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iCT 



Obstetrics 

and Gynaecology 



AN ILLUSTRATED COLOUR TEXT 



Joan Pitkin 
Alison B. Peattie 
Brian A. Magowan 



Obstetrics and 
Gynaecology 

AN ILLUSTRATED COLOUR TEXT 



Commissioning Editor: Ellen Green 

Project Development Manager: Jim Killgore/ Helen Leng 

Project Manager: Nancy Arnott 

Designer: Sarah Russell 



Obstetrics and 
Gynaecology 



AN ILLUSTRATED COLOUR TEXT 




Joan Pitkin bscfrcsfrcog 

Consultant Obstetrician and Gynaecologist 

Northwick Park & St Mark's Hospital 

NW London Hospitals NHS Trust 

Harrow 

Honorary Senior Lecturer, Faculty of Medicine 

Imperial College 

London 

UK 

Alison B. Peattie frcog 

Consultant Obstetrician and Gynaecologist 
The Countess of Chester Hospital 
Chester 
UK 

Brian A. Magowan mrcog 

Consultant Obstetrician and Gynaecologist 

Borders General Hospital 

Melrose 

UK 



Illustrated by Ian Ramsden 



/!> 



CHURCHILL 
LIVINGSTONE 



EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2003 



IV 



CHURCHILL LIVINGSTONE 

An imprint of Elsevier Science Limited 

© 2003, Elsevier Science Limited. All rights reserved. 

The right of Joan Pitkin, Alison Peattie and Brian Magowan to be identified 
as authors of this work has been asserted by them in accordance with the 
Copyright, Designs and Patents Act 1988 

No part of this publication may be reproduced, stored in a retrieval system, 
or transmitted in any form or by any means, electronic mechanical, 
photocopying, recording or otherwise, without either the prior permission of 
the publishers, or a licence permitting restricted copying in the United 
Kingdom issued by the Copyright Licensing Agency, 90 Tottenham Court 
Road, London WIT 4LP. Permissions may be sought directly from 
Elsevier's Health Sciences Rights Department in Philadelphia, USA: phone 
(+15 215 238 7869, fax: (+1) 215 238 2239, email: healthpermissions® 
elsevier.com. You may also complete your request on-line via the Elsevier 
Science homepage (http//www.elsevier.com), by selecting 'Customer 
Support' and then 'Obtaining Permissions' 

First published 2003 

ISBN 044305035X 

British Library Cataloguing in Publication Data 

A catalogue record for this book is available from the British Library 

Library of Congress Cataloging in Publication Data 

A catalog record for this book is available from the Library of Congress 



Note 

Medical knowledge is constantly changing. Standard safety 
precautions must be followed, but as new research and clinical 
experience broaden our knowledge, changes in treatment and 
drug therapy may become necessary or appropriate. Readers are 
advised to check the most current product information provided 
by the manufacturer of each drug to be administered to verify the 
recommended dose, the method and duration of administration, 
and contraindications. It is the responsibility of the practitioner, 
relying on experience and knowledge of the patient, to determine 
dosages and the best treatment for each individual patient. 
Neither the publisher nor the authors assumes any liability for 
any injury and/or damage to persons or property arising from 
this publication. 



ELSEVIER 



your source for books, 
journals and multimedia 
in the health sciences 

www.elsevierhealth.com 



Cover image 

Infertility: false-colour hysterosalpingogram of the abdomen of a woman 
suffering from blocked fallopian tubes. 

Credit 

Science Photo Library 



The 

publishers 

policy is to use 

paper manufactured 

from sustainable forests 



Printed in China 



Preface 




Obstetrics and gynaecology is a dynamic 
and rapidly changing speciality. Great 
advances have been made in prenatal 
diagnosis, the management of infertility 
and contraceptive techniques. The 
introduction of minimally invasive 
surgical procedures has reduced bed 
occupancy and analgesic requirements 
allowing women to return home more 
rapidly. Service delivery development, 
required to meet improving NHS 
standards, has seen the introduction of a 
new multidisciplinary approach, new 
roles for midwives and the emergence of 
the gynaecological nurse practitioner. 
Obstetrics and gynaecology is both 
rewarding and demanding. Maternity 
care challenges all of us to be more 



women-centred and to provide similar 
standards of care worldwide. Nowhere 
else in medicine are we faced with the 
exhilaration of the arrival of new life; 
equally, our speciality remains the 
highest area for litigation - an added 
burden for clinicians - so that audit, 
clinical governance and an evidence- 
based approach are especially pertinent. 

There continues to be areas of great 
controversy surrounding the speciality, 
especially assisted conception, 
termination of pregnancy and hormone 
replacement therapy. In no other branch 
of medicine are such private and 
intimate details discussed regarding 
dysparunia, vaginal discharge and 
psychosexual problems. The trust placed 



in the clinician by the woman is a 
privilege to be valued and respected. 
This book aims to encompass the 
breadth and depth of our speciality in a 
vivid, easy-to-use fashion. Based on a 
double-spread format for each topic, the 
subject comes alive through the 
generous use of illustrations but retains 
considerable up-to-date detail and covers 
some topics overlooked in other texts. 
The use of tables and 'key-point' boxes 
facilitates easy reference. We hope it will 
be instructive and enjoyable to read. 



London 
2003 



Joan Pitkin 
Alison Peattie 
Brian Magowan 



VI 







Acknowledgements 



We would like to acknowledge all those 
who have lent material, the secretarial 
support received and the patience of the 
publishers and our long-suffering 
partners. 



Joan Pitkin 


Alison Peattie 


Brian Magowan 



vii 



Contents 



Obstetrics 



Normal pregnancy - physiological 
signs and symptoms 2 

Antenatal care 4 

Pre-conceptual counselling 6 

Fetal chromosomal abnormality 8 

Fetal abnormality 10 

Infections in pregnancy 14 

Human immunodeficiency virus 
(HIV) 16 

Preterm labour and preterm premature 
rupture of the membranes 
(PPROM) 18 

Hypertension 20 

Small for dates fetus 22 

Medical disorders in pregnancy 24 

Diabetes in pregnancy I 28 



Diabetes in pregnancy II 30 

Anaemia in pregnancy 32 

Haemoglobinopathies in pregnancy 34 

Antepartum haemorrhage 36 

Multiple pregnancy 38 

Breech presentation 40 

Venous thromboembolic disease 42 

Psychosocial problems in antenatal 
care 44 

Mechanisms of normal labour 46 

Induction of labour and prolonged 
pregnancy 48 

Intrapartum fetal monitoring 50 

Abnormal labour 52 

Operative delivery 54 

The perineum 58 




Postpartum haemorrhage and 
abnormalities of the third stage of 
labour 60 

Obstetric emergencies 62 

The normal puerperium 64 

The abnormal puerperium 66 

Alternative approaches to delivery 68 

Analgesia in labour 70 

The changing face of maternity care 72 

Drug misuse and physical abuse 74 

Common problems in pregnancy 76 

Vital statistics 78 

The newborn 80 

Problems in the first week of life 82 

Bereavement in obstetrics and 
gynaecology 84 



Gynaecology 

Gynaecological assessment 
of the patient 86 

Developmental and paediatric 
gynaecology 88 

Puberty and its abnormalities 90 

Miscarriage 92 

Induced abortion (termination 
of pregnancy) 94 

Trophoblastic disorders 96 

Ectopic pregnancy 98 

Pelvic inflammatory disease 100 

Genital infections 102 



Oestrogen-dependent hormonal 
contraception 106 

Progestogen-dependent hormonal 
contraception 108 



Non-hormonal methods 
of contraception 110 

Amenorrhoea 112 

Polycystic ovarian syndrome 114 

Day care surgery 116 

Uterine fibroids 118 

Physiology of menstruation 120 

Disorders of menstruation I 122 

Disorders of menstruation II 124 

Acute and chronic pelvic pain 126 

Endometriosis 128 

Investigation of infertility 130 

Management of infertility 132 

Cervical intraepithelial neoplasia 
(CIN) 134 



Cervical carcinoma 136 

Carcinoma of the uterus 138 

Benign ovarian conditions 140 

Ovarian carcinoma 142 

Benign vulval conditions 144 

Vulval carcinoma 146 

Menopause: physiological changes 148 

Menopause: management 150 

Uterovaginal prolapse 1 52 

Urinary incontinence 1 54 

Emotional disturbances 
in gynaecology 1 56 

Psychosexual disorders 1 58 

Postoperative care 160 



Index 162 



OBSTETRICS 



Normal pregnancy - physiological signs and 
symptoms 



Changes to the maternal physiology in 
pregnancy (Fig. 1) allow maximum 
efficiency of fetal growth and 
metabolism. As this is very different 
from the normal maternal physiology 
it cannot be equally advantageous. 
Normally homeostatic mechanisms, 
after detecting a change, return the 
organism to the resting state, but 
manipulation of the mother's 
homeostatic mechanisms is done by the 
fetus in anticipation of its needs as it 
grows. So, many changes are noted by 
the mother in early pregnancy when the 
actual needs of the fetus are minimal. 
Changes to the energy balance and 
respiratory control occur via the 
hypothalamus and are typically 
mediated by progesterone, while 
changes to the more peripheral 



Table l Changes in the cardiovascular system 
Change 

Increased blood volume 2600 to 3000 ml 
Increased red celt mass 1400 to 1650-1000 ml 
Decreased haeiriogloum (Hb) and haematocru 

Increased resting cardiac output 4.5 to 6 l/mm 

Raised heart rale 80 to 90 bpm 

Increased oaygen consumption by 30-50 ml/min 

Decrease in total peripheral resistance (TPR] to 

parallel rise in cardiac output [CO) 

Mid trimester fall in blood pressure due to 

greater drop in TPR than rise in CO 

Increased incidence of heart murmurs due To increased 

flow across valves 



functions such as blood volume, blood 
constituents and coagulation, and total 
body water are mediated by oestrogen. 




Cardiovascular system 
Gastrointestinal tract 



I I Urinary tract 
] The thyroid 



Respiratory system 



Resu Its/requirements 

Raised from eany in pregnancy [6-9 weeks] 

Needs r eady iron supply for optimal rise (see p. 3] 

Proportional to the above two factors- termed the 

physiological anaemia oi pregnancy 

Early rise maintained through pregnancy and iabour. 

Declines in puerpenum 

Weeds increased stroke volume 

Increased cardiac Output needed to distribute this 

Vasodilatation - also allows dissipation of heat produced 

by the fetus 

Need to know blood pressure [BP] in first trimester when 

assessing a raised BP in pregnancy (sec p. 20) 

Need to distinguish pathology from functional murmurs - 

consider antibiotics in labour foi stiucloral head disease 



Fig. 1 Maternal systems changed by pregnancy. 



Cardiovascular system 

The main changes seen in the 
cardiovascular system are shown in 
Table 1. At term the distribution of the 
raised cardiac output is: 

■ Uterus 400 ml/min extra 

■ Kidneys 300 ml/min extra 

■ Skin 500 ml/min extra 

■ Elsewhere 300 ml/min extra. 

Urinary tract 

The anatomy of the renal tract changes 
in pregnancy. Cellular hypertrophy 
causes a 1 cm increase in renal length. 
The diameter of the ureters is 
increased due to the relaxant effect of 
progesterone on the smooth muscle 
and in later pregnancy there may be 
ureteric obstruction due to uterine 
enlargement. Increased filtration of 
glucose may lead to glycosuria as the 
proximal tubular ability to reabsorb 
glucose is overloaded. The patient is 
aware of urinary frequency due to 
increased renal blood flow and the 
pressure of the pregnant uterus on her 
bladder in early pregnancy. There is a 
diuresis immediately following delivery 
of the placenta as the vascular bed is 
contracted down by nearly 500 ml. 
Table 2 lists the changes in values seen 
during pregnancy. 

Gastrointestinal tract 

Progesterone causes smooth muscle 
relaxation and thus decreased gut 
motility with adverse effects for the 
mother. The resultant constipation can 
be very uncomfortable and may be 
exacerbated by treatment with oral 
iron therapy. Straining at stool may 



Normal pregnancy - physiological signs and symptoms 3 



Table 2 Changes in values 

Renal blood flow increases 

Glomerular filtration rate uses doe to raised blood flow 

Serum urea falls due to increased filtration 

Serum creatinine falls doe to greater filtration 



From 1 21/minto 1.51/min 
14D ml/mm up to l7Dmi/min 
4.3 mmol/l down to 3. 1 mmol/l 
73 mmol/l falls to 47 mmol/l 



increase the pain of haemorrhoids 
caused by raised pressure in the 
venous system with blockage to 
venous drainage due to the enlarged 
gravid uterus. 

Heartburn due to reflux of acid 
stomach contents is common in 
pregnancy. It is caused by relaxation of 
the gastro-oesophageal sphincter 
combined with delayed gastric 
emptying. Diagnosis of acute surgical 
problems such as appendicitis can 
prove difficult due to the altered site of 
intra-abdominal contents with the 
enlarged uterus displacing organs 
upwards and outwards. 

The thyroid 

Many patients may have enlargement 
of their thyroid during pregnancy as a 
result of changes in the renal handling 
of plasma inorganic iodide. Raised 
filtration of this causes a fall in plasma 
levels and the thyroid hypertrophies in 
an attempt to maintain normal iodide 
concentrations. Development of a 
goitre in pregnancy may indicate mild 
relative iodine deficiency. 

Body water 

Total body water increases by 8.5 1 : G 1 
distributed to placenta, amniotic fluid, 
blood volume, uterus and breasts - 2.5 1 
as extracellular water causing oedema. It 
is normal in pregnancy to experience 
dependent oedema (legs). The ground 
substance of the connective tissues stores 
much of the increase making ligaments 
softer, which can result in backache due 
to lumbar lordosis putting abnormal 
strain on the lower back and 
separation of the symphysis pubis 
causing pain during walking. 

Tingling of the fingers supplied by 
the median nerve may be due to extra 
fluid causing compression as the nerve 
passes under the flexor retinaculum. A 
beneficial effect is the increased 
stretchability of the cervix noted during 
labour. 

Respiratory system 

The respiratory centre is reset to less 
than 4 kPa pCO, (from 6 kPa) under 
the influence of progesterone, enabling 
the fetus to offload its waste gas. 
Ventilation is increased by 40% in the 
first trimester due to increased tidal 



Late 
Non- P re 9 nanc * 



3000 
ml 

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1000 
Fig. 2 Respiratory changes of pregnancy. 

volume but as pregnancy progresses 
there is a decrease in total lung 
capacity by 200 ml due to uterine size. 
There is no change noted in expiratory 
peak flow rate during pregnancy (Fig. 2} 
Dyspnoea noted in early pregnancy 
may be due to the lowered pC0 2 which 
the mother is unused to. Mild exercise 
may reduce pCO, to a level which 
reduces cerebral blood flow and causes 
dizziness. The low pCO, is paralleled by 
low plasma bicarbonate to maintain 
normal pH. The resulting low plasma 
osmolality remains uncorrected and 
may be responsible for polyuria and 
thirst in early pregnancy. 

Energy balance 

The average weight gain in pregnancy 
is 12 kg in the second half of 



pregnancy. This is distributed between 
the fetus, uterus, breasts, increased 
blood volume and body fat The body 
fat is distributed centripetally and is 
increased due to both extra intake and 
decreased utilization due to the more 
sedentary lifestyle dictated by 
pregnancy. 

Glucose 

The handling of a glucose load is 
altered during pregnancy with the rise 
higher than in non-pregnant females 
and elevated for longer. However, 
insulin levels are also raised above the 
usual - pregnancy is a time of insulin 
resistance most marked in the third 
trimester. Fasting plasma glucose is 
lowered in early pregnancy but rises in 
weeks 16-32. These facts mean that 
gestational diabetes is most likely to be 
detected in the third trimester. 

Iron 

As the red cell mass increases (18%] by 
less than the blood volume there is a 
fall in haemoglobin as pregnancy 
progresses. A lowered mean cell 
volume (MCV) is the most sensitive 
indicator of iron deficiency - serum 
iron is low and total iron-binding 
capacity raised. Routine iron 
supplementation is associated with an 
increased red cell mass of 30% and 
debate still exists as to whether to offer 
routine iron to all pregnant women or 
to treat those found to be iron 
deficient. 

Coagulation changes in 
pregnancy 

A hypercoagulable state exists from 
early in the first trimester, thought to 
be advantageous to meet the sudden 
haemostatic demand as the placenta 
separates. The increased ability to 
neutralize heparin in late pregnancy 
rapidly returns to normal on delivery 
of the placenta - important to note in 
patients on heparin therapy. Increased 
levels of fibrinogen, factors VII, VIII, 
and X are found, with decreased levels 
of factors XI, XIII and fibrinolytic 
activity. 



J Normal pregnancy - physiological signs and symptoms 

■ Changes to maternal physiology anticipate the needs of the fetus rather than the usual 
mechanism where change returns physiology to the normal state once disturbed. 

■ Progesterone causes relaxation of smooth muscle, so changes are seen in the unnary and 
gastrointestinal tracts. 

■ Many symptoms the mother experiences due to these physiological alterations are normally 
signs of disease. Therefore, interpret symptoms in pregnancy with caution. 



OBSTETRICS 

Antenatal care 



Aims of antenatal care 

The main aim of antenatal care is to 
have a healthy mother and a healthy 
baby at the end of the pregnancy. 
Antenatal care thus becomes risk 
assessment - trying to identify from the 
patient's history and from examination 
whether there are any factors which may 
have an adverse effect on the patient or 
her fetus during the pregnancy and the 
correction of these problems. 

Pattern of antenatal care 

The traditional pattern for antenatal care 
was laid out in the early 20th century 
with monthly visits until 28 weeks' 
gestation, visits every 2 weeks until 
3G weeks and weekly visits until 
delivery. This entails 12 to 14 visits per 
pregnancy and is probably more than is 
necessary to enable detection of the 
major complications of pregnancy such 
as hypertension and fetal growth 
restriction. The usual aim is to hold the 
booking visit early in the pregnancy - if 
possible in the first trimester - to enable 
advice to be given on diet smoking, 
alcohol, and medication, much of which 
might be more appropriately dealt with 
under pre-conceptual counselling (see 
p. G). A detailed history is usually taken 
at this visit enabling identification of 
factors which would place the patient at 
higher risk of perinatal mortality 

Epidemiological factors 

m teenager - at risk of hypertension, 

intrauterine growth restriction 

(IUGR) 

■ elderly primigravida (over 35 years) 
- increases in fetal chromosomal 
abnormalities, perinatal mortality, 
and obstetric intervention. 

Past obstetric histoij 
m previous stillbirth or neonatal death 
(NND) 

■ previous fetal abnormality 

■ preterm labour or precipitate labour 

■ caesarean section 

■ pregnancy complication likely to be 
repeated - pre-eclampsia, IUGR, 
abruption, postpartum haemorrhage 
(PPH). 

Maternal medical history 
m cardiac disease, diabetes, thyroid 
disorder, drug misuse, renal 
problem, thromboembolic disorder, 
hypertension, epilepsy (see p. 25) 

■ factors on examination: cardiac 



murmur, hypertension, size of 
mother (large with risk of 
gestational diabetes, small with risk 
of'IUGR), pelvic mass, uterine size 
not in keeping with dates. 

Clinical examination 

Few women have had any medical 
examination since starting school and 
routine examination to exclude disease 
should cover cardiovascular, 
respiratory, renal and locomotor 
systems. Clinical examination to 
exclude breast disease is supplemented 
in pregnancy by an examination of the 
nipples so that the woman who wishes 
to breast feed may be prepared, with 
treatment for inverted nipples as 
appropriate (nipple shields or massage). 
The presence of varicose veins should be 
managed by adequate support hosiery 
during pregnancy to prevent worsening 
varicosities with the possibility of 
thrombophlebitis. 

Palpation of the pregnant 
abdomen 

This skill is developed with much 
practice but a structured approach will 
ensure maximum information is 
obtained. 

■ Inspection - look for the degree of 
distension; the presence of umbilical 
eversion suggests excessive 
distension (consider twins or 
polyhydramnios). Watch for fetal 
movements (presence confirms this 
is distension due to pregnancy and 
not an ovarian cyst). The linea alba 
may become pigmented during 
pregnancy - called a linea nigra. 

■ Fundus - determination of the 
position of the fundus (uppermost 
part of the uterus) is with the ulnar 
border of the left hand palpating 
gradually down from the 
xiphisternum. 

■ Symphysis fundal height (SFH) - 
measured with a tape measure from 
the fundus through the umbilicus to 
the upper border of the symphysis 
pubis. The measurement in 
centimetres in the third trimester 
corresponds approximately to the 
number of weeks' gestation 

(+ 3 weeks). 

■ Lateral palpation - to determine 
the lie (longitudinal axis of the fetus 
with respect to the longitudinal axis 
of the uterus) both hands are placed 




Fig. 1 Lateral palpation of the pregnant 
abdomen. 



flat, one on either side of the 
maternal abdomen (Fig. 1), The fetus 
is then gently ballotted between the 
hands to ascertain the fetal parts. 
The lie may be longitudinal (most 
commonly), oblique or transverse 
(see p. 53). The volume of amniotic 
fluid is described as clinically 
normal when fetal parts can be felt 
through a fluid cushion, increased 
(clinical polyhydramnios) when 
fluid prevents determination of the 
fetal parts, or decreased (clinical 
oligohydramnios) when fetal parts 
can easily be felt through the 
abdominal wall. 

■ Presenting part - both hands are 
used to palpate the lower pole of the 
uterus and determine what fetal part 
lies there (Fig. 2). It is usual to 
decide whether the presenting part 
is engaged (widest presenting 
diameter has passed through the 
pelvic inlet) or not engaged. 
Alternatively with a cephalic 
presentation you may say how 
many fifths of the head you can feel 
(Kg. 2). 

■ Fetal health - auscultation for the 
fetal heart with a Pinard's 
stethoscope or Doppler hand-held 
device completes the examination. 
Maternal reporting on fetal 
movements may replace listening 
for the fetal heart. 

Presentation of the findings 

It is usual to start with a one-line 
summary of your history details - for 
example: Mrs X is a 30-year-old, para 
2+0 at 36 weeks with raised blood 
pressure. On examination the 
abdomen is distended compatible with 
pregnancy and old striae are noted. 



Antenatal care 




Completely Sinciput +++ Sinciput ++ Sinciput + Sinciput + No part of 

above Occiput ++ Occiput + Occiput just Occiput not head palpable 

felt felt 
5/5 4/5 3/5 2/5 1/5 0/5 







^5K 



Fig. 2 The relationship between abdominal palpation of the 
presenting part and degree of engagement. 



The SFH is 35 cm (1), with a longitudinal lie (2) of a 

singleton infant [3). There is a cephalic presentation (4), 3/5 

head palpable 

(5), fetal heart sounds heard (G) and an adequate liquor 

volume (7). (Remember - 7 points to relate regarding your 

examination.] 

The antenatal visit 

Enquiry as to the mother's well-being and whether fetal 
movements have been satisfactory often opens the discussion 
at an antenatal visit. Some units will ask mothers to keep a 
fetal movement chart after 28 weeks. This is based on the 
finding that the movements diminish or disappear up to 24 
hours before fetal demise. A 'count to ten' chart is kept with 
recording of 10 movements from 09.00 - if fewer than 10 
movements are noted by 21.00 the mother is asked to 
contact her local hospital and attend for fetal assessment 
(usually a CTG). 

Blood pressure is measured and urine tested for 
proteinuria. The development of hypertension in later 
pregnancy may have profound effects on fetal well-being and 
maternal health (see p. 20). Oedema is common in later 
pregnancy but is usually peripheral. 

All recent tests (Table 1) should be reviewed and treated 
as required. Anaemia may develop, needing iron therapy. 
Rhesus negative patients need antibody checks at 28 and 34 
weeks. Examination of the abdomen to check for normal 
growth of the fetus and to determine its position is then 
carried out. A growth scan may be requested if the fetus is 
smaller than expected. This can be repeated at 2-weekly 
intervals to ensure a reasonable growth rate. A larger than 
expected uterus may be due to polyhydramnios. 

In the primigravid patient the presenting part should be 
engaged by 37 weeks, so check to exclude placenta praevia or 
fetal abnormality if the head is high. As the mother comes 
closer to labour she may have worries she wishes to discuss. 
Some draw up a birth plan which needs careful discussion of 



Tabic i Blood 


and urine tests in pregnancy 


Tu4* luff ■ !■! 1 ■■ Hi 

ww» inufpreumon 


Haemoglobin 




Anaemia should fie conected before labour 


Sickle cell Screen 




For Afro-Canbbeans - prenatal diagnosis 


Haemoglobin electrophoresis 


For irraiassaema [seep 39) 


Rhesus status and aniibooY litres 


Rhesus negative will reed monitoring 


1 Rubella lilies 




Most will be immune as vaccinated in school 


Hepatitis B 




Roijline testing if posil rve check H 1 V siatus 


HlVanubodies 




Only teslcd after counselling 


,fTAandTPHA 




Allows bealmem to prevent congenital syphilis 


Uf irw for proflem 




Treaimcni needed for .-nfeclion or bactenuna 


Urine for sugar 




ftenal threshold decreased therefore frequer% 
positive even if serum glucose normal 



any points where the mother's wishes diverge from accepted 
principles. 

Mothercare and parentcraft classes are offered in 
developed countries, though in the developing world 
facilities are more variable, to prepare the mother for labour 
by ensuring understanding of the process. Fear of the 
unknown enhances perceived pain (see p. 70). Teaching on 
breathing techniques to help the sense of control during 
contractions is set alongside teaching on posture when lifting 
and how to lessen backache. A visit to the delivery ward may 
be reassuring. Baby handling is taught to both parents and 
feeding covers the benefits of breast feeding. 

Much of the above will be impossible to achieve in 
developing countries where blood sampling may be limited 
to only haemoglobin assessment and a test for HIV status. 
There may be no ultrasound facility. Care personnel will 
therefore have different aims in delivering antenatal care. All 
women should receive iron orally (see p. 32) and folic acid. 
Regular antimalarial prophylaxis in endemic areas has been 
shown to reduce the incidence of anaemia and increase 
birthweight As hypertension is a major cause of maternal 
mortality, blood pressure screening may save lives. Female 
circumcision is common in some countries and necessitates 
discussion about how to avoid damage at delivery, perhaps 
with elective incision before labour starts. 

Delivery itself may not have any formally qualified person 
present, the traditional birth attendant having trained by 
observing a more experienced birth attendant in action. In 
many countries training programmes for traditional birth 
attendants have been developed as a means of increasing the 
quality of care available for women and children, under the 
guidance of the World Health Organization. 



Antenatal care 



> Antenatal care is risk assessment. 

■ The quality of antenatal care delivered correlates with the perinatal 
mortality. 

■ Antenatal care covers all aspects of the mother's life whilst 
[jikik'm'i; 

■ There are seven key findings on palpation of a pregnant abdomen. 



6 OBSTETRICS 



Pre-conceptual counselling 



Pre-conceptual counselling is helpful in a wide variety of 
circumstances. There is potential for general advice, an 
opportunity to plan care in those with background medical 
disease, a chance to review those with previous obstetric 
complications and a discussion with those at increased risk 
of fetal anomaly. In reality, what should ideally be pre- 
conceptual counselling is often carried out in the first 
trimester of the pregnancy. 

General 

Mothers at extremes of reproductive age are at increased risk 
of obstetric complications, particularly hypertensive 
disorders, and they carry an increased perinatal mortality. 
Smoking also increases the perinatal mortality and should 
ideally be stopped. Alcohol may reduce fertility and is also a 
potential teratogen. Poor nutrition is rare in the UK, but 
significant maternal malnutrition is associated with 
intrauterine growth restriction (IUGR) and subsequent risks 
to the offspring of coronary heart disease, non-insulin- 
dependent diabetes and stroke (Fetal Origins Hypothesis). 

Daily folic acid taken from before conception reduces the 
recurrence risk of neural tube defects in those who have had 
a previously affected child (Fig. 1). A pre-conceptual 
prophylactic dose for all pregnant women probably also 
offers some protection. There are, at present, no known 
teratogenic effects from folate. 

Medical 

Chronic maternal disease may have a deleterious effect on 
fertility that may lessen as the disease process itself 
improves. Maternal disease can affect the fetus, and the 
pregnancy itself may affect the disease. See particularly SLE 
(p. 24), Diabetes (p. 28), HIV(p. 16), Renal disorders (p. 26), 
Thromboembolic disease (p. 42) and Thyroid disorders 
(p. 27). 

It is rare to advise against pregnancy in those with cardiac 
disease, although those with fixed pulmonary output may be 
advised that the risks to their own health are too great (e.g. 
in those with pulmonary hypertension). Active SLE nephritis 
is associated with significant maternal and perinatal 
mortality, and in particular with a risk of pre-eclampsia. 

Those on warfarin for valvular problems or venous 
thromboembolic disease are at increased risk of teratogenic 
problems (particularly midfacial hypoplasia). Consideration 
should be given to timing of pregnancy and whether a 
change to heparin, at least in very early pregnancy, is 
appropriate. As anticonvulsants for epilepsy may also be 
teratogenic (Fig. 2), seizure control with a single drug regime 
is ideal or, if seizure-free for 2-3 years, drug withdrawal may 
be considered (this may have implications for the patient's 
work and/or driving licence). Pre-conceptual folate 
supplements should be given because anticonvulsants lead to 
a reduction in serum folate. 

Obstetric 

Women who have experienced obstetrical difficulties in a 
previous pregnancy are often anxious to talk these through 
and consider the likelihood of recurrence. This is frequently 
a listening exercise so that anxieties and occasionally anger 
can be expressed, especially in cases of previous fetal or 
neonatal loss. An explanation followed by discussion of 




Fig. 1 Spina bifida - large lumbosacral myelomeningocele. Folic 
acid should ideally be started pre-conceptually. 




Fig. 2 Anticonvulsants are associated with neural tube defects, 
cardiac and craniofacial defect. The figure shows a unilateral cleft lip. 



possible recurrence risks and a plan for the next pregnancy 
are useful. It is also an opportunity to identify those with 
abnormal grief reactions who might benefit from further 
counselling before considering another pregnancy. 

Pre-eclampsia tends to improve with subsequent 
pregnancies, with the possible exception of severe pre-term 
disease. The incidence of proteinuric pre-eclampsia in a 
second pregnancy is 10-15 times greater if there was pre- 
eclampsia in the first pregnancy compared to those with a 
normal first pregnancy. It has been suggested that low-dose 
aspirin taken from early pregnancy (< 17 weeks and 
probably from the first trimester) may reduce the incidence 
of IUGR or perinatal mortality in those with previous severe 
disease. Studies in this area have provided conflicting 
evidence. 

Those who have had a previous difficult instrumental 
delivery usually have a much more straightforward delivery 
next time around, but may occasionally request an elective 
caesarean section. This is controversial and careful 
consideration of the advantages and disadvantages is 
required (see p. 56). In general, those with a previous 
caesarean section for a non-recurrent indication, e.g. breech, 
fetal distress or relative cephalopelvic disproportion 
secondary to fetal malposition, should be offered a trial of 



Pre -conceptual counselling 



labour, but repeat elective caesarean section may be 
considered in certain circumstances. 

In situations where there has been previous IUGR or an 
intrauterine death, subsequent management depends on the 
cause and the estimated likelihood of recurrence. More 
intensive antenatal monitoring is usually offered and the 
outcome is usually good, particularly when the loss was 
'unexplained'. 

Risk of fetal anomaly 

Those who have had a previous baby with a fetal anomaly 
are often anxious to know the risk of this happening again 
and whether any prenatal testing can be carried out. This 
discussion has usually taken place after the problem 
pregnancy, but further discussion is sometimes welcomed. 

A couple who have had a previous Down's syndrome 
baby, or fetal loss from Down's syndrome, carry a risk of 
0.75% above their baseline age-related risk (p. 11). Down's, 
however, may rarely also be inherited from a parental 
translocation (e.g. 14 : 21) or mosaicism, which increases this 
recurrence risk significantly. The complexities of these issues 
often require specialist advice from a clinical geneticist 
(Fig. 3). This also applies to many other abnormalities, for 
example congenital heart disease: while in general the 
recurrence risk of this is = 5%, it is dependent on the family 
history, drug history and whether the anomaly was isolated 
or part of some other syndrome. Other structural 
abnormalities, for example Potter's syndrome or 
diaphragmatic herniae, usually carry a low recurrence risk. 

There may be a family history of certain conditions, and 
others have a racial predisposition, e.g. Tay- Sachs disease in 
Ashkenazi Jews or haemoglobinopathies in those of 
Mediterranean origin. Invasive fetal testing may be 
appropriate after parental gene testing if both partners are 
homozygous for a recessive condition. It is possible to test 
for some of the trinucleotide repeat disorders (e.g. myotonic 
dystrophy, Huntington's chorea or fragile X syndrome) but 
the ethics of such testing is complex and it is not necessarily 
desirable in every couple. Other autosomal recessive 
conditions are also amenable to testing, e.g. the screening of 
saliva for the commoner mutant alleles of cvstic fibrosis (the 




commonest being A F508), and again subsequent invasive 
fetal testing if both parents are carriers. 

Lifestyle education 

Smoking is associated with low- birthweight babies, probably 
related to fetal hypoxaemia and ischaemia from both carbon 
monoxide and nicotine. Although there is no evidence to 
support association with fetal abnormality, long-term follow- 
up has demonstrated intellectual and emotional impairment 
Smoking is also associated with an increased risk of 
abruption, preterm labour, intrauterine fetal demise and 
sudden infant death syndrome. Alcohol and drug misuse 
also carry significant fetal risks and/ in the ideal world, all of 
these substances should be avoided in pregnancy. 

Those whose work environment exposes them to 
radiation, hazardous gases or specific chemicals should be 
appropriately counselled. There is no evidence that VDUs 
are harmful, or indeed that work itself is harmful to the 
mother or fetus. The mother should be advised that she may 
continue working providing she is not unduly tired. 
Moderate exercise is likely to be of benefit and should be 
encouraged, but should probably be avoided if there are 
complications, e.g. hypertension, multiple pregnancy, 
cardiorespiratory compromise, antepartum haemorrhage or 
preterm labour. 

Drug treatment in pregnancy 

It is never possible to confirm the safety of any drug in 
pregnancy one can only report on problems that seem to 
have arisen. As a general principle, all drugs should be 
avoided in pregnancy unless clinical benefits are likely to 
outweigh the risks to the fetus. A useful treatment, however, 
should not be stopped without good reason. 

The major body structures are formed in the first 12 
weeks (organogenesis) and drug treatment before this time 
may cause a teratogenic effect. If a drug is given after this 
time it will not produce a major anatomical defect, but may 
affect the growth and development of the baby. 

Drug-related teratogenic problems were highlighted by the 
drug thalidomide introduced in West Germany in 1956 to 
combat morning sickness. By the end of 19G1, thalidomide, 
sold under 51 brand names in at least 4G countries, was 
identified as a human teratogen and removed from the 
market. More than 10 000 infants worldwide were born with 
malformations attributed to the use of thalidomide in 
pregnancy 

Other drugs known to cause fetal abnormality include 
anticonvulsants, warfarin and isotretinoin, a vitamin A 
derivative, which is highly teratogenic and can produce 
almost any type of malformation in small doses. Ionising 
radiation kills rapidly dividing cells and can produce virtually 
any type of birth defect depending on the dose. 

Alcohol is able to cross from the maternal circulation 
through the placenta into the fetal circulation and is 
potentially teratogenic. Fetal alcohol syndrome is discussed 
on page 44. 



Pre -conceptual counselling 



Fig. 3 Atrioventricular canal defect in a baby with Down's 
syndrome. There is a large ventricular septal defect (VSD) and no 
identifiable atrial septum. 



■ Folic acid reduces the incidence of neural tube defects. 

■ Certain medical disorders, particularly structural cardiac disease and 
renal failure, may have major implications lor mother and baby. 

■ Screening for structural or genetic fetal abnormality may be possible. 



^^^^^^^m 



8 OBSTETRICS 



Fetal chromosomal abnormality 



About 2-3% of couples are at high risk 
of producing offspring with genetic 
disorders and 5% of the population 
will have displayed some form of 
genetic disorder by the age of 25 years. 
Particular risk factors are: 

■ Advanced maternal age (e.g. Down's 
syndrome) 

■ Family history of inherited diseases 
(e.g. fragile X syndrome, 
Huntington's chorea) 

■ Previous child with genetic disorder 
(e.g. Tay-Sachs disease, congenital 
adrenal hyperplasia). 

The techniques for prenatal diagnosis 
that can be used and the appropriate 
timings are given in Table 1. 

Here we will focus on screening for 
Down's syndrome which is 
characterized by an extra chromosome 
21. The overall incidence is 1 : GOO live 
births, but depends on maternal age, 
being 1 : 2000 at age 20 and 1 : 100 at 
age 40. In affected individuals, 
although walking, language and self- 
care skills are usually attained, 
independence is rare. There is mental 
retardation (with a mean IQ of around 
50) and an association with congenital 
heart disease, particularly 
atrioventricular canal defects, 
ventriculoseptal defect, atrioseptal 
defect and Fallot's tetralogy. 
Gastrointestinal atresias are common 
and there is early dementia with 
similarities to Alzheimer's disease. 
Twenty per cent die before age 1 but 
45% reach age GO. 

Serum screening 

Antenatal screening for Down's 
syndrome is possible by measuring 



levels of serum markers at 15+ weeks 
- low levels of a-fetoprotein (AFP) 
± high levels of unconjugated oestriol 
and human chorionic gonadotrophin 
(hCG) are corrected for maternal 
weight and age. This allows ~ G0% of 
cases of Down's syndrome to be 
picked up, with amniocentesis 
required on - 4% of the screened 
population. The pick-up rate is higher 
in older women, but the chance of 
being recalled with an elevated risk is 
also higher. It is therefore not essential 
to advise women over the age of 35 
years to have an amniocentesis as 
serum screening is more sensitive in 
this age group. Fluorescent in situ 
hybridization (FISH) techniques may 
be used to exclude the commoner 
aneuploidies within 72 hours. Routine 
karyotyping does take up to 3 weeks 
because of the need to culture cells 
first. 

Screening for open neural tube 
defects is also carried out by 
measuring the maternal serum AFP at 
1G weeks. 

Nuchal translucency 

Screening for aneuploidy is also 
possible by measuring the fetal nuchal 
thickness on first trimester ultrasound. 
Sensitivities of 70-90% have been 
quoted for detecting Down's 
syndrome, particularly when combined 
with first trimester serum levels of 
specific fetal proteins. Increased nuchal 
translucency is also a marker for 
structural defects (4% of those 
> 3 mm) particularly cardiac, 
diaphragmatic hernia, renal, abdominal 
wall and other more rare 
abnormalities. The overall survival for 



Table 1 Techniques for prenatal diagnosis 


Technique 


Tests employed 


Indications 


Chorionic villus 


Chromosomal analysis 


Chromosomal abnormalities, fetal sexmg in X-lmked 


sampling 
(n-ia weeks) 


DNA analysis 


conditions 


Enzymotogy 


Inborn errors ol metabolism 






Haemoglobinopaihies. Duchenne muscular dystrophy 


Amniocentesis 


Chromosomal analysis 


As above 


[15+ weeks] 




As above 
As above 


Maternal venoms 


AFP. Triple lest screening for 


High incidence of neural tube defects 


blood sample 


Down's syndrome 




Ultrasound 


USS 


Spina bifida, anencephaly. hydrocephaly, cystic renal 


[10-20 weeks) 




disease, renal tract dilatation, exomphalos. gastroschisis. 
duodenal atresia, limb abnormalities, cardiac 
abnormalities 


Cordocentasis 


Enzyme logy 


As above 


Ol 8 weeks) 


Chromosomal analysis 


As ahove 




Biood testing 


Heamoglobin studies, fetal viral infection, rhesus disease, 
unexplained hydrops and fetal anaemia pH 




Fig. 1 Low-power view of chorionic villi. 



those with nuchal translucency 
> 5 mm is ~ 53%. 

