산부인과학지침과 개요 4판

산부인과학에 많은 관심을 가져주신 여러분께 대한산부인과학회에서 정성껏 준비한 “산부인과학 지침과 개요”제 4판을 출간하
게 되어 대단히 기쁩니다. 아시는 것처럼 그동안 산부인과학 학습교재로 산부인과학회에서 출간한 “산과학’’과 “부인과
학’’, 그리고 “Williams Obstetrics’’와 “Novak’s Gynecology’’를 사용하여 왔으나, 산부인과학을 전공하지 않는 의과
대학/의학전문대학원 학생들에게는 너무 전문적이고 그 양이 방대하여 학생 수준에는 적합하지 않았습니다. 이에 따라 학생들만
을 위한 표준화된 교과서가 절실히 요구되어 2008년에 “산부인과학지침과 개요” 초판을 발간하였고 이후 지속적으로 개편을
거
듭하여 현재에 이르게 되었습니다.

초창기에는 소수의 교수님들이 봉사하는 마음으로 시작하였지만, 이후 차차 체계를 갖추어 이번 4판에서는 산과와 부인과를 나
누
고 또한 세부 분야를 나누어 많은 전문 교수님들에게 원고집필을 의뢰하였습니다. 책의 내용을 접하시면 아시겠지만 우선적으
로
학생들이 알아야 할 산부인과 영역의 기본 내용 위주로 수록하였으며, 이에 더 나아가 의사 국가고시를 대비한 내용과 의대생들
이 반드시 숙지해야 할 산부인과 전문적 내용을 일부 담고 있습니다.

새로운 내용을 완성하기 위하여 노력해주신 박형무 편찬위원장님과 편찬위원님들에게 감사의 말씀을 드리고, 또한 산부인과 학
회
와 산부인과학 분야의 발전을 위하여 기꺼이 시간과 노력을 할애해 주신 집필 교수님들에게 감사와 격려를 드립니다.

우리나라의 산부인과 현실이 현재는 많은 어려움을 겪고 있습니다. 전공의 지원율은 낮아진 상태이며 여러 산부인과 전문의가
본
연의 일과는 다른 일에 종사하게 되는 등 작금의 상태를 보는 학회의 마음은 무겁습니다. 하지만 이제 조금씩 변화의 바람이 일
어나고 있는 것 같습니다.

의학에 있어서도 기본에 충실한 분야가 다시 인정받고 존중받는 사회가 될 것을 기대하며, 산부인과학의 새로운 도약의 시초가
될 “산부인과학 지침과 개요”가 많은 분들에게 산부인과학의 보람됨을 일깨우길 기대해 봅니다. 아울러 많은 의과대학/의학전
문대학원 학생들이 이 책을 통해 산부인과학에 흥미를 느끼고 산부인과를 사랑하는 계기가 되기를 바랍니다.

