2 American College of Obstetricians and Gynecologists with LEAD AUTHORS Robert Casanova, MD, MHPE, FACOG Adjunct Professor, Department of Medical Education, Assistant Dean for Clinical Sciences Curriculum, Assistant Vice Dean Medical Education Covenant Branch Campus, Texas Tech University Health Sciences Center, Lubbock, Texas Alice Chuang, MD, MEd, FACOG Professor, Department of Obstetrics and Gynecology, Clerkship Director, University of North Carolina School of Medicine, Chapel Hill, North Carolina Alice R. Goepfert, MD, FACOG Professor, Department of Obstetrics and Gynecology, Associate Dean for Graduate Medical Education and Designated Institutional Official, University of Alabama School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama Nancy A. Hueppchen, MD, MSc, FACOG Associate Professor, Department of Gynecology and Obstetrics, Associate Dean for Undergraduate Medical Education, Johns Hopkins University School of Medicine, Baltimore, Maryland Patrice M. Weiss, MD, FACOG Professor, Department of Obstetrics and Gynecology, Virginia Tech Carilion School of Medicine, Executive Vice President and Chief Medical Officer, Carilion Clinic, Roanoke, Virginia ORIGINAL AUTHORS Charles R. B. Beckmann, MD, MHPE, FACOG Former Professor of Obstetrics and Gynecology, Thomas Jefferson University College of Medicine, Former Director, Offices of Ambulatory Care and of OB-GYN Academic Affairs, Department of Obstetrics and Gynecology, Albert Einstein Medical Center, Philadelphia, Pennsylvania Frank W. Ling, MD, FACOG Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine and Meharry Medical College, Nashville, Tennessee; Partner, Women’s Health Specialists, PLLC, Germantown, Tennessee William N.P. Herbert, MD, FACOG Former William Norman Thornton Professor and Chair, Professor Emeritus, Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, Virginia 3 Douglas W. Laube, MD, MEd, FACOG Professor and former Chair, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Past President (2006–2007), American College of Obstetricians and Gynecologists Roger P. Smith, MD, FACOG The Robert A. Munsick Professor of Clinical Obstetrics and Gynecology, Director, Medical Student Education, Director, Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana 4 Acquisitions Editor: Matt Hauber Development Editor: Laura Horowitz/Andrea Vosburgh Editorial Coordinator: Laura Horowitz/Annette Ferran Editorial Assistant: Brooks Phelps Marketing Manager: Mike McMahon Production Project Manager: Bridgett Dougherty Design Coordinator: Steve Druding Manufacturing Coordinator: Margie Orzech Prepress Vendor: Newgen Knowledge Works Pvt. Ltd., Chennai, India 8th edition Copyright © 2019 Wolters Kluwer. Copyright © 2014, 2010, 2006, 2002, 1998, 1995, 1992 by Lippincott Williams & Wilkins, a Wolters Kluwer business. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China 9781496353092 Library of Congress Cataloging-in-Publication Data available upon request This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all 5 medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. LWW.com 6 The new lead authors would like to dedicate the eighth edition to the original authors who paved the way with the first six editions and invited us to collaborate on the seventh. We hope to continue the long tradition with this edition. In addition, we would like to dedicate this edition to the medical students who have inspired us and to the women who, as patients, have entrusted us with their care. Finally, we want to thank our families who supported us through the edits and rewrites. 7 About the Authors Drs. Beckmann and Ling embarked on the project that would become this textbook as a response to the conventional wisdom of the day that medical students should “know all of Williams.” They decided that this was unreasonable and opted to write a “core” textbook based on the APGO Learning Objectives instead. The rules were simple: fully address the objectives but only with essential information, not all that the author knows (i.e., the task was to decide what NOT to include, a much more difficult task than writing all you know). They also noted a lot of "here at ... we do..." kind of text, also useless, and agreed not to do that. In addition, they noted that many of the figures and some tables really added nothing, hence the rule that a figure or table must be able to "stand alone" and teach. If it could not pass that test, it was not worthy of the book. The first two editions were well received, but it was only when they added information they knew students were being asked on rounds (despite the first two rules) that the book gained its present popularity. Thus, from the earliest planning meetings for the first edition of Obstetrics and Gynecology , the authors have remained focused on the needs of the primary audience, medical students rotating through their clerkship in this specialty. Having medical education as a primary focus of their respective academic careers has made this team of authors uniquely