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 Univer sity \200\231s objective of excellence in research, scholarship, and education by publishin g worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and cer tain other countries. Published in the United States by Oxford University Press Inc., New Y ork Oxford University Press, 2013 The moral rights of the authors have been asserted Translations: Greek Spanish German Hungarian Fifth edition 1999 Sixth edition 2003 Seventh edition 2006 Eighth edition 2008 First published 1987 Second edition 1989 Third edition 1991 Fourth edition 1995 Romanian Russian Polish Portuguese All rights reserved. No part of this publication may be reproduced, stored in a retrieval s ystem, 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 license or under terms ag reed with the appropriate reprographics rights organization. Enquiries concerning reproduct ion outside the scope of the above should be sent to the Rights Department, Oxford Universi ty 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 Cataloging in Publication D ata Data available Library of Congress Cataloging in Publication Data Data available Typese t by GreenGate Publishing Services, Tonbridge, UK; printed in China on acid-free paper thro ugh CC Off 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 d oses on the basis of ideal body weight (IBW): see p621. We have made every eff 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 co rrect. Readers are urged to check with the most up-to-date product information, codes of co nduct, 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 mater ial in this work. \200\207For updates/corrections, see oup.co.uk/academic/medicine/handbooks/updates. Contents Front cover Back cover Drugs Preface to the ninth edition Preface to the \201 rst edition v Con \202 icts of in terest: 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 pronou ns x Symbols and abbreviations xi ii iv 1 Obstetrics 2 Pediatrics 3 Gynecology 4 Psychiatry 5 Ophthalmology 6 Primary care 7 Ear, n ose and throat diseases 8 Dermatology 9 Anesthesia 10 Unusual eponymous syndromes 11 Orthop edics and trauma 12 Pre-hospital immediate care 1 98 240 312 410 466 534 582 612 638 656 790 817 The content of each chapter is detailed on each chapter \200\231s \201 rst page. Index Preface This is the \201 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 expen se of another (their doctor). It is an unsettling paradox that when we study medicine our o wn health goes out of the window ( \201 g 1), with long hours of coal-face working often w ithout joy or sustenance as our health is shattered by the weight of an over-full curriculu m (no doubt because there are too many organs and we know far too much about them). What can a book do about this defenestration ( \201 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 bo ok intends to make plain the idea that for every such spiral of down-drill- ing, there is a corresponding upward spiral (the swarf, \201 g 2) towards the in \201 nite \200\224and we aim the help the reader \201 nd the jumping-off point where these spirals intersect, s o that the movement down (reductionism) is complemented by a movement up (integrative medic ine). Can this in \202 uence the heath of our readers? The answer lies in a single word: e nlightenment. Fig 1. Defenestration 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 opp or- tunity to widen the horizons of your patients, or to have your own hori- zons widened b y 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 \200\224and from this prem ise it is a short step to accept that a resilient mind is central to maintaining heath. We aim to \201 nd magnetic correspondences in the jumping-off points between the down- ward- drilling helix and the upward-spinning swarf-spirals using philosophy, literature, humor, a nd tinctures of hope. Ultimately we would like readers to develop their own methods, thereb y converting passive acceptance of an overfull curriculum into wealth, life, and beauty. Fig 2. Swarf \200\234The way up is the way down \200 Whether on the shores of Asia, or in the Edg- ware Road. \200\235 The dry salvages TS Eliot; 1941 JABC, KM & JML \200\224Preface to the 9th edition \200\224Cape Clear iv Preface to the 1st Edition When someone says that he is \200\230doing obstetrics \200\231 \200\224or whatever, this should not hide the fact that much more is