Both these tests are screening tests 
for chromosomal problems. This 
allows selection of a group of mothers 
who can then be considered for an 
invasive diagnostic test 

Methods of obtaining tissue 

Chorionic villus sampling (CVS) 

Samples of mesenchymal cells of the 
chorionic villi are obtained for 
chromosomal and DNA analysis. The 
transabdominal technique is now more 
favoured, as the transcervical technique 
may give a higher infection and fetal 
loss rate. 

Chorionic villus sampling is 
performed at 11-14 weeks' gestation. A 
needle is introduced through the 
maternal abdomen under ultrasound 
guidance, into the placenta and along 
the chorionic plate. A sample of the 
villi (Fig. 1) is aspirated. Cells from the 
direct preparation allow preliminary 
karyotype and DNA analysis within 
24 hours, but this is usually confirmed 
with a cultured preparation as well. 

Chorionic villus sampling only 
rarely leads to erroneous results, due 
to placental mosaicism (placental 
tissue of different cell lines can be 
identified from one placenta, e.g. XO, 
XX) but errors from this can be 
virtually eliminated providing decisions 
are deferred until both the direct and 
culture results are available. Karyotypic 
discrepancy between fetus and placenta 
increases with increasing gestation and 
if rapid results are required over 20 
weeks fetal blood sampling or 
amniocentesis with FISH is preferable 
(see below). 



Fetal chromosomal abnormality 9 



X I ii % » 


K »)c 


h i[ :: n < ( n « 

•> 10 11 13 13 11 IS 


II II II 

Ifi 17 "B 


-- ft it s* J 

If 20 21 22 B 

(a) 


T 




Fig. 3 Karyotyping for Turner's syndrome, (a) 45, XO karyotype, [b) Fetus with Turner's 
syndrome. 



Fig. 4 FISH analysed cell showing trisomy 
21 (Down's syndrome). 



The advantage of chorionic villus 
sampling is that there is no breach of 
the amniotic cavity and that it allows 
an early diagnosis with the option of a 
suction termination of pregnancy. 
There is, however, good evidence to 
suggest that psychological parental 
morbidity is independent of whether a 
diagnosis is made in the first or second 
trimester and indeed medical 
termination of pregnancy may carry 
less psychological morbidity than 
surgical (even if medical complications 
are higher). 

Amniocentesis 

Amniocentesis involves withdrawing a 
sample of amniotic fluid containing 
fetal cells by passing a needle (using 
direct ultrasound control) through the 
maternal abdomen (Fig. 2). A karyotype 
of the fetal cells is obtained (see 
above). In approximately 98% of cases 
cell culture will be successful, enabling 
karyotypic analysis. This is performed 
from 15 weeks' gestation so that 
sufficient viable fetal cells can be 
obtained but at a fetal loss rate of 
about l°/o. Amniocentesis performed in 
the presence of a raised maternal AFP 
level appears to be associated with a 
significant increase in miscarriage 
rates. 




Cordocentesis 

This technique may be used later in 
pregnancy when a rapid result is 
required. Often this will be at a later 
gestation after an ultrasound scan has 
shown an anomaly that is strongly 
associated with a genetic defect. 

A needle is introduced 
transabdominally into the umbilical 
artery or vein. The most stable portion 
of the cord suitable for this is at the 
point of insertion. The blood sample 
obtained can be used for karyotyping 
and for the diagnosis of other 
conditions such as 

haemoglobinopathies, viral infections 
and metabolic disorders. The 
disadvantage of cordocentesis is that it 
requires a highly skilled operator. 
Complications include fetal 
haemorrhage, cord haematoma and 
fetal bradycardia. 

Diagnostic tests for 
chromosome abnormality 

Karyotyping 

Human chromosomes can be 
examined directly in rapidly dividing 
tissue. However it is more usual to 
culture cells and then use colchicine to 
inhibit the formation of the spindle 
and arrest cell division at metaphase 
which allows the preparations that we 
are familiar with (Fig. 3). 
Chromosomes can then be paired 
according to their size, position of the 
centromere, and the Giemsa stain (this 



shows a characteristic banding pattern 
for each chromosome allowing 
individual identification). 

DNA analysis 

In an increasing number of inherited 
diseases it is now possible to identify a 
single gene defect or omission that is 
responsible. Fetal cells obtained by the 
various sampling techniques are 
cultured and their chromosomal DNA 
separated. This DNA is digested with 
restriction enzymes. The resulting 
fragments are separated by Southern 
blotting. A radioisotope-labelled DNA 
probe is then added and 
autoradiography allows identification 
of any hybridization. Specific probes 
are available for sickle cell disease, 
thalassaemia, and cystic fibrosis. 

Fluorescent in situ hybridization 
(FISH) 

In situ hybridization permits the 
analysis of genetic material of a single 
nucleus, by incubating a fixed dried 
cell with a specific probe, which binds 
to the gene of interest (Fig. 4). The use 
of a fluorescent marker tagged to the 
gene probe leads to the acronym FISH. 
This technique is sensitive enough to 
demonstrate each allele on individual 
chromatids but is not yet reliable 
enough for single cell analysis so is 
applied to larger samples. It provides a 
rapid diagnosis of trisomy, triploidy or 
sex chromosome problems if 
appropriate markers are used. 



Fetal chromosomal abnormality 



Fig. 2 Insertion of needle under 
ultrasound guidance 



■ Screening tests for genetic abnormality include nuchal translucency measurement, maternal 
serum screening and ultrasound examination of the fetus. 

■ Screening tests will nor detect all abnormalities. 

* Diagnostic tests are usually used after an abnormal screening test and include chononic villus 

sampling, amniocentesis and cordocentesis. Amniocentesis is associated with the lowest fetal 
loss r ste 



to OBSTETRICS 



Fetal abnormality 



The finding of some 'abnormality* in 
pregnancy transforms what was 
previously an exciting and joyous event 
into an extremely worrying and 
distressing time. This remains true 
even when the potential risks are 
small; for example being recalled with 
an abnormal level of cc-fetoprotein 
(AFP), or with the finding of a choroid 
plexus cyst on routine ultrasound scan. 
The very greatest of care should be 
taken in explaining any findings to 
parents. Tact, understanding and 
reassurance [if appropriate) are 
paramount. The advice given to 
parents is of such importance that it 
will frequently be necessary to involve 
senior members of the obstetrics team 
as well as members of other 
specialties, particularly paediatricians, 
clinical geneticists and radiologists. 

The aims of prenatal diagnosis are 
fourfold: 

■ the identification at an early 
gestation of abnormalities 
incompatible with survival, or likely 
to result in severe handicap, in order 
to prepare parents and offer the 
option of termination of pregnancy 

■ the identification of conditions 
which may influence the timing, site 
or mode of delivery 

■ the identification of fetuses who 
would benefit from early paediatric 
intervention 

■ the identification of fetuses who 
may benefit from in utero treatment 
(rare). 

It should not be assumed that all 
parents are going to request 
termination of pregnancy even in the 
presence of lethal abnormality. Many 
couples have opted to continue 
pregnancies in the face of severe 
defects that have resulted in either 
intrauterine or early neonatal death, 
and have expressed the view that they 
found it easier to cope with grief 
having held their child. Others say that 
they were glad of the opportunity to 
terminate the pregnancy at an early 
stage and that they could not have 
coped with going on. More 
controversial still are the problems of 
chronic diseases with long-term 
handicap and long-term suffering for 
both the child and its parents. The 
parents themselves must decide what 
action they wish to take - it is they 
who will have to live with the 



consequences. It is our role to advise, 
guide and respect their final wishes, 
irrespective of our own personal views. 

Screening for fetal abnormalities 

Structural anomalies are best seen on 
ultrasound scan and many clinicians 
advocate that all mothers should be 
offered at least one detailed ultrasound 
at around 18-20 weeks or earlier. This 
has the advantage that previously 
unsuspected major or lethal anomalies 
(e.g. spina bifida, renal agenesis) can be 
offered termination, and it also allows 
planned deliveries of those conditions 
which may require early neonatal 
intervention (e.g. gastroschisis, 
transposition of the great arteries). It 
has the disadvantage, however, that 
many defects are not identified (it is 
likely that < 50% of cardiac defects are 
recognized) and the false reassurance 
provided by this scan may become a 
source of parental resentment. 
Furthermore, problems may be 
uncovered; for example one of the 'soft 
markers' (see below), the natural 
history of which is uncertain. This may 
generate unnecessary anxiety and 
increase the number of invasive 
diagnostic procedures (and thereby the 
loss rate) in otherwise healthy 
pregnancies. 

Chromosomal abnormalities are 
much more difficult to identify on 
scan. While around two-thirds of 
fetuses with Down's syndrome will 
look normal at 18 weeks, most with 
Edwards' or Patau's syndrome do show 
some abnormality, even though these 
are often not specific or diagnostic. 

In the absence of routine ultrasound 
scans, it is possible to screen for open 
neural tube defects by measuring the 
maternal serum AFP at 1G weeks. AFP 
is an alpha-globulin of similar 
molecular weight to albumin, which is 
synthesized by the fetal liver. Any 
break in the integrity of the fetus 
allows the AFP to escape into the 
maternal circulation and therefore be 
elevated on serum testing. Those with 
levels greater than 2.0-2.5 multiples of 
the median should be recalled for an 
ultrasound scan, giving a sensitivity for 
picking up neural tube defects of 
around 85%. Raised levels are also 
found following first trimester 
bleeding, or with intrauterine death 
(fetal autolysis), abdominal wall 
defects, or multiple pregnancy 




Fig. 1 Echogenic focus in the left ventricle 
of a four-chamber cardiac view. 

(increased synthesis). Even if the scan 
is normal, raised AFP is still a marker 
for later pre-eclampsia or intrauterine 
growth restriction. 

Increased nuchal translucency (NT) 
is also a marker for structural defects 
(4% of those > 3 mm), particularly 
cardiac, diaphragmatic hernia, renal, 
abdominal wall and other more rare 
abnormalities. The overall survival for 
those with NT > 5 mm is = 53%. 

Aneuploidy — soft markers 

These are structural features found on 
ultrasound scan which in themselves 
are not a problem, but which may be 
pointers to chromosomal problems. 
Examples include choroid plexus cysts, 
mild renal pelvic dilatation, an 
echogenic focus (Fig. 1) in the heart 
('golf-ball'), or mild cerebral ventricle 
dilatation. They are found in 
approximately 5% of all pregnancies in 
the second trimester and are the cause 
of a lot of parental anxiety. If isolated, 
the risk of chromosomal problems is 
low, but if more than one is found, or 
if there are any other structural defects, 
the risk is very much higher. 

Congenital heart disease 

This is the commonest congenital 
malformation in children and affects 
about 5-8:1000 live births. Of defects 
diagnosed antenatally, about 15% are 
associated with aneuploidy, most 
commonly trisomies 18 and 21. 

The four-chamber view of the heart 
can be used as a screening test (Fig. 1) 
and will identify 25-40% of all major 
abnormalities, particularly ventricular 
septal defect, ventricular hypoplasia, 
valvular incompetence and 
arrhythmias. In addition, viewing the 
aorta and pulmonary artery increases 



Fetal abnormality 1 1 




Fig. 2 Fallot's tetralogy. The aorta [a] 
overrides the interventricular septum (s). 

Arrienor neuropore — 





Neural fold 

Pericardial 
o.i ge 



Otic placode 
Somite 



Cut edge 
Of amnion 



Posterior neuropore — . 

22 days 23 da Y s 

Fig. 3 Dorsal view of embryo on days 22 
and 23, demonstrating neural tube closure 



the sensitivity to GO+% by screening 
for Fallot's tetralogy (Fig. 2) and 
transposition of the great arteries. At 
18 weeks most of the major 
connections can be seen, but high-risk 
pregnancies (e.g. those with diabetes, 
or taking anticonvulsants, or who have 
a personal or family history of 
congenital heart disease) should be re- 
scanned at 22-2G weeks for more 
minor defects. 

Neural tube defects 

The neural tube is formed from the 
closing of the neural folds, with both 
anterior and posterior neuropores 
closed by G weeks' gestation (Fig. 3). 
Failure of closure of the anterior 
neuropore results in anencephaly or 
an encephalocele, and failure of 
posterior closure in spina bifida. 

Anencephaly. The skull vault and 
cerebral cortex are absent. The infant is 
either stillborn or, if liveborn, will 
usually die shortly after birth (although 
some may survive for several days). 

Encephalocele. There is a bony defect 
in the cranial vault through which a 




Fig. 4 Spina bifida in association with 
large exomphalos. 



dura mater sac (+ brain tissue) 
protrudes. This may be occipital or 
frontal. Isolated meningoceles carry a 
good prognosis, whereas those with 
microcephaly secondary to brain 
herniation carry a very poor prognosis. 

Spina bifida (Fig. 4). In a meningocele, 
dura and arachnoid mater bulge 
through the defect, whereas in a 
myelomeningocele, the central canal of 
the cord is exposed. Those with spinal 
meningoceles usually have normal 
lower limb neurology and 20% have 
hydrocephalus. Those with 
myelomeningoceles usually have 
abnormal lower limb neurology and 
many have hydrocephalus. In addition 
to immobility and mental retardation, 
there may be problems with urinary 
tract infection (UTI), bladder 
dysfunction, bowel dysfunction, and 
social and sexual isolation. 

Spina bifida and anencephaly make 
up more than 95% of neural tube 
defects. There is wide geographical 
variation in births with a higher 
incidence in Scotland and Ireland 
3 : 1000), and a lower incidence in 
England (2 : 1000), USA, Canada, Japan 
and Africa (< 1 : 1000). There is good 
evidence that the overall incidence has 
fallen over the past 15 years 
(independently of any screening 
programmes). Daily folic acid taken 
from before conception reduces the 
recurrence risk of neural tube defects 
in those who have had a previously 
affected child. A pre-conceptual 
prophylactic dose for all pregnant 
women probably also offers some 
protection. There are, at present, no 
known teratogenic effects from folate. 
There is an increased incidence of 
recurrence in subsequent pregnancies. 

Abdominal wall defects 

Exomphalos (Fig. 5) 

This occurs following failure of the gut 

to return to the abdominal cavity at 8 



Fig. 5 Small exomphalos. 




Fig. 6 Gastroschisis, with Doppler flow to 
highlight the cord. 



weeks' gestation and results in a defect 
through which the peritoneal sac 
protrudes. This may contain both 
intestines and liver. There are 
chromosomal abnormalities in 30% 
(especially trisomy 18) and 10-50% 
have other lesions, particularly cardiac 
and renal. There is also an association 
with ectopia vesicae and ectopia cardia 
(midline bladder and cardiac hernias). 
If the exomphalos is isolated (i.e. no 
other structural abnormalities), the 
chromosomes are normal and there is 
no bowel atresia or infarction, the 
prognosis is good O 80% long-term 
survival). The sac rarely ruptures at 
vaginal delivery. 

Gastroschisis (Fig. G) 
There is an abdominal wall defect, 
usually to the right and below the 
insertion of the umbilical cord. Small 
bowel (without a peritoneal covering) 
protrudes and floats free in the 
peritoneal fluid. Gut atresias and 
cardiac lesions occur in 20% but the 
association with chromosomal 
abnormality is very small (probably 
< 1%). The prognosis is good if the 
bowel is viable, although 10% end in 
stillbirth despite apparently normal 
growth. Gut dilatation may be 
associated with bowel obstruction or 
ischaemia but is not directly linked to 
prognosis. These babies are usually 
small for dates and require very close 
surveillance. The recurrence risk 
is < 1%. 



12 OBSTETRICS 




Fig. 7 Dysplastic renal scan. Note the enlarged kidney containing fluid-like cysts, (a) Ultrasound. 

(b) Postmortem specimen. 



Genitourinary abnormalities 

Renal dysplasia (Fig. 7) 

Multicystic dysplastic kidneys (sporadic 
inheritance). The kidneys have large, 
discrete, non-communicating cysts with 
a central, more solid core and are 
thought to follow early developmental 
failure (Fig. 7 a). If the cysts affect only 
one kidney, the other is normal, and 
there is adequate liquor, the prognosis 
is good. If the cysts are bilateral and the 
liquor is reduced, the prognosis is poor. 

Polycystic kidney disease 

Adult polycystic kidney disease (AD). 
The corticomedullary junction is 
accentuated and the condition is 
relatively benign, often not producing 
symptoms until the fifth decade of life. 
Many individuals have ultrasonically 
normal kidneys at birth. There are at 
least two genes on different 
chromosomes, however, so that DNA 
studies are only possible in families 
with multiple affected members. 

Infantile polycystic kidney disease (AR). 
There is a wide range of expression 
with the size of cysts ranging from 
microscopic to several millimetres 
across. Both kidneys are affected, and 
there may also be cysts present in the 
liver and pancreas. Ultrasound features 
of oligohydramnios, empty bladder 
and large symmetrical bright kidneys 
(Fig. 8) may not develop until later in 




Fig. 8 Infantile renal cystic scan. Note 

anhydramnios and bright real echoes from the 
microscopically small cysts. 



pregnancy. If there is survival beyond 
the neonatal period, there may be later 
problems with raised blood pressure 
and progressive renal failure. Long- 
term survival is rare. 

Pyelectasis 

Renal pelvic dilatation may be 
unilateral (79-90%) or bilateral. It is 
probably caused by a neuromuscular 
defect at the junction of the ureter and 
the renal pelvis, and presents with 
increasing pelvic dilatation in the 
presence of a normal ureter. As there 
is an association with postnatal UTIs 
and reflux nephropathy, it is 
reasonable to start all neonates on 
prophylactic antibiotics and arrange 
postnatal radiological follow-up. Even 
in those with mild dilatation (> 5 mm 
and < 10 mm) there is vesicoureteric 
reflux in 10-20%, although only a 
small proportion require surgery. 

Posterior urethral valves 

Folds of mucosa at the bladder neck 
prevent urine leaving the bladder. The 
fetus is usually male, there is often 
oligohydramnios and on ultrasound 
there are varying degrees of renal 
dysplasia. There is a chromosomal 
abnormality in 7% of isolated defects, 
and in one-third of those with other 
abnormalities. It may be possible to 
insert a pigtail shunt between the 
bladder and amniotic cavity to relieve 
the obstruction, but the long-term 
prognosis is still poor as the renal 
damage may not be reversible. 

Potter's syndrome 

There is bilateral renal agenesis which 
is associated with extreme 
oligohydramnios and leads to the 
Potter's sequence of pulmonary 
hypoplasia (see below) and limb 
deformity (due to fetal compression). 
The condition is lethal. The recurrence 
risk is approximately 3% although AD 
forms with variable penetrance have 
been described. 



Lung disorders 

Pulmonary hypoplasia 

Liquor is important for alveolar 
maturation, particularly in the second 
trimester when the alveoli are forming. 
Without liquor there will be 
pulmonary hypoplasia. Severe 
oligohydramnios occurs with very 
preterm pre-labour membrane rupture 
or Potter's syndrome (see above). 
Pulmonary hypoplasia also occurs with 
diaphragmatic herniae as there is no 
room for lung expansion. 

Diaphragmatic hernia 

Stomach, colon and even spleen can 
enter the chest through a defect in the 
diaphragm, usually on the left. The 
heart is pushed to the right and the 
lungs become hypoplastic. The 
incidence of aneuploidy is 15-30% and 
there is an association with neural 
tube defects, congenital heart disease 
and renal and skeletal abnormalities. 
The overall survival of those diagnosed 
antenatally is -20% with a better 
prognosis for isolated left-sided 
herniae. Polyhydramnios, mediastinal 
shift and left ventricular compression 
are poor antenatal prognostic factors. 
Postnatally, those that survive undergo 
surgery to reduce the hernia and close 
the diaphragmatic defect. 

Cystic fibrosis 

The UK gene frequency is 1 : 25 (i.e. 
heterozygote frequency), giving an 
estimated overall couple risk for a live 
birth around 1 : 2500. Clinically there 
is respiratory, gastrointestinal, liver and 
pancreatic dysfunction and 
azoospermia is the rule. The prognosis 
is very variable and although death in 
the 20-30 age group still occurs, the 
prognosis is improving and many now 
live considerably longer. The health of 
an affected sib is not a prognostic 
guide to the health of other sibs. Four 
mutant alleles account for 85% of the 
gene defects in the UK (the 
commonest being AF508) and 
antenatal screening for these is 
possible using saliva specimens, with 
chorionic villus sampling (CVS) being 
performed if both parents are gene 



Other disorders 

Cystic hygroma (Fig. 9) 
Cystic hygromas are fluid-filled 
swellings at the back of the fetal neck 
and probably develop from a defect in 
the formation of lymphatic vessels — it 



Fetal abnormality 



13 




Tanle 1 Polyhydramnios: causes and 


path 


ology 


Cause of polyhydramnios 




Pathology 


Increased product™ From high urine output 




Macrosomia. diabetes, recipient of twin-twin transfusion, 
hydrops fetalis 


Gastrointestinal obstruction 




Oesophageal atresia, duodenal atresia, small intestine ur 
colonic ohstrucuon. Hirschsprung's disease 


Poor swallowing because of neuromuscular 




Anencephaly. myotonic dystrophy, maternal myasthenia. 


problems or mechanical obstruction 




facial tumour, macrogtossia or micrognathia 



Fig. 9 Cystic hygroma. 



is likely that the lymphatic system and 
venous system fail to connect and 
lymph fluid accumulates in the jugular 
lymph sacs. Larger hygromas are 
frequently divided by septae and may 
be associated with skin oedema, 
ascites, pleural and pericardial 
effusions, and cardiac and renal 
abnormalities. There is also an 
association with aneuploidy 
(particularly Turner's, Down's, 
Edwards') and it is appropriate to offer 
karyotyping. If generalized hydrops is 
present the prognosis is bleak. Isolated 
hygromas may be surgically corrected 
postnatally and have a good prognosis. 
Only rarely are they so large as to 
result in problems with labour. 

Fragile X syndrome 

This is the commonest cause of 
moderate mental retardation after 
Down's syndrome and the commonest 
form of inherited mental handicap. It 
is X-linked. Males are usually more 
severely affected than females. Speech 
delay is common and there is an 
associated behavioural phenotype with 
gaze aversion. The condition is caused 
by the expansion of a CGG triplet 
repeat on the X chromosome. Normal 
individuals have an average of 29 
repeats but for an unexplained reason 
this may increase to a premutation of 
50-200 repeats. Those with a 
pre-mutation are phenotypically 
normal but the pre-mutation is 
unstable during female meiosis and 



can expand to a full mutation of more 
than 200 repeats. There is an 
approximately 10% chance of this 
occurring (in the absence of a full 
mutation in that generation already). 
This causes the fragile X phenotype in 
99% of males and around 30-50% of 
females. Parental screening is possible 
and CVS may be used to identify the 
degree of amplification of the CGG 
repeats in potential offspring. 

Huntington's chorea 

The onset of this autosomal dominant 
condition is usually after the age of 30, 
although it may present as early as 
10-15 years of age. There is dementia, 
mood change (usually depression) and 
choreoathetosis, progressing to death 
in approximately 15 years. There is a 
CAG trinucleotide expansion on 
chromosome 4p allowing accurate 
carrier and prenatal testing. 

Tay-Sachs disease 

The gene frequency is 1:30 in 
Ashkenazi Jews, but is rare in other 
groups. There is a build-up of 
gangliosides within the CNS leading to 
retardation, paralysis and blindness. By 
the age of 4 years, the child is usually 
dead or in a vegetative state. Carriers 
may be screened by measuring the level 
of hexosaminidase A in leucocytes. 

Polyhydramnios 

Liquor is produced by fetal kidneys 
and is swallowed by the fetus. Excess 
liquor, polyhydramnios, may be 
defined as more than 2-3 litres of 
amniotic fluid, but for practical clinical 
purposes may be considered as: 

■ a single pool > 8 cm 

■ amniotic fluid index > 90th centile. 



This is a measurement of the 
maximum depth of liquor in the 
four quadrants of the uterus. 

Polyhydramnios occurs in 0.5-2% of 
all pregnancies and is associated with 
maternal diabetes (-20%) and 
congenital fetal anomaly (-5%). Its 
causes are listed in Table 1. 
Even in the absence of an 
identifiable cause (> 60%), 
polyhydramnios is associated with an 
increased rate of: 

■ placental abruption 

■ malpresentation 

■ cord prolapse 

is requiring a caesarean section 

■ perinatal death 

■ earning a large for gestation age 
infant. 

It is important to arrange a growth 
and detailed ultrasound scan, glucose 
tolerance test (GTT), and fetal well- 
being assessment. The rhesus status 
should also be checked to exclude 
immune hydrops fetalis. Only rarely is 
it necessary to aspirate fluid for 
maternal comfort or decrease the 
chance of preterm labour. Increased 
antenatal fetal surveillance is 
important, and an increased awareness 
of the risks of intrapartum 
complications. A paediatrician should 
be present for delivery. 

Investigations may suggest that the 
baby is large for dates. It should be 
remembered that clinical examination 
and ultrasound measurements are 
relatively poor predictors of 
birthweight and it is rarely justifiable 
to use these assessments alone to plan 
an elective caesarean section. 



Fetal abnormality 



i Not everybody wishes prenatal diagnosis, and not everybody wishes the option of termination if 
there is a severely abnormal fetus. 

t Ultrasound scanning is the best screening tool (or structural abnormalities but will still miss many 
problems, particularly cardiac defects. 



14 OBSTETRICS 

Infections in pregnancy 



Infections in pregnancy are important 
because of potential risks to the fetus. 
A number of agents are known to be 
teratogenic, particularly in the first 
and early second trimesters. Others 
carry the risk of miscarriage, 
premature labour, severe neonatal 
sepsis or long-term carrier states. 

Infection risks 
Occupation 

Farm workers 

A chlamydia (which causes 
miscarriage in sheep), toxoplasma 
(which causes abortion in cows and 
sheep) and listeria can all cause 
miscarriage in humans. 

Working with farm animals should 
therefore be avoided when pregnant, 
particularly in the lambing and 
calving seasons. At these times, basic 
hygiene precautions should be 
observed by everyone else on the 
farm to prevent transmission. 

Nurses 

Nurses may be concerned about 
cytomegalovirus (CMV), particularly 




those in contact with small children 
(Fig. 1). Serology is of little benefit as 
the presence of antibodies does not 
necessarily denote immunity (see 
Table 1). If hands are washed well 
and often, the risk of transmission is 
very small. 

Food 

The following foods carry potential 
infection risks in pregnancy: 

■ Soft: cheeses. Unpasteurized milk 
and its products may contain 



(b) 

Fig. 1 Hepatosplenomegaly (a) and 
thrombocytopenia (b) occur with 
congenital CMV infection. 



listeria. Those made from 

pasteurized milk are safe. 

Raw eggs. These must be avoided 

as there is a risk of salmonella 

(remember puddings). 

Meat or pdti. Undercooked meat 

may transmit toxoplasma or rarely 

listeria. 

Fruit. This should always be 

washed before eating as it may be 

contaminated with salmonella, 

toxoplasma or one of several 

intestinal parasites. 



Taole 1 Infections in pregnancy 










Agent 


Epidemiology 


Maternal features 


Fetal features 


Risk 


Treatment 


Rubella 


Person to person 


Asymptomatic or mild 


IUGR. i platelets, hepaiosplenomegaly. 


Riskof aflected fetus. 


Consider TOP if < 12 weeks 




UK immunity now 


maculopapular rash 


jaundice, deafness. CHD, mental 


< A weeks 50^r 


Postnatal vaccination if not immune 




97% and congenital 




retardation, cataracts, mi crop h thai ftna. 
abortion, microcephaly and cerebral 


5-8 weeks 25% 
9-1 2 weeks 10% 






infection is rare 




palsy [Fig, 2) 


> l 3 weeks 1% 




Toxoplasmosis 


From cats, uncooked 


May have fever, rash 


Hydrocephalus, chorioretinitis. 


< 1 2 weeks transmission is 


Consider TOP only if primary infection 


[protozoan - 


meats and unwashed 


and lymphadenopathy. 


intracranial calcification. 1 platelets 


10- 25%. of which 75% will 


< 2D weeks 


Toxoplasma gondii) 


fruits 


but most are 
asymptomatic 




be severely affected 

12-28 weeks transmission is 

5S%, of which 25% will be 

severely affected 

> 28 weeks transmission 

13 55-90*. of which 

< 10* will he severely 

affected 

40% of fetuses infected. 


Even primary infection carries only 


CMV 


Person to person 


Mearly always 


Hepatosplenomegaly, I platelets. IUGR, 


(herpesvirus) 




asymptomatic 


microcephaly, sensorineural deafness. 
CR chorioretinitis, hydrops fetalis, 
exornphalos 


Risk is unaffected by gestation 
Of these, 90% are normal at 
birth, although 20 W develop 
late sequelae Ohhe 1 0% who 
are symptomatic. 33% die and 
the rest have long-term 
problems 


3 10 25% riskof severe abnormality 



Parvovirus B 19 


Respiratory 


Erythema mleclEosum 


Aplastic anaemia, hydrops fetalis and 


[f less than 20 weeks and 


Intra uterine transfusion may be 




transmission 


(slapped cheek 


myocarditis t fetal loss [if < 20 weeks] 


fetus survives the infection 


possible 




Seroprevaience 50<*t 


disease} 


Transmission < 20 weeks ■ lO^fcof 


O 90^ K it is likely to result in 








May be asymptomatic 


which ^ 10^: are lost 

[f>20 weeks, transmission 60%. but 

no adverse effects have been 

demonstrated 


a heaLthy live birth 




Chickenpox 


Person to person 


Papules and pustules 


Limb hypoplasia. sKin scarring, IUGR, 


2 5 (to transmission Probably 


Treat with ZIG [zoster 


(.varicella zoster 






neurological abnormalities ami 


< 1 -2% have problems it 


immunoglobulin) if< 10 days from 


virus) 






hydrops f eta Ijs 


< 20 weeks, No structural 
problems > 20 weeks 
See 'Chickenpox at ierrtV 


contact or < 4 days from onset of 
rash, although the benefits are 

not proven 



Key. CHD, congenital heart disease; CMV,. cytomegalovirus; CP, cerebral palsy; IUGR, intrauterine growth restriction; TOP, termination of pregnancy 



Infections in pregnancy 15 



Specific infections 
General principles 

The fetus does not make IgM until 
beyond 20 weeks' gestation. Absence 
of fetal IgM at birth does not mean 
that infection has not occurred and 
IgG is usually passive (i.e. 
transplacental from the mother) unless 
the baby is older than 1 year. Evidence 
of infection does not imply damage. 

Chickenpox 

Chickenpox at term (see Table 1 for 
early pregnancy). Severe and even 
fatal cases of chickenpox can occur in 
neonates whose mothers develop 
chickenpox from 7 days before to 1 
month after delivery (usually 2 days 
before to 2 days after). This is because 
the baby is born before maternal IgG 
production has increased sufficiently 
to allow passive transplacental 
protection. The baby should be given 
varicella zoster immunoglobulin 
(VZIG) as soon as possible if maternal 
symptoms develop. 

Hepatitis 

Hepatitis A has not been associated 
with significant complications in 
pregnancy. All mothers should be 
screened antenatally for hepatitis B 
virus as vertical transmission can 
occur. The initial serological response 
is with HBsAg, followed by HBeAg, a 
marker of high infectivity. 

Transmission is most likely to 
occur with acute infection (especially 
third trimester), or in the presence of 
HBeAg. The risk of maternofetal 
transmission for mothers who are 
HBeAg +ve is 90%, falling to 10% in 
those with antibodies to the HBeAg. 
The baby should be given hepatitis B 
immunoglobulin i.m. at birth as well 
as active hepatitis B immunization, 
the latter repeated at 1 month and at 
G months. 

With hepatitis C, vertical 
transmission is related to viral load but 
is unlikely in the absence of detectable 
RNA. There is no evidence that 
treatment during pregnancy reduces 
the chance of transmission and 
ribavirin is probably teratogenic. 
Caesarean section or breast feeding is 
unlikely to alter the incidence of 
neonatal infection. Hepatitis E infection 
in pregnancy, whilst uncommon, 
carries a 30% maternal mortality rate 
and possible risk of fetal loss. 

Herpes simplex virus 

An acute attack of primary herpes 
shortly before delivery may lead to a 




Fig. 2 Microcephaly in association with 
congenital rubella infection. Now rare in 
countries with childhood vaccination 
programmes. 

neonatal infection [~ 40%) and this 
may be localized or systemic, 
occasionally including encephalitis. 
The risk of infection is greatest with a 
primary infection, but can occur with 
recurrence, although this risk 
decreases with time from the first 
attack. Antenatal screening at 36 
weeks does not predict transmission, 
and indeed, 70% of neonatal 
infections occur to mothers with no 
overt signs of infection. Membrane 
rupture in the presence of a primary 
infection (i.e. within G weeks of 
delivery) is considered by many to be 
the only indication for caesarean 
section, providing the operation is 
carried out within the first 4 hours. It 
is possible, however, that caesarean 
section is appropriate in recurrent 
herpes if active lesions are present. 
The very small risk of fetal infection 
in this situation must be weighed 
against the risk to the mother of 
caesarean section. 

Rubella 

Rubella infection is discussed in 
Table 1 but its importance lies in its 
potential for prevention through 
vaccination. Immunity from natural 
infection is lifelong. Seroconversion 
and lifelong immunity occur in about 
95% of vaccinated individuals, and as 
the benefits of herd immunity have 
been clearly demonstrated, many 
countries now immunize all 
preschool children. Rubella antibodies 
are commonly checked at booking, 
and postnatal vaccination is offered to 
those with low titres. 



Fig. 3 Jaundice and sepsis with perinatal 
group B |}-haemolytic streptococcal 
infection. 



Listeria monocytogenes 

This is a rare bacterial infection 
transmitted in food (usually soft ripe 
cheeses, pate, cooked-chilled meals 
and ready-to-eat foods that have not 
been thoroughly cooked). Following 
an initial gastroenteritis, which may 
be fleeting, bacteraemia results in 
bacilli crossing the placenta leading to 
amnionitis, preterm labour (which 
may result in stillbirth) or 
spontaneous miscarriage. There may 
be meconium, neonatal jaundice, 
conjunctivitis or meningoencephalitis. 
Diagnosis is made by blood culture 
or by culture of liquor or placenta. 
Treatment is with high-dose 
amoxicillin or erythromycin. 

(3-haemolytic streptococci - 
group B 

Between 5% and 20% of women carry 
this organism in the vagina. It is 
associated with preterm rupture of the 
membranes. About 50% of babies 
become colonized at delivery but only 
about 1% of these develop infection. 
The mortality from infection may be 
up to 80%, with 50% of those surviving 
meningitis having subsequent 
neurological impairment (Fig. 3). 
Antenatal screening is not indicated in 
the UK (initial screen positives may 
become negative and vice versa) but 
those with known infection should 
receive intrapartum antibiotics (e.g; 
amoxicillin or erythromycin). There 
is no evidence to support antenatal 
treatment of asymptomatic carriers, 
as carriage is rapidly re-established 
following treatment 



J 



Infections in pregnancy 

■ CMV, toxoplasmosis and rubelia are teratogenic. 

■ Parvovirus B19 may lead to hydrops fetalis. 

■ Primary varicella zoster and herpes simplex infections just before the onset of labour may 
result in serious neonatal morbidity and mortality. 



16 OBSTETRICS 



Human immunodeficiency virus (HIV) 



HIV is a retroviral infection which may be transmitted 
sexually/ via blood or blood products/ or from mother to 
child (vertical transmission]. The incidence worldwide is 
steadily rising (Fig. 1) with HIV-1 most widely found and 
HIV -2 predominantly in West Africa and Portugal. 

The median interval between HIV infection and 
development of AIDS is 8-10 years (Fig. 2). HIV-2 has a 
longer incubation period and slower rate of progression. 
More than 70% of HIV infections worldwide have occurred 
in sub-Saharan Africa, the major route of transmission being 
heterosexual, but there is a markedly expanding epidemic 
affecting South East Asia. 

Over five million people worldwide acquired HIV infection 
in 1999 and it is estimated that 34.3 million adults and 
children were living with HIV/AIDS at the end of 1999, 24.5 
million of them in sub-Saharan Africa. Publicity campaigns are 
essential to keep the risks of HIV infection in the public mind. 

Clinical features 

Pneumocystis carirdi pneumonia (PCP) presenting with 
dyspnoea on exertion and a non-productive cough, Kaposi's 
sarcoma (which is rare in women) and cervical carcinoma 
are agreed AIDS-defining illnesses when present in HIV- 
positive individuals. Viral load (monitored by HIV-1 plasma 
RNA) is the most important prognostic marker of risk of 
progression. Those with a low (< 500 x 10 6 /1) CD4 count (a 
T-cell subset) need antiretroviral therapy (Fig. 3). 

Early symptoms and signs of progression include malaise, 
weight loss, fevers and night sweats. Persistent generalized 
lymphadenopathy is common throughout the course of the 
disease and has no prognostic significance, but asymmetrical 
or atypical lymphadenopathy needs further evaluation as it 



{[& *w) ^'V virus attached to T cell 



CD4 receptor 




CD4 lymphocyte 



**^$\\ //r^O\\ Infectious 
\\&yi tO^y) virus {virion) 



Fig. 2 HIV entry into a CD4 lymphocyte. 



may represent a neoplastic process such as a lymphoma. 

Obstetrics 

The vertical transmission rate is somewhere between 13 and 
30% before treatment, with 90% of all infants infected 



=af,4o° 




Fig. 1 Numbers of people living with HIV/AIDS, numbers of new infections and numbers of deaths due to HIV/AIDS in 2000. 



Human immunodeficiency virus (HIV) 17 



perinatally being born in sub-Saharan 
Africa. There are obvious advantages to 
the mother in knowing her HIV status 
during pregnancy (Fig. 4). 

A very small minority of women 
may wish to terminate their pregnancy 
but knowledge of HIV status allows an 
informed decision about future 
pregnancies. Antenatal testing thus has 
advantages and should be on offer to 
all patients, though uptake of testing is 
low in the UK compared to France and 
Sweden. A 1997 survey of children 
born in the UK and developing AIDS 
found that 53% of the maternal 
infections were diagnosed only once 
the child developed AIDS. Only 4.5% 
were diagnosed during pregnancy. 
Most women who know they are HIV- 
positive act to reduce the risk of 
vertical transmission (Fig. 4], so uptake 
of testing antenatally must be more 
universally encouraged. 

There are also advances in the 
treatment of HIV in adults, including 
combination drug therapies, leading to 
increased benefits to the woman 
herself in knowing that she is HIV- 
infected. The use of triple therapy 
(generally consisting of two nucleoside 
analogues and a protease inhibitor] 
hopes to prevent emergence of drug- 
resistant strains due to incomplete 
suppression of replication (note: 
protease inhibitors are teratogenic). 

Gynaecology 

There are three areas where HIV- 
positive status impacts on gynaecology: 




AZT therapy antenatally 
results in two-thirds' 
reduction 



Caesarean section (C/S) - 
meta analysis suggests 
overall that C/S lowers 
transmission. In women 
on antiretroviral therapy, 
the rarity with which they 
transmit HIV to their babies 
questions the need for C/S 



Delay ARM (artificial 
rupture of membranes) - 
more than 4 hours from 
ARM there is increased 
rate of transmission 



V 




VERTICAL TRANSMISSION 




Avoid use of fetal scalp 
electrode and fetal blood 
sampling in labour - these 
interventions bring maternal 
and fetal blood 
into contact 



Douches to the birth canal 
may limit spread - under 
investigation 



Avoid breast feeding - 
halves the rate of 
transmission. Where there 
is high infant mortality 
associated with malnutrition 
and infectious disease, 
WHO/UNICEF support breast 
feeding by the baby's own 
mother, regardless of her HIV 
status 



Fig. 4 Reducing vertical transmission from mother to baby. 



gynaecological manifestations of HIV, 
termination of pregnancy and infection 
control. 

Gynaecological manifestations of 
HIV 

Immunosuppressed HIV-positive 
patients are at increased risk of genital 
tract malignancy and an annual 
cervical smear is probably appropriate. 
Cervical carcinoma is an AIDS-defming 
diagnosis but the malignancy may be 
multifocal with lesions of the cervix, 
vagina, vulva and perianal area. Human 
papilloma virus (HPV) types 1G and 18 
have oncogenic effects which may be 
enhanced in the HIV-positive patient 
who also has a higher prevalence of 
such infection. 