2015년 8월

대한산부인과학회 이사장 김장흡



도서목차
PArt 1 기초산부인과학

Chapter 01 해부학 ··· 3

1. 외음부 ···························· 3

2. 내부생식기관 ··················· 6

3. 뼈골반 ···························· 8

4. 골반 바닥 ······················ 10



Chapter 02 태생학 ··11

1. 성의 분화 ······················ 11

2. 생식 세포의 발달 ············ 12

3. 성기의 분화 ··················· 13



Chapter 03 생식 생리 ································17

1. 시상하부 ······················· 17

2. 뇌하수체 ······················· 20

3. 생식샘에서 분비되는 호르몬: 성호르몬 ················· 22

4. 월경주기 ······················· 25

5. 난포의 성장 ··················· 27







PArt 2 일반부인과학

Chapter 04 생식기 기형과 성 발달 이상 ········33

1. 외부 생식기 기형 ············ 33

2. 내부 생식기 기형 ············ 35

3. 성 발달 이상 ·················· 36



Chapter 05 유산 ······41

1. 정의 ····························· 41

2. 자연유산 ······················· 43

3. 유발유산 ······················· 47

4. 유산 방법 ······················ 47

5. 반복유산 ······················· 51

6. 자궁경부 무력증 ············· 54



Chapter 06 자궁외 임신 ·····························59

1. 정의, 빈도 및 발생 부위 ··· 59

2. 난관임신의 원인 및 위험인자 ····························· 61

3. 난관임신의 병태생리 ······· 62

4. 임상적 증상 ··················· 62

5. 진단 ····························· 63

6. 치료 ···························· 64

7. 난관이외 부위의 자궁외 임신 ······························ 66



Chapter 07 가족계획 ·································69

1. 서론 ····························· 69

2. 자연피임법 ···················· 71

3. 장벽방법과 살정제 ·········· 72

4. 자궁내 장치 ··················· 73

5. 호르몬 피임제 ················ 76

6. 응급 피임 ······················ 81

7. 영구피임 방법 ················ 82



Chapter 08 자궁근종 ·································85

1. 병태생리 ······················· 85

2. 위험 인자 ······················ 86

3. 증상 ····························· 86

4. 위치에 따른 분류 ·········· 87

5. 진단 ····························· 88

6. 감별진단 ······················· 89

7. 생식능력에 대한 근종의 영향 ······························ 89

8. 임신과 자궁근종 ············· 90

9. 치료 ····························· 91



Chapter 09 자궁내막증 ······························95

1. 정의 ···························· 95

2. 호발 부위 ······················ 95

3. 역학 ····························· 96

4. 위험인자 ······················· 97

5. 병인론 ·························· 97

6. 임상 양상 ····················· 98

7. 진단 ····························· 99

8. 복강경 소견 ················· 100

9. 치료 ··························· 101



Chapter 10 골반통과 월경통 ·····················105

1. 서론 ··························· 105

2. 급성 골반통 ················· 105

3. 주기성 통증: 일차성과 이차성 월경통 ················ 109

4. 만성 골반통 ················· 111



Chapter 11 비정상 자궁출혈 ·····················115

1. 서론 ··························· 115

2. 정상 월경의 양상 ·········· 116

3. 비정상 월경을 설명하는 용어의 정의 ················· 116

4. 기능성 자궁출혈의 원인에 따른 분류 ················· 116

5. 진단 ··························· 117

6. 감별진단 ····················· 118

7. 치료 ··························· 119

8. 연령에 따른 비정상 자궁출혈 ··························· 120



Chapter 12 성매개병과 요로감염 ···············125

1. 외음부 감염 ················· 125

2. 기생충 감염 ················· 128

3. 생식기 궤양 ················· 131

4. 질염 ··························· 136

5. 자궁경부염 ·················· 141

6. 골반염 ························ 145

7. 난관난소농양 ··············· 147

8. 자궁내막염 ·················· 148







PArt 3 산과학

Chapter 13 서론 ····151

1. 산과학의 정의 ·············· 151

2. 산과학 용어의 정의 ······· 151

3. 역학 및 통계 ·············· 153



