance test) at
18 ± 28
wks) if previous (GDM); at
24
wks if BMI
>30
, previous baby
>4
.
5
kg,
1
st

degree relative diabetic, family origin (
FO) from area of high risk of diabetes.
•Past mental illness? If serious (schizophrenia, bipolar disorder) or past post-
natal problems, get antenatal assessment; put management plan in notes.
•Is she poor (eg gas/electricity supply cut o )? Unmarried? Unsupported?
Subject to domestic violence? (p
514
) A substance abuser? (p
362
). ‘Healthy
Start Vitamins for Women’—folic acid

+
vitamins C & D (
10
μg/d) are free to
some during pregnancy and for
1
year after birth (Healthy Start Scheme
UK
).
•Avoid pâtés & blue/soft cheese (eg Brie, Camembert, to avoid listeria, p
35
);
Toxoplasmosis advice: p
34
. Avoid liver (p
2
). Advise UK mothers to have vita-
min
D (above) if family of origin is African, or as listed below,
1
or housebound,
covered when outdoors, have
BMI
>30
, or are diet vit. D depleted.
2
Examination: Check heart, lungs, BP, weight (record BMI), and abdomen. Is a
cervical smear needed? Varicose veins? Sensitively ask if genitally ‘cut’ (p
246
).

Tests: Blood: Hb, group (antibodies if Rh–ve, p
116
), syphilis & rubella (
±
chick-
en-pox) serology,
HBsAg (p
36
& p
26
) HIV test; sickle test if black, Hb electro-
phoresis (p
22
) and
25
-hydroxyvitamin D if relevant. 28 Take an MSU (protein;
bacteria). Arrange tests to exclude Down’s (p
12
). If she is foreign, a TB contact,
or a hospital worker, consider
CXR after
14
weeks.
O er early ultrasound to establish dates, exclude multiple pregnancy and aid
with Down’s tests and an
18
–
20
-week anomaly scan.
Suggest: Parentcraft/relaxation classes; dental visit. Enquire about problems

and anxieties. Consider need for iron and folate (p
85
and p
22
).
Advise on: Smoking, alcohol, diet, correct use of seat belts (above or below
the bump, not over it) and adequate rest. Ensure knowledge of social secu-
rity benefi ts. Usual exercise and travel are
OK (avoid malarious areas) up to
36

weeks (singleton): 29 check with airline. Intercourse
OK if no vaginal bleeding.
Later visits Check urine for albumin,
BP, fundal height. Check lie and presen-
tation at
36
weeks. Do Hb and Rh antibodies at
28
&
34
weeks and give anti-D
then if needed (p
9
). Visits are at
<12
weeks then at
16, 25, 28, 31, 34, 36, 38, 40,
and
41

weeks (primip). Weigh only if clinically indicated.
The head is usually engaged (p
40
) by
37
weeks in Caucasian primips (if not,
consider: large (or malpositioned) head, small pelvis or obstruction, placenta
praevia, or wrong estimation of dates).
1 FO
=
family of origin from India, Pakistan, Bangladesh, Saudi Arabia, United Arab Emirates, Iraq, Jor-
dan, Syria, Oman, Qatar, Kuwait, Lebanon, Egypt, or if black Caribbean.
2 Vitamin
D containing foods include oily fi sh, meat, eggs, fortifi ed margarine, and breakfast cereal.
Antenatal care