positioned to create an effective learning tool. In this eighth edition, the “second generation” of leading ob/gyn clinician– educators took over as lead authors for each chapter. They, too, have dedicated their careers to enhancing the quality of women’s health through medical education. As evidence of their collective involvement and success in ob/gyn education, the author team 8 features the following current and past achievements: University Educational and Administrative Appointments Department Chair 4 Department Vice-Chairs 5 Fellowship Directors 1 Residency Directors 8 Student Clerkship Directors 11 Assistant/Associate Deans 7 Department Director of Undergraduate Medical Education 2 President Academy of Educators 1 Designated Institution Official 1 Chief Medical Officer 1 National Organizations American College of Obstetricians and Gynecologists (College) President 1 Committee Chair 3 District Chair 1 SASGOG Board 1 Association of Professors of Gynecology and Obstetrics (APGO) President 3 Council Member 7 Undergraduate Medical Education Committee Chair 2 Undergraduate Medical Education Committee Member 7 Academic Scholars and Leaders, Scholar 4 Academic Scholars and Leaders, Faculty 2 Academic Scholars and Leaders, Advisors 6 American Board of Obstetrics and Gynecology (ABOG) President 1 Vice President 1 Board Examiner 8 9 Chairman of the Board 1 Council on Resident Education in Obstetrics and Gynecology (CREOG) Chairman 1 Vice Chair 1 Education Committee Chair 3 Council Member 4 Program Chair 3 InTraining Exam 2 Other National Educational Activities and Honor National Test Committee Member 5 National Test Committee Reviewer 4 Peer-Reviewed Educational Research Publications 214 Medical Student Teaching Award 57 Resident Teaching Award 12 Resident Review Committee Member 5 District IV Mentor Award 2 The authors remain committed to not only including the most up-to- date evidence-based information but also presenting it in a fashion that meets the needs of the ever-evolving adult learner. This eighth edition of Beckmann and Ling’s Obstetrics and Gynecology is the latest step in our collective journey in the field of women’s health education. 10 Foreword Welcome to one of the most innovative and useful textbooks in obstetrics and gynecology. The chapters in this book are organized around the Association of Professors of Gynecology and Obstetrics (APGO) Medical Student Education Objectives, tenth edition. In fact, each chapter of Beckmann and Ling’s Obstetrics and Gynecology , eighth edition, begins with the relevant APGO Educational Topics, learning objectives, and a clinical case to set context. The body of the text will give you the information needed to achieve the learning objectives. The APGO educational objectives were created by the APGO Undergraduate Medical Education Committee. This committee consists of renowned medical educators, clerkship directors, and program directors from across the United States and Canada. The objectives are revised on a regular basis to assure currency and relevance in developing a curriculum for the obstetrics and gynecology clerkship. Students on their first, or even elective, obstetrics and gynecology clerkship experience will find that these objectives guide learning and mastery of the concepts needed to succeed in their ob-gyn clerkship. Through this organization, the text is easy to read, yet is very complete in giving all the information necessary to master the learning objectives. APGO is an organization dedicated to providing optimal resources and support to educators who inspire, instruct, develop, and empower the women’s healthcare providers of tomorrow. APGO has proudly provided 55 years of service to students and faculty. APGO’s resources are designed to assist faculty and students in meeting their educational goals. Through its Web site, www.apgo.org, medical students will find a host of useful modules and resources to aid in their learning of obstetrics and gynecology. The APGO 11 Undergraduate Web-Based Interactive Self-Evaluation (uWISE) is an interactive self-exam designed to help medical students acquire the necessary basic knowledge in obstetrics and gynecology, regardless of future medical specialty choice. This self-learning resource is a widely used tool in gaining an understanding of the fundamental concepts in obstetrics and gynecology. The APGO Web site has many other useful tools for students and educators to use in their development. Most medical school programs are members and can provide students and faculty members with free access to the rich and robust resources on this Web site. We at APGO wish you an enjoyable and successful journey through your learning experience in obstetrics and gynecology. Maya M. Hammoud, M.D., M.B.A. Association of Professors of Gynecology and Obstetrics President-Elect Donna Wachter Association of Professors of Gynecology and Obstetrics Executive Director 12 Preface The primary goal of this book, which has evolved since its inception more than 