Chapter 14 태아 순환 ······························155

1. 정상 태아 순환 ············· 155

2. 출생 후 순환 ················ 157



Chapter 15 모체의 변화 ···························159

1. 대사기능의 변화 ··········· 159

2. 내분비계의 변화 ··········· 161

3. 혈액학적 변화 ·············· 162

4. 심장혈관계의 변화 ········ 164

5. 호흡기계의 변화 ··········· 165

6. 소화기계의 변화 ··········· 166

7. 비뇨기계의 변화 ··········· 167

8. 피부의 변화 ················· 168

9. 근골격계의 변화 ··········· 169

10. 중추신경계의 변화 ······ 169

11. 유방의 변화 ················ 169

12. 생식기 계통 ················ 170



Chapter 16 산전관리 ·······························173

1. 산과용어 ····················· 173

2. 임신의 진단 ················· 174

3. 임신주수 판정과 출산예정일 계산 ····················· 176

4. 산전관리의 목적 ··········· 177

5. 초기 산전평가 ·············· 177

6. 추적 산전관리 ·············· 180

7. 임신 중 영양 ················ 182

8. 임신 중 동반되는 증상과 일반 상식 ··················· 184



Chapter 17 정상 분만진통 및 분만 ·············189

1. 정상 분만의 기전 ·········· 189

2. 분만진통 ····················· 194

3. 후두위에서의 정상 분만 기전 ··························· 198

4. 정상진통의 분만의 관리 202



Chapter 18 비정상 분만진통과 유도분만 ····213

1. 난산 ··························· 213

2. 유도분만 ····················· 215

3. 비정상 태위 ················· 218

4. 급속 분만 ··················· 223



Chapter 19 생식관의 이상 ························225

1. 생식관의 발달이상 ········ 225

2. 후천성 생식기계 이상 ···· 229



Chapter 20 수술적 산과학 ························233

1. 흡입분만 ····················· 233

2. 제왕절개술 ·················· 235

3. 제왕절개술 후의 질식분만 ······························· 237



Chapter 21 산과마취 ·······························241

1. 부위마취 ····················· 241

2. 부위마취의 합병증 ········ 242



Chapter 22 산후관리 ·······························245

1. 산욕기의 정의 ·············· 245

2. 산욕기의 변화 ·············· 245

3. 모유수유 ····················· 248

4. 산욕기 이상 ················· 250



Chapter 23 산전 태아 안녕평가 ·················257

1. 서론 ··························· 257

2. 태아운동 ····················· 257

3. 태아호흡 ····················· 259

4. 비수축검사 ·················· 260

5. 생물리학계수 ··············· 261

6. 탯줄동맥 도플러 초음파 검사 ··························· 262



Chapter 24 분만 중 태아 건강평가 ·············265

1. 분만 중 자궁수축 ·········· 265

2. 태아 심박동수의 양상 ···· 265

3. 태아곤란증 ·················· 270



Chapter 25 조산 ····273

1. 용어의 정의 ················· 273

2. 조산의 개괄 ················· 274

3. 조산의 원인 ················· 275

4. 조산 위험이 있는 임신부의 예측 및 조기 발견 ····· 277

5. 임신 유지에 있어서 Progesterone의 역할 ··········· 278

6. 조기양막파수의 관리 ····· 279

7. 양막파수가 없는 상태에서의 조기진통 ················ 280



Chapter 26 과숙임신 ·······························285

1. 정의 ··························· 285

2. 빈도 ··························· 285

3. 원인 ··························· 285

4. 진단 ··························· 285

5. 과숙임신의 병태생리 ····· 286

6. 과숙임신의 합병증 ········ 287

7. 과숙임신의 처치 ··········· 287



Chapter 27 태아성장 이상 ························289

1. 정상 태아 발육 ············· 289

2. 태아 발육부전 ·············· 290

3. 태아과도성장 ··············· 293



Chapter 28 양수량의 이상 ························295

1. 양수량의 조절과 측정방법 ································ 295

2. 양수과다증 ·················· 296

3. 양수과소증 ·················· 297



Chapter 29 다태임신 ·······························301

1. 다태임신의 원인 ··········· 301

2. 다태임신의 진단 ··········· 305

3. 다태임신 모체의 임신적응 ······························· 305

4. 임신 결과 ···················· 306

5. 다태임신의 특이 합병증 309

6. 다태임신의 분만 ··········· 312

7. 선택적 감수술 및 중절술 314



Chapter 30 태아 및 신생아 질환 ················315

