Preface

One of the chief benefits enjoyed by Academics is the chance to have exchange and interchange with both specialists and trainees. During our respective careers, we have derived, and continue to derive, great rewards from this invaluable communication, and this was indeed the driving force behind the undertaking of this editorship. The field of Obstetrics differs substantially from that of plain Gynecology as from other specialties as well, since the wishes and expectations of the pregnant woman are very specific and unusually exacting. This multi-author book includes a wide selection of clinical and experimental issues of the most challenging nature and many of the most up-to-the-minute advances in clinical and research topics; thus, we anticipate that it will be of considerable value to the health professionals.

Chapter 1 of this book, which contains a total of 18 chapters, comprises an article outlining the personality and make-up of students who elect to follow Obstetrics and Gynecology as a career, along with and the various features which attract them, and those which, conversely, may deter them. In this connection, it is considered that the faculty and residents will make a positive impression upon students in their clerkship, while there is an avid ongoing effort to minimize residents' overload and stress. Moreover, there is also a keen awareness that the Obstetrics and Gynecology departments should not be dominated by a single gender or ethnic group. The second Chapter consists of an author's commentary concerning the fact that women with a normal pre-pregnancy BMI accompanied by a normal pregnancy weight gain usually have minimal risk for abnormal fetal growth and exhibit better pregnancy outcomes in terms of short- and long termconsequences. Next chapter (Chapter 3) describes how an aberrant immunological response at the maternal-fetal interactions could result in an unsuccessful pregnancy outcome. The fourth Chapter examines the reproductive effect of electromagnetic field (EMF) exposure in the rat ovary which acts via a mechanism closely resembling apoptosis so as to investigate possible protective mechanisms for the reproductive system during IVF treatment.

The following article (Chapter 5) demonstrates the potential value of Ca-125 in the detection of spontaneous abortion and in the prognosis of pregnancy outcome in ICSI cycles. The next contribution (Chapter 6) deals with the varying attitudes to abortion around the globe, this ranging from entirely free access in the majority of developed countries to a total ban on abortion in several of the developing countries. With regard to most western countries, although first trimester abortion is widely available, access to second trimester abortion is somewhat more limited. A discussion on medically and surgically induced abortion is at this point undertaken. The seventh Chapter explores the question of high maternal mortality resulting from the restrictive abortion laws of certain countries, this necessitating the increasing presence of post-abortion care (PAC) services in these places. Better organization of PAC services in such countries combined with adequate training of the care providers in these units will hopefully lead to reduced mortality rates. The eighth Chapter explores the potential value of ultrasound assessment of blood flow redistribution in fetal hypoxemia which results in a reduction in both renal perfusion and fetal urine production rate. These findings promise to be of considerable value since determination of whether a growth-restricted fetus is further comprised would be of great clinical interest. In Chapter 9, the authors respond to the following crucial queries. First, which comes earlier: preeclampsia or deregulation of the tuned balance among the insulin-like growth system components? Second, precisely what correlations exist between the varying concentrations of IGFs (Insulin-like Growth Factors) and their binding proteins in maternal circulation and preeclampsia risk? Bon and associates (Chapter 10) examined a group of fetuses with malformations of varying clinical expression and severity and compared them with a group of fetuses with normal growth and morphology in order to investigate whether essential biochemical parameters measured in fetal blood could be associated with fetal wellbeing. A review article by Gourvas and associates (Chapter 11) aim to present the critical role of angiogenesis in placental development and how disruption in the balance of angiogenic factors may complicate pregnancies with fetal growth restriction. Chapter 12 discusses the relative safety and effectiveness of external cephalic version (ECV) for breech presentation in order to bring about a reduction in cesarean section rates. In the context of an obstetrics service that offers daily ECV, a major key to successful outcome is the skill and expertise of the obstetrician who performs the technique. In order to minimize or eliminate adverse effects and increase the success rate, tocolytics are recommended during the procedure. Unterscheider and O'Donoghue (Chapter 13) have recently reported on significant variations in the clinical management of pregnancies demonstrating reduced fetal movements, these being at variance with current information, which is provided to pregnant women, with the available literature as well as with expert guidelines. This comprehensive review is based on recently accumulated evidence and experience from expert groups and reflects good clinical practice.