being done besides, not just a little of each of medicine, psychiatry, gynecology and pediatrics, but also a good deal of work to elicit an d act upon the patient \200\231s unspoken hopes and fears. At the operating table he must c oncentrate 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 t o be on the operating table, and how this might have been prevented. All the best special- ists practice a holistic art, and our aim is to show how specialism and holism may be succe ssfully interwoven, if not into a fully watertight garment, then at least into one which ke eps 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 medic ine a little less exhausting, so allowing more energy to be spent at the bedside, and on th e wards. For a medical student coming fresh to a specialty the great tomes which mark the r oad to knowledge can numb the mind after a while, and what started out fresh is in danger o f becoming exhausted by its own too much. It is not that we are against the great tomes the mselves \200\224we are simply against reading them too much and too soon. One starts off st rong on \200\230care \200\231 and weak on knowledge, and the danger is that this state of aff airs becomes reversed. It is easier to learn from books than from patients, yet what ou r patients teach us may be of more abiding signi \201 cance: the value of sympathy, the us es 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 t omb, 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 serve d its purpose \200\224and can then be discarded. Because of the page-a-subject format, the balance of topics in the follow- ing pages may at \201 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 apportionin g space according to how common a particular topic is \200\224just as the great Terrestrial Globes made by George Phil- lips in the 1960s may seem at \201 rst to provide an odd bal ance 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 \200\230 balance \200\231 is to miss a good opportunity to be useful. George Phillips did not miss t his opportunity, and neither we hope, have we. It is inevitable that some readers will be d isappointed that we have left out their favored subjects (the Phillips \200\231 Globe does not even mention Oxford!). To these readers we off er over 300 blank pages by way of apolog y. JABC & JML \200\224Preface to the 1st edition \200\224Ferring, 1987 Con \202 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 \201 nancial contacts with the pharmaceutical industries concerned,1 we wish to place on re cord that we have no contacts with any pharmaceutical company, and no pharmaceutical compan y employs us in any capacity, and neither have we re- ceived any \201 nancial input beari ng upon our research for this publication. We have a policy of not seeing representatives f rom the pharmaceutical industry, or receiving their gifts or hospitality. We assert that th e drugs recommended in this book have been selected on the basis of the best available evid ence. v DRs LONGMORE, COLLIER, and AMARAKONE, 2012 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 wit h 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 counte r-productive from the patient \200\231s point of view. For two human beings to understand e ach other \200\231s inner life is a rare event, and if we off ered this understanding to al l 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 s o 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 w e have reached a therapeutic impasse \200\224for example if the illness is untreatable, or the patient has rejected our treatment, or if the patient seems to be asking or appealing f or something more. Eye contact is important here. One of the authors (JML) recalls forever his very \201 rst patient \200\224found on a sur- gical ward recovering from the repair o f 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 th e color of his eyes. Luckily, the house offi cer who was really looking after him did not a sk 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 \200\224that my patie nt was a drug addict and under great stress as he could no longer \201 nance his activity . So, the \201 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 mutua l respect. If the relationship is all one way, with the doctor \201 nding out all about t he patient, but revealing nothing of him or herself, this mutual respect can take a very lo ng time to grow. But