20 years ago, is to provide foundational knowledge about obstetrics and gynecology that all medical students need to successfully complete an obstetrics and gynecology clerkship, to pass national standardized examinations in this content area and to competently care for women in their future practice regardless of specialty. The field of medicine continues to change, and we have strived to ensure our text has as well. We hope that practitioners of all backgrounds and training who care for women will find this book helpful in their practice and their educational endeavors. This edition promises to fulfill these goals better than ever before. In publication since 1992, Obstetrics and Gynecology features chapters extensively revised and reviewed in a team-style fashion among the authors, rather than written by individual authors. This collaborative effort serves the dual purpose of cross-checking content accuracy as well as preserving continuity throughout the text while maintaining the focus on the needs of the reader. In addition, Obstetrics and Gynecology is proud to continue its fruitful collaboration with the American College of Obstetricians and Gynecologists (College)—the leading group of professionals providing health care to women. With over 52,000 members, the College maintains the highest clinical standards for women’s health care by publishing practice guidelines, technology assessments, and opinions emanating from its various committees on a variety of clinical, ethical, and technologic issues. These guidelines and opinions were rigorously applied as evidence- based resources in the writing of each chapter. This eighth edition has incorporated many suggestions offered by users of past editions to make it even more user-friendly. Key features of this 13 edition include the following: • The book has been restructured and helpfully divided into six units: I. General Obstetrics and Gynecology, II. Obstetrics, III. Medical and Surgical Problems in Pregnancy, IV. Gynecology, V. Reproductive Endocrinology and Infertility, and VI. Gynecologic Oncology and Uterine Leiomyoma. • Also designed to enhance organization and readability, additional subheadings demarcate topics and break up long passages. An ancillary benefit is that anyone seeking to merely review a chapter can more quickly scan through headings to locate relevant spots. • Chapter opening and closing cases frame the chapter material in a clinical context to aid learning and recall. • The interior is color-coded by section to facilitate navigation. The design is understated and elegant to provide an appropriate background for the text. • The Common Medical Problems in Pregnancy chapter has been separated into several smaller chapters specific to each topic for increased depth as well as easier assimilation. • The Ethics chapter includes a paramount consideration in women’s health care—Patient Safety. • The Gynecologic Procedures chapter has been updated to reflect the latest techniques, including minimally invasive as well as robotic surgery. • Several new ultrasounds of common disorders and anomalies such as bicornuate uterus and Müllerian anomaly have been added to the art program. Continuing the innovations unveiled in the sixth edition, other popular features that will assist the medical student in reading, studying, and retaining key information include the following: • Correlation of chapters with the tenth edition of Medical Student Educational Objectives published by the Association of Professors of Gynecology and Obstetrics (APGO). The Educational Topic Area numbers and titles employed in this text are used with permission of APGO. The use of these objectives has been invaluable to educators and students alike. The complete version of the APGO Medical Student Educational Objectives is available through their Web site at www.apgo.org. • The artwork in the book has been rendered in full color and in an 14 anatomical style familiar to today’s medical students. Great care has been taken to construct illustrations that teach crucial concepts. Photos have been chosen to illustrate key clinical features, such as those associated with sexually transmitted diseases. Other photos provide examples of the newest imaging techniques used in obstetrics and gynecology. • Integration of the latest information and guidelines regarding several key topics. • Appendices include the latest versions of the Well-Woman Care: Assessments and Recommendations by Age Group, the American College of Obstetricians and Gynecologists Antepartum Record and Postpartum Form and the Edinburgh Postpartum Depression Scale. • An extensive package of study questions is available in an online format at the Lippincott Williams & Wilkins student Web site. • Chapters are concise, yet eminently readable, and focused on key clinical aspects. • Shaded, italicized text provides critical clinical “pearls” focusing on specific issues encountered in gynecologic and obstetric practice. • An abundance of lists, boxes, and tables