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Challenging Concepts in Obstetrics and Gynaecology Titles in the Challenging Concepts in series Anaesthesia (Edited by Dr Phoebe Syme, Dr Robert Jackson, and Professor Tim Cook) Cardiovascular Medicine (Edited by Dr Aung Myat, Dr Shouvik Haldar, and Professor Simon Redwood) Emergency Medicine (Edited by Dr Sam Thenabadu, Dr Fleur Cantle, and Dr Chris Lacy) Infectious Disease and Clinical Microbiology (Edited by Dr Amber Arnold and Professor George Griffin) Interventional Radiology (Edited by Dr Irfan Ahmed, Dr Miltiadis Krokidis, and Dr Tarun Sabharwal) Neurology (Edited by Dr Krishna Chinthapalli, Dr Nadia Magdalinou, and Professor Nicholas Wood) Neurosurgery (Edited by Mr Robin Bhatia and Mr Ian Sabin) Obstetrics and Gynaecology (Edited by Dr Natasha Hezelgrave, Dr Danielle Abbott, and Professor Andrew Shennan) Oncology (Edited by Dr Madhumita Bhattacharyya, Dr Sarah Payne, and Professor Iain McNeish) Oral and Maxillofacial Surgery (Edited by Mr Matthew Idle and Group Captain Andrew Monaghan) Respiratory Medicine (Edited by Dr Lucy Schomberg and Dr Elizabeth Sage) Challenging Concepts in Obstetrics and Gynaecology Cases with Expert Commentary Edited by Dr Natasha Hezelgrave NIHR Clinical Research Fellow in Obstetrics, Women’s Health Academic Centre, King’s College London, UK. Dr Danielle Abbott Clinical Research Fellow, Women’s Health Academic Centre, King’s College London, UK. Professor Andrew H. Shennan Professor of Obstetrics, Women’s Health Academic Centre, King’s College London, UK Series editors Dr Aung Myat BSc (Hons) MBBS MRCP BHF Clinical Research Training Fellow, King’s College London British Heart Foundation Centre of Research Excellence, Cardiovascular Division, St Thomas’ Hospital, London, UK Dr Shouvik Haldar MBBS MRCP Electrophysiology Research Fellow & Cardiology SpR, Heart Rhythm Centre, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton & Harefiled NHS Foundation Trust, Imperial College London, London, UK Professor Simon Redwood MD FRCP Professor of Interventional Cardiology and Honorary Consultant Cardiologist, King’s College London British Heart Foundation Centre of Research Excellence, Cardiovascular Division and Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK 1 3 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom 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 in certain other countries © Oxford University Press, 2014 The moral rights of the authors have been asserted Impression: 1 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 work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2014947259 ISBN 978–0–19–965499–4 Printed in Great Britain by Ashford Colour Press Ltd, Gosport, Hampshire Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent 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. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work. FOREWORD I feel honoured to be asked to write the foreword for this new book Challenging Concepts in Obstetrics and Gynaecology as I believe that it offers the reader a new learning experience. It is well recognised in educational circles that each of us learns in different ways and the majority use a plurality of methods to embed knowledge, skills, and attitudes. The use of storytelling in learning is increasingly acknowledged as a powerful part of the teaching armamentarium. This new book combines the stories of women presenting with complex clinical conditions with a holistic exploration of the issues that the obstetrician and gynaecologist needs to consider in order to manage these patients most effectively. The cases cover all areas of obstetrics and gynaecology without being a reading list ticking off elements of the curriculum. Each case is written by a doctor in postgraduate medical training supported by a local mentor with comments and further emphasis on essential learning points from international experts. It is therefore up to date and relevant to cases that the reader will face in their practice. The layout makes it easy to read extracts and presents learning points, clinical tips, and identifies the evidence base for further reading. I would recommend this book as a must to all in Obstetrics and Gynaecology as a readily available resource to deliver best care to your patients and as a teaching aid to learn or pass on those clinical gems we all value so much. Diana Hamilton-Fairley MD, FRCOG, Consultant Obstetrician and Gynaecologist, Director for Health Education and Quality, South London CONTENTS Expert Faculty Profiles vii Contributors x Abbreviations xii MRCOG syllabus: curriculum map xvi ATSM curriculum guide xvii Case 1 A ‘classic’ case of heavy menstrual bleeding? 1 Case 12 The challenges and controversies of pregnancy and diabetes 147 Case 13 HIV in pregnancy: the dilemmas of management 161 Case 14 SLE in pregnancy: lupus nephritis flare or pre-eclampsia—a diagnostic challenge 177 Case 15 Management of a pregnant woman with morbid obesity 191 Case 16 Early-onset preeclampsia: balancing maternal and neonatal morbidity 201 Case 17 Vaginal birth after caesarean section 213 Case 2 Severe endometriosis in a young woman with unexpected end-organ failure 15 Case 3 Pregnancy of unknown location: a diagnostic and management dilemma 31 Case 4 Pre-implantation genetic diagnosis in oligozoospermia 49 Case 18 Maternal pyrexia: challenges in optimal perinatal management 229 Case 5 Recurrent miscarriage: is conservative management the best we can offer? 