The risk of developing neoplasia is 
directly related to the degree of HIV- 
induced immunosuppression as 
measured by decreasing CD4 
lymphocyte number and advancing 
clinical disease. 

There is a strong association 
between HIV and other sexually 
transmitted diseases (STDs), 
particularly those involving genital 
tract ulceration, such as chancroid, 
syphilis and genital herpes. These 
disrupted mucous membranes allow 



organisms to bypass normal defences 
but are also a potent source of virus in 
those who are seropositive. Vigorous 
treatment of STDs would help to 
reduce the worldwide progression of 
HIV infection. 

Pelvic inflammatory disease has not 
been found to occur more often in the 
HIV-positive patient but may be more 
severe and ideally requires inpatient 
therapy to prevent peritonitis and 
abscess formation. 

Termination of pregnancy 

Once pregnancy is confirmed a full 
discussion of the risks to mother and 
baby should be available. Though 
some patients who are HIV-positive 
may wish termination, others will 
proceed successfully with their 
pregnancy. Proper disposal of the 
products of conception, handling them 
as high risk and sending for 
incineration in line with all 
contaminated hospital waste, is 
important. 

Infection control 

Gynaecological and obstetric practice 
exposes practitioners to bodily fluids 
infected by HIV so universal use of 
safe handling techniques is logical. 



Human immunodeficiency virus 



Fig. 3 AZT (zidovudine), an antiretroviral 
drug. 



H IV is important in obstetrics and gynaecology because of the contact with bodily fluids and the 
impact of AIDS on gynaecological diseases. 

I Knowledge of HIV status can have a large impact on pregnancy management. 

i Reduction of vertical transmission can be achieved by two-thirds with the use of AZT therapy 
and by hall with avoidance of breast feeding. 

i Low rates of diagnosis of HIV antenatally limit the ability to reduce vertical transmission. 



is OBSTETRICS 



Preterm labour and preterm premature rupture 
of the membranes (PPROM) 



Preterm labour 

Preterm labour is defined as labour 
occurring before 37 completed weeks. 
It affects 5-10°/o of all pregnancies but 
it accounts for approximately 75% of 
perinatal mortality. 

Diagnosis 

Diagnosis is made with difficulty as 
uterine activity is not always associated 
with cervical dilatation and may settle 
down with no untoward effect on the 
pregnancy, hence the apparent 
spontaneous cessation of the labour in 
50% of cases. Causes of preterm labour 
include: 

■ preterm rupture of the membranes 

■ polyhydramnios 

■ multiple pregnancy 

■ cervical incompetence 

■ uterine abnormalities 

■ antepartum haemorrhage 

■ fetal death 

■ maternal pyrexia, particularly 
associated with urinary infection 

■ idiopathic - the majority of cases. 

Management 

The benefits of in utero existence are 
weighed against the risks of threatened 
preterm delivery and in each case a 
decision is reached about the best 
treatment options. Maternal infection 
should be sought and treated 
appropriately - mid-stream urine 
sample (MSU), full blood count (FBC) 
and high vaginal swab (HVS) should 
be obtained on admission, as should a 
clean-catch liquor sample in cases with 
ruptured membranes. 

A cardiotocograph (CTG) will 
determine the status of the fetus but 
interpretation of the CTG in the 
extremely preterm infant (24-26 
weeks) is complicated by lack of 
knowledge about normal parameters 
(see p. SO). Assessment of cervical 
dilatation over the first few hours after 
admission will show if there is 
progressive cervical dilatation and the 
need for uterine suppression. 

Uterine suppression (tocolysis) 

Various medications are used to try to 
suppress uterine contractions 
including intravenous betamimetic 



drugs, calcium channel blockers, 
oxytocin receptor antagonists and 
antiprostaglandins. Side effects which 
limit use of the betamimetics are 
palpitations, tremor, headache, 
restlessness, nausea and vomiting, and 
hypotension. If chest discomfort or 
breathlessness develops this may 
indicate pulmonary congestion - one 
of the more serious side effects of 
therapy. 

There are no studies which show 
any decrease in perinatal mortality 
with the use of betamimetics, though 
there is a reduction in the proportion 
of deliveries occurring within the next 
24-48 hours. This allows time to 
administer steroid therapy and transfer 
the patient to a centre with neonatal 
intensive care facilities. 

Intravenous ritodrine has been 
studied extensively but salbutamol and 
fenoterol are also used. All will have an 
effect on carbohydrate metabolism and 
should be used with caution in the 
diabetic patient Maintaining uterine 
suppression after the acute event by use 
of oral therapy has not been shown to 
reduce the incidence of preterm delivery. 

As there is good evidence that 
prostaglandins are involved in the 
initiation of labour, suppressing 
prostaglandin synthesis is logical. 
Indomethacin, p.r. or orally, has been 
shown to suppress uterine 
contractility, reducing delivery within 
48 hours and reducing preterm birth. 
It too has side effects - gastrointestinal 
tract irritation even amounting to 
peptic ulceration, nausea and vomiting, 
diarrhoea and headache. For the fetus, 
the theoretical adverse effects include 
impaired renal function and prolonged 
bleeding time but the major worry is 
constriction of the ductus arteriosus 
which may result in persistent 
pulmonary hypertension in the new- 
born. 

Nifedipine (a calcium channel 
blocker) and glyceryl trinitrate have 
also been used, with possible success. 
Magnesium sulphate is the preferred 
treatment in the US. As infection may 
be an aetiological feature, there may be 
a role for empirical treatment with 
broad-spectrum antibiotics, particularly 
following preterm premature rupture 
of the membranes (PPROM). 



When should tocolysis be used? 

■ Where prolongation of the pregnancy 
will have beneficial effects for the 
fetus, to allow time to administer 
steroids to ensure fetal lung 
maturation; tocolysis works only in 
early labour (less than 4 cm cervical 
dilatation) 

■ Not in the presence of an antepartum 
haemorrhage as the vasodilatation 
caused may potentiate the bleed 

■ With caution in the diabetic patient as 
betamimetics cause gluconeogenesis 
and may precipitate diabetic 
ketoacidosis 

■ Not with evidence of chorioamnionitis 
- maternal pyrexia, uterine 
tenderness, raised white blood count 
(WBC) (steroids used for fetal lung 
maturation cause a rise in WBC, so 
use of C-reactive protein may be more 
accurate), fetal tachycardia 

■ Not with evidence of fetal 
compromise when conditions ex 
utero may be more favourable. 

Cervical cerclage 

There are two main ways this 
technique is employed: 

1, In the acute situation when the 
cervix is found to be dilated on 
admission - usually in a patient with 
suspected preterm labour. If the cervix 
does not continue to dilate whilst the 
patient rests in bed then a suture may 
be placed (rescue cerclage) to prevent 
further passive dilatation. This may be 
unsuccessful with membrane rupture 
during suture placement The suture 
may cut through the thinned cervical 
tissue or intrauterine infection may 
follow. 

2. In patients with a history of 
previous cervical incompetence, or 
history of gynaecological procedures 
which may leave the cervix 
incompetent, cerclage may be 
considered. The suture is placed 
circumferentially at the level of the 
internal os taking four large bites into 
the substance of the cervix. 

A large, multi-centre study assessing 
cervical cerclage failed to show benefit 
in prolonging pregnancy. Practice is to 
assess cervical length ultrasonically in 
the high-risk patient and use cerclage if 
there is evidence of shortening of the 
cervix. 



Preterm labour and preterm premature rupture of the membranes CPPROM) 1 9 



The cerclage suture is usually removed at around 37 weeks 
and onset of spontaneous labour is awaited. This may occur 
some days later. 

Benefits and risks of in utero existence 

The survival rates for infants between 24 and 28 weeks' 
gestation vary from 25% early to 80% later and determine 
whether intervention will offer benefits over the in utero 
state. From 28 weeks onwards the survival rates climb 
gradually from 80% to 98% and give greater confidence in 
delivering a preterm infant Extremely preterm infants have 
better survival prospects if delivered in a neonatal intensive 
care unit and should be transferred in utero if possible. 

Delivery 

If labour ensues, a controlled delivery with intact membranes 
and a short second stage offers the best outcome for the 
infant. The preterm breech presentation risks delivery of the 
small trunk through an incompletely dilated cervix resulting 
in fetal head entrapment In these circumstances it may be 
best to deliver by caesarean section, between 26 and 34 
weeks' gestation - though the evidence for this is limited. 
The lower uterine segment will be poorly formed in these 
circumstances, so a longitudinal incision in the lower uterine 
segment may be needed (de Lee incision). 

PPROM 

Premature rupture of the membranes (PROM) is when the 
membranes rupture before the onset of labour. In 80% of 
patients labour ensues within 24 hours. Once the 
membranes are ruptured the barrier to ascending infection is 
gone and if labour does not follow within 24-48 hours, 
induction of labour to prevent chorioamnionitis in the 
mother and systemic neonatal infection is usual. 

Preterm PROM (PPROM) is when the membrane rupture 
occurs before i7 weeks and induction of labour may not be 
the optimal management. It occurs in 2-3% of pregnancies 
and accounts for about one-third of preterm deliveries. A 
more conservative approach may be used dependent on the 
gestation (see Fig. 1). In uncomplicated cases: 

< 34 weeks - benefits of in utero development outweigh the 
risks of ascending infection and a conservative approach is 
appropriate. Pulmonary hypoplasia and skeletal deformities 
may be seen due to oligohydramnios following spontaneous 
rupture of the membranes (SRM) in extreme prematurity. 
Pulmonary hypoplasia after SRM occurs in 50% of cases less 
than 20 weeks but in only 3% over 24 weeks. Two doses of 
corticosteroid given 12 hours apart are associated with increased 
fetal surfactant production so long as there are 24 hours after 
the completion of the dose before delivery. The use of 
antibiotics prophylactically is of unproven benefit for the fetus. 

34-37 weeks - no suppression of uterine activity and if 
no evidence of infection conservative management. The risk 
of respiratory distress syndrome (RDS) in the infant is about 
5% and this dictates conservative management Antibiotic 
therapy may be given to reduce maternal infection but it 
may be preferable to treat infection if detected rather than 
subject all patients to therapy. Induction of labour at 36 
weeks avoids the continued risk of ascending infection, 
whilst the chance of RDS is small. 

> 37 weeks - if no labour ensues within 24-48 hours of 
membrane rupture then induction of labour avoids the 
development of infection with the associated morbidity. 







Is there any evidence 


Preterm rupture 


of infection - *WBC 








(PROM) 




foul discharge 
tender uterus 


r 






Yes 


i No- 


1 


r 


1 


Induce 


Gestation 


Gestation 


labour 


> 37 weeks 


< 37 weeks 


(IOL) 


1 


(= PPROM) 




Wait 24 hours 


Conservative 




for spontaneous 


management 




onset of labour 


- daily CTG, 


If nol in labour 
> 24 hours after 
PROM ,, 


temperature 
- twice a week 

HVS, FBC 
until 37 weeks or 




IOL ■* 


— signs of infection 



Fig. 1 Management plan. 

Complications include: 

■ infection 

■ antepartum haemorrhage 

■ fetal compromise. 

The presence of complications makes a more active 
approach to delivery appropriate. If there are no 
complications it is acceptable to wait up to 96 hours for 
labour. 

Making the diagnosis 

After palpation of the abdomen to confirm the fetal lie, 
presentation and size, a sterile speculum examination is 
performed to observe the cervix for amniotic fluid leakage - 
unless there is obvious liquor at the vulva or on a pad. 
Amniotic fluid has a characteristic odour and presence of 
vernix caseosa is diagnostic A high vaginal swab should be 
taken to check for infection or amniotic fluid aspirated and 
sent for microscopy and culture. If doubt exists the patient 
may be asked to wear a pad whilst ambulant and check the 
pad for presence of liquor. If there is still doubt, then an 
ultrasound scan to measure the amniotic fluid index and a 
check for the presence of fluid below the presenting part will 
refute the diagnosis. 

Management of chorioamnionitis 

Labour should be induced with Syntocinon and a 
continuous CTG is needed. Caesarean section is only 
performed if clinically indicated as there will be an increased 
risk of postoperative pelvic sepsis and subsequent tubal 
blockage. Intravenous antibiotics should be broad spectrum. 



j Preterm labour and PPROM 

i Preterm labour accounts for 75% of perinatal mortality, 
■ Most preterm labour is due to unknown reasons. 

i Rupture of the membranes is associated with ascending infection 



20 OBSTETRICS 



Hypertension 



Hypertension in pregnancy may be 
coincidental (usually background 
essential hypertension) or related to 
pregnancy (gestational hypertension, 
pre eclampsia or in association with 
eclampsia). 

■ Hypertension in pregnancy is 
defined as a diastolic blood pressure 
(BP) > 110 mmHg on any one 
occasion or > 90 mmHg on two 
occasions > 4 hours apart. 

■ Severe hypertension is a single 
diastolic BP > 120 mmHg on any 
one occasion or > 110 mmHg on 
two occasions > 4 hours apart. 

In normal pregnancy the BP will fall 
during the first trimester, reaching a 
nadir in the second trimester and 
rising slightly again during the third 
trimester. It should be measured in the 
sitting position with an appropriate 
size of cuff (Fig. la). Although 
controversial, it is suggested that the 
phase IV Korotkoff sound (i.e. 
'muffling' rather than 'disappearance') 
should be taken when reading the 
diastolic pressure. 

Raised BP at booking(e.g. before 
1G weeks) is usually due to chronic 
hypertension (usually essential 
hypertension, only rarely renal disease 




or phaeochromocytoma). Gestational 
hypertension and pre-eclampsia 
(hypertension and proteinuria) only 
very rarely occur before 20 weeks 
(unless associated with trophoblastic 
disease). 

Essential hypertension 

This is commoner in older women 
and the prognosis overall for 
pregnancy is good. The main risk is 
from superimposed pre-eclampsia 
(which is more common with pre- 
existing essential hypertension). The 
hypertension itself is rarely of 
significance, although there might be a 
slightly increased risk of placental 
abruption. Those women who are 
already taking antihypertensive drugs, 
and who have mild to moderate 
hypertension (140/90-170/110), may be 
able to discontinue the medication in 
pregnancy. Those with more severe 
hypertension should continue. 
Appropriate preparations include 
methyldopa, p blockers (e.g. labetalol) 
or nifedipine. Diuretics and ACE 
inhibitors may cause fetal compromise 
and are contraindicated. 

Gestational hypertension and 
pre-eclampsia (gestational 
hypertension and proteinuria) 

■ Gestational hypertension: see 
definitions above, but note that 
some authorities also consider an 
incremental diastolic rise of > 25 
mmHg above the level recorded at 
booking to be significant. 

■ Gestational proteinuria: > 300 mg/ 
24 hours (~ '+' or more on Dipstix 
testing). 

Pre-eclampsia is a multisystem 
disorder of unknown aetiology specific 
to pregnancy characterized by 
hypertension, proteinuria and often 
fluid retention. Those with bilateral 




Fig. 2 Uterine artery Doppler notching at 
24 weeks is predictive of pre-eclampsia 
and IUGR in high-risk mothers. 

uterine artery Doppler notching 
(Fig. 2) at 24 weeks are at increased 
risk of developing pre-eclampsia. 

Primary placental pathology 

There is a lack of trophoblast 
infiltration of placental arterial walls 
leading to failure of arterial dilatation, 
and acute atherosis with aggregates of 
fibrin and platelets blocking the 
arteries. 

Secondary effects 

These are summarized in Table 1. 
It is an extremely variable and 
unpredictable condition, and 
progression is often more rapid the 
earlier in pregnancy it occurs. Some 
have minimal symptoms and then 
have fits, others look worryingly 
unwell and are fine. The purpose of 
antenatal screening is to prevent both 
the maternal complications (cerebral 
injury, multisystem failure) and fetal 
complications (intrauterine growth 
restriction (IUGR), intrauterine death 
and abruption) of severe disease by 
timely delivery of the baby. Treatment 
of the mother with antihypertensives 
masks the sign of hypertension but 



Table 1 Secondary effects of primary placental pathology 



Fig. 1 Early detection of pre-eclampsia is 
paramount. 



System 

Cardiovascular system 

Renal 



Clotting 

Liver 

Central nervous system 

Fetus 



Effects 

Increased peripheral resistance leading to hypertension 

Reduced maternal plasma volume and increased vascular permeability 

Glomerular damage leading to proteinuria. hypoproteinaemra. reduced oncotic pressure. 

which further exacerbates the hypovolemia. May develop acu'e renal failure ± cortical 

necrosis 

Hypercoagulable. with increased fibrin formation and fibrinolysis 

Fibrin deposition in the hepatic sinosoids. HELLP syndrome 

Thrombosis and fibrinoid necrosis of the cerebral arterioles 

Eclampsia [convulsions], cerebral haemorrhage and cerebral oedema 

Impa red uteroplacental circulation leading to IUGR and increased perinatal mortality 



Hypertension 21 



does not alter the course of the 
disease, although it may allow 
prolongation of the pregnancy and 
thereby improve fetal outcome. The 
only true 'cure' is delivery of the 
placenta. 

Management of gestational 
hypertension 

The following may be used as 
guidelines: 

■ If the BP is found to be elevated at 
an antenatal clinic, it should be 
rechecked after 10-20 minutes. If it 
has settled, no further action is 
required. 

■ If the BP is elevated on two or more 
occasions > 4 hours apart, fetal size 
should be appraised clinically and 
enquiry made about maternal well- 
being. Serum urate [rises with pre- 
eclampsia]. U &{ Es, and platelets 
(which fall with pre-eclampsia) 
should be checked twice weekly 
along with BP recording and urine 
Dipstix measurement (Fig. lb). 
Advice should be given to present if 
unwell, or if there is frontal 
headache or epigastric pain. 

m If there are abnormal blood results, 
the diastolic is > 100 mmHg or has 
risen from booking by > 25 mmHg, 
or there is clinical suspicion of IUGR 
poor fetal well-being or maternal 
compromise, arrangements should 
be made for a cardiotocograph 
(CTG) and ultrasound assessment of 
fetal size and liquor volume. Also 
arrange BP recording and Dipstix 
three times per week, with at least 
weekly measurement of serum 
urate, U Sf Es, full blood count, and 
platelets. 

It is important to consider the overall 
picture rather than make decisions on 
the basis of a single parameter. It is 
appropriate to admit the mother for 
more intensive monitoring if there are 
symptoms or if she has significant 
proteinuria or severe hypertension. 
Oral antihypertensives may be 
considered and plans can be made for 
delivery. 

The decision to deliver and the 
method of delivery are dependent on 
many of the above factors. There are 
advantages to conservative 
management up to 34 weeks if BP, 
laboratory values and fetal parameters 
are stable. 

It has been suggested that low-dose 
aspirin taken from early pregnancy 
(< 17 weeks and probably from the 



first trimester) may reduce the 
incidence of IUGR or perinatal 
mortality in those with previous 
disease. Studies in this area have 
provided conflicting evidence. 

Severe disease 

The aim is to: 

■ Reduce diastolic BP to < 100 mmHg 
with labetalol, hydralazine or 
nifedipine. 

■ Consider delivery, the timing of 
which depends on maternal well- 
being, and fetal gestation and well- 
being. Delivery is the only thing that 
will improve the course of the 
disease. 

■ Assess fluid balance. There is 
increased vascular permeability and 
a reduced intravascular 
compartment - giving too little fluid 
risks renal failure and giving too 
much risks pulmonary oedema. 
Urine output should be measured 
hourly, and Sa0 2 also monitored. 

U &f Es, liver function tests (LFTs), 
albumin, urate, haemoglobin (Hb), 
haematocrit, platelets and clotting 
should be monitored. Central 
monitoring with a central venous 
pressure (CVP) or Swan-Ganz line 
is often helpful in oliguria to 
differentiate intravascular depletion 
from renal impairment. 

■ There is very good evidence 
supporting the use of 
anticonvulsants in established 
eclampsia, and magnesium sulphate 
is known to be significantly more 
effective than phenytoin or 
diazepam in preventing further 
convulsions. Although the use of 
magnesium sulphate in severe pre- 
eclampsia has been shown to be 
effective in preventing eclampsia, 
treatment is not without risk. 

Eclampsia is said to have occurred 
when there has been a convulsion. The 
UK national incidence is 4.9/10 000 
maternities with 38% antepartum, 18% 
intrapartum and 44% postnatal. Of 
these, 38% occur before proteinuria 
and hypertension have been 
documented. The maternal mortality is 



1.8% with a neonatal death rate of 
34/1000. In the developing world, 
incidences of 20-80/10 000 maternities 
have been quoted, with a maternal 
mortality around 10%. 

■ The patient should be turned onto 
her side to avoid aortocaval 
compression. An airway and high- 
flow O, should be given. 

■ MgSOj should be given immediately 
by intravenous injection to terminate 
the convulsion and then by 
intravenous infusion to reduce the 
chance of further convulsions. 
MgS0 4 can depress neuromuscular 
transmission, so the respiratory rate 
and patellar reflexes should be 
monitored. 

■ Consideration should be given to 
urgent delivery if the fit has 
occurred antenatally 

■ Consideration should also be given 
to paralysis and ventilation if the fits 
are prolonged or recurrent 

HELLP syndrome 

HELLP is an acronym from 
haemolysis, elevated liver enzymes 
(particularly transaminases) and low 
platelets. It is a variant of pre- 
eclampsia, affecting 4-12% of those 
with pre-eclampsia/eclampsia and is 
commoner in multigravidae. There 
may be epigastric pain, nausea, 
vomiting, and right upper quadrant 
tenderness. There may be acute renal 
failure and disseminated intravascular 
coagulation (DIC), and there is an 
increased incidence of placental 
abruption. There is also an increased 
incidence (although still rare) of 
hepatic haematoma and hepatic 
rupture leading to profuse 
intraperitoneal bleeding. Management 
is to stabilize coagulation, assess fetal 
well-being and consider the need for 
delivery. It is generally considered that 
delivery is appropriate for moderate to 
severe cases, but management may be 
more conservative (with close 
monitoring) if mild. Postpartum 
vigilance is required for at least 48 
hours. The incidence of recurrence in 
subsequent pregnancies is about 20%. 



Hypertension 



i Pre- eclampsia is a multisystem disorder, and a major cause of fetal and maternal morbidity and 
mortality. 

i Medication, including antihypertensive agents, does not alter the progress of the condition ; the 
only cure is delivery. 

i HELLP syndrome is a variant of pre-eclampsia and is an acronym from haemolysis, elevated liver 
enzymes (particularly transaminases) and low platelets. 



22 OBSTETRICS 



Small for dates fetus 



The detection of poor fetal growth is 
one of the aims of antenatal care. 
Perinatal mortality rises from 12 in 
1000 in those over 5th centile for 
growth to 190 in 1000 in those less 
than 10th centile. Although there is 
little that can be done to promote 
growth in utero, the option exists for 
delivery of the fetus when it is decided 
that the environment outside the 
uterus is healthier than that inside. 
There is increased risk of intrauterine 
death, intrapartum hypoxia, neonatal 
hypoglycemia and possible long-term 
neurological impairment for the small 
fetus. 

Categories of small infants 

Born too soon 

These babies are a normal size for 
their gestation. Perinatal mortality is 
more strongly associated with low 
gestation than with birth weight 

Low birth weight 

These infants are by definition < 10th 
centile for gestation. 

Intrauterine growth restriction 
CIUGR) 

Infants in this category may show two 
different patterns of growth. 
Asymmetric IUGR. In this case 
uteroplacental insufficiency means the 
fetus fails to achieve its growth 
potential. There is an association with 
preeclampsia, abruptio placentae, 
maternal disease and maternal 
smoking. The asymmetry arises from 
the 'brain-sparing' effect with blood 
preferentially diverted to the fetal 
brain, maintaining its growth at the 
expense of the liver. Thus the head 
circumference follows the same centile 
for growth while the abdominal 
circumference falls to a lower centile. 
These infants are born with a wasted 
appearance - being long and thin. 
Symmetric IUGR. The fetus is noted to 
be growing in proportion but is small. 
Some of these infants will just be at 
the lower end of the normal range for 
size (e.g. babies of Asian parents) but 
others will be small due to an insult 
such as viral infection or chromosomal 
abnormality. 

In practice all infants where growth 
is on a lower centile than predicted are 
monitored, looking for other signs of a 
problem (decreased liquor volume or 
Doppler abnormality). 



Assessment of the fetus 

Fetal movement charts 

Asking the mother to record the time 
at which 10 fetal movements have 
been noted is based on the recognition 
that a reduction or cessation in fetal 
movements may precede fetal death by 
24 hours or more. This is not true in 
all cases and thus action to prevent 
fetal loss is not always possible. Trials 
assessing movement counting do not 
show a reduction in the incidence of 
intrauterine fetal death in late pregnancy 
but in the high-risk pregnancy this 
method does allow daily monitoring 
and is sometimes used. 

Symphysis-fundal height (SFH) 

Assessment of fetal size is undertaken 
by all involved in antenatal care, with 
palpation of the maternal abdomen 
performed at each antenatal visit. This 
is notoriously unreliable at predicting 
either large or small infants but use of 
a tape measure to record the 
symphysis-fundal height may give a 
useful guide for an individual observer. 
This may then be plotted against a 
chart of expected measurements and 
any change from the expected size 
noted (Fig. 1). The inter-observer error 



3<i- 


• 






• • 


30- 




• 
• 


25- 






20- 







20 24 28 32 36 40 

Weeks of pregnancy 

Fig. 1 Plot of the symphysis-fundal height. 



with this measurement is large but 
studies of the ability of SFH 
measurement to predict low birth 
weight have shown quite good 
sensitivity. 

Ultrasound 

Ultrasound measurements of the fetus 
can give an idea of the growth pattern 
by plotting the measurements serially 
against standardized charts (Fig. 2). 



400 



a 


350 


1 


300 


c 




S 

03 


250 




200 



<^ 



1 150 ■ 



n 100 



50 



g| 200 
|'E 

|| 100 



u 50 



V — ]^ ¥ * 



Example of asymmetric IUGR 
Example of symmelric IUGR 



400 



350 
300 
250 

400 

[350 

300 

250 



16 20 24 28 32 

Weeks of pregnancy 



36 40 



Fig. 2 Ultrasound measurement of the fetus, (a) Asymmetric IUGR. (b) Small for dates 
(symmetric IUGR]. 



Small for dates fetus 23 




l - ..ii. -.'' -. 




ii.uU.i./.-V'' '.iiuli'il . JiJh i l i ii 



Fig. 3 The amniotic fluid index plotted Fig. 4 Doppler ultrasound of the umbilical artery- (a) Normal, (b) Absent end diastolic 

against gestation showing normal range blood flow, 

[mean ± 2 standard deviations). 



The fetal head circumference is 
measured to try to get around the 
problem of variations in the biparietal 
diameter (BPD) due to different head 
shape depending on fetal position (e.g. 
dolicocephaly or the more oval head 
shape in the breech infant). This is 
plotted against the abdominal 
circumference on the charts and the 
pattern of growth noted. Curve a 
depicts asymmetric IUGR and curve b 
shows a small for dates fetus. 

Ultrasound is also used to measure 
the amount of liquor around the fetus. 
This varies with the gestation but also 
changes with IUGR when, due to poor 
perfusion of the fetal kidneys, there is 
less liquor than usual at that gestation. 
The volume is assessed by measuring 
the pools of liquor without limbs or 
cord in them. Pools between 3 and 
8 cm are normal but are not thought 
to give a very representative overall 
picture of the volume, so an amniotic 
fluid index measuring the greatest 
pool in each quadrant of the uterus 
may be preferred (Fig. 3). The amniotic 
fluid index has been plotted against 
gestation to give a normal range. 

Alterations in fetal umbilical blood 
flow may occur as an early event in 
conditions of placental insufficiency. 
Doppler ultrasound (Fig. 4) of the 
umbilical artery is used as an 
assessment of downstream vascular 
resistance (i.e. placental resistance) and 
may help to identify placental 
insufficiency in high-risk pregnancies 
(eg. IUGR, PET). The Doppler probe 
is directed at the umbilical cord and 
detects velocity (the Doppler shift - the 
effect noted as an ambulance with its 
siren on passes and you note a change 
in the tone). 

Figure 4a shows the normal pattern 
obtained with flow during systole and 
diastole indicated and below the line 
the continuous venous flow. Reduction 
of end diastolic blood flow may 



identify those at risk of hypoxia 
(Fig. 4b). It is likely that the hypoxia 
precedes the Doppler changes. This 
can give further information to aid a 
decision on whether to deliver a small 
fetus early to achieve a better outcome. 

Biophysical profile 

This looks at five variables (fetal 
movement, tone, reactivity, breathing 
and amniotic fluid volume) considered 
to be of prognostic significance in 
assessment of the high-risk pregnancy. 
Comparison of this profile with 
antenatal CTG for care of high-risk 
pregnancies does not result in 
improved outcome for the baby so the 
test is not universally used, though it 
often produces useful information. 

Monitoring 

Once the small infant has been 
identified there is usually a period of 
monitoring to try to assess the optimal 
time to deliver the baby. Twice weekly 
measurement of amniotic fluid volume 
(plotted against the chart - see above) 
and CTG may be supplemented by 
Doppler studies. Abnormalities in any 
of these tests may make the 
obstetrician feel that the extrauterine 
environment may be safer for the baby. 
The decision is based on the likely 



survival rates of infants at the gestation 
the pregnancy has reached once tests 
become abnormal. 



Management 

Delivery of the baby removes the 
infant from a hostile intrauterine 
environment but the mode of delivery 
has to be decided upon. A caesarean 
section offers immediate extrauterine 
conditions but there is a higher risk of 
respiratory distress syndrome in babies 
born by caesarean section compared 
with babies born vaginally at the same 
gestational age. Vaginal delivery, 
however, is recognized to be stressful 
for the infant and if there are already 
signs of fetal compromise, it is not 
reasonable to induce labour. There are 
no scientific studies to give an answer, 
and each case is assessed individually 
in the light of all the facts to try to 
decide on the best method of delivery. 
Antenatal corticosteroid therapy has 
been shown to reduce the incidence of 
respiratory distress syndrome. 
Maximum benefit is achieved for 
babies delivered more than 24 hours 
and less than 7 days after 
commencement of the medication. In 
elective preterm deliveries it is usual to 
give corticosteroid therapy between 24 
and 34 weeks' gestation. 



Small for dates fetus 



i Asymmetrical growth restriction is associated with low amniotic fluid index and raised perinatal 
mortality, and may necessitate early delivery. 

i Ultrasound measurements of the fetal abdominal and head circumference plotted on growth 
charts allow detection of the fetus whose growth pattern deviates from the normal. 

i Symphysis-fundal height is better than abdominal palpation alone in detecting low birth weight 
for gestation. 

i Doppler ultrasound gives additional information when monitoring the high-risk pregnancy. 



24 OBSTETRICS 



Medical disorders in pregnancy 



(See also Diabetes mellitus, p. 28; 
Hypertension, p. 20; Venous 
thromboembolic disease, p. 42; 
Infections in pregnancy, p. 140 

Cardiac disease 

Heart disease of varying types 
complicates less than 1% of all 
pregnancies but accounts for 9°/o of 
UK maternal deaths. While rheumatic 
heart disease remains a significant 
problem in the developing world, there 
are increasing numbers of fertile 
women in western countries who have 
had surgery for congenital heart 
disease (CHD) as children. Maternal 
mortality is highest in those conditions 
where pulmonary blood flow cannot 
be increased to compensate for the 
increased demand during pregnancy, 
e.g. in those with pulmonary 
hypertension (particularly 
Eisenmenger syndrome, where 
maternal mortalities of 40-50% have 
been reported). 

Unfortunately, many of the 
symptoms and signs usually 
considered indicative of heart disease 
occur commonly in normal pregnancy, 
making clinical diagnosis difficult: 
breathlessness and syncopal episodes 
are present in 90% of normal 
pregnancies, atrial ectopic beats are 
common and up to 96% of women 
may have an audible ejection systolic 
murmur. Further investigation should 
be considered if the murmur is > 3/G, a 
thrill is present, or if there are any 
other suspicious features. 

If significant problems are 
discovered, a cardiologist should be 
involved. If there is no haemodynamic 
compromise (e.g. as with congenital 
mitral valve prolapse), then the 
prognosis is good and, after initial 
assessment, there is no need for 
cardiac follow-up, although antibiotic 
prophylaxis may be required. If there 
are significant potential 
haemodynamic problems, then 
consideration of pregnancy 
termination is an option (e.g. with 
Eisenmenger syndrome, primary 
pulmonary hypertension and 
pulmonary veno-occlusive disease). If 
the maternal pO, is decreased, the 
fetus is at risk from asphyxia and 
intrauterine growth restriction (IUGR) 
and should be monitored with regular 
ultrasound scans (USS) for growth, 
Doppler studies, cardiotocographs 



Table 1 Cardiac disease and delivery 

■ Labour should be conducted in a hgh-depcndency 
or intensive care unit setting, airreng tor a vaginal 
delivery, and avoiding J BP. hypoxia or fluid overload 

m Ep'dura! analgesia may be jsec. and is probably 
preferable to sp nal o' serosa! anaesthesia 

■ Endocarditis prophylaxis s^oud be given if required 

■ The second stage s-oi ; : d be kept shcrt 

B Particular care is roqu red in the im'redrale 
postpartum period as t~ere is an increased 
circulating voiunie follcw.ng uterine retraction, which 
may lead to fluiri overload and congestive failure 



(CTGs) and biophysical profiles. 

Severe cardiac disease can cause 
problems at delivery, particularly in 
those with prosthetic valves, aortic 
stenosis, severe mitral stenosis and 
those with pulmonary hypertension. 
Important aspects of the management 
of delivery in cases of severe cardiac 
disease are listed in Table 1. 

Puerperal cardiomyopathy is rare 
(< 1 : 5000), carries a 25-50% 
mortality, and is associated with 
hypertension in pregnancy, multiple 
pregnancy, high multiparity and 
increased maternal age. It presents 
with sudden onset of heart failure and 
there is a grossly dilated heart on 
echocardiography. 

Connective tissue disease 

Although these diseases are rare, they 
occur most commonly in women 
during their child-bearing years and it 
is therefore relatively common to find 
them in association with pregnancy. 

Systemic lupus erythematosus 
CSLE) 

There is no effect of pregnancy on the 
long-term prognosis of SLE. There is 
probably an increased chance of flare- 
ups occurring in pregnancy (Fig. 1). 
Women should be discouraged from 
becoming pregnant during disease 
flare-ups to minimize fetal problems. 
Active SLE nephritis during pregnancy 
is associated with a significant 
maternal and perinatal mortality and 
in particular with a risk of pre- 
eclampsia. 

SLE is associated with increased 
fetal loss rates from an increase in 
spontaneous miscarriages and preterm 
delivery. This is particularly so in those 
with raised anticardiolipin antibodies 
(p. 93). There is an increased incidence 
of preeclampsia and this may be 
difficult to differentiate from a disease 




Fig. 1 There is a characteristic butterfly 

rash. This patient's SLE tlarec up at 22 weeks, 
with marked hypertension and lenal impairment. 




Fig. 2 Pacemaker in baby with 
congenitaling heart block in association 
with anti-Ro antibodies. 



flare-up, as both are associated with 
hypertension and proteinuria. There is 
no increase in the rate of fetal 
abnormalities, although there is a risk 
of fetal congenital heart block in 
association with the presence of anti- 
Ro and anti-La antibodies (Fig. 2). 
Neonatal lupus may rarely occur and 
is characterized by haemolytic 
anaemia, leucopenia, 
thrombocytopenia, discoid skin 
lesions, pericarditis and congenital 
heart block. 

If lupus anticoagulant or 
anticardiolipin antibodies are present, 
low-dose aspirin should be given, and, 
in those with a previous history of 
thromboembolic disease, low-dose 
heparin may also be required. Careful 
monitoring of renal function is also 



Medical disorders in pregnancy 25 



appropriate. Flare-ups should be 
managed where possible with oral 
prednisolone (if not already on oral 
prednisolone) and there should be 
regular growth scans looking for 
IUGR as well as regular fetal 
monitoring with CTGs and biophysical 
profiles in the third trimester. 

Epilepsy 

Around a third of those with epilepsy 
have an increase in seizure frequency 
independent of the effects of 
medication, particularly those with 
secondary generalized or complex 
partial seizures. The fall in 
anticonvulsant levels owing to dilution, 
reduced absorption, reduced 
compliance and increased drug 
metabolism is partially compensated 
for by reduced protein binding [and 
therefore an increase in the level of 
free drug). There is an increased 
incidence of fetal anomaly in those 
with epilepsy irrespective of the effects 
of drugs C3-4°/o vs 2°/o in the general 
population), possibly owing to a 
combination of hypoxic and genetic 
factors (Fig. 3). For those on 
anticonvulsants, the incidence of 
anomaly is ~ 6%. Single-drug regimens 
are less teratogenic than multidrug 
therapy. 

The management of epilepsy in 
pregnancy is summarized in Table 2. 




Fig. 3 Anticonvulsants are associated 
with neural tube defects, cardiac and 
craniofacial defects. 



Hepatic disorders 

A history of a prodromal illness, 
overseas travel or high-risk group for 
blood-borne illness may suggest viral 
hepatitis. Itch is suggestive of 
cholestasis. Abdominal pain is 
associated with gallstones, HELLP 
syndrome and acute fatty liver. Clinical 
signs are often unhelpful in diagnosis. 
U Sf Es, urate, liver function tests 
(LFTs), blood glucose, platelets and 
coagulation screen should be checked 
and blood sent for hepatitis serology. 
An abdominal ultrasound scan of the 
liver may show obstruction or fat 
infiltration. 

Liver disorders specific to 
pregnancy 

Hyperemesis gravidarum 

This may be associated with abnormal 
LFTs. 

Intrahepatic cholestasis of 
pregnancy 

Jaundice is mild, usually presenting 
after 30 weeks' gestation, possibly 
because of a genetic predisposition to 
the cholestatic effect of oestrogens. 
Pruritus is generally severe, affecting 
limbs and trunk. There is a positive 
family history in up to 50% of cases. 

Transaminases are increased (less 
than threefold), and alkaline 
phosphatase levels are raised (above 
normal pregnancy values). Bilirubin is 
usually < 100 umol/1, and there may be 
pale stools and dark urine. Serum total 
bile acid concentration is increased 
early in the disease and may be the 
optimum marker. 

There are no serious long-term 
maternal risks but there is a risk of 
preterm labour, fetal distress and 
intrauterine fetal death. The fetus must 
be monitored closely and there is 
growing evidence that delivery at 
37-38 weeks is appropriate. The 
combined oral contraceptive pill is 
contraindicated. 



HELLP syndrome 

See page 21. 

Acute fatty liver of pregnancy 

This is very rare, but carries a high 
maternal and fetal mortality and may 
progress rapidly to hepatic failure. It 
usually presents with vomiting in the 
third trimester associated with malaise 
and abdominal pain followed by 
jaundice, thirst and alteration in 
consciousness level. LFTs are elevated, 
urate is very high and there is often 
profound hypoglycaemia. 

Liver disorders coincidental to 
pregnancy 

Viral hepatitis 

This is the commonest cause of 
abnormal LFTs in pregnancy. Titres for 
hepatitis A, B and C as well as for 
cytomegalovirus (CMV) and 
toxoplasmosis should be checked. 

Gallstones 

Asymptomatic gallstones do not 
require treatment. Cholecystitis should 
be managed conservatively. 

Cirrhosis 

In severe cirrhosis there is usually 
amenorrhoea. If pregnancy occurs, and 
the disease is well compensated, there 
is usually no long-term effect on 
hepatic function. The main risk is from 
bleeding oesophageal varices. 

