Introduction

The preliminary estimate of total births in the USA for 2005 was 4,138,349. Intrapartum fetal heart-rate (FHR) monitoring was used in more than 85% of the deliveries. Fetal heart-rate monitoring was introduced into clinical practice in the 1970s. At that time, obstetric providers and researchers in fetal physiology believed electronic fetal monitoring (EFM) would identify changes in the FHR and/or rhythm that reflect fetal acidosis. It was presumed that detection would be early enough to allow clinical intervention that would prevent perinatal asphyxia. Despite 30 years of widespread use and multiple randomized clinical trials, FHR monitoring has not yet been shown to decrease perinatal mortality other than by decreasing intrapartum fetal deaths. Moreover, some experts believe that the use of EFM leads to over-detection of non-reassuring FHR patterns, thereby directly contributing to the escalating rate of cesarean-section deliveries in the USA, which by 2005 increased to 30.3%. We will review the physiology underlying FHR patterns, and the possible reasons why randomized trials of EFM have so far failed to demonstrate efficacy. The current knowledge that guides interpretation of EFM in the intrapartum period will be discussed, with special emphasis on newer methods for intrapartum fetal surveillance.

The adnexa are in an anatomic region in the pelvis that includes the ovaries, the fallopian tubes, and the structures within the broad ligament. The differential diagnosis of an adnexal mass is complex because of the wide spectrum of disorders that involve the adnexa. Most frequently, adnexal masses involve the ovary itself because of its inherent growth properties through ovulation and thus its propensity for neoplasia. During the evaluation of an adnexal mass, the picture may be further complicated as imaging does not always clearly delineate the adnexa from other nearby organs. An estimated 5% to 10% of women in the United States will undergo a surgical procedure for a suspected ovarian neoplasm during their lifetime. Although the majority of adnexal masses are benign in nature, the primary goal of the diagnostic evaluation is the exclusion of malignancy.

ETIOLOGY

The differential diagnosis of the adnexal mass varies with age (Table 9.1.1). Age is also the most important factor in determining the potential for malignancy. In fact, the risk that an ovarian neoplasm is malignant increases 12-fold from ages 12 through 29 and 60 through 69. Although there is emerging evidence that the presence of an adnexal mass in postmenopausal women is more common than once thought, masses found in premenarchal and postmenopausal women should be considered abnormal and must be promptly evaluated.

The introduction of the laparoscopic approach for the management of intramural and subserosal uterine myomas has to a great extent revolutionized the modern management of myomas. Previously the only way to remove intramural and subserous myomas was by laparotomy, a procedure associated with significant postoperative morbidity. Therefore, physicians traditionally reserved abdominal myomectomy for a selected group of women where the risks and discomfort involved with laparotomy were judged worthy of the potential to preserve and enhance their fertility. Studies published in 1999 confirmed the advantages of laparoscopic myomectomy, such as the low morbidity and rapid recovery, which has led to the growing application of the technique towards women with symptomatic uterine myoma. However, laparoscopic operation is also associated with potential disadvantages including prolonged anesthesia, increased blood loss and possibly postoperative adhesion formation. This has led to a renewed interest in regard to the precise indications for performing laparoscopic myomectomy.

Indications

The primary reason for performing myomectomy in women of reproductive age is the preservation of the uterus for the purpose of childbearing. However, an increasing number of women currently elect to undergo laparoscopic removal of myomas, due to various symptoms associated with a rapidly growing or bulky uterus. In addition, some women resort to laparoscopic myomectomy when fibroids that are associated with heavy menstrual bleeding cannot be removed hysteroscopically.

Clinical chorioamnionitis is a primary infection that involves the chorioamniotic membranes and the intraamniotic cavity. Microscopically, clinical chorioamnionitis is defined by bacteria and leukocytes that are found between the chorion and the amnion, and by isolation of bacteria from the amniotic fluid. Other terms used in the literature are intraamniotic infection, amnionitis, amniotic fluid infection, intrauterine infection, and intrapartum infection. However, clinical chorioamnionitis is distinct from histological chorioamnionitis, which is defined by the infiltration of polymorphonuclear cells into the placenta and choriamniotic membranes.

The clinical manifestations of chorioamnionitis include fever, maternal and fetal tachycardia, uterine tenderness, foul odor of the amniotic fluid, and leukocytosis. Although a combination of these signs may be present in most women with chorioamnionitis, they are by no means universal. Recent studies are usually based on the clinical criteria defined by Gibbs and Duff which include maternal fever of 37.8°C or greater as a mandatory sign, plus two or more minor signs (maternal tachycardia >100 beats/min, fetal tachycardia >160 beats/min, uterine tenderness, foul odor of the amniotic fluid and leukocytosis >15000/mm3).

Fever accompanies virtually all cases of clinical chorioamnionitis. The criteria that define maternal and fetal tachycardia exceed the 90th percentile and are discovered in a wide range (20–80%) of patients with intraamniotic infection. Leukocytosis can be a normal finding in women during labor without obvious signs of infection. The mean intrapartum white blood cell count is 12500±3900/mm3 and increases in linear fashion with an extending duration of labor.