Professional Documents
Culture Documents
GYNAECOLOGY
Jaideep Malhotra
MD FICOG FICS FRCOG FRCPI
Professor, Dubrovnik International University, Croatia
President, FOGSI
Past President, The Asia Pacific Initiative on Reproduction (ASPIRE)
Managing Director, ART Rainbow-IVF
Agra, Uttar Pradesh, India
Richa Saxena
MBBS MD (Obstetrics & Gynaecology)
PG Diploma in Clinical Research
Obstetrician and Gynaecologist
New Delhi, India
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Acharya Neema MBBS DGO DNB DFP FICOG Bahadur Anupama MBBS MD (Obstetrics and
Gynaecology)
Professor
Department of Obstetrics and Gynaecology Sub-Dean (Academics)
Datta Meghe Institute of Medical Sciences Additional Professor
(Deemed University) Department of Obstetrics and Gynaecology
Wardha, Maharashtra, India All India Institute of Medical Sciences
Rishikesh, Uttarakhand, India
Agrawal Kavita MBBS MD (Obstetrics and
Gynaecology)
Banerjee Dipanwita MBBS MS (Obstetrics and
Assistant Professor Gynaecology) DPMIACA
Lady Hardinge Medical College Department of Gynaecological Oncology
New Delhi, India Chittaranjan National Cancer Institute
Kolkata, West Bengal, India
Agrawal Mohit MBBS MD (Obstetrics and
Gynaecology)
Assistant Professor Bansal Kanthi MD DGO FICOG
Department of Obstetrics and Gynaecology Director
Wardha, Maharashtra, India Safal Fertility Foundation
Ahmedabad, Gujarat, India
Agrawal Ragini MBBS MS (Obstetrics and
Gynaecology) MS FICOG FICMCH
Director Bansal Shemi MBBS DIPGO
W Pratiksha Hospital and IVF Centre Consultant, Rainbow Hospital
Gurugram, Haryana, India Agra, Uttar Pradesh, India
Kale Ashwani MBBS DGO DNB (Obstetrics and Malik Jyoti MBBS DGO DNB MNAMS FICS
Gynaecology) J J Institute of Medical Sciences
IVF Consultant and Embryologist Bahadurgarh, Haryana, India
Ashakiran Hospital and Asha IVF Centre
Pune, Maharashtra, India
Malik Sonia MBBS MD DGO
Kashyap Vivek MBBS MD (Radiology) Director and Head
Chairman and Consultant Southend Fertility and IVF
Dr Kashyap’s Diagnostics New Delhi, India
New Delhi, India
Mehta Manjeet PhD (Human Genetics)
KD Reubina MBBS MS (Obstetrics and Gynaecology) Director, Neogenetics, New Delhi
Director Director-Technical
Grace IVF Centre DNA Diagnostics Center, Gurugram
Chandigarh, India Director-Partner, Genetic World Mumbai,
Maharashtra, India
Malhotra Hemant MBBS MD FRCP (London) Mittal Bhawana MBBS MS (Obstetrics and
FACP (USA) MNAMS FICP FUICC FIMSA Gynaecology)
Senior Professor Director, Shivam IVF Centre, Delhi
RK Birla Cancer Center Consultant, Max IVF
SMS Medical College and Hospital Ghaziabad, Uttar Pradesh, India
Jaipur, Rajasthan, India
Mukherjee Basab MBBS MD FRCOG FICOG
Malhotra Jaideep MD FICOG FICS FRCOG FRCPI Consultant Gynaecologist
Professor Kolkata, West Bengal, India
Dubrovnik International University, Croatia
President, FOGSI
Past President The Asia Pacific Initiative on
Reproduction (ASPIRE) Naik Bijouy MBBS MS (Obstetrics and Gynaecology)
Managing Director, ART Rainbow-IVF Senior Consultant
Agra, Uttar Pradesh, India Manipal Hospital
New Delhi, India
Malhotra Narendra MD FICOG FRCOG (Honoris
Causa) FICS FMAS
Professor Panchal Sonal MBBS MD (Obstetrics and
Dubrovnik International University, Croatia Gynecology)
Past President, FOGSI Consultant
Managing Director Dr Nagori’s Institute for
Global Rainbow Healthcare Infertility and IVF
Agra, Uttar Pradesh, India Ahmedabad, Gujarat, India
Sharma Manpreet MBBS MS (Obstetrics and Singh Rakhi MBBS DGO FICOG FIAOG DRM ARCOG
Gynaecology) Director
Consultant Abalone Clinic and IVF Center
Department of Obstetrics and Gynaecology Noida, Uttar Pradesh, India
Rainbow Hospital
Agra, Uttar Pradesh, India
Vats Garima MBBS MS (Obstetrics and Gynaecology)
Shinde Prerna MBBS MD DGO DICOG
Assistant Professor
Director Jaipur National University and Medical
Shinde Hospital and Test Tube Baby Center College
Ahmednagar, Maharashtra, India Jaipur, Rajasthan, India
It is an honour yet again to update this “Bible of Gynaecology”, Prof Sir Norman Jeffcoate had written this book
on the basis of what he saw in those days. His style of describing gynaecology as a story telling is still appreciated.