Chronic active hepatitis 

This is usually associated with 
amenorrhoea. Pregnancy does not 
usually have any long-term effect on 
liver function. Obstetric complications 
are common and fetal loss rate is high. 
Immunosuppressant therapy with 
prednisolone and azathioprine should 
be continued in those with 
autoimmune disease. 



faD e 2 Management of epilepsy in pregnancy 
Consider 

pre-pregnancy counselling 
Anticonvulsant dosage 

Detailed ultrasound scan at 18-22 weeks 
Vitamin K for women on enzyme-inducing 
anticonvulsants 

Fits 
Postnatal 



Discussion 

Monotherapy "deal Folate supplementation should be continued until at least 12 weeks 

Anticonvulsant doses adjusted on clinical grounds There are Fetal risks from the ant convuisant medication as well as 

from not laking the drugs [from increased fit frequency} 

Meural tube, cardiac and craniofacial abnormalities as well as diaphragmatic hermae are marc common 

Vitamin K p.o. daily from 36 weeks (anticonvulsant are vitamin K antagonists and increase me risk ol liaemorrhagic 

disease ot the newborn) The babyshould be given vitamin K i.m. stal al birlh and the paediatrician alerted 10 ine 

possibilities of anliconvulsanl drug withdrawal 

Most fits in pregnancy will be self- limiting hut il prolonged give diazepam p.r./i v _i ventilation 

Postnatally. the mother may breastfeed safely [drugs pass into the milk but are ot little clinical significance). Advice 

should be given ataut safe and suitable settings tor feeding, bathing, etc Carbarnazepme. phenytom primidone and 

phenobarbilal induce liver enzymes, reducing the effectiveness of standard dose combined ora J contraceptives 

therefore a higher dose oestrogen preparation is required 



26 OBSTETRICS 



Acute hydronephrosis 

- loin pain 

- ureteric colic 




Chronic renal impairment 

- creatinine <125 umol/l - good 
perinatal outcome 

- creatinine >125 umol/1 - often 
subfertility; fetal prognosis less good 

■ dialysis - usually amenorrhoea; if 
pregnant, fetal prognosis very poor 



Those with asymptomatic bacteriuria 
should be treated as there is a 
30—40% risk of developing 
symptomatic infection 



Fig. 4 The genitourinary system in pregnancy. 



Primary biliary cirrhosis 

This is variable in severity. The 
prognosis for mother and fetus is 
good in mild disease. It may present 
during pregnancy for the first time in a 
similar way to intrahepatic cholestasis 
of pregnancy. 

Renal disorders [Fig. 4] 
In pregnancy, there is an increase in 
the size of both kidneys and dilatation 
of the ureter and renal pelvis. This is 
greater on the right than on the left 
because of the dextrorotation of the 
uterus. There is also an increase in 
creatinine clearance because of the 
increased glomerular filtration rate 
(GFR) [maximal in the second 
trimester). Urea should be < 4.5 
mmol/1 and creatinine < 75 p.mol/1. 

Infection 

Urinary tract infections (UTIs) occur in 
3-7% of pregnancies and if untreated 
may lead to septicaemia and 
premature labour. Asymptomatic 
bacteriuria should be treated in all 
pregnant women, as there is a 30-40% 
risk of developing a symptomatic UTI. 
Pyelonephritis should be treated 
aggressively. 

Obstruction 

Acute hydronephrosis is characterized 
by loin pain, ureteric colic, sterile urine 
and a renal USS showing dilatation of 
the renal tract greater than normal in 
pregnancy [Fig. 5}. If the symptoms are 
not settling and the USS does not 
demonstrate the cause of the 
obstruction, a limited intravenous 
urogram (IVU) should be considered. 



Chronic renal impairment 

The fetal prognosis with chronic renal 
disease in pregnancy is best if maternal 
renal function and BP are optimized. If 
the plasma creatinine is < 125 umol/1, 
the maternal and perinatal outcome is 
usually good. If it is > 250 umol/1, 
there is usually amenorrhoea and if 
pregnancy occurs there may be a risk 
of renal deterioration (therefore 
consider termination of pregnancy). 
Between these levels, women should 
be advised that pregnancy may cause 
their renal function to deteriorate and 
that there are also risks to the fetus 
(mainly IUGR). Pre-existing 
hypertension, proteinuria and a pre- 
pregnancy GFR < 70ml/minute are 
also associated with a poorer maternal 
and fetal outcome. Some renal diseases 
carry a worse prognosis than others 
(specialist advice is required). 

Close fetal monitoring is important 
in the third trimester. It is difficult to 



distinguish preeclampsia from 
increasing renal compromise as both 
may present with hypertension and 
proteinuria. 

Pregnancy should be discouraged in 
patients on dialysis as the fetal 
prognosis is poor. Pregnancy in 
patients with renal transplant is 
possible. 

Respiratory disorders 

Breathlessness due to the physiological 
increase in ventilation is a common 
symptom in pregnancy. This is due 
partly to low pC0 2 , the effect of 
progesterone, and partly to a raised 
diaphragm, which occurs even before 
the uterus causes direct physical 
pressure. A normal chest X-ray and 
physical examination virtually excludes 
a pathological problem in the absence 
of other symptoms. 

Asthma is common. In most, the 
disease is unchanged, but it may 
improve, or less commonly, 
deteriorate. Treatment is similar to that 
in the non-pregnant patient Inhaled 
(3-sympathomimetics and inhaled 
steroids are safe. Oral steroids may be 
indicated. 

Thrombocytopenia 

Maternal thrombocytopenia in 
pregnancy 

In the second half of 8% of normal 
pregnancies there is a mild 
thrombocytopenia (platelet count 
100-150 x 10 9 /1) which is not 
associated with any risk to the mother 
or fetus. Pre-eclampsia (see p. 20) 
should be excluded. 

Autoimmune thrombocytopenic 
purpura is the commonest cause of 
thrombocytopenia in early pregnancy 
(but can also arise in later pregnancy) 
and may be acute or chronic. 




Fig. 5 Ultrasound of left kidney with ureteric obstruction and 
calyceal clubbing. There was a calculus in the lower third of the ureter. 



Medical disorders in pregnancy 27 



Antiplatelet antibodies may be 
detected. These may cross the placenta 
and cause fetal thrombocytopenia, 
although this is rarely associated with 
long-term morbidity (cf. alloimmune 
thrombocytopenia). No treatment is 
required in the absence of bleeding, 
providing the platelet count remains 
above 50 x 10 9 /1. If the platelet count 
falls below this level, steroids and 
immunoglobulin can be given. 

Fetal (alloimmune) 
thrombocytopenia 

This is a rare disorder in which there 
are maternal antibodies to fetal 
platelets (similar to Rhesus disease 
except for platelets rather than red 
blood cells). The maternal platelet level 
is normal, but there may be profound 
fetal thrombocytopenia and antenatal 
or intrapartum intracranial bleeds. The 
diagnosis should be suspected when a 
previous child has had neonatal 
thrombocytopenia and maternal 
antiplatelet antibodies have been 
identified (often to the HPA-la 
antigen). Treatment is usually with 
antenatal immunoglobulin and elective 
caesarean section. 

Thyroid disorders 

1% of pregnant women in the western 
world are affected by thyroid disease, 
with hypothyroidism being commoner 
than hyperthyroidism. The fetal 
thyroid gland is active and secretes 
thyroid hormones from the 12th week. 
It is independent of maternal control, 
although maternal thyroid hormones 
do cross the placenta. 

Hypothyroidism 

This may present with fatigue, hair loss, 
dry skin, abnormal weight gain, poor 
appetite, cold intolerance, bradycardia 
and delayed tendon reflexes. If 
untreated, there is double the rate of 
spontaneous miscarriages and stillbirths 
compared to the normal population, as 
well as a risk of fetal neurological 
impairment. There is minimal fetal risk 
if the mother is treated and euthyroid. 
Thyroid function should be regularly 
monitored, aiming to keep thyroid- 
stimulating hormone within the normal 
range and free thyroxine (T4) at the 
upper end of the normal range. Fetal 
hypothyroidism may occur when the 
mother carries antithyroid antibodies or 
is receiving antithyroid drugs. 

Hyperthyroidism 

Thyrotoxicosis presents with weight 
loss, exophthalmos, tachycardia and 



restlessness. It is usually due to Graves' 
disease but may occur secondary to 
toxic thyroid adenoma or multinodular 
goitre. Untreated thyrotoxicosis is 
associated with approximately 50% fetal 
mortality and a risk of maternal thyroid 
crisis at delivery. Well-controlled 
hyperthyroidism is not associated with 
an increase in fetal anomalies but there 
is a tendency for babies to be small for 
gestational age. Graves' disease usually 
improves during pregnancy. 
Carbimazole and propylthiouracil cross 
the placenta and can potentially cause 
fetal thyroid suppression. In low doses, 
however, this is rarely significant. 
Radioactive iodine is absolutely 
contraindicated, and surgery is indicated 
only for those with a very large goitre or 
poor oral compliance. 

Postpartum thyroiditis 

This occurs following 5-10% of all 
pregnancies, with initial 
hyperthyroidism followed by 
hypothyroidism (at around 1-3 months, 
which therefore may be confused with 
depression) and then recovery. 
Symptoms of hyperthyroidism may be 
treated with propranolol (antithyroid 
drugs accelerate the appearance of 
hypothyroidism). Hypothyroidism may 
be treated with thyroxine as above, 
withdrawing it around 6 months 
postnatally. A small proportion may 
require long-term treatment or may 
develop hypothyroidism later in life. 

Gastrointestinal disorders 

Peptic ulceration 

Ulcers are rare in pregnancy but, when 
present, tend to improve. If ulcer 
symptoms occur, first-line treatment is 
with simple antacid/alginate 
compounds. If not resolving then 
ranitidine, an H2 antagonist, should be 
started. Those with problematic 
recurrent ulcers should also take 
ranitidine. Endoscopy is the 
investigation of choice, if necessary. 



Inflammatory bowel disease 

Fetal loss rate is similar to that of the 
normal population providing that the 
disease is not active at the start of the 
pregnancy. Flare-ups of the disease 
occur most commonly in the first 
trimester. There is no evidence of fetal 
problems with prednisolone or 
sulfasalazine and these should be 
continued at the minimum dose 
necessary. Constipation should be 
avoided and the mother should receive 
folic acid supplementation. 

Acute episodes of inflammatory 
bowel disease present with abdominal 
pain, diarrhoea and passage of blood 
and mucus p.r. Patients should be 
admitted and fluid and electrolyte 
balance checked. Stool samples should 
be sent for culture to exclude 
gastroenteritis. Treatment is with 
topical steroid enemas, oral 
sulfasalazine and prednisolone daily. If 
the patient deteriorates, the possibility 
of intestinal perforation or toxic 
megacolon should be considered. 

Colostomies and ileostomies may 
become temporarily obstructed during 
pregnancy. Vaginal deliveries are 
preferable to caesarean section (as 
there is a risk of adhesions from 
previous surgery), although care is 
needed with operative vaginal 
deliveries if the disease involves the 
perineum. Although sulfasalazine 
crosses into breast milk, there is no 
evidence of any neonatal problems. 

Coeliac disease 

Presentation may occur in pregnancy 
with non-specific gastrointestinal 
symptoms, anaemia and weight loss. 
Diagnosis is by duodenal biopsy via 
endoscopy. Treatment is with gluten- 
free diet and vitamin supplementation. 
Patients with known coeliac disease 
should be encouraged to comply with 
a strict gluten-free diet in pregnancy. 
Iron and folate supplements are 
recommended. The prognosis for the 
mother and fetus is good. 



Medical disorders in pregnancy 



i Structural heart disease in pregnancy has potentially serious implications for both mother and 
fetus. 

i Abnormal liver function tests may be related to the pregnancy, but are commonly coincidental. 

i Asymptomatic UTIs should be treated. 

i The fewer anticonvulsants, the less the risk of fetal abnormality. 

i Well -control led thyroid disease poses little serious risk. 



28 OBSTETRICS 



Diabetes in pregnancy I 



Physiology 

The hormonal changes of pregnancy 
profoundly affect carbohydrate 
metabolism. The levels of oestrogen, 
progesterone, human placental lactogen 
(HPL), prolactin and free Cortisol rise 
progressively throughout pregnancy. 
Cortisol and HPL, especially, are insulin 
antagonists, so women become relatively 
insulin resistant in pregnancy. To 
overcome this trend, normal women 
compensate by producing increased 
amounts of insulin. 

Definitions 

When the obstetrician is faced with 
diabetes in pregnancy it represents 
either gestational diabetes or pre-existing 
disease. 

Gestational diabetes 

By definition, this is carbohydrate 
intolerance that develops during 
pregnancy and disappears after delivery. 
Normally in the second half of 
pregnancy, and particularly in the third 
trimester, there is a further increase in 
insulin resistance and a slight 
deterioration in glucose tolerance. 
Women who develop gestational 
diabetes are unable to meet this with a 
compensatory rise in insulin production 
and pregnancy-onset diabetes is 
therefore most commonly detected at 
this time. 

The situation is often not as clear-cut 
as this. Some women have had pre- 
existing subclinical diabetes which was 
missed and therefore they appear to 
present as 'gestational' diabetes, since 
the diabetes was first detected in 
pregnancy. Some women with true 
pregnancy-related diabetes will continue 
to be diabetic post-delivery (about 15%). 
These are often missed, as postnatal 
glucose tolerance tests (GTTs) are not 
widely performed. Some will develop 
diabetes in later life. 

Pre-existing diabetes 

The classical syndrome of diabetes is 
characterized by hyperglycaemia due to 
a deficiency or diminished effectiveness 
of insulin. This results in the well- 
known symptoms and signs of polyuria, 
polydipsia, weight loss and glycosuria. 
The effects, if untreated, are profound. 
Eventually, cellular damage can occur, 
especially to vascular endothelial cells in 
the eye, kidney and central nervous 
systems. 



In general the majority of diabetics 
are non-insulin dependent (NIDDM), 
controlled by diet or oral hypoglycemic 
agents. There is a hereditary element and 
an association with obesity. NIDDM is 
less common in the childbearing years. 

Insulin-dependent diabetes (IDDM) 
occurs most often in young adults and 
is due to cellular and humoral 
autoimmunity to pancreatic beta cells. 

In pregnancy, diabetic control needs to 
be as careful for NIDDM as IDDM to 
avoid adverse perinatal outcome. White's 
classification [Table 1) is often used to 
grade the severity of the disease. In 
general, the more severe the disease the 
greater the perinatal mortality and 
incidence of congenital malformations. 

Potential diabetes 

This term is often used to define a group 
of women who are more likely to 
develop diabetes at some time in their 
lives than normal based on family, 
medical or obstetric history. These risk 
factors are still widely used in antenatal 
clinics today as part of screening for 
gestational diabetes (Table 2). 

Diagnosis and screening 

Screening and diagnosis aims to identify 



Ta-jle ' 


White's classification of 


established diabetes 


,\ 


Asymptomatic diabetes diagnoses by GTT 


B 


Diabetes onset after age 20 years 




Diabetes duration 0-9 years 




No vascular complications 


C 


Diabetes onset 1 D- 1 9 years 




Diabetes duration 10 19 years 




No vascular disease 


D 


Diabetes unset before 1 years of age 




Diabetes duration > 20 years 




Vascular disease present 


F 


Diabetes with nephropathy 


R 


Diabetes with retinopathy 



Tabic 2 Antenatal screening risk factors 
for gestational diabetes 

m S ig n ificant glycos u n a on two occa s ions i n antenatal 
clinic, or one occasion if a fasting urine sample is 
tested, or one it less than IB weeks' gestation 

■ Family history of diabetes, particularly parents or 
siblings [IDDM in the father is of greater predictive 
value than in the mother; predictive value is greater if 
a sibling or both parents are diabetic; grandparents 
are less significant) 

■ Frevmus nig babies > 90th cennle for gestational age 
and sex 

■ Diabetes in a previous pregnancy 

■ Previous unexplained intrauterine death or stillbirth 

■ Polyhydramnios 

■ Maternal obesity f> 20% abdve the ideal weight) 



all women who may develop gestational 
diabetes. Various risk factors may be 
assessed from the booking history 
(Table 2) and if a patient exhibits two or 
more of these, then a glucose tolerance 
test (GTT) can be organized for 24-28 
weeks' gestation. 

Impaired glucose tolerance (IGT) is 
present if the fasting glucose is > G and 
< 7.8 but rises to 8.0-10.9 mmol/1 within 
2 hours of the 75 g glucose load. These 
women may develop gestational diabetes 
as the pregnancy progresses or remain 
with slightly impaired metabolism as 
pregnancy advances, reverting to normal 
afterwards. The significance of IGT is 
controversial. There is no evidence that 
treatment is of benefit but commonly, if 
the preprandial sugar is > 6 or the 
postprandial value is > 8, treatment with 
dietary control and possibly insulin can 
be introduced. 

Gestational diabetes is diagnosed if 
the fasting glucose is > 8 mmol/1 and the 
2 -hour level is > 11 mmol/1. 

Alternative screening 

Although the above method is most 
widely used there are considerable 
limitations: 

■ 30% of gestational diabetics have none 
of the recognized risk factors 

■ glycosuria can be found in up to 50% 
of all pregnant women at some stage 
in their pregnancy 

■ not all women with gestational 
diabetes, or even IGT, have persistent 
glycosuria and may be clear on 
testing. 

Thus some gestational diabetics are 
missed and a lot of normal women have 
unnecessary GTTs. Routine screening 
for everyone has been suggested as a 
more accurate approach, performing 
random blood glucose tests at booking, 
28 weeks and 32 weeks (referring 
equivocal cases for a GTT). Some 
centres perform a modified GTT at 
booking. 

Pre-conceptual counselling 

For the patient with pre-existing diabetes 
pre-conceptual counselling is vital (see 
p. 6). There is an increased incidence of 
congenital malformations amongst 
babies born to mothers whose diabetes 
is poorly controlled, with a 3-4 times 
higher rate of abnormality than in their 
non-diabetic counterparts. The incidence 
of all malformations is increased, 



Diabetes in pregnancy I 29 



especially congenital heart disease and 
neural tube defects. 

Multiple abnormalities are common. 
Caudal regression syndrome (absence of 
vertebrae anywhere below T10) is rare 
but peculiar to diabetics. The most 
common form is sacral agenesis 
(Fig. 1). Tight diabetic control is 
therefore very important at the time of 
organogenesis to reduce the incidence of 
congenital malformations. As 
organogenesis occurs during the first 
7-9 weeks of fetal life, and patients 
rarely book for antenatal care before 
10-12 weeks, pre-conceptual counselling 
is the only way to gain diabetic control 
in time. At the pre-conception clinic the 
patient receives: 




■ general advice regarding diet, smoking 
and lifestyle 

■ establishment of tight diabetic control 
with advice for its maintenance 

■ examination of optic fundi 

■ assessment of baseline renal function 

■ plans made for early antenatal referral 
and booking 

■ commencement on folic acid. 

Ongoing diabetic control 

Control of diabetes remains essential 
throughout pregnancy for pre-existing 
and gestational disease. The movement 
of glucose across the placenta is by 
carrier-mediated facilitated diffusion 
(Fig. 2). Fetal blood-glucose levels 
usually remain 20-30 mg/dl lower than 
those of the mother. There is close 
correlation between fetal glucose uptake 
and blood levels. The fetal level is 
normally maintained within narrow 



limits because maternal glucose 
homeostasis is well regulated. Protein 
hormones such as insulin, glucagon, 
growth hormone and HPL do not cross 
the placenta. Ketoacids appear to diffuse 
freely and serve as fetal fuel during 
periods of maternal starvation. Periods 
of maternal hyperglycaemia result in 
fetal hyperglycaemia. 

Perinatal mortality rates (PNMRs) 
(see p. 78) are closely linked to the 
severity of the diabetes and the degree 
of control achieved. Good control, 
however, does not completely preclude 
the development of macrosomia (large 
birthweight infants > 90th centile for 
gestational age and sex, with 
polycythaemia, adiposity and 
organomegaly) as up to 30% incidence 
has been reported in well-controlled 
diabetics (Figs 3 and 4). 



Maternal I 
blood 




Fig. 2 Facilitated diffusion 
of glucose molecules 



o c 
o o 
o t 

through the placenta. 



4 




Fig. 1 Sacral agenesis. 




Maternal 


Placenta 


Fetal 


t Acute ■s/jff'basal 






insulin 












♦ Cell dew 


■lopment 

i 


Unden. 


jtilization 








ancfQ verproduction 








I 




t Facilitated an a bo 1 ism 


? Altered 


^-— *+ 


structure 


/^ 


Postprandial 


and/or 


/ 


t?«/fasfing 


function 


1 Increased 
/ insulin secretion 

\ ( Increased 


* Glucose 


f 


\ / beta-cell number 


* Lipids 


J 


\ t 


+ Selected AA 


y 




* — _ 


~*s 




lutrients 











Diabetes in pregnancy I 



Fig. 4 The modified 
Pedersen hypothesis. 

Glucose and other 
substrates stimulate 
fetal insulin release 
resulting in macrosomia 
and other morbidity 
observed in the infant of 
a diabetic mother. 



■ Pregnancy is a relatively insulin-resistant state. 

• Gestational diabetes occurs it the increased insulin output fails to compensate. 

■ Antenatal screening methods are controversial: screening may be selective, based on risk factors, 
or offered to all. 

m Existing diabetics have a higher incidence of congenital fetal malformations. 

■ The PNMR is closely linked to the seventy of the disease and the degree of control. 

■ Pre-conceptual counselling and control is vital for established diabetics 



Fig. 3 Macrosomic baby. 



30 OBSTETRICS 



Diabetes in pregnancy II 



Antenatal care 

Antenatal care for both existing and 
gestational diabetes should take place 
jointly between physicians and 
obstetricians, preferably at a specially 
run clinic which involves a dietician. 
'Brittle' diabetics may need to be seen 
weekly. The support of a diabetic 
Management Sister is invaluable as she 
can visit the patient at home, offering 
advice and supervision on 
self-monitoring of blood sugars and 
assessment of compliance to therapy. 

Therapy 

In general, gestational diabetics are 
treated with diet alone - unless there 
is evidence that this is failing to 
produce good control, when insulin is 
substituted. 

Established diabetics are changed to 
insulin in early pregnancy if they were 
previously managed by diet or oral 
hypoglycaemics. As hypoglycaemic 
agents cross the placenta it is 
preferable to change to insulin, 
although in developing countries they 
may have an important role. 

Good control can be achieved by a 
combination of a short-acting insulin 
such as Soluble or Actrapid, with a 
medium-acting insulin, such as 
Isophane or Monotard, given twice 
daily. Human or highly purified 
porcine insulins reduce the risk of 
developing antibodies which can cross 
the placenta. 




Fig. 2 Automated finger puncturer. 




Table I Risks associated with diabetes in 
pregnancy 

Maternal 

Adverse effects on existing retinopathy, nephropathy 

end neuropathy 

Increased incidence of infections - urinary, mondial and 

other 

Obstetric complications preeclampsia, 

polyhydramnios, preterm labour 

Trauma to the genital tract, e.g. Iiae mate mas and tears 

due to difficult delivery of large birthweight baby 

[microsomia] 

Fetal 

Congenital malformations 

Prematurity associated with preterm labour 

Intrauterine death 

Fetal trauma [e.g. fractured clavicles. Erb's palsy], due to 

difficult deliveries 

Shoulder dystocia 

Neonatal metabolic problems, e.g. hypoglycaemia 

Increased incidence of respiratory d' stress syndrome 



Fig. 3 'Glucolog' log book. 



Table 2 Assessment of maternal and 
fetal well-being 

Maternal 

Blood sugar control 

Weight 

Blood pressure 

Optic fundi 

Renal function 

Fetal 

Fetal anomalies scan at 18 weeks 

Echocardiography at 20-24 weeKs to detect congenital 

cardiac anomalies 

Serial scans to assess fetal growth 

Kick charts, biophysical profiles. Doppler studies and 

outpatient card lotooog rap hs in the third trimester to 

assess well-being 

Amniotic phospholipid analysis to assess lung 

maturation [if oreterm delivery rooks likely] 



Monitoring 

Home-based monitoring ensures 
optimal control with the patient's 
usual diet and activity levels. Patients 
use a glucometer to check blood sugar 
profiles two or three times a week 
(see Fig. 1). Blood sampling by 




Fig. 1 Glucometer and a Dextrostix colour 
indicator. The glucometer is a more objective 
measurement, removing possible error when 
comparing the filter paper against the colour 
controls provided with the Dextrostix system. 



automated puncture (Fig. 1) is 
performed preprandially, 2-hourly 
postprandially and at bedtime. The 
results are recorded in a log book 
(Fig. 3) and brought to each clinic visit 
A random blood sugar is performed 
at each clinic visit as well as reviewing 
the log book results, checking the 
patient's weight and a urinalysis. A 
glycosylated haemoglobin reading is 
also obtained. This gives retrospective 
evidence of blood sugar control over 
the preceding few weeks rather than 
evidence of current control and checks 
the veracity of the values the patient 
has been reporting. Glycosylated 
haemoglobin is a naturally-occurring 
haemoglobin linked to glucose which 
represents a fairly constant 5-6% of 
the total haemoglobin mass in the 
non-pregnant normoglycaemic state. A 
level above 8°/o in pregnancy indicates 
poor sugar control. 



Management 

The aim is to maintain preprandial 
blood sugars at < 5 mmol/1 and 
1-2 hour postprandial blood sugars at < 
7.5 mmol/1 to reduce the potential risks 
to the mother and fetus (Table 1). In 
practice, most clinics tailor the control 
of blood glucose to the individual needs 
of the patient Nocturnal hypoglycaemia 
can be treated by reducing the evening 
insulin or, more simply, by increasing 
the dietary intake just before bedtime. 
The disadvantage of maintaining the 
maternal blood sugar too low is that it 
may reduce the availability to the fetus 
of essential energy-producing substrates. 
Also, it may produce unpleasant and 
potentially damaging hypoglycaemic 
side effects in the mother. 

The obstetric input to the clinic is to 
maintain a careful watch on maternal 
and fetal well-being as the pregnancy 
advances (Table 2). More intensive 



Diabetes in pregnancy II 31 



outpatient monitoring or admission 
may be indicated if: 

■ good glucose control cannot be 
achieved as an outpatient 

■ hypertension and/or proteinuria 
develop 

■ weight gain is excessive 

■ renal function deteriorates 

■ polyhydramnios develops 

■ fetal growth or well-being cause 
concern. 

Delivery 

Timing 

In the past, sudden intrauterine death 
near term led to a policy of induction 
of labour between 36 and 38 weeks. 
This created a potential difficulty as 
diabetic babies have less appropriate 
surfactant levels for their gestational 
age and are more prone to respiratory 
distress syndrome (RDS) than 
neonates of non-diabetic mothers. 

Improved diabetic control has 
encouraged many centres to allow 
their mothers to go into spontaneous 
labour if the pregnancy is 
uncomplicated. This has reduced the 
incidence of both RDS and caesarean 
sections for failed induction. It has not 
been accompanied by a rise in 
unexplained intrauterine deaths but it 
remains common practice to induce at 
40 weeks. 

If insulin requirements start to fall it 
is prudent to deliver the infant as this 
may indicate placental failure. 

Premature labour 

If the pregnancy has reached 34 weeks, 
no attempt should be made to stop 
labour. If there is genuine concern 
about the state of fetal lung maturity 
an amniocentesis can be performed or, 
in the case of ruptured membranes, a 
sample of liquor can be collected, 
though this is more often considered 
with induction, if required, preterm. 
The presence of phosphatadyl glycerol 
(a lung surfactant) indicates lung 
maturity and a low risk of RDS. If 
levels are low or absent, dexametasone 
should be given to accelerate lung 
maturation. 



Preterm labour prior to 34 weeks 
should generally be stopped if 
possible. Betasympathomimetics (e.g. 
salbutamol or ritodrine) should be 
used with caution, especially if used in 
conjunction with corticosteroids [see 
p. 18) as they cause marked 
hyperglycaemia. Use of tocolytics can 
be covered by an insulin infusion and 
regular blood glucose monitoring, 
along with potassium estimations. 

Route of delivery 

If there are no obstetric or other 
medical complications, the diabetes is 
well controlled and spontaneous onset 
of labour has been achieved, vaginal 
delivery is both possible and desirable. 
Caesarean section is indicated if there 
is evidence of fetal compromise or if 
ultrasound and clinical assessment 
suggest a baby so large that a vaginal 
delivery represents potential trauma to 
mother and fetus. 

Intrapartum care 

During labour, close control of the 
blood sugar is required by a 
continuous infusion of soluble insulin 
and an intravenous infusion of 10% 
dextrose. Blood sugars are checked 
hourly and kept between 5 and 
8 mmol/1. Urea and electrolytes are 
checked 4-hourly. 

Continuous fetal monitoring with 
cardiotocography is mandatory. An 
experienced obstetrician should be 
present at delivery because of the 
increased risk of shoulder dystocia 
(see p. G3). 

Postnatal care 

As insulin sensitivity increases 
immediately after delivery of the 
placenta the insulin infusion is 
stopped at this stage. The gestational 
diabetic will return to normal within 
24 to 36 hours and insulin-dependent 
diabetics will return to their 
prepregnancy dose requirements. 

Breast feeding is to be encouraged. 
An increase in the dietary allowance of 



carbohydrate by 50 g per day is needed 
to cover the extra calories required for 
lactation. Insulin requirements of the 
established diabetic do not alter during 
lactation. 

Family planning should be carefully 
discussed. In the past, the combined 
contraceptive pill has been avoided in 
diabetics both because of the small but 
real risk of thromboembolism and 
because of the effect on carbohydrate 
metabolism. The newer low-dose pills 
can now be used in all but the most 
brittle diabetics. Progestogen-only 
contraception (Mirena coil, Implanon, 
Depo injection, progestogen-only pill) 
offers an alternative, especially if the 
woman is breast feeding, but may 
produce some cycle irregularities. The 
other forms of contraception must be 
considered on merit. 

The neonate 

The management of all infants of 
diabetic mothers calls for expert 
neonatal care. The neonate is at risk of 
a number of complications (Table 3). 

The perinatal mortality has dropped 
dramatically over the past decade. In 
the best centres it now approaches that 
for other pregnancies, after mortality 
for congenital malformations has been 
excluded. 

Infants of diabetic mothers have a 
greater than average chance of 
developing diabetes in later life (a risk 
in the order of 1% compared to 0.1% 
in infants of non-diabetic mothers). 



Table 3 Neonatal complications of poorly 
controlled diabetic pregnancy 

■ Low APGAR scores -onc-thrdcrfail cases require 

intubation 

■ Respiratory distress syndrome (RDS) [see p 83) 

■ Hypoglycaerma. secondary to pancreatic cell 
hyperplasia and hypennsutmaeiuia 

most commonly seen m macrosomic babies 
- usually asymptomatic, but can cause arjnoea. 
rtypertonia. exotab«!ity and fits 

■ Hypocatcaema 

■ Hypomagnesaemta 

■ Potycythaeffiia 

■ Jaundice 



Diabetes in pregnancy II 



| ■ Tight control of diabetes is necessary throughout pregnancy to minimize the risk of maternal and fetal complications. 
I ■ Management should be at a joint clinic run by physician and obstetrician. 

■ Emphasis is on home monitoring and outpatient management, minimizing hospitalization. 

■ Well-controlled uncomplicated pregnancies may be allowed to continue to 40 weeks to improve their chance of spontaneous labour. 

■ The perinatal mortality rate has been dramatically reduced and now approaches 9/1 00 000. 



32 OBSTETRICS 



Anaemia in pregnancy 



A useful guide to the acceptable lower 
limit of haemoglobin (Hb) for each 
trimester is 12.5 g/dl in the first 
trimester, 11.5 g/dl in the second and 
10.5 g/dl in the third. The apparent fall 
in level throughout pregnancy is due to 
the relatively greater rise in maternal 
plasma volume compared to the rise in 
red cell mass. This physiological 
dilution of the maternal blood ensures 
normal circulation with less cardiac 
work than might be expected allowing 
for the increased amount of clotting 
factors and fibrinogen. 

Anaemia may affect 10% of 
pregnancies in developed countries 
and is considerably commoner in 
developing countries, where it is a 
major source of maternal morbidity 
and a contributor to mortality. Up to 
56°/o of all women living in developing 
countries are anaemic (Hb < 11 g/dl) 
due to infestations (particularly 
malaria - Fig. 1), frequent pregnancies 
or haemoglobinopathies (see p. 34). 
Maternal anaemia does not seem to 
pose substantial problems for the fetus 
but it is dangerous to both mother and 
fetus if there is superimposed 
haemorrhage (Fig. 2). It may also 
predispose the mother to 
thromboembolic problems and is 
associated with puerpural infection. 

The proportion of maternal deaths 
due to anaemia has been reported as - 
India 16%, Kenya 11%, Nigeria 9% and 
Malawi 8%. Whether the anaemia is 
directly responsible for death or acts as 
an underlying factor in other causes is 
not clear. Antimalarial prophylaxis in 
endemic areas has been shown to 
decrease moderate to severe anaemia 
in pregnancy by over 50%. The 
increased incidence of low birthweight 
infants in affected women may be 
more related to the malaria than to the 
anaemia. 



N&W* 



Antenatal screening 

Haemoglobin is estimated at booking 
and during the third trimester to 
ensure anaemia is detected and 
treated. If the haemoglobin level is low, 
then the MCV (mean cell volume) is 
probably the most sensitive indicator 
of iron deficiency in pregnancy 
without measuring serum ferritin 
levels. Table 1 lists the indicators for 
anaemia. A macrocytic anaemia may 
suggest folate deficiency. 

Iron metabolism 

There is increased iron absorption 
during pregnancy but despite this the 
most common reason for anaemia is 
nutritional deficiency in both the 
developed and developing world. Iron 
utilization is 700-1400 mg per 
pregnancy with a saving of ~ 500 mg 
due to no menstrual blood loss. 
Dietary advice to eat plenty of green 
vegetables and high iron-containing 
foods may need to be supplemented 
with oral iron (Fig. 3). 



Routine supplements are associated 
with a higher rise in red cell mass thus 
reducing the physiological 
haemodilution - which may have 
benefits in pregnancy. Conversely, 
maternal hypervolaemia may protect 
against supine hypotension and helps 
compensate for haemorrhage at delivery. 

The question of whether to offer 
routine iron supplementation in 
pregnancy remains controversial. Iron 
requirements during pregnancy are 
increased three-fold to approximately 
4 mg/day for the placenta, fetus, 
maternal red cells - as well as 
additional lactational needs. In 
developing countries all pregnant 
women should receive daily iron 
(GO mg) and folic acid (400 ug) and 
should be considered for preventive 
measures against malaria and 
hookworm. 

Folate metabolism 

A normal diet supplies adequate 
amounts of folate for pregnancy but, as 




Fig. 2 Postpartum haemorrhage is likely to be more hazardous with pre-existing 
anaemia, particularly if transport to hospital is a problem. 



Fig. 1 Chronic malarial infections from 
Plasmodium vivax are commonly 
associated with anaemia. 



Table l The diagnosis of 


anaemia in pregnancy 


Fact or 


Result indicating anaemia 


Haemoglobin 


< l l g/dl 


Haematncnt 


<0.30 


MCV 


An MCV of < 8U fl indicates poss;bie fj-thalassaemia. It found, an estimation of 




haemoglobin A2 and haemoglobin electrophoresis should be made 


MCH (mean cell haemoglobin) 


<2apg 


MCHC (mean cell haemoglobin 


< 32 g/dl 


concentration) 




Scrum ferritin 


A level of 10 -50 ug/l indicates a strong possibility that anaemia will develop. 




whilst a level of < ID uq/i indicates severe depletion of iron stores. In the latter 




case iron tablets should be prescribed, irrespective of the haemoglobin level 



Anaemia in pregnancy 33 




Fig. 3 Iron-rich foods. 



Table 2 Response to blood loss 


Usual response in non-pregnant female 


Response in female at term post-delivery 


Fall in blood volume and compensatory 


Fall in blood volume (< Z5% pre- delivery volume) 


vasoconstriction 


with no vasoconstriction 


Rise in plasma volume to bring blood volume to normal 


Fall in plasma volume due to diuresis 


Fall in haemalocnt associated with rise in 
plasma volume 


Hematocrit remains normal due to raised red cell 
mass ol pregnancy 



Tab e ?. The benefits and risks of blood transfusion and parenteral iron therapy 

Risks 

Transfusion reaction 



Blood transfusion 



Parenteral iron 



Hb will rise after transfusion 

Anaemia corrected 

Less risk ol associated haemorrhage 

Malabsorption of iron avoided 

Quicker response with anaemia close to term 



Transfusion of HIV 
CJO. hepatitis C 

Anaphylactic reaction 
Rain at injection site 



body stores are small, any increase in 
demand may require supplementation. 
Conditions requiring folate 
supplementation in pregnancy are: 

■ anaemia responding to iron therapy 

■ haemolytic anaemia 

■ malaria 

■ multiple pregnancy 

■ antepartum haemorrhage. 

Some women will have taken pre- 
conceptual folate as a preventive 
measure against neural tube defect in 
their infants and those on iron therapy 
will find most preparations are 
combinations of iron and folate. 

Response to blood loss [Table 2) 

Blood loss during delivery is inevitable 
and thus may be considered normal. 
The raised plasma volume and red cell 
mass return to pre-pregnancy values 
within G weeks of delivery. Vaginal 
delivery of a singleton infant is 
associated with blood loss of up to 
500 ml, more loss than this being 
defined as a postpartum haemorrhage 
(see p. 60). Caesarean section or 
multiple delivery may be associated 
with greater blood loss. The average 
blood loss which can be tolerated 



without causing a significant fall in 
haemoglobin is around 1000 ml, 
dependent on a normal increase in 
blood volume prior to delivery. 

Treatment 

If iron deficiency anaemia is detected 
during screening, oral iron therapy is 
advised. This should increase the 
haemoglobin concentration by 1 g/dl 
per week of therapy after the first 
week (which goes to marrow stores for 
production). Side effects of this 
treatment include both constipation 
(already a problem in pregnancy due 
to the slower gut motility) and 
diarrhoea. Nausea may also be a 
problem. 

Parenteral therapy is only required if 
there are compliance problems or 



prohibitive side effects with the oral 
route; it is contraindicated in patients 
with thalassaemia. It is also associated 
with the risk of anaphylactic reaction if 
given intravenously or pain at injection 
sites if given intramuscularly. Only if 
iron therapy fails should transfusion 
be considered. In recent years there 
has been much adverse publicity 
surrounding blood transfusion in 
relation to HIV, CJD and hepatitis C 
transmission and many patients are 
understandably reluctant to consider 
this form of therapy. A discussion of 
the risks of blood transfusion, versus 
the risks of parenteral iron, versus the 
risks of haemorrhage superimposed 
upon their anaemia should allow a 
reasonable treatment option to be 
decided in each patient (see Table 3). 

On a worldwide scale, prevention of 
anaemia may depend on food 
enrichment or modification. Although 
genetic modification of food is 
controversial it is recognized that grain 
can be altered to reduce its phytate 
content and increase its content of 
cysteine - and so improve the 
absorption of iron from the intestine. 
This may produce a reduction in 
maternal mortality from anaemia in 
pregnancy. Food fortification would 
benefit both mothers and children 
who are at most risk of nutritional 
deficiencies. 

Table 4 lists some valuable sources 
of dietary iron. 



TaLjie 4 The iron 


content of some iron- 


rich foods 


ib.fpMis.E- "Or] 


Foods high In Iron 


Amount per average 




portion (g) 


Chick pea curry 


8.4 


Cabbage 


03 


Spinach 


1 4 


Frozen peas 


I.I 


Frozen broccoli 


D.5 


Oat and wheal bran 


13.5 


Calves' liver 


122 


Pigs" kidney 


127 


Lamb vinda loo 


10.5 


Lamb chops -loin 


2.9 


Special K" 


23.8 



Anaemia in pregnancy 



i The commonest worldwide cause of anaemia in pregnancy is nutritional deficiency; this could be 
addressed by fortification of food. 

i Iron deficiency anaemia should be prevented with routine iron supplementation in developing 

countries. 

i Routine iron supplementation should not be necessary in patients with an adequate diet 

i Anaemia at the time of delivery may compromise both mother and baby m the face of a 
postpartum haemorrhage. 