beware of sharing too much of your own inner life with your patients: you may overburden them, or put them off . Diff erent patients respond to diff erent approa ches. Understand- ing patients inevitably takes time, and it may be hard in a series of sho rt ap- pointments. A visit to the patient \200\231s home may be very revealing, but for man y doctors trapped in hospital wards or clinics, this is impossible. But it is usual- ly pos sible to have a longish private interview, and take whatever opportunity arises. We once wo rked with a consultant who infuriated his junior staff on busy ward rounds by repeatedly se lecting what seemed to us the most bor- ing and commonplace medical \200\230cases \200\231 (such as someone with a stroke) and proceeding to draw the curtain around the patient \200 \231s bed to exclude us, and engage in what seemed like a long chat with the patient, all i n very hushed voices, so that we never knew what he said \200\224until Sister told us that he never said anything much, and simply received anything that was on the pa- tient \200 \231s 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, a ppreciated more in their entire hospital stay. vi What happens when two ward rounds collide? We once worked with a splendid consultant, Dr B \200\224, who, among other ec- centric but lovable traits, believed that data such as an EC G should be inter- preted according to the mood of the day and in the light of bedside nuan ces. He would not let us label old ECGs with the diagnosis accorded at the time of their re cording, in case this con \202 icted with later nuances. So during ward rounds old ECGs wo uld 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 t hat 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 off from the fast ward ro und, and attach themselves to ours. The faster ward round moved on to some trite destinatio n 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 coll ide. As Paul Verlaine wrote, \200\234There is nothing more precious than a song which is c loudy from the joining of the indistinct with the precise \200\235. We tend to over-value t he precise and undervalue the indistinct. Like Dr B \200\224, we need to re-interpret patie nts \200\231 exact words as if they were a musical score. All too often, though, we rely on summaries of our patients \200\231 stories, massacred by eloquent, but treacherous, medica l jargon. Paul Verlaine knew what to do: \200\234Take eloquence, and wring its neck \200 \235 is his advice, if it \200\231s truth we are after. In its place he recommends systemat ic ambiguity and giving nuance free rein Car nous voulons la Nuance encor, For we want nuance, Not color, nothing but nuance! Oh! la nuance seule \201 ance Only nua nce joins Le r ve au r ve et la \202 te au cor! Dream to dream and \202 utes to hor ns! Pas la couleur, rien que la Nuance! Paul Verlaine, Art po tique So what are the facts? Give me hard facts and I will give you a diagnosis. That was the all uring but dangerous message from the fast ward round. And we all have to make our choice of when to hive off from this ward round and join Dr B \200\224. If we can accord some ambigu ity to the facts we may start to be of real use to our patients. After all, they have to li ve with the facts, so we may as well let the facts breathe and have a complicated life of t heir own. There is something unde \201 ned in every fact. Find what it is, and use the und e \201 ned as a vehicle to explore your patient \200\231s subtleties and contradictions. So, in memory of Dr B \200\224, we propose a new section in the Medical Notes called Nuance s, to be placed before the Functional Enquiry and after the History of the Presenting Compl aint. \200\234The patient pointed to his ear when he said this \200\235 or \200\234He was obviously frightened reliving this moment \200\235 or \200\234The patient ran out of l anguage at this point \200\235 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 \200\231s worthless jewel ( \200\234ce bijo u d \200\231un sou \200\235) that sounds hollow and fake when put to the test. We have to a ccept that language is not very good at dealing with pain \200\224or any internal state. vii Dedication viii 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 hel p with the ENT chapter; Natalie Langdown for help with autism; Pro- fessor Mark Lowenthal f or his indefatigable help with Pediatrics and other chapters. We