I. 조산 태아 및 신생아 질환 ··315

1. 신생아호흡곤란증후군 ··· 315

2. 미숙아 망막병증 ··········· 317

3. 뇌실내 출혈 ················· 318

4. 뇌실주위백질연화증 ······ 318

5. 괴사성 장염 ················· 319

6. 뇌성마비 ····················· 319

7. 동종면역 ····················· 321

8. 태아수종 ····················· 324

II. 만삭 태아 및 신생아 질환 ·326

1. 태변흡인증후군 ············ 326

2. 신생아 뇌병증과 뇌성마비 ······························ 327

3. 신생아 혈액학적 이상 ·· 329

4. 신생아 손상 ················· 331

5. 자궁내 태아사망 ··········· 333



Chapter 31 산과적 출혈 ···························337

1. 서론 ·························· 337

2. 산과적 출혈의 원인 ······· 338

3. 소모성 혈액응고장애 ····· 352

4. 출혈의 관리 ················· 355



Chapter 32 임신 중 고혈압 ·······················357

1. 임신 중 합병되는 고혈압의 진단 기준 ················ 357

2. 전자간증 ····················· 358

3. 자간증 ························ 365

4. 만성고혈압 ·················· 369

5. 중복전자간증 ··············· 371



Chapter 33 임신과 당뇨 ···························373

1. 빈도 및 역학 ·············· 373

2. 임신 중 당뇨병의 분류 · 373

3. 임신성 당뇨병 ············· 374

4. 현성 당뇨 ··················· 379



Chapter 34 임신과 동반된 내·외과 질환 ······383

I. 심혈관 질환 ·······················383

1. 역학 ··························· 383

2. 임신 중 심혈관계의 생리적 변화 ······················ 384

3. 정상임신에서 나타날 수 있는 증상 및 소견 ······· 384

4. 임신 중 심장질환을 의심할 수 있는 증상 또는 진찰 소견························· 385

5. 심장 질환 환자의 임신 전 상담 ························· 385

6. 심장질환 임산부의 처치 ································· 386

II. 폐 및 호흡기계 질환 ··········389

1. 임신과 인플루엔자 폐렴 · 389

2. 임신과 수두 ··············· 389

3. 임신 중 결핵 치료 ······· 390

4. 임신과 천식 ················· 390

III. 간 및 위장관 질환 ·············392

1. 임신 중 위장관계 기능의 변화 ··························· 392

2. 입덧 ··························· 392

3. 역류성 식도염 ·············· 393

4. 소화성 궤양 ················· 393

5. 충수돌기염 ·················· 393

6. 염증성 장질환 ·············· 394

7. 임신성 급성 지방간 ······· 395

8. HELLP 증후군 ············· 396

9. 바이러스성 간염과 임신 ································· 397

IV. 요로계 감염 ·····················399

1. 요로 감염 ···················· 399

2. 요로 감염의 진단 ········ 399

3. 무증상 세균뇨 ············· 400

4. 급성 신우신염 ·············· 400

V. 저혈소판증 ······················402

1. 빈도 및 정의 ················ 402

2. 임신성 저혈소판증 ········ 402

3. 면역성 저혈소판증 ········ 403

VI. 갑상선 질환 ·····················404

1. 갑상샘과다증 ··············· 404

2. 갑상샘저하증 ··············· 406

3. 산후 갑상샘염 ·············· 406

VII. 결합조직계 질환 ·············408

1. 전신홍반루푸스 ············ 408

2. 항인지질항체증후군 ······ 410

VIII. 혈전색전질환 ·················412

1. 역학 ··························· 412

2. 심부정맥혈전증 ············ 412

3. 폐색전증 ····················· 413

IX. 신경 정신학적 질환 ·········415

1. 간질 ··························· 415

2. 산욕기에 발생하는 정신과적 질환 ···················· 416

X. 피부질환 ···························418

1. 임신성 간내 쓸개즙 정체 418

2. 임신소양성두드러기성 구진 및 판 ····················· 419

3. 임신유사천포창 ············ 420

XI. 감염성 질환 ·····················422

1. 바이러스 감염 ·············· 422

2. 세균감염 ····················· 428

3. 원충감염 ····················· 429

XII. 성매개질환 ······················432

1. 매독 ··························· 432

2. 임질 ··························· 433

3. 클라미디아 감염 ··········· 433



Chapter 35 산과 의료윤리 ························439

1. 서론 ··························· 439

2. 의료윤리의 4원칙 ········· 439

3. 의사-환자관계에서의 일반적 윤리 ···················· 441

4. 임신중절 관련 법령 ······· 444

5. 산과 의료윤리 ·············· 445







PArt 4 생식 내분비학

Chapter 36 사춘기 451

1. 정의 ··························· 451