34 OBSTETRICS 



Haemoglobinopathies in pregnancy 



The haemoglobinopathies are genetic 
disorders of haemoglobin structure 
and synthesis. They are important in 
pregnancy because of their effect on 
maternal health and the possibility of 
transmission to the offspring, thus 
raising the question of prenatal 
diagnosis [see p. 8). Table 1 lists the 
various types of haemoglobinopathy. A 
basic resume of haemoglobin structure 
and formation may aid understanding. 

Formation of haemoglobin 

Haemoglobin consists of four haem 
molecules attached to two pairs of 
globin chains (Fig. 1). Each globin 
chain has two genes which code for it, 
so faults in any of the genes may have 
effect on the structure or amount of 
globin produced. All types of 
haemoglobin have a pair of alpha 
chains, so a fault in alpha chain 
production affects all haemoglobins. 
The various types of haemoglobin are 
listed in Table 2 with their globin 
chain composition. 

The thalassaemias 

These disorders result from a reduced 
production of globin chains, limiting 
the amount of normal haemoglobin in 
the red cells available to transport 
oxygen. The clinical manifestation 
during pregnancy is anaemia. The beta 
thalassaemias have the greatest clinical 
impact and are found with an 
incidence varying from one in seven in 
Cyprus to one in a thousand in the UK 
(see Fig. 2 for affected areas]. 
Population movement has resulted in 
some geographical overlap of the 
different haemoglobinopathies leading 
to double heterozygote phenotypes, 
e.g. HbS-beta thai. 




Table 1 The haemoglobinopathies 




Globin gene 


Bands on 






Haemoglobinopathy 
Alpha thalassemia 


composition 


Hb electrophoresis 


HBC features 


Clinical 


a/a a 


A (i.e. normal) 


Normal 


Normal 




a-/a- 


A 


Mild anaemia 


Normal 




- -/a ■ 


A.H 


Severe anaemia 
HbH cells 


Splenomegaly 




--/-- 


H 


- 


Hydrops leial is 


'Non-deletional' 










a-thal 










(abnormal « gene) 


a tthi tt 


A,", ±H 


Variable 


Variable 


Beta thalassemia 










p Ehal minor 


normal [Vreduced P 


A,Aj.F 


Mild anaemia 


Normal 


p thai intermedia 


normal p/absem p 


A.A,,F 


Moderate anaemia 


Hcparo- 




reduced (Vreduced p 


A,A,F 




splenomegaly 


p thai major 


absent p/ieduced p 


(A) (A,) F 


Severe anaemia 


Hepato- 




absenipJabsemp 


F 




splenomegaly 

Bone 

deformity 

Delayed 

pubeny 

Iron overload il 

transfused 


Sickle cell trail 


AS 


AS 


Normal 


Normal 


Sickle cell disease 


SS 


S 


Moderate or severe 


Sickte crises 




SC 


S.C 


anaemia 


Bone infarcts 




SD 


S.D 




Asplenia 
Fetal loss 



Table 2 Types of h 


aemoglobin 






Type 


Globin 


% after 






chains 


6 months 
old 


Adult haemoglobin 


HbA 


ct 3 f\. 


97'* 


Adult haemoglobin 


HbA, 


a, ii. 


- 2<tt 


Fetal haemoglobin 


HtiF 


n t1i 


<1% 



Beta thalassaemias 

This condition only becomes apparent 
after birth when the fetus moves from 
production of fetal haemoglobin with 
gamma chains to adult haemoglobin 
with beta chains. There are many 
possible abnormalities of the beta gene 
leading to a spectrum of clinical and 



OHae 




Oxyhaemoglobin 
Fig. 1 The structure of haemoglobin. 



Deoxyhaemoglobin 



laboratory abnormalities rather than to 
clearly defined beta thalassaemia 
heterozygote or homozygote 
appearances. 

Severe disease with both beta chains 
affected means the disease was 
inherited from both parents (beta 
thalassaemia major with no beta chain 
production - see Table 1]. Management 
is with regular transfusion but iron 
overload from the transfused red cells 
may lead to hepatic and endocrine 
dysfunction and myocardial damage. 
Cardiac failure is a major cause of death 
if an iron chelation programme is not 
used. Some patients can exist without 
regular blood transfusion but the 
expanded bone marrow leads to severe 
bone deformity. This group may 
achieve pregnancy and would require 
folate supplementation but iron in any 
form is contraindicated. 

Beta thalassaemia minor patients 
may become iron deficient during 
pregnancy with lowered MCV, MCH 
and MCHC. They will need both folate 
and iron supplements but should 
never be given parenteral iron therapy. 
Unresponsive anaemia may require 
blood transfusion. Serum ferritin 
should be monitored as this is the best 
indicator of iron store status. 



Haemoglobinopathies in pregnancy 35 









VJ^N--^ o 




1 / 




?V3 




\Lri*= 


Lr^IX 


1 1 Thalassaemia ^H 








i — i Hbs nn 


HbR 



Fig. 2 Distribution of thalassaemia. 



Taule 3 Potential compli 


cations of sickle cell disease in 


pregnancy 


Maternal 


Fetal 


M a n agement p Ian 


Crises due to infection (UTI; 
Spontaneous crises 
Retroplaccntal microthrombi 


- 


Check MSSU each visit 
Check fo r candidiasis 


Feral growth compromised 


Serial growth scans 


Anaemia 

Anaesthesia risks at delivery 


- 


Iron and folate supplements 


- GA leads to hyc-oxia 




} and fluids 


regional Mock gives stasis 




Hind load 


Preterm labou" 


Higher perinatal mortality 


Need high-risk antenatal care 



Alpha thalassaemias 

There are four genes determining alpha 
chain production. The severity of the 
anaemia depends on the number of 
affected genes with production varying 
from reduced amount to total absence, 
when HbH tetramers may form. Daily 
oral folate supplements are needed for 
the chronic haemolytic anaemia, with 
increased supplements during 
pregnancy Iron therapy is unhelpful 
The unstable HbH is affected by 
substances known to trigger haemolysis. 

Antenatal diagnosis in 
thalassaemias 

This will be relevant in communities 
where the prevalence of thalassaemia 
is high. From the known status of the 
parents, prediction of the fetal 
thalassaemia status is possible and 
allows the parents to consider selective 
termination of an infant with a fatal 
variant. If an infant with severe 
thalassaemia is detected then the 
pregnancy can be associated with 
fulminating pre-eclampsia, a dangerous 
condition for the mother, and the 
hydropic infant is likely to die in utero. 

In beta thalassaemia the diagnosis 
has to be made on chorionic villus 
sampling which allows DNA analysis. 
Beta chain production is negligible in 
the fetus and examination of fetal 



blood would not give a complete 
picture. Sampling is obtained at 9-11 
weeks, so early attendance for 
antenatal care is essential. 

Sickle cell syndromes 

A variation in the beta chain structure 
results in sickle haemoglobin (HbS) 
which, although soluble in its 
oxygenated form, in its reduced state 
precipitates, distorting the cell into a 
sickle shape. Hypoxia, acidosis, 
dehydration and cold may produce 
sickling and the distorted cells block 
small blood vessels. This results in 
stasis, exacerbating the hypoxia and 
acidosis. These sickle cells may cause 
placental infarcts which is thought to 
account for the increased fetal loss rate 
in this disease. 

Patients may be homozygous 
(HbSS), or heterozygous [HbS trait), or 
may have a combined condition with 



sickle cell haemoglobin C disease or 
sickle cell thalassaemia. Sickle trait is 
symptom free; HbSC and HbS-thal 
have the same clinical features as sickle 
cell disease. 

Sickle cell disease and pregnancy 

(Table 3) 

The term sickle cell disease (SCD) 
includes sickle cell anaemia (SS), sickle 
haemoglobin C disease CSC), sickle 
beta thalassaemias and sickle cell 
anaemia with alpha thalassaemia. 
Pre-pregnancy counselling allows 
establishment of the haemoglobin 
status of the parents and prediction of 
the likelihood of an affected child. 
Presentation in early pregnancy is 
more common and discussion about 
prenatal diagnosis then is relevant. 

Chorionic villus sampling at 9-11 
weeks offers the chance of DNA 
analysis and establishment of the 
haemoglobin status of the fetus. 
Perinatal mortality is raised in 
association with higher rates of preterm 
labour and premature delivery. 

Debate continues on whether it is 
necessary to offer elective exchange 
transfusion during pregnancy, aiming 
to keep the proportion of sickle cells 
low and keep the risk of sickle crisis to 
a minimum, or whether it is preferable 
to use exchange transfusion only if the 
clinical situation dictates. 

Despite the theoretical risks of 
infection associated with intrauterine 
devices and the thrombotic risk of oral 
contraception, the risk of pregnancy is 
far greater and thus the most effective 
contraception is appropriate. 

Management of sickle cell crises 

Appropriate management includes: 

■ placing the patient in an intensive 
therapy unit 

■ oxygen therapy 

■ rehydration - usually with 
intravenous fluids 

■ opiate analgesia 

■ warmth 

■ appropriate antibiotics (some may 
already be on penicillin because of 
asplenia) 

■ exchange transfusion. 



Haemoglobinopathies in pregnancy 



i Haemoglobinopathy is a disorder of haemoglobin structure and synthesis. 

i Thalassaemia reduces the amount of haemoglobin in the red blood cells, thus reducing (he 
amount of oxyg e n ca rried . 

i Iron overload must be avoided when treating anaemia in thalassaemic patients. 

i Sickle haemoglobin causes the red blood cells to distort, producing placental infarcts and 
causing increased rates of fetal loss. 



36 OBSTETRICS 




Antepartum haemorrhage 



Antepartum haemorrhage (APH) is defined as bleeding from 
the genital tract after the gestation of potential viability 
(approximately 24 weeks). Common causes of APH include: 

■ placenta praevia 

■ placental abruption (abruptio placentae) 

■ local causes. 

The incidence of APH is far greater than the combined 
incidence of placenta praevia and placental abruption and 
many cases remain of unknown origin. 

Placenta praevia 

The incidence of placenta praevia is 0.4-0.8%. It is more 
common in multiple pregnancy and conditions with large 
placental surface area, increasing maternal age and in 
patients with a previous caesarean section scar. 

Grading (Table 1) 

This grading is important as major degrees of placenta 
praevia are likely to require operative delivery whereas the 
minor grades may manage a successful vaginal delivery. 

Clinical presentation 

The lower uterine segment forms during the third trimester 
and with differential growth of the uterus antepartum 
haemorrhage is commoner at this stage. The classic 
presentation is: 

■ recurrent pain-free antepartum haemorrhage 

■ abnormal fetal lie 

■ non-engagement of the fetal presenting part. 

Abdominal palpation will usually reveal a soft uterus with 
readily palpable fetal parts, an abnormal lie and a high 
presenting part. The fetal heart is most commonly audible 
except where there has been overwhelming haemorrhage. 
The diagnosis may be confirmed using ultrasound scanning 
to localize the placenta. This is still most commonly 
performed transabdominally where the maternal bladder 
delineates the upper edge of the lower uterine segment 
anteriorly. Without this landmark a posterior placenta 
praevia is more difficult to diagnose. The presenting part also 
obscures vision posteriorly. 

Vaginal scanning enables more accurate measurement of 
the distance from the edge of the cervical os to the edge of 
the placenta - placental location greater than 2 cm from the 
cervical os would not be expected to cause any clinical 
problem. Transvaginal scanning is used with caution for fear 
of precipitating catastrophic haemorrhage. More clear views 
of the pelvis, fetus and placenta can be obtained with 
magnetic resonance imaging (MRI) scanning. However, this 
is not widely available and its fetal effects are less well 
known than those of ultrasound. 

Management (Fig. l) 

The golden rule for APH is that no vaginal examination 
should be performed until placenta praevia has been 
excluded as this might precipitate torrential bleeding with 
possible maternal and fetal demise. Blood should be cross- 
matched, haemoglobin checked and clotting screen 
performed, with intravenous fluids and blood transfusion as 
necessary. 



Table 1 


Grad 


ngs for placenta praevia 

Encroaches on lower segment 


Minor 


1 




II 


Reaches internal os [marginal pp) 


Major 


III 


Covers pan of os [partial pp) 




IV 


Covers os completely (complete pp] 




Check FBC, clotting 
screen, cross-match blood 




Resuscitate mother 
Expedite delivery 



Heavy bleeding 
continues 



Bleeding stopped 



Immediate caesarean 

section 



Gestation 

> 37 weeks 



Gestation 
< 37 weeks 



Augment and deliver 
vaginally (minor 
placenta praevia) 
Caesarean section 
(major placenta 
praevia) 

Watch for postpartum 
haemorrhage 



Conservative 
management 



Fig. 1 Management plan for placenta praevia. 



Abruptio placentae 

Abruptio placentae (also known as accidental haemorrhage) 
results from retroplacental bleeding. Although it is not 
possible to predict, there are 
recognized associations: 

■ pregnancy-induced hypertension 

■ eclampsia 

* renal disease ± hypertension 

■ rapid changes in uterine size (e.g. release of 
polyhydramnios or after delivery of first twin) - in reality 
very rare. 

The classic presentation is of abdominal pain associated with 
an antepartum haemorrhage. There may be uterine activity. 
The condition is classified into whether the haemorrhage is 
revealed, concealed or a mixture of the two (Fig. 2). 

Examination 

The findings may be: 

m uterus - tense or irritable 

■ fetus - longitudinal, if cephalic presentation head engaged. 



Antepartum haemorrhage 37 



In revealed haemorrhage , most of the 
ret to placenta I bleeding tracks down inside 
the uterus to be revealed as vaginal 
bleeding. The amount of uterine irritation 
caused by this bleeding may be less, pain 
not being such a great feature. 



Concealed haemorrhage , 
however, may have only 
very slight vaginal bleeding 
with a large amount of 
retroplacental clot, causing 
a tense uterus. 



Thromboplastins released 
from the back of the placenta 
into the maternal circulation 
may result in disseminated 
intravascular coagulation (DIC) 




In the case of mixed 
haemorrhage there will be 
some vaginal bleeding and 
perhaps passage of clots 
but also a build-up of some 
clot behind the placenta. 



If there is a large haemorrhage, 
blood may be forced between 
the fibres of the uterine muscle, 
if the abdomen is opened the 
uterus appears bruised 
(Couveiaire uterus) possibly 
with free blood in the 
intraperitoneal cavity. With 
haemorrhage of this degree it is 
likely that the fetus will be dead. 







Fig. 4 Velamentous cord insertion. With 

rupture of the membranes a vessel may rupture 
and APH results. In this case the bleeding is fetal 
and may result in death of the baby if not delivered 
promptly. 



Fig. 2 Classification of abruptio placentae. 



Differential diagnosis 

This should include: 

■ placenta praevia 

■ preterm labour 

■ other causes of acute abdomen. 

Management 

The management plan for abruptio placentae is shown in 
Figure 3. 

In the case where DIC develops, delivery is best vaginally 
to avoid uncontrollable haemorrhage during surgery. A 
logical treatment for severe haemorrhage may be heparin 
therapy to break the clotting cascade and the consumption 
that is occurring of all the patient's clotting factors. In these 
cases the fetus is often dead, so management is not 
complicated by the need for urgent delivery of the fetus. 

Other causes of antepartum haemorrhage 

Vasa praevia 

Vasa praevia may occur when the cord is inserted into the 
membranes and the fetal vessels run in the membranes to 
reach the placenta. If the vessels run over the cervix at the 
time of membrane rupture [vasa praevia) they themselves 
may rupture and lead to rapid exsanguination of the fetus 
[Kg- 4). 




Resuscitate mother, CVP, 
fluid and blood 
replacement, analgesia 



Yes 



Continued pain 
and bleeding 



Cardiotocograph 
monitoring 



Normal - aim 
for vaginal 
delivery 



Fetus alive 



Situation resolving - 

conservative 

management 

or IOL if > 37 weeks 



Abnormal - 
caesarean 

sec!ion 



No 



Observe and manage 
conservatively 



No 





Augment uterine 

activity 

Deliver fetus 

Bereavement 

counselling 

Beware postpartum 

haemorrhage 



Cervical carcinoma 

This is a very rare condition in pregnancy. However, it is 
possible for a cervical carcinoma to bleed, especially as the 
patient goes into labour and the cervix starts dilating. 



Fig. 3 Management of abruptio placentae. 



Cervical lesions 

Occasionally a cervical polyp or an infected cervix may bleed. 
Speculum examination of the cervix is therefore helpful in 
the differential diagnosis of antepartum haemorrhage. 

Ruptured uterine scar 

A scar on the uterus may rupture during labour, and vaginal 
bleeding would be associated with signs of fetal distress. 



j Antepartum haemorrhage 

■ In APH. first exclude placenta praevia and abruptio placentae. 

■ In a large number of cases the cause remains unknown. 

■ Postpartum haemorrhage isa recognized complication of APH 

■ Previous APH predisposes to APH in future pregnancies. 



38 OBSTETRICS 



Multiple pregnancy 



The UK incidence of twins is 12/1000 
pregnancies (3/1000 of these are 
monozygous). Worldwide this ranges 
from 54/1000 in Nigeria to 4/1000 in 
Japan with the differences being almost 
entirely due to variations in dizygous 
rates. The incidence is higher with 
ovulation induction, e.g. clomifene (10%) 
or gonadotrophins (30%). The perinatal 
mortality in twin pregnancies is four or 
five times higher than for singleton 
pregnancies, largely related to preterm 
delivery (40% deliver before 37 weeks 
compared to 6% in singletons), 
intrauterine growth restriction (IUGR), 
feto-fetal transfusion sequence (FFTS), 
malpresentation and an increased 
incidence of congenital malformations. 

Chorionicity (i.e. number of 

placentae) 

Dizygous (non-identical) twins come 

from two eggs; monozygous twins come 

from one egg and are identical. 

All dizygous pregnancies are 
dichorionic, and therefore have separate 
chorions and amnions. The placental 
tissue may appear to be continuous but 
there are no significant vascular 
communications between the fetuses. 
Monozygotic pregnancies may also be 
dichorionic, but may be monochorionic 
diamniotic or monochorionic 
monoamniotic (Figs 1-3) depending on 
the stage of embryonic development at 
which separation occurred (Table 1). 
Most monochorionic placentae have 
inter-fetal vascular connections. 

Chorionicity determination is essential 
to allow risk stratification, and has key 
implications for prenatal diagnosis and 
antenatal monitoring (Table 2). It is 
most easily determined in the first 
or early second trimester by 
ultrasound: 

■ Widely separated first trimester sacs 
or separate placentae are dichorionic 

a Those with a 'lambda' or 'twin-peak' 
sign at the membrane insertion are 
dichorionic (Figs 2 and 3). 

■ Those with a dividing membrane 
> 2 mm are often dichorionic. 




Fig. 1 Diagram of chorionicity. All dizygous twins are dichorionic [a, b}. Monozygotic pregnancies 
may form any of the following combinations: (a) dichorionic diamniotic: (b] dichorionic diamniotic 
(placentae beside each other) ; (c) monochorionic diamniotic: (d) monochorionic monoamniotic. 




Fig. 2 Monochorionic twins -no lambda sign. Fig. 3 Dichorionic twins -lambda sign. 



■ Different sex twin pregnancies are 
always dichorionic (and dizygous!). 

Fetal abnormality 

The incidence is not different per fetus in 
a dichorionic pregnancy compared to a 
singleton pregnancy, but the incidence is 
greater with monochorionicity. 



Structural defects 

These are usually confined to one twin 
(i.e. non-concordant). For example, if 
there is a neural tube defect in one twin, 
the other twin is normal in 85-90%. All 
multiple pregnancies should be offered 
a detailed mid-trimester ultrasound 
scan. Selective termination with 



Table 1 PI ace rotation in twin pregnancies 






Number of chorions 


Number of amniotic 


Percentage 


of twins 


Timing of embryonic separation 


Cplacentae) 


sacs 






post-fertilization 


Dichorionic 


Diamniotic 


30% 




Separation < 4 days 


Monochorionic 


Diamniotic 


66% 




Separation 4-7 days 


Monochorionic 


Monoamniotic 


39b 




Separation 7-M days 


Conpined 




<m 




Separation > 14 clays 



Tables Outcome of twin pregnancies 

Dichorionic Mono- 
chorionic 

Felal toss before 24 weeks 1.8% 12.2% 

Felal toss after 24 weeks 1 .6* 2 . B% 

Delivery before 32 weeks 5.5% 9 2% 



Multiple pregnancy 39 



intracardiac KC1 is possible in 
dichorionic pregnancies only, and is 
most safely carried out before 1S-20 
weeks. 

Chromosomal abnormalities 

These are usually discordant in dizygotic 
twins and usually concordant in 
monozygotic twins. Nuchal translucency 
measurement is probably more 
appropriate than serum screening for 
multiple pregnancies. Two amniocenteses 
are required in dichorionic pregnancies 
(very great care must be taken to 
document which sample has come from 
which sac]. Chorionic villus sampling 
(CVS) is less appropriate for twin 
pregnancies as it is difficult to be sure that 
both placentae have been sampled, 
particularly if they are lying close 
together. 

Management of pregnancy 

Initial visit 

■ As many as 50°/o of twins diagnosed 
in the first trimester will proceed only 
as singletons despite the absence of 
loss per vagina. Parents should be told 
this if twins are diagnosed in the first 
trimester. 

■ The parents are often quite shocked, so 
counselling should focus on the 
positive aspects, while also outlining 
that closer monitoring will be required. 
This can be expanded later. They 
should consider whether they wish 
antenatal screening and consider the 
potential problems of finding one 
normal and one abnormal twin. 

Subsequent visits 

Thereafter, scans may be arranged at: 

■ 18 weeks for growth discrepancy ± 
fetal abnormality if the patient wishes 

■ 24 weeks for growth (average weight 
for twins is 10% lighter than 
singletons) 

■ and every 2-4 weeks thereafter for 
growth; more frequently if there is 
size discordance, with or without 
Doppler, cardiotocograph and 
biophysical profile studies if 
appropriate. 

Antenatal problems specific to 
multiple pregnancies 

Feto-fetal transfusion sequence 
(FFTS) (twin-twin transfusion 
syndrome) 

This complicates 4-35% of 
monochorionic multiple pregnancies. 
The recipient develops severe 
polyhydramnios with raised amniotic 




Fig. 4 Twin-twin transfusion sequence. 

These monochorionic twins were born at 37 
weeks' gestation. Although their weights were 
almost identical, there was significant 
oligohydramnios around the recipient. 

pressure, while the donor develops 
oliguria, oligohydramnios [Fig. 4) and 
growth restriction. Most centres support 
serial amnioreductions if the amniotic 
fluid index exceeds a certain limit while 
other centres support laser division of 
placental vessels. 

Twins with one fetal death 

First trimester intrauterine death (IUD) 
in a twin has not been shown to have 
adverse consequences for the survivor. 
This probably also holds true for the 
early second trimester, but loss in the 
late second or third trimester commonly 
precipitates labour and 90% will have 
delivered within 3 weeks. Prognosis for 
a surviving dichorionic fetus is then 
influenced primarily by its gestation. 
When a monochorionic twin dies in 
utero, however, there are additional risks 
of death (approximately 20%) or 
cerebral damage (approximately 25%) in 
the co-twin. 

Twin reversed arterial perfusion 
sequence (acardia) 

If the heart of one monochorionic twin 
stops, the twin may continue to be 
partially perfused through vascular 
connections from the surviving twin. It 
is very rare, and there is a high 
incidence of mortality in the donor twin 
owing to intrauterine cardiac failure and 
prematurity. Cord ligation has been used 
in isolated cases. 

Management of twin delivery 

The commonest twin presentations are 
cephalic/ cephalic (40%), cephalic/ breech 



(40%), breech/cephalic (10%) and others, 
e.g. transverse, (10%). Triplets and 
higher-order multiples are probably best 
delivered by caesarean section. In 
general with twins, providing the first 
twin is cephalic, evidence would suggest 
that a trial of labour is appropriate. 
With significant growth discordance, 
particularly if twin II is the smaller, it 
may be reasonable to consider 
caesarean section. It is common practice 
to carry out a caesarean section at 38 
weeks in those not suitable for a vaginal 
delivery and to induce at 38-40 weeks 
those who are suitable but have not 
established in labour spontaneously. If 
the labour is preterm (< 34 weeks), 
many clinicians would also consider 
delivery by caesarean section. 

Labour 

An epidural may be very useful in 
assisting the delivery of a second twin. 
The first stage is managed as for 
singleton pregnancies, with both twins 
monitored by CTG. An experienced 
team should be present for delivery and 
a Syntocinon infusion should be ready 
in case uterine activity falls away after 
delivery of the first twin. 

After delivery of the first twin it is 
often helpful to have someone 'stabilize' 
the second twin by abdominal palpation 
while a vaginal examination is 
performed to assess the station of the 
presenting part. If a second bag of 
membranes is present, it should not be 
broken until the presenting part has 
descended into the pelvis. If twin II lies 
transversely after the deliver)' of twin I, 
external cephalic or breech version is 
appropriate. If still transverse 
(particularly likely if the back is towards 
the fundus), the choice is between 
breech extraction (gentle continuous 
traction on one or both feet through 
intact membranes) or caesarean section. 
There is an increased incidence of 
postpartum haemorrhage. 

Triplets and higher multiples 

Most clinicians would deliver those 
with triplets or higher-order gestations 
by caesarean section because of 
problems with malpresentation and 
difficulties with intrapartum fetal 
monitoring. 



r^ 



Multiple pregnancy 



It is essential to establish chononicjiy early to help advise about prenatal diagnosis and stratify 
subsequent care, 

Monochorionic pregnancies have the additional nsks of feto-fetal transfusion sequence, loss of 
co-twin problems, and twin reversed arterial perfusion sequence. 



40 OBSTETRICS 






Breech presentation 



Breech presentations account for 2-3% 
of all labours. The incidence falls with 
gestational age, being 20% at 28 weeks, 
1G% at 32 weeks, falling to 3-4% at 
term as most breeches will turn 
spontaneously. Therefore there is only 
a problem if premature labour ensues 
or the presentation persists. Up to 30% 
are undiagnosed by clinical 
examination. Breeches may be frank, 
complete or footling [Fig. 1). 

Causes 

Excluding prematurity, in which the 
incidence is increased, there are several 
possible reasons why breech 
presentations persist to term: 

■ extended legs preventing spontaneous 
version, by 'splinting' the body 

■ uterine anomalies 

■ something preventing engagement, 
placenta praevia, fibroid, head of twin 

■ fetal anomalies, especially 
hydrocephalus and anencephaly. 

In the majority of cases no cause is 
found. 

Antenatal management 

External cephalic version (ECV) 

Spontaneous version becomes 
increasingly unlikely with advancing 
gestational age. ECV is usually 
attempted at around 36-37 weeks with 
the intention of ensuring that the baby 





Frank breech 65% 
Both legs extended 



Complete breech 10% 
Both legs flexed at knee 
arid hip 




Fig. I Types of breech presentation. 

is cephalic before labour begins. The 
procedure results in a lower incidence 
of caesarean section. The success rate 
is quoted to be 4G-G5% (UK and US 
studies], although it has been reported 
to be as high as 80% in Africa. 

Cases must be carefully selected 
(Fig. 2). A number of factors have been 
found to increase the likelihood of 
success, including multiparity, 
adequate liquor volume and the station 
of the breech above the pelvic brim. 
Although intended for the 
management of the uncomplicated 



Footling breech 25% 
One foot up, one foot down 
(more common in multiparae 
due to lax abdominal 
muscles) 



term breech, ECV has also been 
carried out after previous caesarean 
section and during early labour. 
Various interventions have been tried 
to further improve the success rate, e.g 
vibroacoustic stimulation, 
amnioinfusion and epidural analgesia, 
but these are still under evaluation. 
After the procedure mothers are 
reviewed weekly to check that the 
cephalic presentation persists. Some 
would advocate a second attempt at 
ECV if the presentation reverts to 
breech. 




Technique 

- talc the abdomen 

- use tocolytics 
-administer anti-D 

to rhesus negative 
mothers 



Hazards 

- preterm labour 

- abruplio placentae 

- cord accident 

- uterine rupture (if 
previous scar) 




Contraindications 




Absolute 


Relative 


- multiple pregnancy 


- previous caesarean 


- previous antepartum 


section 


haemorrhage 


- intrauterine 


- ruptured membranes 


growth restriction 


- oligohydramnios 


- pre-eclampsia 




- flh-isoimmunization 




- grand multiparity 




- anterior placenta 




- obesity 



Fig. 2 External cephalic version. The mother lies flat and a tocolytic is used to ensure that the 
uterus is relaxed. The obstetrician disengages the breech with one hand and encourages the baby's 
head forward towards the pelvis with the other. 



Elkin's manoeuvre 

Some National Childbirth Trust (NCT) 
members may advocate attempting to 
influence the fetal presentation by 
natural means. The woman is 
instructed to adopt the knee-chest 
position for 15 minutes every 2 hours 
during the day for 5 days. Studies have 
failed to show significant benefits with 
this approach. 

The persistent breech 

If ECV is unsuccessful or not suitable, 
a decision has to be made on the 
mode of delivery - either by elective 
caesarean section or vaginal delivery. 

The data for term breeches is 
irrefutable following the Canadian 
international multicentre randomized 
control trial, which showed perinatal 
morbidity three times higher in the 
group delivered vaginally compared to 
those delivered by elective caesarean 
section. 



Breech presentation 41 



Therefore, each case must be judged 
carefully by an experienced 
obstetrician before a decision is made 
to allow a vaginal breech delivery. 
Abdominal palpation may reveal a 
baby that is obviously so large that 
elective caesarean section is required. 
An ultrasound is performed at 37 
weeks to estimate the fetal birthweight 
(EBW) and more importantly the 
biparietal diameter [BPD) (Fig. 3). The 
scan will also indicate the degree of 
extension or flexion of the head and 
legs. The baby may have adopted a 
complete or footling presentation. 

Vaginal delivery is safest in the case 
of a frank breech as there is an 
increased risk of cord prolapse with an 
ill-fitting presenting part. An attempt 
must also be made to assess the size of 
the pelvis. Clinically, this can be done 
by a gentle vaginal examination to 
estimate: 

■ the width of the subpubic angle 

■ the gap between the ischial spines 

■ the sacral curve. 

An erect lateral pelvimetry X-ray may 
be helpful or magnetic resonance 




Indications for caesarean 
section (or term breech even if vaginal 
delivery requested 

Elective caesareans 

Pelvic 

■ small pelvis, flat sacrum, bony abnormalities, e.g. 
rickets 

Fetal 

■ esli mated birihw eig lit 3 5 kg or over 

■ Large bipaneial diameter, e g Hydrocephalus 

■ Hypereilension of fetal head 
Pre- existing obstetric problems 
m pre-eclarnpsia 

■ bad obstetric history 

■ placental insufficiency 
Pre-existing maternal problems 

■ history ofinfertility 

■ older pnmigravida 

■ diabetes 

Emerg ency ca e sa reans 

Failure to progress in first stage 
j Failure of descent of breech in second stage 



imaging (MRI) pelvimetry can be 
performed. It is essential to see the 
films as well as the measurements 
(ideally inlet: 13.5 x 11.5 cm, outlet 
12.5 x 10.5 cm]. A well-curved sacrum 
provides a large pelvic cavity; a flat 
sacrum limits the space available to the 
aftercoming head and may cause 
problems during a vaginal delivery, 
even if the inlet and outlet are adequate. 
If obstetric or medical problems co- 
exist, operative delivery is necessary 
(Table 13. 

Management of labour 

Preterm labour 

Prospective data are still unavailable. 
The poor outcome for very low 
birthweight infants is mainly related to 
prematurity and not the mode of 
delivery. Some labours advance too 
rapidly to allow delivery by caesarean 
section. The baby may fare better if it 
is delivered within its intact 
membranes, a caul delivery. The main 
concern with vaginal delivery of very 
small preterm infants is that the trunk 
and limbs will slip through an only 



partially dilated cervix and that the cervix 
may clamp down on the fetal head. 
Immediate intravenous administration of 
tocolytics may be helpful. In extreme 
cases the cervix can be incised or the 
baby pushed upwards from below and 
delivered by caesarean section. 

Labour of the term breech 

The management of a breech labour is 
the same as for a cephalic 
presentation. The rate of cervical 
dilatation and descent of the 
presenting part are plotted on a 
partogram (see p. 50). Continuous fetal 
monitoring is usual. An epidural may 
be desirable as it prevents the mother 
pushing involuntarily before full 
cervical dilatation (a more common 
problem with breech than vertex 
presentations) and provides pain relief 
during the assisted delivery. 

Augmentation with Syntocinon 
should be used with caution. The 
breech should descend easily into the 
pelvis. Fetal distress may intervene 
despite good progress in labour and 
should be dealt with in the same way 
as a vertex presentation. 

Even at full dilatation the breech may 
not descend. The baby should be born 
by the mother's own efforts with a little 
assistance from the obstetrician at key 
points, an assisted breech delivery. The 
overriding priority is control of the 
aftercoming head. There is no time for 
moulding, and if the head is allowed to 
descend rapidly great pressure 
differences occur that may cause 
tentorial tears and intracerebral bleeds. 
Occasional difficulty is encountered with 
extended arms but there are special 
manoeuvres available to overcome this. 
There is no merit in strong traction to 
bring down an undescended breech, a 
breech extraction, because perinatal 
outcome is poor. 

Most mothers will opt for external 
cephalic version. If this fails, most 
request caesarean delivery. 




Breech presentation 



Age (weeks) 



Fig. 3 Assessment of mode of breech 
delivery. In this case the biparietal diameter is 
close to size of outlet. 



■ Most breeches spontaneously turn to the cephalic presentation by 36 weeks. 

■ Prematurity is associated with an increased incidence of breech presentation. 

■ ECV increases the chances of vaginal delivery. 

■ Careful selection must be made to decide which term breeches should be considered for an 
attempt at vaginal delivery. 

■ Selection involves assessment of the biparietal diameter and estimated birthweight of the fetus 
together with the size of the pelvis. 

■ Caesarean section may be best for some preterm babies. 

■ The most important aspect of an assisted vaginal breech delivery is careful delivery' of the 
aftercoming head. 



42 OBSTETRICS 

Venous thromboembolic disease 



Obstetrics 

Antenatal 

In pregnancy the clotting system is 
altered towards clot formation. There 
are increased levels of fibrinogen, 
which lead to increased risk of clot 
formation. This is in part offset by an 
increase in fibrinolysis. Mechanical 
obstruction from the uterus leads to 
reduced venous return from the lower 
limbs and therefore venous stasis. 

Venous thromboembolic disease is 
very rare in Africa and the Far East but 
is the commonest direct cause of 
maternal mortality in the UK The 
reason for such wide racial difference 
remains unclear. The incidence of 
pulmonary thromboembolism (PTE) is 
between 0.3 and 1.2% of all UK 
pregnancies with just over 40% 
occurring antenatally, often in the first 
trimester. Over 80% of deep vein 
thromboses (DVTs) in pregnancy are 
left sided, probably because the left 
common iliac vein is more compressed 
by the uterus where it is crossed by 
the right common iliac artery. More 
than 70% are ileofemoral. 

Risk factors include 

■ obesity 

■ age > 35 

■ high parity 

■ previous thromboembolism 

■ immobility 

■ pre-eclampsia 

■ varicose veins 

■ congenital or acquired 
thrombophilia 

■ intercurrent infection 

■ caesarean section [particularly 
emergency caesarean section). 

DVT may be asymptomatic or, in 
addition to the traditional symptoms 
and signs, it may present with lower 
abdominal pain. It is essential to make 
a definitive diagnosis if possible, not 
just for management of the current 
pregnancy but because there are major 
implications for subsequent 
pregnancies as well. Duplex Doppler 
ultrasound is particularly useful for 
identifying femoral vein thromboses, 
although iliac veins are less easily seen 
(Fig. 1). It is safe and should be the 
first-line investigation. Venography is 
better, but has the disadvantage of 
radiation exposure and should be 
carried out if Doppler gives equivocal 




Fig. 1 Normal Doppler flow 
in the femoral artery (red, 
right) with no flow through 
the occluded femoral vein 
(black, left). 





Fig 3 Positive Q scan - note the lack of 
perfusion in the right lower lobe. The 

ventilation scan was normal. 



Table 1 Potential thrombophilias 

■ Activated protein C resistance tit present, test for the 
factor V Leiden mutation) 

■ Anmhrombinlll 

■ frotem C deficiency 

■ Protein S deficiency 

■ Lupus anticoagulant and anttpnospholipid antibodies 

■ Prothrombin gene variant 
* Hyperhomocystmaarnia 



Fig. 2 Thrombus occluding the left 
common iliac vein, with patent left femoral 
vein. 



results or is not available (Fig. T). It is 
also essential to fully investigate a 
suspected pulmonary embolism, and 
pregnancy is not a contraindication to 
a ventilation-perfusion (VOJ scan - 
any risks are far outweighed by the 
benefits of accurate diagnosis (Fig. 3). 
A normal scan virtually excludes the 
diagnosis of pulmonary embolism. 



Venous thromboembolic disease 43 



Management of DVT or pulmonary 
embolism in pregnancy is with 
therapeutic subcutaneous heparin. 
Postnatally the patient may choose to 
continue with subcutaneous heparin 
or start warfarin, continuing 
anticoagulation for 6-12 weeks as 
decided by timing of onset and clinical 
severity. Once anticoagulants are 
stopped, the patient should be 
screened for thrombophilia. 

Management of those with a 
previous thromboembolic history 
carries more uncertainties. Women 
who have had a single episode of 
DVT/PTE should be screened for 
thrombophilia (Table 1). If the screen 
is negative, and the event occurred 
outside pregnancy and was not severe, 
thromboprophylaxis may not be 
required. If positive, or there are other 
risk factors, antenatal and postnatal 
prophylaxis can be considered. 
Heparin treatment may induce 
thrombocytopenia and may also rarely 
lead to osteoporotic fractures. 

Postnatal risk assessment 

The risks of thromboembolism should 
be assessed in all patients who have 
undergone caesarean section (see 
Table 2). It is also essential to consider 
prophylaxis in those who have had 
vaginal deliveries, whether 
instrumental or not, who may be 
considered to be at increased risk. 

Gynaecology 

Venous thromboembolic disease 
accounts for around 20% of 



perioperative hysterectomy deaths. As 
prophylaxis is effective in reducing 
thromboembolism, all gynaecological 
patients should be assessed for risk 
factors and prophylaxis prescribed 
accordingly (Table 3). The incidence is 
higher in those with malignancy 
(35%), lower for 'routine' abdominal 
hysterectomy (12%) and lowest for 
vaginal hysterectomy. 

As some prophylactic methods may 
be associated with side effects (e.g. 
wound haematomas and 
hypersensitivity reactions with heparin), 
the methods chosen must be based on 
some form of risk vs benefit assessment. 
The benefits to the patient of heparin 
in moderate/high-risk groups are felt to 
outweigh the approximately 2/100 risk 
of wound haematoma, which may be 



minimized by avoiding injection close 
to the wound. Graduated compression 
stockings would be an alternative, 
although compliance with stockings 
may be reduced in those who find 
them uncomfortable. In addition, they 
have not been shown to reduce the risk 
of fatal pulmonary thromboembolism. 
Dextran carries a significant risk of 
anaphylaxis. 

Any benefits to stopping the 
combined oral contraceptive (COC) 
4-6 weeks prior to surgery must be 
weighed against the risk of unwanted 
pregnancy. In the absence of other risk 
factors there is insufficient evidence to 
support a policy of routine COC 
discontinuation. It may be advisable to 
stop hormone replacement therapy 
(HRT) before major surgery. 