thank all the authors who have joined us for previous editions: Ju- dith Harvey, Tim Hodgetts, Duncan Brown, Peter Sc ally, Mark Brinsden, Ahmad R. Ma \201 , and Tom Turmezei. Specialist Readers We are hugely indebted to our Specialist Readers for their advice, encouragement, and constructive criti cism. Each chapter in this book has bene \201 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 R eaders showed commitment, intelligence, and ingenuity in their contributions to the referen cing and cross- referencing of this edition. We have a better book for it. Thank you to Mat hura- nayagham Niroshan, Shahzad Arain, Rashmi Singh, Josh Hurn, Konstantinos Kritikos, Mar k Cassar, William Hunt, David Lee, Aaron Lai, Winnie Chen, Yong De Jun, Pooja Sarkar, Xuebi n 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 . Th eir 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 pur pose: 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 \201 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. ix 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 colored tabs on the sides of the pages. References (1) Every reference has an indi vidual identi \201 cation indicated by a pink superscript number. The full details of ever y reference are held online at www.oup.com/ohcs9refs. Cross references There are cross refe rences 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 opinio n of the content inside. Symbols and abbreviations See opposite. Corrections and suggestion s Found a mistake? Have a suggestion for the next edition? Let us know at www.oup.com/uk/oh cs9efeedback. Major changes are announced online at www.oup.co.uk/academic/series/oxhmed/up dates. A note on the use of pronouns For brevity, the pronoun \200\230he \200\231 or \200 \230she \200\231 has been used in places where \200\230he or she \200\231 would have been appropriate. Such circumlocutions do not aid the reader in forming a vivid visual impressio n, which is one of the leading aims of good au- thorship. Therefore, for balance and fairne ss, and where sense allows, we have tried alternating he with she. x Symbols and abbreviations \200 don \200\231t dawdle! Prompt action saves lives \200\207 this phrase is important \200 ( \200 ) guide for 1st-time readers more (or less) vital topic; a rough \201\201 an opportunity for holistic/non- reduction ist thinking con \202 ict (controversial topic) 1,2,3 references at oup.co.u k/ohcs9refs 1,2,3 drug dose not in BNF, see C3 complement Ca carcinoma CBRN chemical, biological, radiological, xi xi nuclear CBT cognitive-behavior therapy CCDC consultant in communicable disease control C CF combined (right & left sided) cardiac failure CHC combined hormonal contraception oup.co.uk/ohcs9refs # fracture \200 \200 diff erential diagnosis \200 : \200 ma le to female ratio \200\201 decreased \200\211 normal (eg plasma lev el) \200\200 increased about \211\210 approximately equal \200\223ve negative +ve positive \200\223 on account of/bec ause of \200\230 therefore A&E emergency department A2A angiotens in 2 receptor (blockers) ABC air, breathing, circulation A(P)LS advanced (pediatri c) life support ChVS chorionic villus sampling CI contraindications CIN cervical int ra-epithelial neoplasia CMV cytomegalovirus; controlled mandatory ventilation CNS central nervous system CoC combined oral contraceptive COM chronic otitis media CPA care program approach CPAP continuous +ve airways pressure CPR cardiopulmonary resuscitation CRP c-reactive protein CRPS complex regio nal pain syndrome CSF cerebrospinal \202 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 diarrh ea and vomiting dB decibel DHS dynamic hip screw DIC disseminated intravascular 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 a ttention de \201 cit disorder ADH antidiuretic hormone AFP \200 -fetoprotein ( \200 =alpha) AIDS acquired immunode \201 ciency syn. Alk alkaline (phos=pho sphatase) ALL acute lymphoblastic leukemia ALT alanine aminotransferase ANA . antinuclear antibody ANF antinuclear factor ANS autonomic nervous system AP anteroposterior APH antepartum hemorrhage APLS advanced pediatric li fe support APM auto-premotor syndrome ARF acute renal failure ARM arti \201 cial rupture of membranes ASD atrioseptal defect ASO antistreptolysin O (titre) ASW approved social worker ATLS Advanced Trauma Life Support coagulation DIP distal interphalangeal DKA diabetic ketoacidosis dL decilitre