However, from the years of Prof Jeffcoate the practice of medicine, especially in the field of gynaecology, has
changed a lot as there is an incorporation of transvaginal sonography, colposcopy and office hysteroscopy in the
clinic and this has simplified and quickened the diagnosis and treatment. Leaps of advances have occurred in
diagnosis, management, procedures and drugs.
In this revised edition, new chapters, pictures, photographs and discussions have been incorporated keeping
in mind the recent guidelines and updates in this field. New topics like genetics in gynaecology, precocious and
delayed puberty, pregnancy of unknown location, female genital mutilation, adenomyosis, assisted reproductive
technology, urinary tract infection, contraception, and single incision laparoendoscopic surgery, etc. have been
introduced.
We have tried to update all the chapters to include the latest evidences and preserving Prof Norman Jeffcoate
narrative style. This issue has been updated with the efforts of multiple authors and experts. We hope this updated
Bible of Gynaecology will be useful to all students, teachers and practitioners.
Happy Reading!
Narendra Malhotra
Jaideep Malhotra
Richa Saxena
Neharika Malhotra Bora
It was inevitable that following Professor Sir Norman Jeffcoate’s retirement, there would be pressure to continue to
publish the Principles of Gynaecology.
In the last revision in 1974, Sir Norman emphasised that he had endeavoured to preserve his personal approach,
bearing in mind the objectives and principles outlined in the preface to the First Edition. In addition, some of Sir
Norman’s comments in the preface to his Fourth Edition are included to emphasise the guidelines the present
author has taken in an attempt to maintain the format of the Principles of Gynaecology.
Much of the material presented is retained from the last edition, since it also reflects the gynaecological training
of the author under Professor Jeffcoate in Liverpool. The views expressed are therefore personal ones from a pupil
of Sir Norman Jeffcoate against the background of all the information available. Once given, the views expressed
mean that references are excluded for the special reasons given in the preface to the First Edition.
In the process of being taught Obstetrics and Gynaecology by Sir Norman, one was encouraged to consider all
the facts about a case, to come to a conclusion and to be able to justify it. Even though a critical approach to each
case was expected, we were never allowed to forget that we were dealing with a woman, mother or child with a
personal problem. Indeed, Professor Jeffcoate’s personal approach was such that in a clinic with many students
and postgraduates present, it was obvious that as far as the patient was concerned Sir Norman was the only person
there. I have never been able to achieve the same effect, but I hope that my efforts in revising this book will be
acceptable to an outstanding teacher, guide and friend. If so, then I am sure it will benefit all those who read it.
Victor Tindall
The book is meant to add to rather than replace clinical and tutorial instruction, so those matters which can best
be taught beside the patient, or which are easy for any student to learn and understand from other sources, receive
little attention. In planning the text, I recalled those subjects which I myself found (and still do find) difficult to
master, or on which I had to search far and long for information, and gave them disproportionate emphasis. This
and other considerations resulted in a disregard for the relative importance, as judged by their clinical frequency, of
different conditions. Indeed, the reader will find that quite rare conditions are mentioned, illustrated or described
at length; and that all manner of asides—even some with an obstetrical flavour—creep in. This is partly because
they are of special interest to me but mainly because they appeared to offer scope for presenting an attitude of
mind; for discouraging loose thinking and empiricism; for inculcating a scientifically and ethically honest outlook;
for emphasising the art as well as the science of gynaecology.