':-:::■ 



Risk factors following caesarean section 



Low risk - early mobilization and hydration 

Elect ve caesarean sect on uncomplicated stagnancy and nc other risk factors 

Moderate risk — heparin (e.g. heparin 5000 n b.i.d. or enoxaparin 20 mg/day) and TED stockings 

Age > 35 years 

Obesity [>8ukoJ 

Pats 4 of more 

Gross vati cose veins 

Current infection 

Pre-eclamosia 

Immobility prior to surgery r> A days] 

Mapr current illness, e.g. heart or lung disease. cancel . inflammatory bowel disease, nephrotic syndrome 

Emergency caesarean section in labour 

High risk - heparin (e.g. heparin 5000 U t.i.d. or enoxaparin 40 mg/day) and TED stockings 

A patient with three nr more moderate risk factors from .a hove 

Extended niaior pelvic or abdominal surgery, e y caesarean hysterectomy 

Patients win a personal or family history of deep vein thrombosis, pulmonary embolism or thrombophilia: pa : alvs s ol 

lowei limbs 

Patients with aniiphospholipid antibody (ca rciohpin antibody oi lupus antcoagj am I 



tube 3 Ris 


k factors for venous thromboembolic disease in gynaecology 










Group 


Risk factors 


Deep vein 


Proximal 


Fatal 


Suggestion for 






thrombosis 


vein 


pulmonary 


prophylaxis 






(DVT) 


thrombosis 


embolism (PE) 




Lew risk 


Minor surceiy (■■ 30 minutes); no risk factors other than age 

.Vlaj or surgery l< 30 minutes), age < 40; no other risk factors (as beloiv) 


<10% 


< m 


0.01* 


Early mobtatori + TEO 
stockings 


Moderate risk 


Minor surgery {< 30 minutes] with personal or family history of DVT, 

PE- or thrombophilia 

Major gynaecological surgery [> 30 minutes] 

Age > 40 years, obesity [> 80 kg), gross varicose veins, current infection 

Immobility onor to surgery (>4 days] 

Mai or medical illness: heart or lung disease, cancel, inflammatory' 

nov.e: disease 


10-40% 


1-10* 


.1 - 1 <*. 


tarly mnhiliSlliOn +■ 1 tt) 
stockings -■ low -dose 
Heparin 


High risk 


Throe or more of above risk factors 

Major pelvic or abdominal surgery for cancer 

Major surgery in patients with previous DVT. PE. thrombophilia. 

or lower limb paralysis [e g. hcmiplegic stroke, paraplegia) 


40-80% 


• 0-30* 


i iow 


Early mobilisation -TED 
stockings • high-dose 
heparin 



1 Venous thromboembolic disease 






i Although pregnancy-related venous thromboembolic disease is very rare in Africa and Ihe Far East, it is the commonest direct cause ot maternal 
mortality in many western countries. 

i Any symptoms should be investigated fully, even if this requires X-rays or isotope scanning. 

i Prophylaxis is important in both obstetrics and gynaecological practice. 



44 OBSTETRICS 



Psychosocial problems in antenatal care 



Clinicians should be careful, when 
focusing on medical disorders of 
pregnancy, to be sensitive to 
psychosocial and cultural issues that 
may impact on care. 

Teenage pregnancy 

The UK has the worst record for 
teenage pregnancies in Europe. Over 
90 000 teenagers become pregnant 
each year, including 8000 who are less 
than 16 years old. Teenage mothers are 
less likely to finish their education or 
find a good job and more likely to end 
up as single parents. The children run 
a greater risk of poor health and have 
a higher chance of becoming teenage 
mothers in their turn (Table 1). Certain 
risk factors have now been identified 
(Table 2). The risk for teenage 
motherhood is 10 times higher in 
social class V than in social class I. The 
risk is 3 times higher for a girl in local- 
authority housing than owner- 
occupied housing. There is a strong 
link between teenage pregnancy and 
not being occupied either in education, 
training or work between 1G and 17 
years of age. High truancy rates and 
social exclusion at school are also 
factors. 

Antenatal care 

Teenage mothers achieve less good 
antenatal health care. There are a 
number of reasons for this: 

■ The majority of teenage pregnancies 
are unplanned, so preparations, e.g. 
prophylactic folic acid, are less likely. 



Table 2 Risk factors for teenage 
pregnancies 

■ Poverty 

• Children currently, or previously, m cere are at higher 
risk 

■ Children of teenage mothers 

■ Low educational achievement 

■ Low expectations 

■ Previous sexual abuse 

■ Mental health problems 

■ Crime 



Many young people share several of these risk factors and 
therefore have a very high chance of becoming a teenage 
parent (from UK Parliamentary Report on Teenage 
Pregnancy, June 1999]. 

■ Teenagers present much later for 
booking and may miss accurate 
dating scanning and advice on 
health precautions. 

■ Nearly two-thirds of under 20-year- 
olds smoke before pregnancy and 
almost half during pregnancy. 

■ Pregnancy under the age of 1G can 
be complicated by poor fetal growth, 
independent of social circumstances 
including smoking and poor 
nutrition (teenage mothers are 25°/o 
more likely than average to have a 
baby weighing less than 2500 g). 

■ For many, formal planned antenatal 
care is very difficult as they face 
family conflict, relationship stress or 
breakdown, and moving home. 

There is an increased incidence of 
anaemia, urinary tract infection and 
hypertension. Postnatal depression is 
three times as common and teenage 
mothers are half as likely as older 
mothers to breast feed. 



Table 1 Teenage pregnancies 

■ Teenage birth rates. 

The Netherlands 3.5 per 1 ODD girls 15- 19 years 

France 7 per 1000 girls 15-19 years 

Germany 10 per 1000 girls 15- 19 years 

UK 20 per 1000 girls 15-19 years 

US 55 per 1000 girls 15-19 years 

H Just under 3D% of teenagers are sexually active by age 16 

■ 50% of these do not use contraception the first time 

■ Teenagers who do not use contraception have a 90^ chance of conception within 1 year 
a In one single act of unprotected intercourse with an infected partner there is: 

- 1% chance of acqumng HIV 
30% risk of genital herpes 

- 50% chance of gonorrhoea 
a Of those wh o do get pre g n ant : 

- 50% under 1 6 opt for abortion 

- 30% of 1 7 - 1 B-yea r-ol ds opt for a bortion, i . e 1 5 abortions per year in under 1 8-yea r-olds 

■ 90% of teenage mothers have their babies outside marriage 

■ The mortality for babies born to teenage mothers is 6% higher than for babies of older mothers. 

- increased low birthweights 

increased childhood accidents (especially poisoning or burns) 

- increased hospital admissions (mainly accidents or gastroenteritis] 



From UK Parliamentary Report on Teenage Pregnancy, June 1999 by the Social Exclusion Unit. 



Smoking 

Numerous studies have shown that 
smoking reduces the birthweight by 
13 g per cigarette smoked daily. 
Educational campaigns have succeeded 
in encouraging some women to stop 
smoking when they conceive but few 
interventions have been successful in 
women still smoking at booking. Some 
studies have shown that smokers 
reduced or stopped smoking when 
they were told that it caused a fetal 
tachycardia or if the effects of smoking 
were explained. 

Alcohol 

Fetal alcohol syndrome 

Alcohol is a fetal teratogen. Chronic, 
heavy ingestion is associated with the 
fetal alcohol syndrome (FAS). 
Diagnosis requires signs in the 
following categories: 

■ central nervous system involvement 
including neurological 
abnormalities, developmental delay, 
intellectual impairment, head 
circumference below the third 
centile and brain malformation 

■ characteristic facial deformity, 
including short palpebral fissures, 
elongated mid-face and flattened 
maxilla. 

Although the facial dysmorphic 
features may regress with age, the 
mental impairment does not. 

Alcohol affects all fetal systems and 
FAS will occur in approximately one- 
third of children born to women who 
drink the equivalent of 18 units of 
alcohol per day. Other factors dictating 
susceptibility to alcohol include 
genetic factors, social deprivation, 
nutritional differences and the 
possibility of associated tobacco and 
drug abuse. 

Social alcohol consumption 

There is growing evidence that even as 
little as two units of alcohol a day has 
a small negative effect on intrauterine 
fetal growth, reducing the birthweight 
by GO-70 g. Impairment of neural 
development, however, seems to occur 
only at higher levels of consumption. 
Alternative methods for screening 
for heavy alcohol consumption during 
pregnancy have been devised as the 
routine tests (serial mean corpuscular 
volume and gamma glutamyl 
transferase) are less reliable in 



Psychosocial problems in antenatal care 45 



pregnancy. A full dietary and 
substance-abuse history should be 
taken. A more searching questionnaire 
for alcohol is the TACE questionnaire. 
A total score of two points or more is 
considered positive and correctly 
identifies approximately 70% of heavy 
drinkers. 

Nutritional problems are common. 
Trace element deficiencies [e.g. zinc 
and copper) and vitamin deficiency 
states [folate, thiamine and pyridoxine) 
may exist. 

Alcohol passes freely to the milk. 
Regular heavy drinking by the mother 
may impede psychomotor 
development of the breast-fed infant, 
although mental development is 
probably unaffected. Heavy binging 
may lead to neonatal sedation. 

Specific counselling, referral for 
specialist treatment and a telephone 
contact number provide support. 

Domestic violence 

Most acts of domestic violence are 
directed by men against women, and 
are unrelated to social class. An 
estimated 835 000 incidents were 
reported in 1997. One woman in nine 
is subjected to severe beatings by her 
partner each year. 

Violence against a partner is often 
linked to wider family problems. In 
three out of five cases where children 
suffered abuse, their mother was 
abused. Midwifery staff and health care 
workers should be vigilant for any 
signs of domestic violence. Self-help 
groups and one-parent hostel facilities 
may need to be considered. 

Psychological issues 

Depression and psychosis 

Patients who have been previously 
treated with antidepressants or 
antipsychotics will need to be 
reassessed in the antenatal period. The 
social, economic and domestic factors 
that may have contributed to any 
depression will need to be reassessed 
and social service support provided 
early if deemed necessary. 

It is preferable to try to withdraw 
any medication if possible, but if the 
mental condition is brittle, the dose 
should be reduced to the lowest 
possible to maintain stability, or a 
milder alternative substituted. It is 
better to use behavioural and 
psychotherapeutic treatments during 
pregnancy if possible. 



Racial aspects 

Every woman must be treated with 
respect and her religious and cultural 
views acknowledged wherever 
possible. 

Female genital mutilation 

Female genital mutilation (FGM) 
affects more than 80 000 women and 
children worldwide. The type of 
mutilation performed varies from 
Sunna [excision of the clitoral 
prepuce) to excision of the clitoris, 
labia minora and majora (in the most 
severe form) [Fig. 1). The age at which 
FGM is performed varies from birth to 
immediately prior to marriage, but 
most commonly is between G and 7 




Fig. 1 Female circumcision. 



years. Anaesthetic is rarefy given and 
asepsis is limited. The raw edges of the 
labia are sutured together with catgut 
or more commonly thorns. The girl's 
legs are bound together and a small 
aperture is left to allow drainage of 
urine and menstrual fluids. 

The practice is widespread in a band 
from the Horn of Africa through 
Central Africa to parts of Nigeria, and 
involves 90% of female children in 
Somalia and Ethopia. Immediate 
complications include severe 
haemorrhage and infection and there 
is a significant mortality. Long-term 
problems include recurrent urinary 
tract infections, dysmenorrhoea, non- 
consummation and lack of sexual 
enjoyment Circumcision increases the 
marriage prospects within that society. 
Failure to undergo circumcision may 
lead to social rejection. 

Women who have been victims of 
FGM and book for antenatal care 
should, if possible, be treated in a 
specific African Well Woman Clinic 
with access to a translator and 
psychologist if required. They should 
be encouraged to have the 
circumcision reversed in the second 
trimester under spinal anaesthetic 
between 20-28 weeks. This allows 
adequate examination vaginally to 
assess progress in labour. If a patient 
declines, reversal should be performed 
in the first stage of labour, to allow 
catheterization, examination and 
continuous fetal monitoring where 
required. 

It is illegal under the terms of the 
1985 Prohibition of Circumcision Act 
to resuture these women after delivery. 



Psychosocial problems in antenatal care 

i The USA has the highest teenage pregnancy rate. 

i The UK has the worst record of teenage pregnancies in Europe. 

i There is increased morbidity and mortality in babies born to teenage mothers 

i Smoking is implicated in low birth weight babies 

i Chronic heavy alcohol ingestion is associated with the fetal alcohol syndrome [FAS). 

i Domestic violence continues to be the most common violent crime against women in England 
and Wales. 

i Although victims of female genital mutilation should be advised to undergo de-infrbulation 
between 20-28 weeks or certainly in the first stage of labour, this will depend on consent and 
consideration of cultural issues. 



46 OBSTETRICS 



Mechanisms of normal labour 



Labour is the process whereby regular 
uterine activity causes progressive 
cervical dilatation and usually results 
in delivery of the fetus. It is divided 
into three stages, each with defined 
normal progression which aids 
identification of problems. 

Prior to the onset of labour it is 
usual for cervical effacement to occur. 
The cervix becomes shorter, softer and 
moves from its position in the 
posterior vaginal fornix towards the 
anterior vaginal fornix. If full cervical 
effacement has not been achieved 
before the onset of regular uterine 
activity there may be a prolonged 
latent phase when uterine activity 
C± pain) completes the process of 
cervical effacement but the patient is 
not in labour. Labour is diagnosed 
once the cervix starts dilating, so the 
diagnosis of the time of onset of 
labour has to be made retrospectively. 

Spontaneous rupture of the 
membranes (SRM) may occur prior to 
the onset of labour but is more usual 
during the first stage. If labour has not 
begun after SRM, it is common 
practice to induce within the first 
48 hours providing gestation is 
>37 weeks (see p. 19). Membrane 
rupture may be preceded by loss of the 
cervical mucous plug (show) which is 
often blood stained. 

Mechanism of labour 

The most common presenting part is 
the fetal head - 95%. The vertex is the 
area bounded by the parietal 
eminences, the anterior and posterior 
fontanelles. With the vertex presenting, 
the smallest presenting diameter 
occurs - suboccipito-bregmatic (Fig. 1). 
Any deflexion will result in larger 
diameters - the occipitofrontal and, 



Suboccipito-bregmatic 
Well-flexed head (9.5 cm) 



Occipitofrontal 
Deflexed head 
(11.5 cm) 





Gynaecoid 

or female type 




Android 

or male type 

Fig. 2 The four pelvic types. 

with further deflexion, a brow. These 
presentations decrease the likelihood 
of a normal delivery. 

The head has to pass through the 
bony pelvis and thus the shape of the 
maternal pelvis is important (Fig. 2). 
The commonest pelvic type is the 
gynaecoid pelvis, found in about 50% 
of women. It has parallel sides which 
allow passage of the fetal head. The 
anthropoid pelvis (25%) similarly does 
not cause problems by shape, whereas 
the android (male type) pelvis (20%) 
with its converging pelvic side walls 
gives increasing problems as the head 
descends. The fourth pelvic type, flat 
(5%), presents problems at the inlet 
but widens with further descent. 

Initiation of labour 

Possible mechanisms include a change 
in the progesterone : oestrogen ratio, 




Anthropoid 

or ape type 




Platypalloid 

or flat type 



releasing uterine activity from 
progesterone inhibition, local release 
of prostaglandins stimulated by 
oxytocin or tissue trauma. 

Stages of labour 

First stage 

Stage one is from the onset of labour 
until full cervical dilatation - usually 
1 cm/hour in primigravidae and 
1-2 cm/hour in parous women. 
Uterine activity during labour shows 
fundal dominance with spread of a 
wave of uterine contraction down 
towards the cervix (Fig. 3). As uterine 
muscle displays the property of 
retraction (shortening) the uterus is 
thus pulled towards the fundus 
dilating the cervix and encouraging 
descent of the fetus down the birth 
canal. Monitoring of labour progress is 




Mento-vertical 

Brow oresentation (14 c ml 



Fig. 1 The fetal skull. 



Fig. 3 Contractions start from the fundus. 



Mechanisms of normal labour 47 



Occurrence 


Position 
of head 


Engagement of head 


OT 


Descent to pelvic floor where 
guttering encourages rotation 
of head 90= 


OA/OP 


Further descent ol head and 
occiput under symphysis 


OA (or OP) 


Head extends and face passes 
over perineum 




Restitution - head realigns with 
shoulders 


OT 



The anterior shoulder is then delivered under the symphysis 
with downward traction then an upward sweep to deliver 
the posterior shoulder carefully over the perineum. Finally, 
the infant is delivered onto the mother's abdomen. 



Fig. 4 Movement of the fetus through the birth canal 



facilitated by use of the partogram (see 
p. 51). 

Second stage 

Stage two is from full cervical 
dilatation until delivery of the infant - 
usually 1 hour or less in parous 
patients but may be 1-3 hours in 
primiparae. The second stage may be 
either passively managed, where the 
mother pushes when she feels the 
need, or with active encouragement to 
push with each contraction. There is 
no evidence that passive management 
is of benefit 

Third stage 

Stage three is from delivery of the 
infant to delivery of the placenta - 
usually 15 minutes or less. Figure 4 
shows the stages in the movement of 
the fetus through the birth canal. 

The episiotomy 

The need for an episiotomy is 
determined by signs of tearing or 
excessive blanching of the perineum. 
Infiltration with lidocaine (lignocaine) is 
performed prior to cutting the 
episiotomy, which is most commonly 
right posterolateral The cut is made at 
the start of the contraction during which 
it is considered the head will deliver. 
The episiotomy avoids uncontrolled 
tearing in a downward direction which 
might involve the rectal mucosa and 
rectal sphincters to the detriment of the 
mother's future bowel control (Fig. 5). A 
midline episiotomy does not offer 
sphincter protection. 

Third stage 

Signs of placental separation 

These comprise: 

■ lengthening of the umbilical cord 




■ a gush of blood vaginally 

■ firming of the fundus. 

Once signs of separation have 
occurred the placenta may be delivered 
by controlled cord traction where the 
left hand is placed suprapubically 
holding the uterine fundus in the 
abdomen. The right hand is placed on 
the cord and gentle downward traction 
in the direction of the birth canal 
ensures delivery of the placenta. The 
mother may prefer to make expulsive 
efforts herself to deliver the placenta. 

Active management of the third 
stage of labour is by prophylactically 
administering Syntometrine 
intramuscularly to the mother with the 
delivery of the anterior shoulder. This 
encourages contraction and retraction 
of the uterus with separation of the 
placenta and minimizes the blood loss 
during this stage. The practice of 
'fundus fiddling' - trying to rub up a 
contraction of the uterus by massaging 
the uterine fundus - may encourage 
incomplete separation of the placenta 
with attendant haemorrhage. 

If there are no signs of placental 
separation an infusion of Syntocinon 
may be set up or the baby put to the 
breast to encourage uterine contraction 
by release of oxytocin. Alternatively, 
gentle downward traction on the cord 




Fig. 5 Performing an episiotomy. 

(a) Episiotomy incisions, (b) Local anaesthetic is 

infiltrated before the incision is made. 

f_c) Midline episiotomy does not protect the 

sphincter. 



while protecting the fundus may allow 
delivery of the placenta. However, it 
may also result in avulsion of the cord 
and the need for a manual removal of 
the placenta (see p. GO). Requests for a 
'natural' third stage (no medication) 
are associated with a greater blood loss 
and are thus inappropriate in anaemic 
patients. 



Mechanisms of normal labour 



■ There are th ree stages of labour. 

i The shape of the maternal pelvis will affect the progress of labour. 

i The second stage of labour may be managed passively, but active encouragement to push is 
more usual, 

i Episiotomy is used only if needed. 



48 OBSTETRICS 



Induction of labour and prolonged pregnancy 



Induction of labour is indicated when 
the risks of continuing the pregnancy 
are felt to be greater than that of the 
induction itself. The induction is 
usually carried out in the interest of 
fetal well-being, occasionally for that of 
the mother, and only rarely for 'social' 
reasons. Labour should not be induced 
unless there are good medical reasons 
to do so. The decision is often difficult, 
particularly at preterm gestations, and 
many factors, including neonatal 
facilities, need to be considered. 

Fetal indications 

These include: 

■ Intrauterine growth restriction 
(IUGR) with risk of fetal 
compromise (based on estimated 
growth, biophysical assessment - 
including cardiotocograph (CTG) 
and Doppler studies). There may be 
associated pre-eclampsia. While it 
may, for example, be appropriate to 
induce for mild pre-eclampsia at 
term, the pre-eclampsia would need 
to be severe in a markedly preterm 
infant. 

■ Certain diabetic pregnancies. 

■ Worsening fetal abnormalities (very 
rare), e.g. cardiac lesions, hydrops or 
twin-twin transfusion syndrome. 

■ Deteriorating haemolytic disease of 
the newborn. 

Maternal indications 

■ Pre-eclampsia. This is a condition in 
which both maternal and fetal 
interests are relevant. 

■ Deteriorating medical conditions 
(cardiac or renal disease, severe 
systemic lupus erythematosus). 

■ In rare situations in which treatment 
is required for malignancy. 



Unfavourable cervix 



Induction 

The main risks of inappropriate 
induction are uterine hyperstimulation, 
increased obstetric intervention, and 
failed induction. The gestation should 
be checked, presentation confirmed 
and contraindications excluded (e.g. 
placenta praevia). Caution is required 
with previous caesarean section and 
uterine surgery (risk of uterine 
rupture), and grand multiparity or 
previous precipitate labour (risk of 
hyperstimulation). 

The cervix should be assessed using 
the modified Bishop's scoring system 
(Table 1 and Fig. 1). 

Prostaglandins 

Intravaginal PGE, gel has fewer side 
effects than oral preparations and also 
has a lower failure rate than using the 
intracervical route (Fig. 2). The gel is 
inserted into the posterior fornix. If 
there is no uterine activity, the cervix is 
reassessed in 6 hours. If the Bishop's 
score is < 7, further gel is given and 
the cervix reassessed again 6 hours 
later. Further doses may then be given 



Tdule Bishop's scoring system 
cervical assessment 


for 


Score 







1 


2 


Cervical dilatation (cm) 


<1 




1-2 


a -t 


Length of cervix (cm) 
Station of presenting 
part in relation to the 
ischial spines (cm) 


> 2 
-3 




1-2 
-2 


< i 
-i 


Consistency 


Firm 




Medium Soft 
Central Anterior 


Position 


Posterior 



If the score is<7 the cervix should be 'ripened' with 
prostaglandins (gel or pessary) 
If > 6, consider either prostaglandins or ARM ± 
Syntocinon (there may be greater patient satisfaction 
with the former, but the latter may allow more control). 



Favourable cervix 





An unfavourable cervix is 
long, closed, firm and uneffaced 



A favourable cervix is soft, 
effaced and admits a finger 



Fig. 1 Unfavourable (low Bishop's score) and favourable (higher Bishop's score) cervix. 



Fig. 2 Prostaglandin gel is used to ripen 
the cervix. Amniotomy may be performed when 
trie cervix is favourable. 

or the patient may be left for 12-18 
hours (e.g. overnight). If at any stage 
the Bishop's score is > 6, artificial 
rupture of the membranes (ARM) may 
be performed, reassessment made in a 
further 2 hours and Syntocinon started 
if still no change. Gel should not be 
given if there is regular uterine activity. 

Sustained-release preparations are 
also available in the form of a polymer- 
based vaginal insert, with retrieval 
thread, containing PGE,. It is placed in 
the posterior fornix for 12 hours, after 
which it is removed. This technique 
has the advantage that the pessary can 
be removed if hyperstimulation 
develops, and trials indicate that it is 
probably safe. It has not been shown 
to be superior to gel. 

Artificial rupture of the 
membranes (ARM) 

ARM (amniotomy) is used to induce 
labour in those with a sufficiently 
favourable cervix and is also used for 
augmentation. Further, it allows 
assessment of the colour of the liquor 
(see Meconium, p. 51). Its routine use 
in early labour is surrounded by a 
degree of controversy, as it can be 
argued that there is less cushioning of 
the fetal head and therefore a greater 
incidence of fetal heart rate 
decelerations. Early ARM and 
Syntocinon probably do not confer 
benefit over conservative management 
in nulliparous women with mild 
delays in early spontaneous labour. 

The fetal head should be well 
applied to the cervix to minimize the 
risk of cord prolapse. With asepsis, the 
tips of the index and middle fingers of 
one hand should be placed through 
the cervix onto the membranes (Figs 2 
and 3). The amni-hook should be 
allowed to slide down the groove 
between these fingers (hook pointing 
towards the fingers) until the cervfx is 
reached. The point is then turned 
upwards to break the membrane sac. 



Induction of labour and prolonged pregnancy 49 




Membranes 
Uterine wall 



Fig. 3 Artificial rupture of the membranes. 



Liquor is usually seen, but may be 
absent in oligohydramnios or with a 
well-engaged head. Cord prolapse 
should be excluded before removing 
the fingers. The fetal heart should be 
rechecked. Absent liquor following 
ARM should be treated as meconium 
staining until proven otherwise. 

Syntocinon 

This may be used for induction 
following ARM with a favourable 
cervix, or for augmentation of a slow, 
non-obstructed labour. It should only 
be started if the membranes have been 
ruptured, and continuous CTG 
monitoring is mandatory. The dose 
should be titrated against the 
contractions, aiming for not more than 
6-7 every 15 minutes with a reduced 
dose in highly parous women 
O 5 labours). 

For induction, the use of Syntocinon 
immediately following ARM reduces 
the time to delivery, the rates of 
postpartum haemorrhage (PPH) and 
the need for operative delivery. As 
labour will begin within 24 hours in 
88%, however, it is unclear whether 
these advantages outweigh the 
maternal inconvenience of an 
intravenous infusion, restricted 
mobility and continuous fetal 
monitoring. An individual approach is 
advised. 




Fig. 4 Sweeping the membranes. 

Prolonged pregnancy 
G> 42 weeks) 

This occurs in 10% of pregnancies and 
is associated with an increased 
perinatal mortality (perinatal mortality 
is 5 : 1000 between 3 7-42 weeks and 
9.7 : 1000 after 42 weeks) owing to 
intrauterine death (IUD), intrapartum 
hypoxia and meconium aspiration 
syndrome. Dating the pregnancy by 
ultrasound before 18 weeks is more 
reliable than last menstrual period 
(LMP) in reducing the incidence of 
prolonged pregnancy. 

Sweeping the membranes. If this is 
done once after 40 weeks it doubles 
the incidence of spontaneous labour 
over controls, especially in those with a 
low Bishop's score. The risk of 
infection is considered to be minimal 
but the procedure is uncomfortable 
CHg. 4). 

Routine induction of labour. Induction 
after 41 weeks reduces the incidence of 
fetal distress and meconium staining 
over those managed conservatively 
with monitoring. There is also a 
reduction in the caesarean section rate 
and no increase in the incidence of 
uterine hypertonus. It has been 
estimated, however, that 500 
inductions may be required to prevent 
one perinatal death. Dissatisfaction 
with labour is strongly associated with 



operative delivery, and does not seem 
to be associated with induction of 
labour. 

Monitoring of postdates pregnancy. 
Monitoring with ultrasound and CTG 
confers no demonstrable benefit but is 
frequently performed. 

Other methods of induction 

Antiprogesterones 

Mifepristone, a progesterone 
antagonist, has been studied in early 
pregnancy and has been shown to 
increase uterine activity and lead to 
cervical softening. Research into its use 
as an induction agent later in 
pregnancy has shown promising 
results, but it is not yet in clinical use. 

Extra-amniotic saline 

This involves passing a Foley catheter 
through the cervix and infusing 
normal saline into the extra-amniotic 
space. The infusion volume should be 
limited to 1500 ml. Success at cervical 
ripening has been shown to be similar 
to PGE2 but the process carries a small 
risk of introducing infection. It is a 
much cheaper technique than using 
PGE2 and this, together with the fact 
that PGE2 needs to be refrigerated, 
may make it a more suitable method 
for less affluent countries. It has not 
yet been compared in studies to 
misoprostol, a much cheaper 
prostaglandin preparation than PGE2. 

Failed induction 

Despite the above techniques, 
induction of labour is sometimes 
unsuccessful. The plan then depends 
on the reason for the induction. If it 
was for some significant fetal or 
maternal indication, there is probably 
little choice but to consider caesarean 
section. If, on the other hand, the 
induction was for some 
epidemiological reason then it may be 
reasonable to consider a more 
conservative approach. This would 
depend on an informed discussion 
with the patient and her partner. 



Induction of labour and prolonged pregnancy 

i Induction should only be earned out for medical reasons as it carries risks, particularly of hyperstimulation 

t Prostaglandins are useful to ripen' the cervix. 

i Routine induction ot labour after 41 weeks reduces the incidence of fetal distress, caesarean sections and meconium siaming over ihose managed 
conservatively with monitoring. 





so OBSTETRICS 



Intrapartum fetal monitoring 



Cardiotocography 

Continuous electronic fetal heart rate 
monitoring - cardiotocography (CTG) - 
provides more information than 
intermittent auscultation with a fetal 
stethoscope. Abnormalities of fetal heart 
rate are used as a screening test for fetal 
acidosis and therefore poorer fetal 
outcome. There is no evidence that 
continuous monitoring reduces the risk 
of low Apgar scores or the rates of 
admission to special care nurseries. 

Neonatal encephalopathy has been 
labelled hypoxic-ischaemic and thought 
to be due to fetal asphyxia during labour 
but evidence for this is surprisingly thin. 
A growing number of other significant 
non-asphyxial risk factors are being 
recognized. The abnormality to be 
detected is poorly defined and the 
screening test poorly assessed. 

Interpretation of the CTG is a skill 
acquired over many years of practice but 
differing interpretations may be made 
by the same clinician on different dates 
or by different clinicians viewing the 
trace together. There are some basic 
rules to guide the uninitiated. 

It is most important to interpret the 
CTG as part of the whole process of 
labour. For example, if there is 
meconium-stained liquor with an 
abnormality on the CTG this will be 
more likely to be significant than the 
same CTG abnormality with clear liquor 
draining. The stage the labour has 
reached will also influence decisions, 



with the same tracing needing different 
actions if the cervical dilatation has 
reached 3 cm or 10 cm. Initial 
assessment should follow a pattern 
designed to ensure that nothing is 
missed. 

Baseline heart rate 

Normally accepted limits are a rate 
between 110 and 1G0 bpm [beats per 
minute). A baseline rate above 160 bpm 
may be associated with a maternal 
tachycardia or pyrexia but other 
abnormalities of the tracing or progress 
of labour should be sought. Fetal blood 
sampling may be appropriate to 
determine whether there is fetal 
acidosis. Baseline rates below 110 bpm 
may suggest fetal distress. 

Baseline variability 

This is dependent on the fetus having an 
intact neurological system and a normal 
cardiac conducting system. Normal 
variability is more than five beats and 
gives the tracing a jagged appearance. 
Fewer than five beats' variation makes 
the tracing appear flat - almost a 
straight line. This can happen after 
opioid analgesia with acidosis or may be 
noted during phases of fetal sleep, 
which last for 20-40 minutes only. 

Accelerations 

An increase of more than 15 bpm for 
more than 15 seconds in response to 
fetal movement or a maternal 



contraction is termed an acceleration 
(Fig. 1). This shows development of 
good autonomic nervous system 
control and is indicative of a fetus that 
is not distressed. Absence of 
accelerations may be a sign of fetal 
distress and might warrant further 
investigation in the antenatal situation. 
During labour absence of accelerations 
as a sole sign would require 
continuation of the monitoring and 
observation for other indicators of 
problems such as loss of variability, 
presence of meconium-stained liquor, 
or development of decelerations. 

Decelerations 

A decrease in the fetal heart rate of 
more than 15 bpm below the baseline 
is a deceleration. They are divided into 
three categories - early, late and 
variable. 

Early - these occur in time with the 
maternal contraction and are thought 
to be due to the fetal head being 
compressed, which stimulates the 
vagus and thus slows the fetal heart 
rate. 

Late - these occur with their nadir 
beyond the peak of the maternal 
contraction and tend to be slow to 
recover to the baseline. They are 
suggestive of acidosis and if persistent 
warrant further assessment (e.g. fetal 
blood sampling) or delivery (Fig. 2). 



Ja^^wv* ' \A{ AlA/ 



30,10,92 I em,™ 

I I vm* I 

80 
40 



80 



H !n 44AM 30,10,92 lon/mr 
I li OBHli < II 



A 



A 



aV 



\ f s jJ V^-v^^/^/Vy-- 1 \y\j 



FiQ. 1 Normal CTG showing accelerations and good baseline 
variability. 



SO 



ia 



• 50 



""Vorvv-^J 



82 



S3 



Fig. 2 CTG showing late decelerations. 



Intrapartum fetal monitoring 51 




Fig. 3 Partogram. 



Variable - these have a variable pattern 
and may be found in any relation to 
maternal contractions. They tend to 
conform to an M-shaped wave with an 
initial acceleration followed by a 
deceleration, then rebound acceleration. 
These occur with compression of the 
cord, the deceleration being found as the 
arteries are compressed. Changing the 
maternal position may see a resolution. 

The partogram 

Plotting the progress of labour on this 
chart (Fig. 3) allows, at a glance, an 
assessment as to whether labour is 
proceeding at an appropriate pace. 
Other recorded parameters enable the 
full picture to be clearly visualized. The 
progress of labour is determined by the 
rate of cervical dilatation and the 
corresponding descent of the head [or 
presenting part). 

Latent phase 

The latent phase is of variable length. In 
induced labour it can be shortened with 
use of prostaglandin gel to ripen the 
cervix 

Active phase 

The active phase is when the minimum 
rate of cervical dilatation in a 
primigravid patient reaches 1 cm per 
hour. Multigravid patients are usually 
much quicker so a problem should be 
sought if the slope of this part of the 
partogram is less steep than illustrated. 

Descent of the presenting part 

When a primigravid patient enters 
labour the head is usually engaged but 
in highly parous patients engagement 
may not occur until the second stage of 
labour. There should be no head 
palpable abdominally before an assisted 
delivery is attempted. 



Other parameters 

Other parameters which should be 
recorded during labour are given in 
Table 1. 

Liquor amnii 

This fluid that surrounds the fetus is 
normally clear. Green or yellow 
discolouration suggests that the fetus has 
passed meconium (faecal material) which 
is a response to vagal stimulation and 
may be a sign of post dates or fetal 
distress. In a breech presentation the 
passage of the abdomen through the birth 
canal may cause passage of meconium 
which thus has less sinister significance. 

Contractions 

Assessment of the timing of contractions 
can be made from the CTG; however, 
this gives no information about their 
strength. An experienced midwife or 
intrauterine pressure monitoring will 
inform about the strength of 
contractions. The optimum is to aim for 
coordinated contractions lasting 1 
minute with a frequency of 3 to 4 in 10 
minutes. In the second stage of labour 
contractions lasting 1 minute with 1 
minute space between are most likely to 
result in reasonable progress. 

Fetal blood sampling (FBS) 

In the presence of a non-reassuring 
CTG, a blood sample is taken from the 
presenting part - usually possible for an 
experienced operator by 3 cm dilatation. 
Analysis gives the fetal pH and the base 
excess (Table 2). 

The base excess gives additional help 
by suggesting how much further 
buffering is available if the fetus 
continues to produce lactic acid 
(anaerobic metabolism). When the base 
excess is negative there is no further 
buffering for the lactic acid and the pH 
might be expected to fall rapidly so an 
earlier repeat FBS may be appropriate. 

Indications for fetal blood sampling 
include: 



Ti i l : e 1 Param e le rs reco rd ed d u ri ng 


labour 








Parameter 


Frequency 


Maternal 


Pulse 


1 5 in ms 




Temperature 


60 nuns 




Contractions 


Number per 1Q mms 




Cervical dilatation 


2-* hours 




Urinary output 


Ai least a hourly 




i.v. f, li ids 






Drugs administered 






including Syntoanon 


Fetal 


Heart rate 


ISmins 




Liquor colour 


15 nuns 




Descent nf 


2 * hours 




presenting part 





Tarjie 2 Analysis of fetal blood pH 
pH value Action 

> ?25 Observe CTG and if abnormality persist 

leyeat sample in 1 hour 

7.20-7.25 II delivery imminent, episioioiry oi 

assisted delivery - if CTG changes persist 
repeal sample n 30 'Tins arid ac] 
according to the value and clinical 
situation 

< 7.20 Expediie delivery 



■ persistent late decelerations on CTG 

■ persistent loss of baseline variability 

■ persistent fetal tachycardia with no 
maternal tachycardia 

■ marked fetal bradycardia 

■ complicated CTG patterns (combining 
abnormalities) 

■ sinusoidal (saw tooth) pattern 

■ any CTG abnormality accompanied 
by meconium-stained liquor. 

If fetal distress is suspected then: 

■ Stop Syntocinon infusion - this may 
decrease the frequency of the 
contractions and allow a greater time 
for the fetus to obtain oxygenated 
blood from the placental bed. 

■ Turn the mother onto her left side - 
which should relieve any aortocaval 
compression, again allowing the fetus 
to obtain oxygenated blood. 

■ Seek the cause for the problem and 
correct it or determine the optimum 
timing for delivery of the fetus. 



Intrapartum fetal monitoring 



i Labour can be very stressful for the fetus with interruption of the biood supply dunng maternal 
contractions. 

i Continuous intrapartum electronic monitoring is only necessary for the high-risk fetus. 

i If abnormalities of the fetal heart rate are noted during auscultation or the liquor becomes 
meconium-stained then this low-risk labour becomes high risk and warrants continuous 
electronic fetal monitoring. 

i Labour management requires use of the partogram. 

i Interpretation of cardiotocography is a skill that requires practice. 

i Fetal blood sampling gives additional information to the cardiotocography about fetal well-being. 

i pH correlates poorly with Apgar scores. 



52 OBSTETRICS 

Abnormal labour 



Abnormal labour 

Although normal labour can be 
denned as that ending in a healthy 
mother and baby, it is more 
traditionally defined as beginning 
between 37 and 42 weeks, progressing 
at an acceptable rate and resulting in 
the spontaneous vaginal delivery 
(SVD) of a live non-distressed neonate 
in the occipitoanterior position. 
Deviation from this latter definition 
may therefore occur if progress is too 
fast (precipitate labour), or too slow 
(often in association with malposition 
or malpresentation). 

Precipitate labour 

This occurs especially with induction 
of labour, augmentation and grand 
multiparity. The risk is that excessively 
frequent or prolonged contractions 
reduce the blood supply to the baby 
and may lead to hypoxia and 
consequent damage. Such hypoxia may 
occur over a short period of time to an 
otherwise healthy fetus, so that the 
prognosis is usually good. 

If prolonged contractions occur, 
Syntocinon should be stopped, and the 
fetal condition assessed with the 
cardiotocograph (CTG). If there is 
evidence of 'distress' a vaginal 
examination (VE) should be performed 
and consideration given to delivery. If not 
fully dilated, caesarean section should be 
considered. The uterine hypertonus 
may respond to a bolus of i.v. ritodrine 
or subcutaneous terbutaline. 



Slow labour 

There may be an initial and sometimes 
prolonged (hours/days) latent phase 
before true labour begins, but an 
acceptable rate of dilatation after 3 cm 
is 1 cm per hour in a primigravida and 
1-2 cm an hour in a multigravida. 
Slow labour may be due to inadequate 
uterine activity or to cephalopelvic 
disproportion, i.e. too small a pelvis, or 
too big a presenting part. A partogram 
is very useful to assess progress 
(Fig. 1). 

Inadequate uterine activity 

In clinical practice, the strength of 
contractions is difficult to measure, 
and the diagnosis is usually made by 
excluding obstruction of whatever 
cause. Obstruction is suggested by 
malposition, caput (oedematous 
swelling on the fetal head) and 
moulding (1+ if the sutures of the fetal 



PRIMIGRAVID LABOUR RECORD 



Name 

TimE Q J Admission . 



Pains 
DELIVERED 

FULL iocm 
9 cm 




Snow 










Ruptured Membranes 


























Scm 
>< 

j£ 7 cm 

LU 

° 

sx o cm 

O 














— 1> ~. y 
















































5 cm 












































i- 
< 
b 4 cm 

a 3 cm 












































2 cm 
























1 cm< 








































JNEFFACED 


















5 


2 3 


t 


5 




7 


3 


9 10 11 12 



HOURS AFTER ADMISSION 



180 
140 
120 
100 



++++ + ^n+ + : 








-H- 1 •-*♦- 




■ t • • r*V%^ 


* 























LIQUOR 


ffl 


CI at 


a 


H* 


Mk 


Uk 


hUc 


r)K 


Mte 




OXYTOCIN 














?#M, 


<v» 




ANALGESIA 


fc. 

