provides rapid access to crucial points. • We are justifiably enthusiastic about the significant changes that have been made to this edition, and we believe that they will be of tremendous benefit to medical students and other readers who need core information for the primary and obstetric–gynecologic care of women. As a new generation enters the health care professions and the dynamics of providing health care continue to change, women’s health care remains central to the promotion of our society’s health and well-being. This eighth edition of Beckmann and Ling’s Obstetrics and Gynecology intends to be at the forefront of medical education for this new generation of health care providers and will continue its authors’ commitment to providing the most reliable evidence-based medical information to students and practitioners. 15 Acknowledgments We extend our appreciation to Matt Hauber at Wolters Kluwer for his seemingly tireless help and encouragement during the arduous preparation of the eighth edition of Obstetrics and Gynecology . We continue to be grateful for the innovative art provided by Rob Duckwall and Dragonfly Media Group for this edition and Joyce Lavery for previous editions and for the thoughtful indexing of Barbara Hodgson, which adds to the usefulness of the book for new learners. A special “shout out” goes to our development editor Laura Horowitz, whose wisdom and insight into the educational process as well as the needs of the reader can be seen throughout the final product. We would especially like to thank the original authors, RB, Frank, Bill, Doug, and Roger for the opportunity to collaborate with them on this time-honored text. 16 Contents SECTION I GENERAL OBSTETRICS AND GYNECOLOGY 1 Women’s Health Examination and Women’s Health Care Management 2 The Obstetrician–Gynecologist’s Role in Screening and Preventive Care 3 Ethics, Liability, and Patient Safety in Obstetrics and Gynecology 4 Embryology and Anatomy SECTION II OBSTETRICS 5 Maternal–Fetal Physiology 6 Preconception and Antepartum Care 7 Genetics and Genetic Disorders in Obstetrics and Gynecology 8 Intrapartum Care 9 Abnormal Labor and Intrapartum Fetal Surveillance 10 Immediate Care of the Newborn 11 Postpartum Care 12 Postpartum Hemorrhage 13 Multifetal Gestation 14 Fetal Growth Abnormalities: Intrauterine Growth Restriction and Macrosomia 15 Preterm Labor 16 Third-Trimester Bleeding 17 Premature Rupture of Membranes 18 Post-term Pregnancy 19 Ectopic Pregnancy and Abortion SECTION III MEDICAL AND SURGICAL DISORDERS IN 17 PREGNANCY 20 Endocrine Disorders 21 Gastrointestinal, Renal, and Surgical Complications 22 Cardiovascular and Respiratory Disorders 23 Hematologic and Immunologic Complications 24 Infectious Diseases 25 Neurologic and Psychiatric Disorders SECTION IV GYNECOLOGY 26 Contraception 27 Sterilization 28 Vulvovaginitis 29 Sexually Transmitted Infections 30 Pelvic Support Defects, Urinary Incontinence, and Urinary Tract Infection 31 Endometriosis 32 Dysmenorrhea and Chronic Pelvic Pain 33 Disorders of the Breast 34 Gynecologic Procedures 35 Human Sexuality 36 Sexual Assault and Domestic Violence SECTION V REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY 37 Reproductive Cycles 38 Puberty 39 Amenorrhea and Abnormal Uterine Bleeding 40 Hirsutism and Virilization 41 Menopause 42 Infertility 43 Premenstrual Syndrome and Premenstrual Dysphoric Disorder SECTION VI GYNECOLOGIC ONCOLOGY AND UTERINE LEIOMYOMA 44 Cell Biology and Principles of Cancer Therapy 18 45 Gestational Trophoblastic Neoplasia 46 Vulvar and Vaginal Disease and Neoplasia 47 Cervical Neoplasia and Carcinoma 48 Uterine Leiomyoma and Neoplasia 49 Cancer of the Uterine Corpus 50 Ovarian and Adnexal Disease Appendices A The American College of Obstetricians and Gynecologists Well-Woman Recommendations by Age Group B The American College of Obstetricians and Gynecologists Antepartum Record and Postpartum Form C Edinburgh Postnatal Depression Scale (EPDS) Index 19 I General Obstetrics and Gynecology CHAPTER 1 Women’s Health Examination and Women’s Health Care Management This chapter deals primarily with APGO Educational Topic Areas: TOPIC 1 HISTORY TOPIC 2 EXAMINATION TOPIC 3 PAP TEST AND DNA PROBES/CULTURES TOPIC 4 DIAGNOSIS AND MANAGEMENT PLAN TOPIC 5 PERSONAL INTERACTION AND COMMUNICATION SKILLS Students should be able to refine their communication and clinical care skills in taking a pertinent comprehensive medical history and assessing risk and patient adherence to health care recommendations. They should be able to perform a comprehensive breast and pelvic exam, including a Pap test and appropriate screening. They should be able to use this information to formulate a diagnosis and management plan while communicating important findings and recommendations to the patient, incorporating her socioeconomic and cultural context, as well as her gender identity (heterosexual, lesbian, gay, bisexual, or transgender). CLINICAL CASE On a pleasant, rather warm summer’s day, a 72-year-old woman comes 20