I have not played safe by stating only generally accepted views, nor have I played fair by giving the differing
views of various authorities. Instead, after weighing the evidence, I have attempted to reach a conclusion which
satisfies me as being as rational as present knowledge allows. Without intended disrespect, mention by name of
authors and workers has been avoided as a rule; references clutter up the text, destroy continuity and are hardly
ever used properly. On the other hand, I have not hesitated to give my own views and have, at times, been more
dogmatic than clinical experience ever really justifies. I have even gone so far as to enunciate ideas which in many
respects are conjectural, if not fanciful. I do not expect these all to be accepted; if they are I shall be disappointed
because their object is to provoke trains of thought and discussion.
In offering this book to fellow students, I remember with affection and gratitude William Blair-Bell, one of the
great gynaecologists of this century. He not only taught me gynaecology and a particular approach to it, he taught
me to think and to write. He, more than anyone else, provided me with the stimulus and the opportunity to obtain
the experience which has led to this work.
Norman Jeffcoate
To edit a book written by a legend Professor Jeffcoate is a mammoth task. I and Dr Jaideep Malhotra did a lot of
researches and asked all our students to suggest what more they wanted in the ninth edition. Dr Neharika Malhotra
Bora and Dr Richa Saxena have helped immensely in adding a lot of material to the chapters and updating many
of them.
We are thankful to all the contributors (names mentioned in the contributor list), for their valuable inputs and
contributions to update all the chapters.
We are grateful to all those who have helped us to do this mammoth job. Special appreciations and thanks to
Shri Jitendar P Vij (Group Chairman) and Mr Ankit Vij (Managing Director) of M/s Jaypee Brothers Medical
Publishers (P) Ltd, New Delhi, India. Simultaneously we would like to acknowledge the help of various doctors,
editors and content strategists (Dr Arun Bhatia, Kanav Midha, Mampi Debnath, Priyanka Diwan, Dr Sudha Chamoli
and Shallu Mann), who helped in editing of the manuscript within a short span of time.
We are thankful to our families for bearing with us and sharing family time for work like this.
We thank Dr Prabha Malhotra, Dr Deepali, Dr Deepika, Dr RM Malhotra, Dr Rishab Bora and Dr Kehsav.
We hope the students of gynaecology will like what we have produced in the ninth edition.
We have tried to retain Professor Jeffcoate’s style and some of the valuable photographs from the first edition.
Narendra Malhotra
Jaideep Malhotra
Richa Saxena
Neharika Malhotra Bora
Chapter 2: Anatomy 23
Vulva 23
Vagina 27
Uterus 32
Fallopian Tubes 36
Ovary 38
Urethra and Bladder 39
Ureter 43
Sigmoid Colon 43
Rectum and Anus 44
Pelvic Peritoneum and Ligaments 45
Pelvic Musculature 46
Pelvic Fascia and Cellular Tissue 47
The Supports of the Genital Organs 47
Blood Vessels of the Pelvis 48
Lymphatic Drainage 52
Innervation of Pelvic Organs 54
Vulva 258
Errors Arising in Connection with the Cloaca 260
Malformations of the Urinary Tract 261
Oedema 528
Retention Cysts 528
Benign Neoplasms 529
Malignant Neoplasms of Vulva 531
Histology 531
Tumours of Bartholin’s Gland 538
Urethral Tumours 539
Tumours of the Inguinal Canal 542
Insemination 829
Embryo Transfer 831
Outcome 832
Cryopreservation 832
Oocyte Donation 833
Embryo Donation 834
Surrogacy 834
Intrauterine Insemination 834
Donor Insemination 836
Other ART Methods 836
Results of Treating Infertility 838
Dangers of Investigating and Treating Infertility 838
Complications of ART 839
Adoption 840
Index 1167