Time of Delivery Msinori 



m 



Fig. 1 Partogram. Progress was arrested at 8 cm and the baby was in right occipitoposterior 
position (i.e. relative cephalopelvic disproportion). As the patient was a primigravida and the CTG was 
reassuring, Syntocinon was commenced, the head rotated and there was an SVD. 



skull are aligned, 2+ if overlapping and 
3+ if irreducible). If there is felt to be 
inadequate uterine activity, 
consideration may be given to 
augmentation with Syntocinon, but 
caution is required in parous women, 
particularly those with a previous 
caesarean section scar, owing to the 
risk of uterine or scar rupture. 

Cephalopelvic disproportion 
(CPD) 

The pelvis may be too small. This may 
occur following trauma to the pelvis, 
but is usually idiopathic Worldwide, 
rickets and osteomalacia are the 
commoner causes (Fig. 2). The role of 
computed tomography or radiographic 
pelvimetry to measure the size of the 
outlet is probably very limited. 

TTte presenting part may be too big. The 
baby's head may be large, particularly 
in association with macrosomia (e.g. 
diabetes). Only rarely is there 
hydrocephalus. More commonly, there 
may be relative disproportion, i.e. the 




Fig. 2 Pelvis in (a) rickets and 

(b) osteomalacia. Pressure deforms the 
softened bones. 



head is extended or rotated in some 
unfavourable way (malposition), 
presenting a larger diameter to the 
pelvis than is ideal. 



Abnormal labour 



Occiput 



Lambdoid sulure 



Sagittal 
suture 



Fronlal sulure 




Frontal 
bone 



Sinciput 
Fig. 3 Diagram of the fetal scalp sutures. 

Malpresentations and 
malpositions 

[see also Breech, p. 40) 
It is possible to establish the position 
of the fetal head at VE by palpation of 
the scalp sutures (Fig. 3). 

Occipitoposterior (Fig. 4). Although the 
head usually rotates to occipitoanterior 
(OA) in normal labour, some arrest in 
the transverse position and a small 
proportion (= 10%) rotate to 
occipitoposterior (OP). There are 
usually longer first and second stages 
of labour with an increased chance of 
requiring a caesarean section, 
rotational forceps or ventouse delivery. 
If still OP and undelivered despite 
second stage pushing, a low/mid-cavity 
OP delivery, manual rotation, 
rotational ventouse, or Kielland's 
rotational forceps delivery will be 
required. 

Face presentation (Fig. 5). Caution is 
required to avoid confusion with a 
breech presentation. Most face 
presentations engage in the transverse 
position and 90% rotate to mento- 
anterior so that the head is born with 
flexion. If mentoposterior, a caesarean 
section will be required unless very 
preterm or there has been an 
intrauterine death, as the extending 
head presents an increasingly wide 
diameter to the pelvis and worsening 
relative CPD. 

Brow presentation (Fig. 6). The 
supraorbital ridges and the bridge of the 
nose are palpable. The head may flex to 
become a vertex presentation or extend 
to face presentation in early labour. If 
the brow presentation persists or there 
is no cervical dilatation, a caesarean 
section will be required. 

Transverse/oblique lie. This usually 
occurs in multiparous women and is 
associated with multiple pregnancy, 
preterm labour and polyhydramnios. It 
may also occur with an abnormal 
uterus or placenta praevia. Vaginal 





Normal 



Malposition (OP) 







Malpresentation (Breech) Malpresentation (Shoulder) 

Fig. 4 Malpresentation and malposition. 




Fig. 5 Face presentation, (a) Mento-anterior - 
impossible. 

delivery is not possible and there is a 
risk of cord prolapse. Pre-labour external 
cephalic version with or without 
induction or elective caesarean section is 
needed. Transverse lie 
(± arm presentation) following 
spontaneous rupture of the membranes 
is an indication for urgent caesarean 
section, which may require a vertical 
uterine incision to enable delivery of the 
fetus. 



delivery possible, (b) Mento-posterior - delivery 




Abnormal labour 



Fig 6 Brow presentation. 



i Slow labour may be due to poor uterine activity or fetal obstruction. 

i Obstruction may be due to true cephalopelvic disproportion (i.e. the baby is too big or the pelvis 
too small). It may also be due to relative cephalopelvic disproportion (i.e. with malposition or 
malpresentation). 



54 OBSTETRICS 



Operative delivery 



Forceps and ventouse can be used to 
deliver a baby in the second stage of 
labour. Caesarean section can be used 
in both the first and second stages. 
Operative delivery may be indicated: 

1. in the presence of fetal distress or 

2. for 'delay 1 or failed progress despite 
good contractions and maternal 
effort. 

Forceps delivery 

There are three main types of forceps 
(Fig. 1): 

■ Low-cavity outlet forceps (e.g. 
Wrigley's), which are short and light 

■ Mid cavity forceps (e.g. Haig 
Ferguson, Neville Barnes, 
Simpson's] for when the sagittal 





Blade Shank ^ g Handle 




Direction knob 



(<fl 



Slight pelvic curve 



Fig . 1 Types of forceps and ventouse cups. 

Ca) Forceps: from left to right, Kielland's, mid-cavity, 
Wrigley's. Ventouse cups: metal [above), Silastic 
(below). Cb) Wrigley's forceps, (c) Simpson's mid- 
cavity obstetricforceps. Cd) Kielland's forceps. 



Table l Criteria for instrumental vaginal 
delivery 

9 1 he cervix fully dilated with the membranes ruptured 

■ T'ie 'lead at spines or below with no head palpable 
abdom na'ly 

■ T he oosit:on of the head known 

■ "The olsdder err.pty 

■ Analgesia satsiactory (perineal infiltration and 
pucenca; blocks usually suffice for mid-cavity and 
ventouse deliveries but spinal or epidural analgesia is 
requi'edfor K eland's) 



suture is in the anteroposterior 
plane (usually occipitoanterior). 
■ Kielland's forceps for rotational 
delivery (the reduced pelvic curve 
allows rotation about the axis of the 
handle). 

The most common indications for use 
of forceps are presumed fetal distress 
or second stage delay. The criteria 
listed in Table 1 should all be met 
before forceps delivery is attempted. 

The most difficult part is often 
identifying the fetal position accurately. 
If there is a suspicion from palpation of 
the sutures that the baby is 
occipitotransverse, it is often helpful to 
try to feel for an ear anteriorly under 
the symphysis pubis (this is painful). 

Low or mid-cavity non-rotational 
forceps (Fig. 2) 

The mother should be placed in the 
lithotomy position with her bottom 
just over the edge of the bed (the 
bottom half of the bed needs to lift 
away). Using an aseptic technique, the 
perineum is cleaned and draped, the 
bladder emptied and the vaginal 
examination findings rechecked. 
A pudendal block and perineal 
infiltration is inserted if required, and 
the forceps assembled discreetly in 
front of the perineum before 
application, care being taken to ensure 
that the pelvic curve will be sitting 
over the malar aspect of the baby's 
head, convex towards the baby's face. 
The handle that lies in the left hand is 
inserted to the mother's left side by 
placing the right hand into the vagina 
to prevent injury and slipping the 
blade between the hand and baby's 
head between contractions 
(Fig. 2a,b,c). Opposite hands are used 
for the right blade and the blades are 
locked into position by lowering the 
handles and allowing articulation to 
occur gently (Fig. 2d). 



(a) 





Fig. 2 Mid-cavity forceps delivery 

(see text). 



Operative delivery 55 




(b) 




(d) 





Traction is applied by pulling 
initially downwards at an angle of 
= 60° (maternal pelvis to obstetrician's 
pelvis if sitting), with the direction of 
traction becoming horizontal and then 
upwards as the baby's head advances 
over the perineum (Fig. 2e,f). It is 
usual to perform an episiotomy as the 
vulva stretches, but occasionally this 
may not be necessary with a low- 
cavity lift-out in a parous woman. The 
forceps are removed after delivery of 
the babys head, and the remainder of 
the baby is delivered as normal. 

Rotational forceps (Fig. 3) 
These lack the pelvic curve of non- 
rotational forceps and can be applied 
directly to the baby's head if it is 
occipitoposterior to allow rotation to 
occipitoanterior before traction. If the 
baby's head is occipitotransverse, the 
blades may be applied directly, or the 
anterior blade applied posteriorly, 
before being 'wandered' past the baby's 
face to the anterior position (Fig. 3a-d). 
After gentle rotation to occipitoanterior, 
delivery is as for the mid-cavity forceps. 
Rotational forceps require considerable 
skill, and may be associated with 
greater maternal injury than rotational 
ventouse. They should only be used by 
experienced obstetricians. 

Manual rotation can be a useful 
alternative for correcting malposition 
as it may be possible to rotate the fetal 
head to occipitoanterior using digital 
pressure on the sutures (usually the 
lambdoid sutures). Some operators 
prefer to rotate during a contraction 
to minimize the risk of pushing the 
head up out of the pelvis. 







Fig. 3 Rotational forceps, (a] The forceps 
blade is inserted posteriorly, (b) It is then 
'wandered'anteriorly over the baby's face. 

(c) It sits unsupported in this position. 

(d) The other blade is applied directly and 
locked to the anterior blade. The head can then 
be rotated to occipitoanterior before delivery by 
direct traction. 



56 OBSTETRICS 



Ventouse (Figs 4,5,6) 

Ventouse may be associated with less 
maternal trauma than are forceps. The 
same criteria for use apply to ventouse 
delivery as to forceps. The use of a soft 
Silastic cup rather than a metal 
vacuum extractor cup is associated 
with more failures but with fewer 
neonatal scalp injuries. Silastic cups 
are therefore often used for 
occipitoanterior deliveries and a metal 
occipitoposterior cup for transverse 
and posterior malpositions. 

The cup is ideally placed in the 
midline overlying, or just anterior to, 
the posterior fontanelle (Fig. 5). 
Suction is applied, care being taken to 
ensure that the vaginal skin is not 
included under the cup. Traction is 
also applied downwards as for forceps, 
but delivery is much more likely to be 
successful if traction is timed with 
contractions and maternal effort. The 
risk of significant fetal injury is 
increased with use of metal cups 
(rather than Silastic), and duration of 
application. 

Whether to use ventouse or forceps 
remains an area for debate, but 
depends to a significant degree on 
operator experience and familiarity. 
The use of ventouse compared to 
forceps is associated with an increased 
risk of failure, less regional/general 
anaesthesia, less maternal perineal or 
vaginal trauma, more 
cephalhaematomata, more retinal 
haemorrhages, and more low Apgar 
scores at 5 minutes. No differences 
between ventouse and forceps were 
found in the one study that followed 
up mothers and children for 5 years. 

The vacuum extractor is 
contraindicated with a face 
presentation. Although it has been 
suggested that it should not be used at 
gestations of less than 3G weeks 
because of the risk of 
cephalhaematoma and intracranial 
haemorrhage, a case control study 
suggests that this restriction may be 
unnecessary. There is minimal risk of 
fetal haemorrhage if the extractor is 
applied following fetal blood sampling 
or application of a spiral scalp 
electrode. No bleeding was reported in 
two randomized trials comparing 
forceps and ventouse. 

Forceps delivery before full dilatation 
of the cervix is contraindicated and 
ventouse before full dilatation should 
only be considered in special 
circumstances and with a very 
experienced operator. 




Fig. 4 Ventouse - the 'flexing median' is the correct position for cup application. The three 
other abnormal positions are much less likely to lead to a successful vaginal delivery and are more 
associated with fetal trauma. 




Fig. 5 Ventouse - method of traction. 

Note the finger-thumb position. 




(a) 




(b) 




Fig. 6 Ventouse delivery. 



Caesarean section (Fig. 7) 
Caesarean section may be: 

1. Pre-labour (i.e. 'elective') for many 
reasons, e.g. placenta praevia, severe 
intrauterine growth restriction 
(IUGR), severe pre-eclampsia, 
transverse lie or breech presentation 
unsuitable for vaginal delivery. 

2. In labour (i.e. 'emergency 1 ), usually 
for the reasons listed under 'Forceps 
delivery if not fully dilated or 
suitable for vaginal delivery. 

Maternal mortality is higher for 
emergency section than for elective 
section. Overall, there is also significant 
morbidity from thromboembolic 
disease, haemorrhage and infection. 
Lower uterine segment caesarean 
section is by far the most commonly 
used and has a lower rate of 
subsequent uterine rupture, together 
with better healing and fewer 
postoperative complications. A 
classical caesarean section (vertical 
uterine incision) will provide better 
access for a transverse lie following 
ruptured membranes, or with very 
vascular anterior placenta praevias, 
very preterm fetuses (particularly after 
spontaneous rupture of the 
membranes), or large lower segment 
fibroids. The chance of scar rupture in 
subsequent pregnancies following a 
vertical uterine incision is, however, 
much greater. 

Preparation includes intravenous 
access, group and save, sodium citrate 
± ranitidine (to reduce the incidence 
of Mendelson's syndrome), 
appropriate thromboprophylaxis and 
antibiotic prophylaxis, anaesthesia 
(spinal, epidural or general), and 
catheterization. The table should be 
tilted 15° to the left side (reduces 
aortocaval compression), and a lower 
abdominal transverse incision made, 
cutting through the fat and the rectus 
sheath to open the peritoneum. The 
bladder is freed and pushed down, 



Operative delivery 57 



and a transverse lower segment 
incision made (Fig. 7a-c). 

The baby's head is encouraged 
through the incision with firm fundal 
pressure from the assistant (Wrigle/s 
forceps are occasionally required). If 
the baby is a breech presentation, 
traction is applied to the pelvis by 



placing a finger behind each flexed 
hip (Fig. 7d) and, if transverse, a leg 
identified to deliver (i.e. internal 
podalic version). After delivery, 
Syntocinon is given i.v. stat. and the 
placenta delivered after uterine 
contraction. Haemostasis is obtained 
with straight artery forceps, a check 



made to ensure that the uterus is 
empty and that there are no ovarian 
cysts, and the incision closed with two 
layers of dissolving suture to the 
uterus (Fig. 7e,f), one layer to the 
sheath and one layer to the skin. 




Fig. 7 Caesarean section [see text). 



Operative delivery 



i Forceps may be low-cavity (outlet), mid-cavrty or rotational [Kielland s). 

i The use of ventouse compared to forceps is associated with less maternal perineal trauma, more cephalhaematomata and more retinal haemorrhages 

i Maternal mortality is higher for emergency caesarean section than for elective section. 



58 OBSTETRICS 



The perineum 



Perineal tears 

Perineal trauma affects women's physical, 
psychological and social well-being in 
both the immediate and long-term 
postnatal periods. It can also disrupt 
breast feeding, family life and sexual 
relations. In the UK, approximately a 
third of women will continue to have 
pain and discomfort for 10-12 days 
postpartum and 10% of women will 
continue to have long-term pain (3-18 
months following delivery). Faecal 
incontinence and urinary incontinence 
can occur postpartum (see below). 

It was previously felt that the use of 
episiotomy reduced the incidence of 
anal sphincter tears. There is, however, 
little good evidence to suggest that this 
is the case, and there is certainly no 
evidence to support routine episiotomy 
in all deliveries to prevent third- or 
fourth-degree tears. Midline episiotomy 
in particular offers little protection and 
right posterolateral episiotomy is 
preferred (see p. 47). 

The rate of episiotomy has wide 
geographic variations from 8% in the 
Netherlands, 20% in England and Wales, 
50% in the USA to 99% in some Eastern 
European countries. It is also high in 
many developing countries. It is 
therefore difficult to define what a 'good' 
episiotomy rate should be. Restricting 
the use of episiotomy to specific fetal 
and maternal indications leads to lower 
rates of posterior perineal trauma and 
healing complications. A tear may be 
less painful than an episiotomy and may 
also heal better. 

There is controversy about whether 
the baby's head should be 'controlled' 
during delivery (i.e. a hand used to slow 
the head as it delivers). A controlled 
head is likely to tear the perineum less, 
but may increase the blood flow and 
distract the mother in her pushing. 

Spontaneous tears are defined as: 

■ first degree involving skin only 

■ second degree involving perineal 
muscles 

■ third degree involving partial or 
complete disruption of the anal 
sphincter 

■ fourth degree involving complete 
disruption of the external and internal 
anal sphincters and anal mucosa. 

Although there is some dispute as to the 
most useful classification for perineal 
tears this system allows a differentiation 
to be made between injuries to the anal 



sphincter and those involving the anal 
mucosa. Anterior perineal trauma is 
defined as any injury to the labia, 
anterior vagina, urethra or clitoris and is 
associated with less morbidity. 

Repair of perineal tears should be 
with an absorbable synthetic material 
(Dexon or Vicryl), using a continuous 
subcuticular (possibly non-locking) 
technique to minimize short- and long- 
term problems. Good perineal toilet 
post-delivery is likely to aid healing, and 
the use of ice packs and analgesia may 
be useful to control symptoms. 

There is some evidence to support the 
use of perineal massage in women 
completing their first pregnancy as a 
preventive measure to reduce the 
incidence of trauma. 



Repair of episiotomy or first- or 
second-degree tear (Fig. i) 

1. Infiltrate with 1% lidocaine 
(Iignocaine) (unless an epidural is in 
situ or the perineum has been 
infiltrated prior to delivery) (Fig. la). 

2. Find the apex of the vaginal incision 
or tear and place the first suture 
above this level (but note that the 
rectum is just posterior to the vaginal 
wall) (Fig. lb). 

3. Use a continuous locking suture to 
appose the vaginal wall, continuing 
until the hymenal edges are apposed. 
The suture can then be tied, or more 
simply locked, and the needle threaded 
between the apposed vaginal edges a 
few centimetres back ready to close the 
perineal body. 




Fig. 1 Repairing an episiotomy (see text). 



The perineum 59 



4. The perineal body sutures should be interrupted, and then 
a continuous finer suture used for the skin (Fig. lc-e). It is 
possible that not closing the skin (i.e. leaving the skin edges 
approximately 5 mm apart] reduces postnatal pain. Check 
instruments and swabs (a retained swab is a common cause 
of litigation in obstetrics). 

Repair of third- or fourth-degree tears 

This should ideally be by an experienced clinician in a theatre 
with good analgesia and light The edges of the sphincter should 
be approximated or overlapped, with the knots tied in the lumen 
of the bowel rather than buried in the perineal tissues. 
Antibiotics, laxatives and fibre are important to allow healing. If 
secondary breakdown occurs, it mav be necessary to perform a 
defunctioning colostomy before re-repairing. 

Postnatal urinary tract problems 

In the first year after delivery, 3-5% of women experience 
urinary tract infection and about 5% report urinary frequency 
for the first time after delivery. The possibility of low-grade 
urinary tract infection should be kept in mind, especially after 
catheterization. 

At least 20% of women suffer from stress incontinence for 
up to 3 months after delivery, mostly from neuropraxia, 
although this commonly resolves spontaneously. Some will 
still be incontinent a year later without treatment. Postnatal 
exercises may be of help. It is possible that targeting women 
who are still incontinent at 3 months may help, but this needs 
further research. 

Bowel problems 

Up to 20% of women report constipation after delivery, which 
may in part be due to narcotic analgesia in labour. 
Haemorrhoids affect around 20% of women, and these 
frequently last long term. They are more common in 
primiparous women and after instrumental delivery. 

Anal incontinence 

Inability to control flatus or faeces occurs in around 4% of 
women after deliver}'. Because of its embarrassing nature, 
women often fail to report it. New evidence has demonstrated 
that 35% of primiparae have demonstrable damage to the anal 
sphincter, although many of the women with damage do not 
have symptoms (Fig. 2). Both direct trauma and nerve damage 
following spontaneous vaginal or instrumental deliver}' 
contribute to this problem. Proper investigation and treatment 
are essential. 

Elective caesarean section on request 

In view of the potential risks of vaginal deliver} 7 to the 
perineum as outlined above, together with the potential for 
fetal injury, a small proportion of women may request an 
elective caesarean section despite a normal antenatal course. 

Performing such a caesarean section when it is not clinically 
indicated has traditionally been considered inappropriate, but 
views may be changing. Elective caesareans under regional 
blockade with antibiotic cover and appropriate 
thromboprophylaxis are relatively safe, and short-term 







(bi 



Fig. 2 Anal sphincter damage on endoanal ultrasound, (a) Normal 
anal sphincter scan, (b) Anterior anal sphincter defect exceeding one 
quadrant. 

neonatal complications from transient tachypnoea and 
respiratory distress syndrome are reduced by delaying the 
operation until 39 weeks of pregnancy. Nonetheless, all surgery 
carries risks and the longer-term possibilities of adhesions, scar 
rupture, visceral damage and the potential for more difficult 
future gynaecological surgery need to be considered. 



The perineum 



i There is no evidence to support routine episiotomy - a tear may be less painful than an 
episiotomy and may also heal better. 

i Right (or left) posterolateral episiotomy is preferable to a midline episiotomy. 

i Perineal damage may affect bladder, bowel and sexual function. 

i Third- and fourth-degree tears need to be repaired by experienced clinicians. 



60 OBSTETRICS 




partum haemorrhage and abnormalities of 
the third stage of labour 



Postpartum haemorrhage (PPH) can be 
sudden, dramatic and life threatening 
and is one of the obstetric emergencies. 
Primary PPH is the loss of more than 
500 ml of blood from the genital tract in 
the first 24 hours after the delivery. 
Secondary PPH is excessive blood loss 
from the genital tract between 24 hours 
and G weeks postpartum (see p. G6). 

The usual mechanism for control of 
uterine blood loss following delivery of 
the placenta is for contraction with 
retraction of the uterine muscle. This 
means shortening of the fibre length 
and the muscle fibres maintaining this 
shortened length. Due to the interlacing 
nature of the muscle fibres this retraction 
will stem the bleeding that has been 
supplying the placenta (Fig. 1). 

Causes of postpartum 
haemorrhage 

The main causes of PPH are given in 
Table 1. 

Primary postpartum 
haemorrhage 

Uterine atony is the commonest cause 
(~ 90%) of primary PPH and may be 
due to many differing factors (Fig. 2). 

Trauma is the second most common 
cause of primary PPH (~ 7%), with 
coagulation disorders making up the 
remainder. Caesarean section may be 
associated with blood loss greater than 
500 ml and therefore constitutes a PPH. 
Additional bleeding will occur if the 
uterine incision extends laterally to the 
uterine artery or down towards the cervix. 

Caesarean section for an anterior 
placenta praevia is highly likely to be 




Table 1 Causes of primary and secondary 
postpartum haemorrhage 

Primary Secondary 

Uterine atony - common Retained products 

of conception 
Cervical lacerations - rare Infection 

Vaginal lacerations - rare 
Uterine tear/rupture - very rare 
Coagulation disorders 



associated with excessive blood loss, 
particularly in the presence of a previous 
caesarean section scar as placenta 
accreta or percreta may have occurred. 
Placenta accreta is abnormal adherence 
of all or part of the placenta to the 
uterine wall - termed placenta increta 
where there is placental infiltration of 
the myometrium or placenta percreta if 
penetration reaches the serosa. 

Tears of the cervix or vagina may 
result in considerable blood loss and 
need suturing. A spiral vaginal tear is 
classically described associated with a 
rotational forceps delivery (see p. 55). 

Management of primary 
postpartum haemorrhage 

Active management 

With the adage that prevention is better 
than cure, active management of the 



APH - blood between muscle 
fibres interfering with retraction 
May also be associated with 
congenital defect and excessive 
bleeding 



FIBROID can interfere 
with contractility 



Grand multiparity Irisk 
of PPH as may have 
more fibrous tissue 
within uterine wa 



Past history of PPH 
associated with + incidence 
of PPH - mechanism unclear 




third stage of labour reduces blood loss 
by 50% - although it leads to a slightly 
increased risk of retained placenta (see 
below). In some high-risk conditions an 
intravenous infusion of oxytocin is used 
in addition to the bolus dose. High-risk 
conditions would include prolonged 
labour, known placenta praevia, 
polyhydramnios, twin pregnancy, high 
parity, uterine fibroids, abruptio placentae 
or previous PPH. 

Retained placenta 

The placenta is usually separated from 
the uterus during the process of uterine 
retraction and maternal effort or 
controlled cord traction used to expel the 
placenta and membranes from the uterus. 

If the placenta does not separate or 
only partially separates and there is 
bleeding, removal needs to be facilitated. 
Controlled cord traction may encourage 
delivery of the placenta. If this measure 
fails, manual removal of the placenta 
will be required. During this procedure 
prevention of infection is important, 
thus obstetric antiseptic cream is used, 
the hand and arm being covered. The 
gloved hand is placed into the uterus 
and the placenta and membranes 
removed. The hand is allowed to be 
placed back into the uterus on one 



Overdistension of uterus 
(twins, polyhydramnios) 
nhibits normal uterine retraction 

Large placental site 
(multiple pregnancy) bleeds 
more 



CLOT 

filling uterine cavity 
prevents muscle retraction 



FULL BLADDER due to 

diuresis immediately after 
delivery, when blood flow 
from placental bed returns 
to main circulation. 
The bladder interferes with 
adequate uterine retraction 



Fig. 1 The usual mechanism for control of 
uterine blood loss following delivery. The 

mesh-like network of smooth muscle fibres, on 
contraction and retraction, controls bleeding. 



CLOT 

in cervix causes intense 
pain, cervical shock and 
prevents retraction 



Fig. 2 The main causes of uterine anatomy. 



Postpartum haemorrhage and abnormalities of the third stage of labour 61 



further occasion to check that all 
products have been removed. This 
procedure is usually done under 
regional blockade and only rarely under 
general anaesthesia, unless in the 
presence of a PPH. 

For practical management of primary 
PPH: 

■ summon senior help 

■ summon an anaesthetist 

■ keep ahead of the blood loss 

■ rub up a contraction and cafheterize 
to ensure bladder empty and allow 
monitoring of urinary output 

■ gain intravenous access with two large 
venflons; run in crystalloid or colloid 
and cross-match G units of blood 

■ give Syntocinon intravenously 

■ remove placenta if possible; ensure no 
blood clot distending the cervix 

■ if apparent uterine atony, further 
intravenous Syntocinon and 
carboprost intramuscularly or 
intramyometrially 

■ if bleeding possibly due to trauma, 
general anaesthetic (not regional 
block] is required before repairing 
lacerations 

■ in the face of persistent bleeding 
consider internal iliac artery ligation, 
hysterectomy or radiological 
embolization 

■ intensive therapy unit support and 
central monitoring; correct 
coagulopathy as disseminated 
intravascular coagulopathy [DIC) is 
likely - fresh frozen plasma and 
uncross-matched or group-specific 
blood may be transfused; monitor for 
development of acute renal failure and 
adult respiratory distress syndrome. 

Secondary postpartum 
haemorrhage 

Distinguishing between retained 
products of conception and infection 
allows effective management of 
secondary PPH. Pyrexia, raised WBC, 
offensive lochial discharge and a closed 
cervical os are found with endometritis 
which will require antibiotics 
particularly covering anaerobic 
organisms. Intravenous therapy for 
24 hours and bed rest will usually see a 
rapid improvement. 

Bleeding, maybe with passage of 
tissue, an open cervical os and failure of 
uterine involution leaving the uterus 
larger than usual for the number of 
postpartum days are all features of 
secondary PPH due to retained products 
of conception. The patient will be taken 
to theatre for evacuation of the uterus 
under anaesthesia. Antibiotic cover may 



prevent the development of 
endometritis. Syntocinon or ergometrine 
are used to control blood loss. It is 
usually unnecessary to request uterine 
ultrasound to make the diagnosis. 

Third stage problems 

These may include: 

■ failure of placental separation 

■ incomplete placental separation 

■ postpartum haemorrhage - due to 
retained portion of placenta 

■ uterine atony - leading to excessive 
blood loss 

■ tear of genital tract 

■ collapse [may be due to excessive 
blood loss, eclamptic fit, amniotic 
fluid embolus, cardiac failure, 
pulmonary embolus, cerebral 
haemorrhage, diabetic coma) 

■ uterine inversion (p. 63). 

Collapse in the third stage needs prompt 
action to ensure maternal well-being. 
Epilepsy and diabetes would be known 
about from the history and there may 
be a relevant cardiac history. Blood loss 
would be obvious. Amniotic fluid 
embolus, cerebral haemorrhage and 
pulmonary embolus would all be 
associated with sudden collapse of the 
mother needing resuscitation and 



investigation to distinguish between the 
pathologies. 

Sheehan's syndrome 

This is an especial problem in obstetrics 
if there is profound hypotension that 
remains uncorrected. During pregnancy 
the pituitary gland increases in size 
predisposing it to circulatory problems 
if there is blood loss. It has end arterial 
blood supply which means no collateral 
supply, and hypotension may result in 
an avascular pituitary gland. If this is not 
corrected quickly enough the pituitary 
gland will undergo avascular necrosis 
(Sheehan's syndrome) (Fig. 3). 

The consequences of this depend on 
which area of the pituitary gland is 
inactivated. If the anterior lobe is lost 
then no follicle-stimulating hormone 
(FSH), luteinizing hormone (LH), 
thyroid-stimulating hormone (TSH), 
growth hormone (GH), prolactin or 
adrenocorticotropic hormone (ACTH) 
will be produced resulting in secondary 
amenorrhoea, atrophy of breasts and 
genital organs, osteoporosis, 
hypothyroidism and Addisonian 
symptoms. 

The importance of adequate and urgent 
blood and fluid replacement in 
postpartum haemorrhage is thus obvious. 




Fig. 3 Histology of pituitary gland in Sheehan's syndrome. 



Postpartum haemorrhage 

i Postpartum haemorrhage can be life threatening. 

i Uterine atony is the commonest cause of primary postpartum haemorrhage. 

i Emergency management includes ensuring contraction of the uterus and adequate fluid 
replacement. 

i If the uterus is well contracted check for trauma to the genital tract and that blood is dotting 

i Active management of the third stage of labour reduces the incidence of primary postpartum 
haemorrhage. 

i Retained products of conception are prevented by a thorough check of the completeness of the 
placenta and membranes at delivery. 



62 OBSTETRICS 



Obstetric emergencies 



Amniotic fluid embolism 

This rare complication occurs when 
amniotic fluid suddenly enters the 
maternal circulation during labour or 
delivery. It carries a high maternal 
mortality Cup to 80%) and is associated 
with multiparity, precipitate labour, 
uterine stimulation and caesarean 
section. Clinically there is sudden 
dyspnoea, fetal distress and 
hypotension, followed within minutes 
by cardiorespiratory arrest with or 
without seizures. It is often followed 
by haemorrhage from disseminated 
intravascular coagulation (DIC) and 
uterine atony, and may lead to acute 
renal failure (ARF) and adult 
respiratory distress syndrome (ARDS; 
Fig. 1). It is often diagnosed by 
exclusion (Table 1), but is ideally 
identified by the presence of fetal 
squamous cells on a blood film from a 
central line. 

Management includes 
cardiopulmonary resuscitation (CPR) 
with high-flow 2 , with or without 
ventilation if required, and 
consideration given to urgent delivery. 
Two large-bore i.v. lines are inserted 
and the patient is rapidly infused with 
a combination of crystalloid and colloid 
until the blood pressure approaches 
normal. This is then stopped to 
minimize the risk of ARDS. As uterine 
atony is common, oxytocics are given 
postnatally. Bloods are sent for clotting, 
screen and cross-match to anticipate 
DIG Cardiogenic shock, ARDS and ARF 
are managed as appropriate. 




Fig. 1 ARDS. There is bilateral alveolar 
consolidation. 

Cord prolapse 

This may occur especially when 
membranes rupture (or are ruptured) 
with a high or poorly fitting presenting 
part (Fig. 2). The risk is of cord 
occlusion with pressure from the 
presenting part, or of vessel spasm and 
constriction following exposure to the 
lower temperature of the air, leading 
to hypoxia and possibly death. It is 
also more likely to occur with twins, 
polyhydramnios, breech or transverse 
lie. 

■ If the cord is palpated before 
artificial rupture of the membranes 
('cord presentation') then caesarean 
section is required. 

■ If cord prolapse occurs, the 
presenting part should be displaced 
upward with a hand and the hand 
kept there until delivery. If the cervix 
is fully dilated and easy delivery is 
anticipated, then an immediate 
forceps or ventouse delivery should 
be carried out. If not, then the 



Table i Causes of 

Problem 

Amniotic fluid embolism 



Anaphylaxis 

Cerebrovascular 
accident 

Eclampsia 

Myocardial infarct 
lens ion pneumothorax 

Pulmonary embolism 

Uterine irwension 



sudden collapse 

Discussion 

Is associated with multiparty, precipitate labour, uterine stimulation arro caesarean 
section There is sudden dyspnoea fetal distress and hypotension : o lowed witnr 
minutes by cardiorespiratory arrest - seizures 

Tbeie may be cyanosis, hypotension wheeling, pallor, prostration and tachycardia 
± urticaria 

May tie history nf severe pregnancy-induced hypertension or past history of intracranial 
problems [e.g. previous subarachnoid haemorrhage]. Nausea and vomiting with 
headache 

There is a tonic-clonic seizure [differentiate from epilepsy and amniotic fluid embolism 

on the basis of the history] 

May be past history of heart disease. Chest pain, sweating, pallor 

There is sudden onset of pleuritic chest pain (differentiate from pulmonary embolus) 
and diminished breath sounds 

There may be apprehension, pleuritic chest pain, sudden dyspnoea, cough, 
haemoptysis and collapse [differentiate from pneumothorax] = antecedent risk factors 

Occurs in the third stage only. It may lead lo profound hypotension (there may be only 
a partial inversion and therefore the diagnosis may not be obvious] 




The most important symptoms and signs are in bold type. 



Fig. 2 Cord prolapse. 

patient should be instructed to adopt 
the knee-chest position (kneeling 
with head down) and transferred to 
theatre for an immediate caesarean 
section under general anaesthesia or 
rapid spinal anaesthesia. 

Mendelson's syndrome 

This is due to pulmonary injury 
following inhalation of acid gastric 
contents, and is more likely during 
obstetric anaesthesia than routine 
anaesthesia because of pressure from 
the gravid uterus and reduced 
competence of the gastro-oesophageal 
sphincter. There is rapid onset of 
cyanosis, bronchospasm, tachycardia 
and pulmonary oedema. Cricoid 
pressure should be used with 
induction of general anaesthesia to 
minimize the risk. 

If inhalation occurs, the patient 
should be given 100% 2 , tilted head 
down and turned onto her left side. 
The pharynx should be aspirated. 
Antibiotics may prevent secondary 
infection. Further management is with 
ventilation if required, physiotherapy 
and rarely bronchoscopic aspiration of 
mucous plugs. 

Shoulder dystocia 

The shoulders are stuck in the 
anteroposterior (AP) plane with the 
anterior shoulder behind the 
symphysis pubis (Fig. 3). Prompt, calm 
action is vital, as the baby will become 
rapidly asphyxiated and will die 
without appropriate action. The 
diagnosis is made after failure to 
deliver shoulders with the. first 
downward pull of the head. 

Management 

The acronym 'PALE SISTER' 
summarizes the management of 
shoulder dystocia. 



Obstetric emergencies 63 




Fig. 3 Shoulder dystocia. The anterior 

shoulder is behind the symphysis pubis. 



P Prepare. There should be a plan, 

and the team should know the plan. 
A Assistance. Experienced help 

should be sent for, and 

management started immediately. 
L Legs into McRobert's position 

[femora abducted, rotated outwards 

and flexed such that the thighs 

touch the abdomen). This 

straightens the sacrum relative to the 

lumbar spine, rotating the 

symphysis anteriorly, and allows the 

anterior shoulder to enter the pelvis. 
E Episiotomy (make it large). 

S Suprapubic pressure. An assistant 
should apply suprapubic pressure 
with 'CPR' hand posture over the 
anterior shoulder both laterally 
(towards the direction the baby is 
facing) and posteriorly (to rotate it 
under the symphysis), while gentle 
traction is applied from below. It 
should be abandoned after 30-GO 
seconds. 

I Internal rotation. Traction should 
be continued and a hand inserted 
to push the anterior shoulder 
forwards with counterpressure on 
the posterior clavicle to rotate the 
trunk to oblique. It should be 
abandoned after 30-GO seconds. 

S Screw manoeuvre. Pressure is 
applied to the posterior aspect of 
the posterior shoulder, attempting 
to place the shoulder into oblique. 
This may disimpact the anterior 
shoulder. It should be abandoned 
after 30-GO seconds. 

T Try recovering posterior arm. 
An attempt should be made to 
deliver the posterior shoulder by 
pulling the posterior arm down, 
flexing it across the chest It should 
be abandoned after 30-GO seconds. 

E Extreme measures. The choice is 
to either: 







Fig. 4 Uterine inversion secondary to cord traction. Ca] Partial inversion (b) Complete 
inversion, (c) Complete inversion with prolapse, (d) Position of the hands to avoid uterine inversion in 
the third stage. 



■ try the above again 

■ fracture the clavicle (it may 
already be fractured after the 
above manoeuvres) 

■ push the baby's head back up 
and perform a caesarean section 
(Zavanelli manoeuvre) or 
perform a symphysiotomy, using 
a scalpel to divide the symphysis 
pubis to increase the size of the 
pelvic outlet 

R Repair, record details, relax. 
Make comprehensive notes. 

Uterine inversion 

This is usually an iatrogenic problem 
caused by pulling on the cord before 
separation and should be suspected if 
there is profound shock without 
obvious explanation (Fig. 4). It may be 
partial or total. 

The placenta should not be detached 
until the uterus is replaced and 
contracted. If the prolapse is easily 
reducible, it should be reduced. If the 
reduction is unsuccessful, hydrostatic 
reduction (O'Sullivan's) is used. The 
inverted uterus is held within the 
vagina by the operator and the 



introitus sealed with the two hands of 
an assistant. Two litres of warm saline 
are infused rapidly (through a wide- 
bore tube). If all this fails, a laparotomy 
may be necessary. 

Uterine rupture 

This may occur if there has been a 
previous caesarean section (risk with 
lower segment incision < 1%, classical 
or De Lee 5-10%). It may also occur 
with obstructed labour in multiparous 
patients and with use of 
prostaglandins or Syntocinon. It is 
virtually unheard of in primigravidae. 

Classically there is maternal 
tachycardia, shock, cessation of 
contractions, disappearance of the 
presenting part from the pelvis and 
fetal distress. Pain may be minimal or 
may be severe and there is variable 
bleeding per vaginum (bleeding is 
intraperitoneal if there is a complete 
rupture). It may present postpartum 
with a continued trickle or bleeding in 
the absence of another cause. 

An immediate laparotomy under 
general or rapid spinal anaesthesia is 
required for delivery. 



| Obstetric emergencies 



■ It is important to practise emergencies in advance: who will be called to do what, how will they 
do it, what will they do. what will they do next and what if that still does not work. 

■ Amniotic fluid embolism may lead to ARDS. DIG or acute renal failure and carries a high maternal 
mortality rate. 

■ Cord prolapse may occur with artificial membrane rupture with a high head- 

■ Shoulder dystocia requires a calm approach and working through a practised protocol. 



64 OBSTETRICS 

The normal puerperium 



1MB 



It is important to understand the 
normal process of the puerperium in 
order to be able to recognize 
complications when they occur, with 
the increasing trend towards early 
discharge from hospital, often before 
lactation is established. 

Physiological changes 

Physiological changes occur rapidly in 
the first week postpartum. 

Structural 

Immediately postdelivery the fundus of 
the uterus is just below the umbilicus. 
It should be impalpable abdominally 
by the end of the first week and 
almost normal size on bimanual 
assessment at G weeks. The lochia is 
the normal discharge from the genital 
tract in the puerperium. It is red for 
the first 3 days, then pink and becomes 
yellow/brown by the end of week one, 
diminishing in volume over 3-6 weeks. 

Endocrine 

Serum progesterone and oestradiol fall 
to non-pregnant levels by 72 hours. 
Human placental lactogen (HPLO levels 
fall rapidly in the first 48 hours but are 
still detectable at the end of the first 
week. Thyroxine and thyroid-binding 
globulin fall slowly to normal over 
S weeks. Fasting plasma, insulin and 
the insulin response curve are normal 
2 days postpartum. 