2. 정상 사춘기 발달 ········ 451

3. 사춘기 발달이상 ··········· 455



Chapter 37 무월경 459

1. 무월경의 정의와 분류 ··· 459

2. 2차 성징의 발현이 없는 원발성 무월경 ············· 461

3. 2차 성징의 발현이 있고 골반 구조가 비정상적인 경우의 무월경··············· 464

4. 2차 성징의 발현이 있고 골반 구조가 정상인 경우의 무월경····················· 465



Chapter 38 내분비 질환 ···························473

1. 고안드로겐증 ·············· 473

2. Prolactin disorder ······· 477



Chapter 39 폐경 ····481

1. 정의 ·························· 481

2. 폐경 주변기 및 폐경기의 생리학 ······················ 482

3. 에스트로겐 감소로 인한 표적 장기의 반응 ········· 484

4. 폐경기의 임상적 양상 ·· 485

5. 호르몬 요법 ················ 489



Chapter 40 여성 불임 ······························493

1. 서론 ··························· 493

2. 여성의 연령과 Fecundity ································· 494

3. 각 불임 요인에 대한 검사와 처치 ······················ 496

4. 원인불명 불임 ·············· 503

5. 보조생식술 ·················· 503







PArt 5 종양학

Chapter 41 난소 양성 종양 ·······················509

1. 기능성 낭종 ················· 509

2. 종양성 양성 종양 ········ 510

3. 기타 난소 종양 ············· 513



Chapter 42 난소암 515

1. 상피성 종양 ················ 515

2. 임상적 평가 ················· 520

3. 병기결정 ····················· 520

4. 상피성 난소암의 병리 ···· 522

5. 전이양상 ····················· 522

6. 예후인자 ····················· 522

7. 치료 ··························· 525

8. 생존율 ························ 529

9. 난소 생식세포종양 ········ 529

10. 성기삭 간질 종양 ········ 533



Chapter 43 자궁경부의 질환과 종양 ···········537

1. 역학 ··························· 537

2. 발병기전 ····················· 538

3. 분류 ·························· 538

4. 진단 ··························· 539

5. 자궁경부상피내종양의 치료 ······························ 543

6. 자궁경부암의 병기 ········ 545

7. 치료 방법 ···················· 546

8. 진행되지 않고, 크지 않은 자궁경부암의 치료 ·······················549

9. 진행되지 않았으나 지름 4 cm를 넘는 자궁경부암 치료··························· 551

10. 진행된 자궁경부암 치료 ································· 551

11. 특수한 상황의 자궁경부암 치료 ······················· 551

12. 치료 후 추적검사 ······· 552



Chapter 44 외음부 및 질의 질환 ················555

1. 선천성 기형 ················· 555

2. 양성 상피성 질환 ·········· 557

3. 양성 낭종 및 종양 ········ 560

4. 감염성 질환 ················· 561

5. 외음부의 비궤양성 감염질환 ···························· 566

6. 악성질환 ····················· 567



Chapter 45 자궁내막증식증과 자궁내막암 ··575

I. 자궁내막증식증 ·················575

1. 분류 ··························· 576

2. 위험요인 ····················· 577

3. 진단 ··························· 577

4. 치료 ··························· 578

II. 자궁내막암 ························579

1. 병태생리 ····················· 579

2. 자궁내막암의 전이경로 ·· 579

3. 선별검사 ····················· 580

4. 증상 ··························· 580

5. 이학적 검사 ················· 581

6. 진단 ··························· 581

7. 치료 전 평가 ················ 582

8. 조직학적 분류 ·············· 582

9. 예후 ··························· 583

10. 치료 ························· 584

11. 자궁내막암의 재발 ······· 586

12. 치료 후 추적관찰 ······· 587

13. 자궁내막암으로 수술 후 난포호르몬 투여 ·········· 588



Chapter 46 임신성 융모성 질환 ·················589

1. 포상기태 ····················· 590

2. 악성 임신성 융모성 질환 ································· 593







PArt 6 비뇨부인과 성학

Chapter 47 비뇨부인과와 골반장기탈출증 ··601

1. 배뇨의 생리학 ············· 601

2. 요실금 ······················· 605

3. 골반장기탈출증 ············ 610



Chapter 48 성징, 성기능 장애, 성폭행 ········615

1. 성징 ··························· 615

2. 성 반응에 영향을 주는 인자들 ·························· 617

3. 성기능 장애 ················· 619

4. 성폭행 ························ 621

찾아보기 ················ 627