D M diabetes mellitus DMSA dimercaptosuccinic acid DNA deoxyribonucleic acid DOH Department of Health (NHS) DPL diagnostic peritoneal lavage DRG do rsal root ganglion DSM-IV Diagnostic & Statistical Manual, 4e DUB dysfunctional uter ine bleeding DVT deep venous thrombosis E-BM evidence-based medicine EBV Epstein \200\223Barr virus ECG electrocardiogram ECT electroconvulsive therap y EEG electroencephalogram EIA enzyme immunoassay ENT ear, nose and t hroat ERPC evacuation of retained products manual; see www.trauma.org ATN acute tubular necrosis AV atrioventricular AVM arteriovenous malf ormation \200 HCG \200 -human chorionic gonadotrophin BJGP British Journal of G eneral Practice BMJ British Medical Journal BNA borderline nuclear abnormality BNF British National Formulary BNFC children \200\231s BNF BP blood pr essure courtesy of the copyright holder of conception ESR erythrocyte sedimentation rate ET endotracheal FB foreign bo dy FBC full blood count FCR \202 exor carpi radialis FDP \202 exor digitorum profundus FDS \202 exor digitorum sublimis FH family history FNA \201 ne needle aspiration xi xi FNT fetal nuchal translucency FSH follicle-stimulating hormone G gauge g gram G( \200 )GT .gamma( \200 )glutamyl trans- peptidase G6PD gluco se-6-phosphate LHRH luteinizing hormone-releasing hormone LMP day 1 of last menstrual period LMWH low molecular weight heparin LP l umbar puncture LVH left ventricular hypertrophy (g) micro(gram) MAOI mon oamine oxidase inhibitor MCP metacarpophalangeal MCV mean cell volume MEA .microwave endometrial ablation MET meta-analysis mg milligrams ( g=microgra m=mcg) MHA Mental Health Act MI myocardial infarction ML milliliter mmHg millimeters of mercury MRI magnetic resonance imaging MSU midstream urine culture MTP metatarsophalangeal mU milliunit(s) MVA motor vehicle acci dent N=20* reference to a randomized trial xi xi xi dehydrogenase GA general anesthesia GCS Glasgow coma scale GFR glomerular \201 l tration rate GH growth hormone GI gastrointestinal GP general p ractitioner h hour Hb hemoglobin HBsAg hepatitis B surface antigen HBV hepatitis B virus HCG human chorionic gonadotrophin HDL high-densi ty lipoprotein HFOV high-frequency oscillatory ventilation HIV human immunode \201 ciency virus HLA human leucocyte alleles HPA Health Protection Agency HPO hypothalamic \200\223pituitary \200\223ovarian HPV human papilloma virus HRT hormone replacement therapy HVS high vaginal swa b ibid ibidem (Latin, in the same place) IBW ideal body weight ICP int racranial pressure IE infective endocarditis Ig immunoglobulin IHD ischaemic heart disease IM intramuscular INR international normalized r atio of prothrombin time IOP intraocular pressure IP interphalangeal IPPV intermittent positive pressure of 20 patients (* or what ever number follows N) n=63* reference to a non-randomized tri al of 63 patients (* or what ever number follows n) N2O nitrous oxide NaCl sodium chloride NAI non-accidental injury NBM nil by mouth (no solids or \202 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-in \202 ammatory ventilation IPT interpersonal therapy IQ intelligence quotient ISQ in status quo (Latin, no change) ISS injury severity score ITP idiopathic thrombocytopenic drug(s) OAE otoacoustic emissions OED Oxford English Dictionary, OUP OHCM Oxford Handbook of Clinical Medicine 8e, OUP OM otitis media OME otitis media with eff usion OMV open mouth view ON omni nocte (take at night) ORh \200\223ve .blood group O, Rh negative ORIF open reduction and internal \201 xation OT occupational therapist PA posteroanterior PaCO2 partial pressure of CO2 in arterial purpura ITU intensive therapy unit IU/iu international unit IUCD intraute rine contraceptive device IUI intrauterine insemination IV intravenous IV F in vitro fertilization IVI intravenous infusion IVU intravenous ur ography JVP jugular venous pressure K+ potassium kg kilogram kpa kilopascal L liter LA local anesthesia LBC liquid-based cytology LCR ligase chain reaction LDH lactate dehydrogenase LFT live r function test LH luteinizing hormone blood PAN polyarteritis nodosa pANCA .perinuclear antineutrophil cytoplasmic antibody PaO2 partial pressure of oxygen in arterial blood PC post cibum (after food) PCA patient-controlled anesthesia PCOS poly cystic ovarian syndrome PCR polymerase chain reaction PCV packed cell volume xii xi xi xi PDA patent ductus arteriosus PE pulmonary embolus PET pre-eclamptic