59 Case 19 Forewarned is forearmed in massive obstetric haemorrhage 243 Case 6 Lethal congenital abnormalities: the importance of a multidisciplinary approach 73 Case 20 Premature ovarian failure: not the same as the ‘normal’ menopause 259 Case 21 Treating urinary incontinence: an evolving challenge for us all 269 Case 22 Post-menopausal bleeding 287 Case 23 Recurrent ovarian cancer 303 Case 7 Monochorionic diamniotic twin pregnancy complicated by twin–twin transfusion syndrome Case 8 ‘Rescue’ cerclage after bulging membranes at 22 weeks: delaying the inevitable? 81 97 Case 9 Early-onset fetal growth restriction 111 Case 24 Cervical cancer 319 Case 10 Dilemmas of preterm birth 121 Index 335 Case 11 Pulmonary hypertension in pregnancy 133 EXPERT FACULTY PROFILES Professor Susan Bewley, Professor of Complex Obstetrics, Women’s Health Academic Centre, King’s College London, UK Dr Sarah P Blagden, Consultant Medical Oncologist and Academic Senior Lecturer, West London Cancer Network and Ovarian Cancer Action Research Centre, Imperial College London, London, UK Dr Fiona Denison, Senior Lecturer and Honorary Consultant in Maternal and Fetal Medicine, MRC Centre for Reproductive Health, Queen’s Medical Research Institute, Edinburgh, UK Dr Ben Fitzwilliams, Consultant Obstetric Anaesthetist, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Dr Christina Fotopoulou Consultant and Adjunct Professor in Gynaecological Oncology, West London Gynaecological Cancer Centre and Ovarian Cancer Action Research Centre, Imperial College Healthcare Academic NHS Trust, London UK Professor Ian Greer, Consultant Obstetrician and Gynaecologist, Faculty of Health & Life Sciences, University of Liverpool, Liverpool, UK Dr Mohamad Hamady, Consultant and Honorary Senior Lecturer in Clinical and Interventional Radiology, Imperial College Healthcare NHS Trust, London, UK Dr Judith Hamilton, Consultant Gynaecologist, Early Pregnancy & Acute Gynaecology Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Dr Kate Harding, Consultant Obstetrician, Guy’s and St Thomas’ NHS Foundation Trust Professor Jenny Higham, Professor and Honorary Consultant Gynaecologist, Imperial College Healthcare NHS Trust, London, UK Dr Fuad Hussain, Consultant Radiologist, Royal Surrey County Hospital, Guildford, UK Mr Lawrence W Impey, Consultant Obstetrician, John Radcliffe Hospital, Oxford University, Oxford, UK Dr Ed Johnstone, Clinical Senior Lecturer in Obstetrics and Fetal Medicine, University of Manchester, UK viii Expert Faculty Profiles Professor Sean Kehoe, Lawson Tait Professor of Gynaecological Cancer, School of Cancer Studies, University of Birmingham, UK Mr Con Kelleher, Consultant Gynaecologist, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Mr Andrew Kent, Consultant Gynaecologist, Royal Surrey County Hospital, Guildford, UK Professor Henry Kitchener, Professor of Gynaecological Oncology, Institute of Cancer Sciences, University of Manchester, UK. Professor Sailesh Kumar, Professor of Fetal Medicine, Obstetrics & Gynaecology, Mater Research Institute, University of Queensland, Brisbane, Australia Professor Pippa Kyle, Professor of Fetal Medicine, Fetal Medicine Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Dr Kate Langford, Consultant Obstetrician/Deputy Medical Director Guy’s & St Thomas’ NHS Foundation Trust, London, UK Professor William Leigh Ledger, Professor and Head of Discipline of Obstetrics and Gynaecology, University of New South Wales, Royal Hospital for Women, Sydney, Australia Dr Geraint Lee, Consultant Neonatologist, Guy’s and St Thomas’ NHS Foundation Trust, London, UK. Professor David Luesley, Emeritus Professor of Gynaecological Oncology, School of Cancer Sciences, University of Birmingham, UK Professor Neil Marlow, Professor of Neonatology, Institute for Women’s Health, University College London, UK Professor David R McCance, Consultant Physician/ Honorary Professor of Endocrinology, Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, UK Professor Catherine Nelson-Piercy, Professor of Obstetric Medicine, Women’s Health Academic Centre, King’s Health Partners, Consultant Obstetric Physician, GSTFT and Imperial College Health Care Trust, London, UK Dr Susan E Robinson, Consultant Haemotologist, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Professor Timothy A Rockall, Consultant Surgeon, Director of Minimal Access Therapy Training Unit, Royal Surrey County Hospital, Guildford, UK Expert Faculty Profiles Dr Annemiek de Ruiter, Consultant in Genitourinary Medicine and and HIV, Guy’s & St Thomas’ NHS Foundation Trust, London, UK Professor Janice Rymer, Professor of Gynaecology, Women’s Health Academic Centre, King’s College London, UK Professor Andrew H Shennan, Professor of Obstetrics, Women’s Health Academic Centre, King’s College London, UK. Professor Philip J Steer, Emeritus Professor of Obstetrics, Imperial College London, Academic Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, London, UK Dr Lorna Swan, Consultant Cardiologist/Clinical Lead for Adult Congenital Heart Disease, Royal Brompton Hospital, London, UK Dr Jason Waugh, Consultant in Obstetrics and Maternal Medicine, Newcastle upon Tyne NHS Foundation Trust, Newcastle, UK External Reviewers Dr Deborah Bruce, Dr Kate Langford, Dr Lucy Chappell, Mr Geoff Lane, Dr Johanna Trinder, Dr Alex Digesu, Mr James English, Dr Sharmistha Guha, Dr Vik Khullar, Dr Kate Harding, Mr Con Kelleher, Professor Pippa Kyle, Dr Joanna Girling, Dr Melanie Allan, Dr Jane Norman, Professor Andrew Shennan, Professor Scott Nelson, Dr Sonji Clarke, Professor Sailesh Kumar, Mr Kumar Kunde, Miss Diana Hamilton-Fairley ix