Contents XI

to develop dystocia in labor by measuring the lactate in amniotic fluid and to implement timely and appropriate interventions so as to remedy inefficient uterine action whenever possible, thereby improving the outcome for mothers and their babies. Contribution 15 deals with the subject of how oxytocin exerts its myometrial and other actions via a transmembrane receptor. In addition, several peptide and non-peptide antagonists are presented which act either as potential tocolytic agents or else as research tools, while the different oxytocin functions are additionally reviewed. Adaji and Ameh (Chapter 16) set out to endorse instrumental vaginal delivery, forceps and ventouse, key elements of essential obstetric care, and the scaling up of its use in resource-poor countries through both training and the provision of appropriate equipment. The important observation reported by Catarino and colleagues is that nearly all the changes undergone by preeclamptic women in their maternal circulation also occur in the cord blood of their newborns, although to a lesser degree (Chapter 17). These women are characterized by alterations in the lipid profile, amplification of the inflammatory process, elevated oxidative stress and endothelial dysfunction as well as cardiovascular disease later in life, all of which comprise aspects of the same disease spectrum. Finally, Chapter 18 comprises an article offering an overview of bioethics given that, in the past few decades, the domain of health care has placed ever more emphasis on the necessity to defend and advance women's sexual and reproductive rights. It also highlights the need for strict ethical principles adopted from medical professionals dealing with women's health in all the fields of reproductive health care, but most

We wish to warmly thank the authors who accepted the invitation to contribute, while expressing our sincere appreciation for the time and effort they expended on this endeavor. We would also like to extend our gratitude to the team at InTech, and particularly the Process Manager Ms Anja Filipovic, for all their expert assistance and their input into the production of this book. Finally, we thank our readers and express

> Crete, Greece

**Nikos Vrachnis, MD, DFFP, PCME,**

University of Athens Medical School,

Obstetrics-Gynecology and Fetal-Maternal Medicine,

> Athens, Greece

particularly with regard to pregnancy.

our earnest hope that they will find this book useful.

University Hospital of Heraklion, Heraklion,

**Stavros Sifakis, MD, PhD,** Obstetrics-Gynecology and Fetal-Maternal Medicine,

The author of the next paper (Chapter 14) has addressed the question concerning failure of progress in labor which has led to the increased frequency of cesarean section worldwide. Regarding this condition, the lactate value in amniotic fluid is a novel diagnostic tool in this field. It is essential to identify those women most likely likely to develop dystocia in labor by measuring the lactate in amniotic fluid and to implement timely and appropriate interventions so as to remedy inefficient uterine action whenever possible, thereby improving the outcome for mothers and their babies. Contribution 15 deals with the subject of how oxytocin exerts its myometrial and other actions via a transmembrane receptor. In addition, several peptide and non-peptide antagonists are presented which act either as potential tocolytic agents or else as research tools, while the different oxytocin functions are additionally reviewed. Adaji and Ameh (Chapter 16) set out to endorse instrumental vaginal delivery, forceps and ventouse, key elements of essential obstetric care, and the scaling up of its use in resource-poor countries through both training and the provision of appropriate equipment. The important observation reported by Catarino and colleagues is that nearly all the changes undergone by preeclamptic women in their maternal circulation also occur in the cord blood of their newborns, although to a lesser degree (Chapter 17). These women are characterized by alterations in the lipid profile, amplification of the inflammatory process, elevated oxidative stress and endothelial dysfunction as well as cardiovascular disease later in life, all of which comprise aspects of the same disease spectrum. Finally, Chapter 18 comprises an article offering an overview of bioethics given that, in the past few decades, the domain of health care has placed ever more emphasis on the necessity to defend and advance women's sexual and reproductive rights. It also highlights the need for strict ethical principles adopted from medical professionals dealing with women's health in all the fields of reproductive health care, but most particularly with regard to pregnancy.

We wish to warmly thank the authors who accepted the invitation to contribute, while expressing our sincere appreciation for the time and effort they expended on this endeavor. We would also like to extend our gratitude to the team at InTech, and particularly the Process Manager Ms Anja Filipovic, for all their expert assistance and their input into the production of this book. Finally, we thank our readers and express our earnest hope that they will find this book useful.