toxemia PG pemphigoid gestations PGD preimplantation genetic diagnosis PIC U pediatric intensive care unit PID pelvic in \202 ammatory disease PIP proximal interphalangeal PKU phenylketonuria PMB postmenopausal bleeding PM S premenstrual syndrome PO per os (Latin for by mouth) PoP progestero ne-only pill POP plaster of Paris PPH postpartum hemorrhage PR per r ectum PTR prothrombin ratio PUO pyrexia of unknown origin PUVA psoralen-u ltraviolet A PV per vaginam (via the vagina) QOF quality & outcomes framewo rk \200\224 treatment (prescribing drugs) RA rheumatoid arthritis; reg ional SGA small-for-gestational age SLE systemic lupus erythematosus SNHL senso rineural hearing loss SpO2 pulse oximetry estimated SaO2; no allowance for carboxyhaem oglobin xi xi xi SSRI selective serotonin reuptake inhibitor(s) stat statim (Latin for once); single dose STD sexually transmitted disease ST I Sexually transmitted infection SUFE slipped upper femoral epiphysis SVC superior vena cava SVP saturation vapor pressure syn syndrome T temperature, degrees Centigrade t half life T3 triiodothyronine T4 thyroxine TB tuberculosis TBW tension band wiring TCRE transce rvical resection of endometrium TED transverse elastic graduated TENS transcutan eous electrical nerve anesthesia RBC red blood cell RCGP Royal College of General Practitioners stimulation TFT thyroid function tests TIA transient ischaemic attack ToP termin ation of pregnancy TPH transplacental hemorrhage TPR temperature, pulse, and respirations TRTS triage revised trauma score TSH thyroid-stimulating hormone T SOH transient synovitis of the hip U unit(s) U&E urea and electrolyt es UK United Kingdom URTI upper respiratory tract infection US(S) ultrasou nd (scan) UTI urinary tract infection UV ultraviolet VLBW very low birt hweight infant VSD ventriculoseptal defect VTE venous thromboembolism VUR vesico-ureteric re \202 ux WCC white blood cell count wt weight WR Wasserman reaction yrs, y years ZN Ziehl \200\223Neelsen (stain for TB) RCOG Royal College of Obstetricians and Gynecologists RCT randomized controlled trial REM rapid eye movement RMO registered me dical offi cer RSD re \202 ex sympathetic dystrophy RSI repetitive strain i njury; rapid sequence induction RTA road traffi c accident(s) RTS revised trauma score RUQ right upper quadrant RVH right ventricular hypertrophy S1 S2 1st and 2 nd heart sounds SAD seasonal aff ective disorder SALT speech and language thera pist SAO2 arterial blood O2 saturation, \211\210 SpO2 (allows for carboxyhaemoglobin) SBE subacute bacterial endocarditis SC subcutaneous SCBU special care baby unit SE side-eff ects sec second(s) SFH symphysis fundal heigh t SERM selective estrogen receptor modulator xiii xi Fig 1. This plan is rendered almost unintelligible by over-use of abbreviations. It might m ean: If in status quo (ISQ=no change in state) in 2 days \200\231 time (/7 in this context means days; /52 would mean weeks), refer to the Sexually Transmitted Infections clinic for treatment ( \200\224) \200\224 if it turns out he does not arrive (DNA), follow-up at the o ut-patient department.2 xi 1 Obstetrics Pre-pregnancy counseling 2 Care plans 3 Booking criteria 4 Physiological changes in pregnan cy 6 Obesity 7 Antenatal care 8 Anti-D 9 Prenatal diagnosis 10 Tests for Down \200\231s syn drome 12 Preimplatation tests 13 Placenta 14 Thromboprophylaxis 16 Minor symptoms 17 Hypere mesis gravidarum 18 Pregnancy & medical conditions \200\223 Sickle-cell disease 19 \200 \223 Cardiac disease 20 \200\223 Psychopharmacology 21 \200\223 Anemia 22 \200\223 HIV 2 3 \200\223 Diabetes mellitus 24 \200\223 Thyroid disease 25 \200\223 Jaundice 26 \200 \223 Malaria 27 \200\223 Renal disease 28 \200\223 Epilepsy 29 \200\223 Connective tissu e disease 30 \200\223 Hypertension 31 \200\223 Thromboembolism 32 \200\223 Thrombophilia 33 Ante/perinatal infection 34 \200\2237 Abdominal pain 38 Abdominal palpation 40 Pelvis a nd head 42 Fetal monitoring 44 \200\2235 Ultrasound 46 \200 Hypertension & eclampsia1 48 Prematurity 50 Small for gestational age 52 Large for ge stational age 53 Postmaturity 54 \200 Fetal distress 55 \200 Obstetric shock 55 \200 Ant epartum hemorrhage 56 Normal labor 58 Membrane rupture 60 Induction of labor 62 Active mana gement of labor 64 Pain relief in labor 66 Multiple pregnancy, IVF 68 \200\2239 Breech 70 O ther malpresentations 71 \200 Prolapsed cord 72 \200 Impacted shoulders 72 Meconium-stain ed liquor 73 Dystocia 74 Forceps/ventouse 76 Cesarean section 78 \200 Uterine rupture 80 \200 Mendelson \200\231s syndrome 80 Stillbirth 82 \200 Postpartum hemorrhage 84 Retained placenta 86 \200 Uterine inversion 86 \200 DIC and coagulation defects 88 \200 Amniotic \202 uid embolism 89 Birth injuries 90, maternal 91 Episiotomy and tears 92 Puerperium 94 Contraception after a baby 95 Maternal mortality 96 Perinatal mortality 97 Sources RCOG Green Top guidelines; Saving Mothers \200\231 Lives (Con \201 dential En- qui ry). 1 Mat mort 2011 Cochrane database (www.liv.ac.uk/lstm/ehcap/pc/nwc-pcl.html). Relevant topics elsewhere: Neonatology, p107 \200\22322; breastfeeding, p124 \200\2236; rhe- sus di sease, p116; ectopic pregnancy, p262; miscarriage/termination, p258 \200\22360; trophoblast ic disease, p264; \201 broids in pregnancy, p277; preterm/light-for- dates babies, p128; chickenpox in pregnancy, p144; parvo virus B19, p142; post- natal depression, p408. 1 The term pregnancy-induced hypertension with proteinuria is tending to replace the term p re- eclampsia. We have not followed this trend as to do so obscures the vital fact about pr e- eclampsia: it may lead on to eclampsia. We favor pre-eclampsia because it is short and s ends the shadow of a shiver down our spines, being a reminder of how dangerous it can be. W e thank Ms Alison Peattie, our Specialist Reader, and Mathuranayagham Niroshan, our Junior Reader, for their contribution to this chapter. \201\201The essence of reproductive health Pregnancy is a risky aff air for babies and mot hers. 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 i t would be to make every pregnancy planned and desired by the mother. Worldwide, a woman di es every minute from the eff ects of pregnancy, and most of these women never wanted to be pregnant in the \201 rst place \200\224but either had no means of contraception, or were without the skills, authority, and self-con \201 dence to negotiate with their partners. S o the real killers are poverty, ignorance, and the unwieldy desires of men, and the real so lutions entail literacy, economic growth, and an equality of dialog between the sexes. Any obstetric or governmental initiatives in reproductive health which do not recognize these f acts are doomed. 2 School-based sex education This can be eff ective, if linked to easy acc ess to contraceptive services. This is the conclusion of a meta-analysis, taking into accou nt cohort studies (if meta-analyzes con \201 ne themselves to the 15 or so randomized stud ies, no bene \201 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 \200\230one-off \200\231 aff air \200\224for educational programs to work. Adolescent pregnancy rates: USA: 116/1000; UK: 57/1000; Canada: 50/1000. In 2007 in England & Wales 160 pregnancy were term inated in those <14 years old (out of 200,000 terminations and 650,000 live births). 4 1 s c i r t e t s b O De \201 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 \200\231 ge station. An example of the shorthand way of expressing pregnancies before and after 28 week s is: para 2+1. This means that she has had 2 pregnancies beyond 28 completed weeks \200 \231 gestation, and 1 which terminated prior to 28 weeks. If she is not pregnant at the tim e of describing her she is gravida 3, but if she is pregnant now she is gravida 4. Twins pr esent a problem as there is controversy as to whether they count as 1 for both parity and g ravidity or should count as 2 for parity. It is unclear whether the cut-off point in these de \201 nitions should now be 24 weeks, t o harmonize with the new de \201 nition of stillbirth (p82). 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: \200\230Mrs Cottard is a 32-year-old lady who is 15 weeks into her 4th pregnancy; the 3rd ended in a miscarriage at 17 weeks, and the others came to term with normal deliveries of children who are now 2 & 8. \200\231 The bal d statement \200\230Para 2+1 \200\231 is ambiguous, incomprehensible to the patient, and m isses 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 \200\231s rule: e xpected delivery date (EDD) \211\210 1yr and 7 days after LMP minus 3 months (not if last period was a withdrawal bleed; for cycles shorter than 28 days, subtract the diff erence fr om 28; if longer, add the diff erence). A revised rule suggests the addition of 10 days rat her than 7 is more accurate. 2 Pre-pregnancy counseling \200