#### **Stavros Sifakis, MD, PhD,**

Obstetrics-Gynecology and Fetal-Maternal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece

developed countries to a total ban on abortion in several of the developing countries. With regard to most western countries, although first trimester abortion is widely available, access to second trimester abortion is somewhat more limited. A discussion on medically and surgically induced abortion is at this point undertaken. The seventh Chapter explores the question of high maternal mortality resulting from the restrictive abortion laws of certain countries, this necessitating the increasing presence of post-abortion care (PAC) services in these places. Better organization of PAC services in such countries combined with adequate training of the care providers in these units will hopefully lead to reduced mortality rates. The eighth Chapter explores the potential value of ultrasound assessment of blood flow redistribution in fetal hypoxemia which results in a reduction in both renal perfusion and fetal urine production rate. These findings promise to be of considerable value since determination of whether a growth-restricted fetus is further comprised would be of great clinical interest. In Chapter 9, the authors respond to the following crucial queries. First, which comes earlier: preeclampsia or deregulation of the tuned balance among the insulin-like growth system components? Second, precisely what correlations exist between the varying concentrations of IGFs (Insulin-like Growth Factors) and their binding proteins in maternal circulation and preeclampsia risk? Bon and associates (Chapter 10) examined a group of fetuses with malformations of varying clinical expression and severity and compared them with a group of fetuses with normal growth and morphology in order to investigate whether essential biochemical parameters measured in fetal blood could be associated with fetal wellbeing. A review article by Gourvas and associates (Chapter 11) aim to present the critical role of angiogenesis in placental development and how disruption in the balance of angiogenic factors may complicate pregnancies with fetal growth restriction. Chapter 12 discusses the relative safety and effectiveness of external cephalic version (ECV) for breech presentation in order to bring about a reduction in cesarean section rates. In the context of an obstetrics service that offers daily ECV, a major key to successful outcome is the skill and expertise of the obstetrician who performs the technique. In order to minimize or eliminate adverse effects and increase the success rate, tocolytics are recommended during the procedure. Unterscheider and O'Donoghue (Chapter 13) have recently reported on significant variations in the clinical management of pregnancies demonstrating reduced fetal movements, these being at variance with current information, which is provided to pregnant women, with the available literature as well as with expert guidelines. This comprehensive review is based on recently accumulated evidence and experience from expert groups and

The author of the next paper (Chapter 14) has addressed the question concerning failure of progress in labor which has led to the increased frequency of cesarean section worldwide. Regarding this condition, the lactate value in amniotic fluid is a novel diagnostic tool in this field. It is essential to identify those women most likely

reflects good clinical practice.

#### **Nikos Vrachnis, MD, DFFP, PCME,**

Obstetrics-Gynecology and Fetal-Maternal Medicine, University of Athens Medical School, Athens, Greece

**1** 

*USA* 

**Possess?** 

Bruce W. Newton

*University of Arkansas for Medical Sciences* 

**Who Selects Obstetrics and Gynecology as a** 

As the title implies, this chapter concerns the traits of students who select obstetrics and gynecology (OB/GYN) as a career, and the various factors which attract or inhibit them from entering a residency. Various professional organizations, medical students, residents and authors have differing opinions whether OB/GYN is considered a primary care residency, or a core surgical specialty (Indyk et al., 2011; Jacoby et al., 1998; Laube & Ling, 1999; McAlister et al., 2007). The reader needs to decide which definition is preferred. Regardless of the choice, the vast majority of these data can be applied to either definition. Although almost all studies collect data about OB/GYN vs. just obstetrics, these data can be applied to both designations.

There are numerous studies which examined the traits of students who enter the various medical specialties. This section will compare traits of students who desire to enter an OB/GYN residency with those who prefer another primary care residency, or a surgical residency. Specialties which are primary care are typified by a continuity of patient care and include OB/GYN, Family Medicine (FM; also known as Family Practice), Internal Medicine (IM), and Pediatrics (PED). Surgery (SURG) is not a primary care specialty, but along with FM, IM, PED and OB/GYN, SURG is considered a specialty that has a non-controllable lifestyle.

Obstetrics and gynecology, FM, IM, PED, and SURG can be contrasted with those specialties which are considered as having a controllable lifestyle, e.g., radiology, ophthalmology, pathology, and anesthesiology. A controllable lifestyle specialty is characterized by the physician controlling the number of hours spent on professional duties, leaving more time for personal activities. Increasingly, students are selecting residencies with a controllable

In the 1970s, McGrath and Zimet (1977) studied the personality traits of male and female students vs. their specialty choice. Women were found to be more self-confident,

Finally, all data are gathered from the US unless otherwise indicated.

**2. Personality traits of students and residents** 

lifestyle (Dorsey et al., 2005; Schwartz et al., 1990, 1989).

**2.1 Medical students** 

**1. Introduction** 

**Career and Why, and What Traits Do They** 