Body weight 

On average a woman will lose G kg 
through labour and parturition (water 
loss and products of conception). Body 
weight stabilizes by 10 weeks 
postdelivery. A diuresis commences 
within the first 3 to 4 days postnatally. 
The haemoglobin level is lowest on 
day 4 to 5 postdelivery and then rises 
slowly until 8 weeks postpartum. 
Changes in platelet levels and other 
coagulation factors produce a relative 
hypercoagulability, persisting for 
approximately 8 weeks. During the 
first 4 weeks postnatally, there is a 
50-fold increase compared to the non- 
pregnant state. 

Milk 

The suckling stimulus releases 
prolactin and oxytocin - the former 
stimulates lactogenesis, the latter 



controls milk ejection. Initially, milk 
rich in colostrum is released. Milk 
production commences by day 3. 

Routine care 

Routine observations carried out 
postpartum include pulse rate, blood 
pressure and temperature. If these are 
normal, daily recordings of the pulse 
rate and temperature will suffice. If the 
blood pressure has previously been 
elevated, 4 -hourly readings are 
continued until it settles. The fundal 
height is checked daily to ensure that 
involution is occurring normally. The 
lochia is inspected and the volume, 
colour and odour noted. Very offensive 
lochia will require further 
investigation. 

It is important to check the urine 
output, as retention can occur 
postnatally secondary to a painful 
perineum, after an epidural, or 
following surgery. A full bladder will 
increase the apparent fundal height 
and may retard uterine contraction. 
Perineal toilet after each bowel action 
should prevent infection of the 
episiotomy and subsequent 
breakdown. The perineum is often 
swollen and painful and many women 
develop haemorrhoids secondary to 
the expulsive efforts of labour. 
Adequate analgesia, laxatives and rectal 
suppositories may be required. 

There must be adequate time for 
supervision and support of the mother 
following delivery. She must become 



familiar with nursing and bathing her 
infant with confidence, and the 
method of feeding to be adopted. 
Supervision of these processes may 
begin in hospital or be initiated in the 
community. 

Breast feeding 

Most women have made the decision 
to breast feed prior to delivery. Many 
units have a breast-feeding counsellor 
to offer guidance. There are some 
obvious advantages to breast feeding 
[Table 1). Consistent advice should be 
given by health care professionals to 
avoid confusion and demotivation. 

The correct positioning of the baby 
on the breast is vital to prevent 
chewing of the nipples, causing sore or 
cracked nipples which can predispose 
to infection and discomfort [Fig- V). 
Milk production requires a good fluid 
intake. Many mothers feed their babies 
'on demand', others introduce a 3- to 
4 -hourly feeding regime. 
Supplementary and complementary 
feeds have not been shown in any 
randomized controlled trials to be of 
benefit to healthy term breast-fed 
infants. Extra fluids are no longer 
recommended for jaundiced babies. 
The best management is demand 
feeding. All babies will initially lose 
weight until lactation is fully 
established. 

Human milk delivered at a rate of 
750-800 ml a day [in a healthy, well- 
nourished mother) contains calcium at 



Tabic 1 Advantages of and contraindications for breast feeding 


Advantages Contraindications 


■ Balanced nutritionally ■ 


Breast implant [breast augmentation) 


■ Passive immunity ■ 


Previous surgery for breast abscess [relative 


M Enhanced bonding 


contraindication] 


■ Reduced infections of ■ 


Maternal phenylketonuria 


- middteew ■ 


Drugs taken by mother 


- respiratory system 


- fithium 


- unnary tract 


cytotoxic drugs 


- gastrointestinal tract 


- immunosuppressants 


■ Reduced incidence of cot death ■ 


Very poor maternal health 


■ Reduced atopy, e.g. eczema ■ 


Puerperal psychosis - in some cases 


■ Reduction in childhood insulin-dependent diabetes ■ 


HIV positive status 


mellitus [by 50%] 




■ Reduced problems of prematurity 




- necrotizing enterocolitis 




- suboptimal neurological development 




■ Cheap and readily available 




■ Easy to deliver [no Sterilization of equipment 




involved] 




■ Reduced incidence in the mother of premenopausal 




breast cancer 




■ Mother more likely to lose weiuM naturally 




■ Babies with cleft palate can be fed with special 




appliances 





The normal puerperium 65 




Incorrect fixing 
Fig. 1 Positioning of the baby on the breast. 



Correct fixing 



Tab e 1 Situations requiring lactation suppression 

■ Bereavement (if the mother wishes] 

- mid-trimester miscarriage 
stillbirth 

- neonalal death 

■ The mother is adamant she wishes to Dottle feed but has a history ol mastitis or breast abscess 

■ Breastfeeding is contiaindicalerl foi whaleve r rea so n 

■ The child is to be given up for adoption 

■ The mother 'S HIV-positive 

Bromocriptine is used, initially 2 o mcj daily increasing to 5 mg a day once it is seen to he tolerated orcabeigo'ine 1 mga 
day stat It must be initiated socri after delivery to be effective as milk production commences on flay 3 Bromocriptine is 
contramdicated in hypertensive women and those with co r onary artery disease. The btood pressure should be monitored 
during treatment. 



Table 3 Contraceptive needs and breast-feeding status 

■ Amenorrhoeic women who are lully breast feeding have a 96^ protection for 6 months 
a 2 fJ K of mothfirs who do not breast feed will ovulate before 28 days 

■ 33V- of mothers who do not breast feed will ovulate before their first period 

■ Ovulation does not occur provided full lactation is maintained, i.e. reduced intervals between feeds, preferably 
2 -hourly feeds, arid 2- to ^-hourly feeds by mght - and complete amenorrhoea 

■ Once supplementary feeds are introduced 5r)ta: of women will ovulate withm 3 months, even if lactation is maintained 

■ All progestogen -based contraception can be used by breast-feeding mothers, eg progestogen -only pill, depot 
injections. Implanon, Mirena 

■ The optimum time to start the contraceptive pill in non -breast-feeding mothers is 3 weeks postpartum, prior to this 
there is a significant risk of thromboembolism 



a concentration of around 34 mg/dl. 
The loss of calcium from the mother is 
substantially more during lactation 
than during pregnancy. Bone density 
studies indicate a loss of bone mineral 
density over 6 months, but this is 
recovered after feeding ceases. 

Bottle feeding 

The mother should be taught how to 
sterilize the bottle correctly, either by 
boiling or immersing in a dilute 
solution of hypochlorite [Milton] or 
using a steam sterilizer. Bottle-feeds 
mimic breast milk as closely as 
possible. Cow's milk is used in 
artificial feeds and contains more 
protein (casein) and less sugar 
(lactose) than is found in human milk. 
The fat content is similar. The higher 
levels of casein make cow's milk less 



digestible. Milk feeds are fortified with 
additional iron and vitamins. 
The volume of milk given 
commences at 20 ml/kg per day and 
builds up to ISO ml/kg per day by the 
seventh day. If babies exhibit an allergy 
to cow's milk, soya milk can be 
substituted. It may sometimes be 
necessary to suppress milk lactation 
(Table 2). 



Postpartum contraception 

The spacing of pregnancies is essential 
for the health of the mother and child. 
Severe anaemia may result if 
pregnancies follow each other too 
closely. 

For breast feeding alone to be effective 
contraception, lactation must be 
complete (Table 3). Progestogen-based 
contraception does not suppress 
lactation and may be used by breast- 
feeding women. For the bottle-feeding 
mother, the combined oral contraceptive 
pill is the most effective method of 
contraception. Hypertension in 
pregnancy is not a contraindication to 
the combined oral contraceptive pill as 
long as the blood pressure has returned 
to normal. Women who intended to 
breast feed but stopped will need to be 
reminded to revise their contraception. 

The coil is traditionally fitted at the 
G-week postnatal visit Risk of uterine 
perforation is slightly higher during 
lactation and following caesarean 
section. Laparoscopic clip sterilization 
carries a higher risk of failure in the 
immediate postpartum period than 
when it is performed as an interval 
procedure. If the previously used 
contraception was the diaphragm, it will 
need to be re-fitted G weeks postpartum. 

The postnatal visit 

Following uncomplicated normal 
vaginal deliveries, the postnatal visit is 
traditionally performed at G weeks at 
the general practitioner's surgery. 
Following difficult forceps deliveries 
and caesarean sections the visit may be 
performed at the hospital. Certainly, if 
there were complications at the time of 
delivery it is important that the parents 
have a chance to discuss the issues 
with the consultant. 

Clinicians should be alert to the 
possibility of postnatal depression. 

It is now thought unnecessary to 
perform a routine vaginal examination, 
which is reserved for symptomatic 
women, or in cases where a smear is 
due or a coil is to be inserted. Most 
women will already have resumed 
coitus without difficulty. 



The normal puerperium 



i A hypercoagulable state exists until approx. 8 weeks postpartum, increasing the risk of venous 
thromboembolism. 

i Breast feeding supplies passive immunity to the infant and reduces the risk of atopy and cot 

:■ :■' 
i Breast milk has a high carbohydrate, but low iron content - it is rich in calcium 
i Bottle milk has a higher protein content, but has less sugar - it is fortified with iron. 
i Contraception is an important issue to allow spacing of pregnancies 



66 OBSTETRICS 



The abnormal puerperium 



Problems occurring in the puerperium 
can be immediate, intermediate or late. 
The most serious complications are 
haemorrhage, infection and 
thromboembolism. 

Haemorrhage 

The incidence of postpartum 
haemorrhage is approximately 7%. 
Haemorrhage may be primary or 
secondary (Table 1). Most severe 
haemorrhages occur within the first 
few hours of delivery. The initial 
management of primary haemorrhage 
is discussed on page GO. 

The most likely cause of secondary 
haemorrhage is retained products of 
conception. Clinically the uterus feels 
large, soft and tender and the cervical 
os is open. An ultrasound scan may be 
useful to confirm the presence of 
retained products if the clinical 
presentation is less obvious. The 
patient will need to return to theatre 
for evacuation of the uterus under 
antibiotic cover. Suction curettage is 
the safest approach. Until full culture 
and sensitivity results are available 
broad-spectrum antibiotics should be 
used that cover both aerobic and 
anaerobic organisms. 



Urinary tract infections are the 
commonest cause of puerperal pyrexia. 
It is always important to repeat the 
urine sample at the end of the course 
of antibiotics to ensure that the 
infection has been eradicated. 

Endometritis is more frequent 
following caesarean section than after 
vaginal delivery. Many centres now 
advocate the use of prophylactic 
antibiotics to cover a surgical delivery, 
especially in cases of prolonged labour 
or prolonged rupture of membranes. 
Cefuroxime or Augmentin are usual. 
Endometritis can be delayed and occur 
secondary to retained products of 
conception. 



Venous thromboembolism 

This is still one of the leading causes 
of maternal mortality. Clinical 
diagnosis of venous thromboembolism 
(VTE) can be difficult. Clinical signs 
are not always clear and initial 
investigations can be normal. 
Venography or duplex Doppler blood 
flow assessment of the femoral veins 
may be necessary. A ventilation- 
perfusion scan is required if 
pulmonary embolism is suspected. 

The most frequent incorrect 
diagnosis is one of chest infection. 
Treatment is mainly with 
subcutaneous, high-dose, twice-daily 
heparin to achieve anticoagulation 



Tabic 1 Postpartum 
Type 


haemorrhage 
Time scale 


Presentation 


Predisposing factors 


Primary haemorrhage 


In the first 24 hours 


Fresh bleeding, often severely 


Uterine atony (9(R' 






heavy Uterus may be soft and 


Trauma, vaginal or cervical 






poorly contracted with the 


lacerations, labia, tears [Fig. 1) 






'undus still above the umbilicus 


Coagulation disorders 


Secondary 


After 24 hours and 


May be fresh 1 dss or o Id . a Iter ed 


Retained products of 


haemorrhage 


up 10 6 weeks 


hloocs. often malodorous. The 


conception 






uterus may feel soft, poorly 


Endometritis 






contracted and poss-biy tender. 


Dysfunctional bleeding 






with the cervical os open 





Infection 

A puerperal pyrexia is defined as any 
febrile illness where the temperature is 
38°C or higher during the first 14 days 
postpartum. This is no longer a 
notifiable illness but still needs to be 
taken seriously. Examination should 
include chest breasts, abdomen, 
perineum and legs. Cervical swab, 
blood cultures and sputum may all 
need to be sent for culture and a mid- 
stream urine sample sent for 
microscopy and culture [Table 2). 

Breast engorgement occurs in the 
first 2-3 days and can be associated 
with a mild pyrexia. This should 
improve spontaneously within 24-48 
hours, particularly if breast feeding is 
encouraged. Mastitis is clinically 
obvious and prompt treatment should 
avoid abscess formation. If an abscess 
occurs the treatment of choice is 
drainage. Lactation need not be 
suppressed. The patient should 
continue to breast feed on the 
unaffected side expressing from the 
infected breast initially. 

Thromboembolism can present with 
pyrexia [see below). 



Table 2 Causes of p 
Site 


lerperal pyrexia 
Timcscalc 


Presentation 


Predisposing factors 


Breast 








B least engorgement 


2 3 days postnatal 


Can cause a transient pyrexia 


Physic log ica 


Mastitis 


2-3 weeks postnatal 


Spreading erythema (cellulitis] 


Milk stasis secondary to 






ever the breast, lymphangitis. 


engorge meni with 






nipple discharge, malaise, 


bacteria entering therm Ik 






fatigue and swinging pyrexia 


ducts v a cracked nipples 
[usually SmpftyfocQcuts 
au.'ous'. 


Breast abscess 


2-3 weeks- postnatal 


Brawny oedema uf overlying skin 
with fluctuating swelling 


Poorly heated mastitis 


Genital trad 








Endometritis 


Variable 


Very unwell, high temperatures 


Repeated vaginal 






[approx. 38°C) tachycardia, bulky 


examinations in labour 






lender uterus ± purulent vaginal 


■~> 4i after rupture of 






discharge 


membranes 
Prolonged rupture of 
membranes 
Cher; cam momtis 
Caesarean sector: 
Episiutomies and tears 
Retained products of 
conception 


Infected episiotomy/tear 


3-4 days postnatal 


Very tender stitch line, often 


Poor surgical technique 






breaking down with oedema. 


Poor perineal hygiene 






haematrjns an d discharge 




Wound infection 


4 /days postnatal 


Tense, tender, erythematous stitch 


Re cms sheath haematoma 


[post LSCS) 




line, occasional abscess formation 


Poo- surgical technique 
Staphylococcal carrier 



Respiratory and urinary tract infections and thromboembolism may all produce pyrexias and would represent differential 
diagnoses [seep. 42). 



The abnormal puerperiuni 67 




Cervix 



Torn edges 



4/ 


J^ervix 


K ^K 


Intact 
anterior lip 


W ^— 


A Torn 
rf surfaces 



Fig. 1 Cervical tears, (a) Lateral 

Cb) 'Bucket handle'. 

(intravenous heparinization is rarely 
used) until symptoms are resolved. 
Initial treatment is followed by 
carefully monitored warfarin treatment 
for 3-4 months. 

Musculoskeletal problems 

Divarication of the recti can occur 
antenatally due to the enlarging uterus 
and effects of raised progesterone 
levels. It is painless but unsightly. 
Treatment is based on improving the 
tone of the abdominal muscles by 
exercise. 

Pregnant pelvic arthropathy (see 
p. 77) may persist postnatally. Treatment 
involves bed rest, non-steroidal anti- 
inflammatory analgesia and a support 
girdle. A zimmer frame may be 
necessary. The condition is self-limiting 
and should improve within the first 
week postnatally. Severe cases may 
continue for several months. 

Bladder and bowel problems 

Urinary retention or voiding difficulties 
may occur postnatally secondary to 
painful episiotomies or use of 
epidurals in labour. Decompression by 
an indwelling catheter for 24-48 hours 
and careful observation of bladder 
function once the catheter has been 
removed is usually all that is required. 




Fig. 2 Mother and baby unit. 

Incontinence can also occur in the 
immediate postnatal period but usually 
improves after a course of pelvic floor 
exercises. Pudendal nerve latency 
conduction studies have shown delayed 
conduction up to G weeks postnatally 
but most have returned to normal when 
the test is repeated at 6 months and 
1 year. In a small proportion of women, 
permanent pelvic floor weakness may 
occur which deteriorates over 
subsequent pregnancies. 

Haemorrhoids are a common 
problem after childbirth, exacerbated by 
bearing down during the second stage 
of labour. Local application of lidocaine 
(lignocaine) gel or anusol cream may 
help, together with bulking agents to 
soften the motions. Occasionally, 
thrombosed piles will occur but these 
usually regress after 5-G days. 

Puerperal affective disorders 

There are a range of presentations from 
transient tearfulness to the frankly 
psychotic. Puerperal depression and 
psychosis are often not detected as early 
as they should be. 

The 'blues' classically present on the 
fourth or fifth day after delivery and 
may be preceded by 24 hours of 
euphoria and elation. Support from 
health care professionals and family 
should be adequate and it will resolve 
spontaneously. 



Postpartum depression usually presents 
within the first 2 weeks, often with low 
mood, inappropriately poor sleep, lack of 
pleasure in motherhood, undue anxiety 
about the baby and feelings of 
unworthiness with restlessness and 
agitation. It is often associated with a 
prior history of depression or with 
traumatic delivery, e.g. caesarean section. 

Antidepressants, either tricyclic or 
serotonin re-uptake inhibitors, are 
commonly used. Progesterone has been 
suggested but without good evidence. 
Oestrogen has been shown to be 
effective therapy, as it is in premenstrual 
and perimenopausal affective disorders. 
Specialist psychiatric help should be 
obtained early if necessary. Management 
is preferred in a dedicated mother and 
baby unit (Fig. 2). Compulsory 
admission to hospital under sections of 
the Mental Health Act is rarely required. 

Puerperal psychosis is rare (1 in 800 
deliveries) and resembles manic 
depressive psychosis. It first presents at 
3-7 days and the peak incidence is at 
2 weeks. Auditor}' and visual 
hallucinations are common features and 
a prior history is not uncommon. 
Lithium prophylaxis in subsequent 
pregnancies may be effective. Urgent 
specialist psvchiatric involvement is 
necessary as there is a real risk of 
suicide and infanticide. Psychotherapy, 
neuroleptics and electroconvulsive 
therapy may be indicated. 



The abnormal puerperium 



■ Secondary haemorrhage presents after the first 2k hours postpartum; the most common cause is 
retained products of conception. 

■ Venous thromboembolism is still a leading cause of death, and diagnosis can be difficult. 

■ Breast engorgement can cause a transient pyrexia in the first 2-3 days postpartum. 

■ Breast feeding may continue on the contralateral side if a breast abscess develops. 

■ Puerperal depression presents within the first 2 weeks: it may be severe and is frequently 
unrecognized and hence neglected. 



68 OBSTETRICS 



P 



Alternative approaches to delivery 



Looking at the history of childbirth 
through time the commonest position 
adopted is the upright or ambulant 
position. This prompted work in the 
1980s to study the effect of change in 
posture on uterine activity, blood loss 
during labour and pregnancy outcomes. 
There was much popular pressure for a 
change in the routine practice found in 
hospitals in the western world of 
pregnant patients lying in bed during 
labour and delivery. 

Figures 1-4 show a variety of birthing 
positions that may be adopted. There is 
little good evidence that posture during 
labour or delivery has a major effect on 
the outcome for mother or baby. 

Water birth 

There have been many trends in 
delivery type. The Leboyer delivery in a 
darkened room is supposed to allow a 
more calm experience for the mother 
and to be less traumatic for the baby at 
delivery. The French obstetrician 
Michel Odent advocated delivery 
upright and had many supporters. He 
was the first person to present data on 
delivery into water (Fig. 5). 

The perceived advantages and 
disadvantages (Table 1) to mother and 
neonate have not been subjected to 
rigorous study but are presumed from 
physiological principles. 

Birthing cushion (Fig. 6), chair 
and stool 

All these have been used in an attempt 
to achieve a more upright position for 
the mother. Work assessing blood loss 
shows a rather higher loss at delivery 
in mothers who use the birthing chair, 
with a higher incidence of low 
haemoglobin and an increased need 
for blood transfusion. This is likely to 
be due to perineal trauma exacerbated 
by obstructed venous return. 

The fetus benefits from a maternal 
upright position with less abnormal 
fetal heart rate patterns seen and a 
higher arterial pH noted in studies 
comparing upright versus recumbent 
posture for the second stage of labour. 
The lateral position seems to have 
similar benefits for the fetus. Mothers 
may also prefer to adopt an upright 
position for the second stage of labour 
and sometimes report less pain. 

In situations when fetal monitoring 
would be considered necessary, this 
can be more difficult unless telemetry 





1 




A- 


-S^^T / / 


:j 


I 


/ 


/" 


^ 


^~~~ 




/ 






"~-y-^ 











Fig. 1 Supine birthing position. Overall reduction in uterine activity, supine hypotension and 
resultant fetal hypoxia. 




Fig. 2 Side birthing position. Contractions of less frequency but greater intensity. 





Fig. 3 Standing birthing position. Possible 
increased pressure on the cervix, increasing the 
dilating effect. 



Fig. 4 Squatting birthing position. The 28% 

increase in pelvic outlet may have benefits for 
second stage but greater blood loss is noted if 
delivery is from an upright position. 



is available. Continuous electronic fetal 
monitoring allows limited maternal 
mobility but the mother may not find 
this acceptable. Intermittent 
auscultation allows sampling of the 
fetal heart rate for only 7% of the time, 
although it should be remembered 



Alternative approaches to delivery 69 




Fig. 5 Water bath. 



Table Advantages and disadvantages of water birth 


Advantages 


Disadvantages 


To the mother 


To the mother 


Pain relieltrom Die warm water 


Vasod Natation with circulatory redistribution, especially to the skin 


Relaxation with the water buoyancy 


Fatigue due to decreased muscle tone 




Fluid loss due to perspiration in the warm water 




Increased hydrostatic pressure against Which to deliver 




Possible increase in blood loss due to hyperaenva with warmth 




Difficult, physically, to gel out if emergency arises (and disappointment) 


To the neonate 


To the neonate 


Gentle exit from the Liter us 


Respiratory depression due to warmth and immersion in water - the exposure 




to a cold stimulus before cessation of oxygen from the placenta is negated 




Infection hazard - maternal organisms m the water from vagina arid bowel 




may be aspirated 




'Wet lungs' it the neonate aspirates and difficulty Initiating breathing 




Adequate fetal monitoring is difficult 




Maternal choice 

Patients wish to be involved in decisions 
regarding their treatment This extends 
to pregnancy when some women wish 
to choose an elective caesarean section 
as their mode of delivery. The mode of 
delivery may be determined by medical 
events either which necessitate 
caesarean section on a mechanical basis 
or where a better fetal outcome is 
associated with delivery by caesarean 
section. If there is no medical indication 
for caesarean section then the risks of 
vaginal delivery and caesarean section 
for both the mother and fetus need to 
be assessed. 

The risk of vaginal delivery for the 
fetus is unpredictable but in those with 
growth restriction the risk is likely to be 
less with caesarean section. However, 
the fetus benefits from vaginal delivery 
by a lower incidence of respiratory 
distress syndrome compared to infants 
of the same gestation delivered by 
caesarean section. 

From the maternal side, elective 
caesarean section increases the mortality 
risk for the mother by 50% compared 
with a vaginal delivery in a healthy 
woman but numerically this is still a 
very small risk. There is an increased 
need for blood transfusion after 
caesarean section and increased infection 
risk, though this has been reduced with 
the use of prophylactic antibiotics. If we 
could predict the women most likely to 
have a long and difficult labour, elective 
caesarean section would probably be 
safer and more acceptable for them 
than the trial of labour. 

Some women may prefer an elective 
caesarean section with a small risk of 
mortality and serious morbidity as a 
way of avoiding the disabling 
complication of incontinence and the 
discomfort of labour. Many see the 
element of predictability and control of 
an elective procedure as important 
advantages with about 50% saying they 
would request another caesarean 
section in a future pregnancy. Looking 
at what is an ideal caesarean section 
rate perhaps the correct answer is the 
rate which gives maximum maternal 
satisfaction for the least risk. 



Fig. 6 Birthing cushion. Alternative approaches to delivery 



that fetal heart rate monitoring in low- 
risk women has not been proven to 
improve neonatal outcomes, but 
increases the chance of operative 
delivery. 



L 



■ Safe delivery of the mother and her baby are most important and how this is achieved may be 
varied to obtain maximum maiernal satisfaction. 

■ The upright posture for delivery may be more efficient at dilating the cervix. 

■ Use of birthing chairs or cushions may be associated with greater penneal damage. 

i Maternal choice regarding mode of delivery should be carefully discussed and all risks and 
benefits considered. 



70 OBSTETRICS 



Analgesia in labour 



The level of pain experienced by 
women in labour varies considerably 
and is influenced by previous 
experience, antenatal preparation, 
length of labour and strength of 
contractions. The value of antenatal 
preparation is largely unproven, but as 
the experience of pain is related to the 
mental state of the patient a lot of time 
is invested in antenatal classes to 
ensure adequate knowledge of the 
process of labour, thereby decreasing 
the stress of the unknown. The various 
methods of analgesia are shown in 
Table 1. 

Non-pharmacological 
approaches 

There are many accepted non- 
pharmacological methods of relieving 
labour pain, some deriving from long 
usage and others from more recent 
understanding of pain and its 
perception. 

Massage - including 
aromatherapy 

Massage, especially to the lower back, 
may work by the same principle as 
TENS (transcutaneous electrical nerve 
stimulation - see below) with 
incoming nerve impulses modifying 
transmission along pain fibres. 
Massage may also relieve 'stress'. The 
'stress' hormones (adrenaline 
(epinephrine) and noradrenaline 
(norepinephrine)) are thought to 
interfere with the coordination of 
uterine contractions and so relaxation 
techniques may enhance the progress 
of labour. Aromatherapy may work in 
a similar way and the use of lavender 
oil has found favour with some 
mothers. 

Acupuncture and acupressure 

Acupuncture may also have a role, 
with use of specific points to provide 
pain relief and possible additional 
electrical current to augment these 
analgesic effects. Acupressure, where 
the fingers are used to press over the 



acupuncture point, may be easier to 
apply in labour and does not restrict 
mobility. 

Mobilization 

Labouring women, if left unrestricted, 
adopt a wide variety of positions. 
Sitting, standing and walking may all 
be used during labour. Patients with 
low back pain often adopt a forward- 
leaning position that may relieve 
pressure on the sacroiliac joint. 
Control of breathing patterns is widely 
taught in antenatal classes - this may 
work by diverting the mind away from 
the pain but is also a technique used to 
relieve stress. 

Hydrotherapy 

Many women already know the 
soothing effect of warm water on the 
uterine cramping pain experienced 
during menstruation. In the past, 
obstetric care tended to confine 
labouring women to bed but with 
greater freedom many select a ^varm 
bath or shower during the first stage of 
labour. The mode of action of any 
analgesic effect is unclear but over the 
centuries hydrotherapy has been used 
for many painful conditions so the 
expectation of a soothing effect may be 
its main method of action. In the mid- 
1950s abdominal decompression found 
a role in labouring women and 
immersion in water may be found to 
act similarly by relieving external 
pressures on the uterus and allowing it 
to assume a more rounded position. 

Transcutaneous electrical nerve 
stimulation 

TENS uses the gate theory of pain 
control and, by application of an 
electrical current to the nerves carrying 
the painful stimuli, transmission of 
pain is partially blocked. Skin surface 
electrodes (Fig. 1) are used to apply a 
low voltage electrical current which is 
modified by the patient. These are 
usually applied across the lower back 
covering the T10-L1 nerve roots (the 




Table 1 Methods of analgesia in 


labour 




Non-pharmacological 




Pharmacological 


Massage inducting aromatherapy 




Inhalations! analgesia 


Acupuncture and acupressure 




Opioid analgesia 


Mobilization 




Regional analgesia, including epidural and spinal 


Audioanalgesia 




Pudendal nerve block 


Hydrotherapy 






TENS 







Fig. 1 Uterine pain can be relieved by the 
application of TENS to the lower back. 

innervation of the uterus) early in the 
first stage for optimum effect. 
Although concern has been expressed 
about the use of TENS applied over 
the lower abdomen as the electrical 
activity may theoretically have an effect 
on the fetal heart, no adverse effect has 
been documented. 

'Audioanalgesia' 

Music can reduce stress and enhance 
other pain-relieving measures. White 
sound has been used during 
contractions and may block external 
stimuli. Studies of the use of so-called 
'audioanalgesia' have suggested a trend 
towards decreased use of analgesic 
medication. 



Pharmacological approaches 

Inhalational analgesia 

This has the benefits of long usage and 
thus familiarity whilst also being 
controlled by the patient in both 
timing and dose. Entonox is most 
commonly used and contains a SO : 50 
mix of oxygen and nitrous oxide. This 
would be expected to have a powerful 
analgesic effect as a 20% mixture is 
equipotent to IS mg subcutaneous 
morphine, but in reality it is a poor 
analgesic. Despite its widespread use - 
it is the most widely used agent in 
labouring mothers in the UK - no 
major side effects have been noted. An 
excess mav theoretically lead to 



Analgesia in labour 71 



demyelination and megaloblastic 
anaemia but these effects have not 
been observed. Many women 
experience light-headedness and 
nausea, and hyperventilation may lead 
to hypocapnia and eventually tetany. 

Narcotic analgesia 

Pethidine was introduced in 1939 by 
the Germans who found it to be useful 
in treatment of war wounds. By 1950 it 
was generally accepted and in use by 
midwives for pain relief in labour. 
Unfortunately it is a rather poor 
analgesic, being associated with a 20% 
reduction in pain score, but it has 
powerful sedative effects on the 
mother at the expense of nausea and 
vomiting. In as many as half of all 
mothers there is no analgesic effect 
and, as it acts to delay gastric 
emptying, it should probably be used 
in labour in conjunction with 
ranitidine. 

All opiates have a depressant effect 
on the neonate. This has led to 
attempts to develop other opioid 
analgesics with better pain-relieving 
properties and less respiratory 
depression in the neonate. Though 
neonatal respiratory depression is 
noted it need not limit the use of 
pethidine, as naloxone will rapidly 
reverse the respiratory effects, after 
delivery. 

Diamorphine is used for its 
enhanced pain-relieving effect though 
some mothers experience considerable 
nausea and vomiting with it. 

Epidural analgesia 

This developed from the need for 
analgesia without neonatal respiratory 
depression and acts by affecting the 
spinal opioid receptors directly. Epidural 
analgesia has indications besides simple 
pain relief during labour: 

■ pregnancy-induced hypertension - 
to control hypertension which may 
worsen during labour (exclude 
coagulopathy) 

■ trial of scar - the epidural has not 
been found to mask the pain of a 



scar dehiscence but will give 
adequate analgesia 

■ preterm labour - there may be 
positive advantages in these cases as 
epidural analgesia has been shown 
to be associated with a reduced 
neonatal mortality rate among low 
birthweight babies 

■ breech presentation - to ensure a 
controlled delivery, by preventing 
the urge to push prior to full 
cervical dilatation - a problem in the 
preterm breech 

■ multiple pregnancy - deliver}' may 
be complicated and the presence of 
an epidural allows intervention as 
necessary 

■ incoordinate uterine activity - pain 
relief in this situation is associated 
with improved uterine action. 

Correct placement of the catheter in the 
epidural space is confirmed by loss of 
resistance as the catheter finds the space 
and the absence of cerebrospinal fluid 
running from the catheter end (Fig. 2). 
Confirmation of correct placement is 
vital before giving the full dose of local 
anaesthetic down the catheter or a 'total 
spinal' (i.e. a high block) may result, 
with rapidly rising numbness and 
dyspnoea which may require ventilation 
until the effect wears off 

Alternatively, the catheter may be 
located intravascularly and during the 
test dose the patient will note light- 
headedness and tingling in the lips and 
fingers. If further anaesthetic is given, 
convulsions and cardiac dysrhythmias 
may ensue, necessitating resuscitation. 




Fig. 2 Equipment used for correct 
positioning of the epidural. 



Methods of administration 

Intermittent doses. These are given as 
the mother requires, which may be at 
an approximate hourly rate. This may 
mean that pain relief is not complete 
and the midwife has to check with 
each dose whether the mother 
experiences any side effects. Patients 
are in bed and immobile. 

Continuous infusion. This allows for 
more smooth pain relief and, if 
problems arise, a lower dose of the 
anaesthetic has been administered. 
Better analgesia, however, ma}? be at 
the expense of an increased 
instrumental delivery rate or caesarean 
section and immobilization. 

Spinal opioids. By acting on the spinal 
opioid receptors these enhance the 
analgesic effect of the epidural. They 
are short acting (2-4 hours) with a 
better analgesic effect in a more even 
distribution. They may be associated 
with pruritus. 

Mobile epidural. These developed from 
the wish to overcome the immobility 
associated with standard epidural 
techniques. The pain-carrying nerve 
fibres are smaller than the motor nerve 
fibres and by giving appropriate 
anaesthetic mixes it may be possible to 
achieve blockage of only the smaller 
fibres. 

Pudendal nerve block 

This technique is used in the second 
stage of labour to obtain analgesia for 
an instrumental delivery. It blocks the 
pudendal nerve (S2,3,4) and is usually 
combined with perineal infiltration to 
allow episiotomy. The pudendal needle 
is guarded so that it can be advanced 
into the vagina in the region of the 
ischial spine. The needle is then 
advanced in turn and lidocaine 
(lignocaine) is introduced around the 
nerve. Once both sides are blocked the 
analgesia achieved should allow outlet 
forceps but would not give complete 
pain relief for a mid-cavity 
instrumental delivery. 



j Analgesia in labour 






Pain is an integral part of the process of labour. 

■ Adequate pain relief is associated with tower levels of maternal catecholamines ('stress' hormones which inhibit co-ordinated uterine activity). 

■ Non- pharmacological methods are widely used - both before the patient presents to hospital and in hospital. 

■ Entonox and opioids have a role but up to 30% may select an epidural, 

■ Excessive volumes of local anaesthetic can cause convulsions, hypertension and bradycardia. 







OBSTETRICS 



The changing face of maternity care 



In the last decade there has been a 
considerable change in attitude on 
how maternity care should be delivered. 
The driving force for change is specific 
to the individual countries' problems. In 
the UK it was felt that the current 
system was too rigid. Important 
conclusions were made: 

■ the policy of encouraging all women 
to give birth in hospitals cannot be 
justified on grounds of safety 

■ a more flexible system based on the 
community, not in the hospital, 
should be established 

■ midwives should have their own 
caseload 

■ the present imposition of a rigid 
pattern of frequent antenatal visits 
was not grounded on any good 
scientific basis. 

Women should be placed at the centre 
of maternity services. 

In less well-developed countries, the 
stimulus to change has been the high 
maternal morbidity and mortality. 
Almost GOO 000 die each year from 
complications of pregnancy or delivery. 
In addition, approximately 40% of 
women suffer long-term complications. 

Different approaches to care 

United Kingdom 

The old model of care in the UK 
sharply divided the community from 
the hospital midwife. Women were 
booked in hospital with a consultant 
as lead clinician and a routine number 
of antenatal visits. The general 
practitioner would see the woman at 
the surgery in between as part of 
shared antenatal care. In designated 
high-risk cases, hospital visits were 
more frequent. 

The Cumberlege Report, 'Changing 
childbirth - how maternity services 
should be delivered', aims to provide a 
more flexible system of care in the UK 
(Table 1). Midwives are now rotated 




Table 1 The Cumberlege Report: indicators of success 

■ Ail women should Lie enlitleo to carry their own noies (Fig 2] 

m Even/ woman should know one midwife wiio ensures continuity of her midwifery care - ;he named mrdwite 

■ At least 30ft of women should have the midwife as the lead professional 

■ Every woman should Know the lead professional who has a key role m [he planning and provision of net care 

■ At least 75% of women should know Ihe person who caiest.T then during ihir delivery 

■ Midwives should have direel access to some beds m all maternity uniis 

■ At least 30^ of women delivered in a maternity unit s'hodd be admitted under Ihe management of ihe midwife 

* The total number of antenatal visits for women with uncomplicated pregnancies should be reviewed m the light of me 
available evidence and of Royal College of Oesletncians and Gynaecologists guidelines 

■ All front -line ambulances should have a paramedic able lo support the midwife who needs (o transfer a woman lo 
hospital in an emergency 

■ All women should have access to information about the services avaiiahle in then locality 



^aolc ; 
care 



Different models of midwifery 



Caseload model 

Midwifery teams 

Midwife-only delrvery units 

Needs-based community services 

M idwife m anag ed services i n a cu Le h ospi La Urijsts 

Midwrves based in primary care settings 



through day and night shifts, through 
clinics into labour ward, and from 
labour ward into the community 
(Fig. 1). This ensures that all midwives 
are fairly exposed to high-pressure, 
high-risk areas of clinical practice. 
They are encouraged to keep up to 
date and have, through their 
professional development training, to 



be re-certified at regular intervals. They 
are encouraged to enhance their skills 
and take on new roles. 

In some cases midwives employed 
in the community have become part of 
an integrated hospital/community 
team (Table 1). In other areas 
midwives have linked with general 
practitioners and have become the lead 
professional. Hospital-based midwifery 
staff may adopt their own caseload 
and follow women throughout the 
entire pregnancy, including postnatal 
visits in the community. Others may 
wish to develop their skills so that they 
form a core of labour ward midwives 
with specialist expertise providing 
intrapartum care for high-risk patients. 



Personal maternity record 

Please ca^ry Ifreae roles wrtri you. *Sp*tiaMy nfl * r rfl * &nd ° 1 v*^' pregnancy 



These are confidential and vary 
Important matwrilty nates. H loujnd. 
return Lo the woman lh*y belong To 
□r her place ol care: for example. 
Ihe health centre Or hospital 



Agreed due dale 

tftotv page 6) 



Name 

Your date of tn rth 
Ychjf address 



Unl or hospital numftjer. 



Planned piece of birth 



Useful phone numbers 



Qn-caJI rrndwihj 

General practiCiooef . . 
Ambulance service 1 , - 



Antenatal dinic -- 

. Delivery Suite 

. Hospital switchboard 



Appointments 



Day 



^ 



Fig. 1 Antenatal home visit. 



Fig. 2 Patient hand-held notes. 



The changing face of maternity care 73 




Fig. 3 Community midwives. 



The rural setting 

Maternity care must adapt to local 
circumstances. Where there are few 
hospital units, often many miles away, 
community midwives (Fig. 3) are 
highly experienced and will conduct a 
higher rate of home deliveries, having 
carefully screened out those 
pregnancies with potential problems. 

General practitioner obstetricians 
still continue to offer intrapartum care 
in some cases, delivering their patient 
at home, in a low-risk community unit 
or in the labour suite of the local 
hospital. Nevertheless, many general 
practitioners feel that they are involved 
in deliveries too infrequently to 
maintain their skills. This is 
particularly true of neonatal 
intubation, one area where midwives 
are expanding their skills and 
undergoing specific training. 

Europe and the USA 

The majority of the original work on 
independent midwifery practice was 
undertaken in the UK. Care models 
differ considerably between countries. 
Holland and especially New Zealand 
are excellent examples of the 
independent midwifery role. In the 
former there is a high rate of home 
confinements; in New Zealand the 
money truly follows the patient The 
midwife is booked and can move freely 
from community to hospital sectors, 
allowing follow-through of care. 

By contrast, the system in Spain is 
hierarchical. Only 50% of hospitals 
allow midwifery-led care, even in 
normal pregnancy and delivery. In the 
rest, care is doctor-led. There is a high 
epidural rate, women are delivered in 



theatre suites in the lithotomy position 
and all have episiotomies. Most 
women remain in hospital for 5 days 
after a normal delivery and there are 
very few community midwives. 
Postnatal care after discharge from 
hospital is provided by an obstetrician 
based at a community health clinic. 
Midwives in the USA are still not 
allowed to practise in certain states. 
Where practice is permitted, they must 
be nurse-midwives and have a Master's 
degree. They are independent 
practitioners but frequently work 
within a group practice with 
obstetricians. Due to litigation, forceps 
deliveries are rarely practised and the 
elective caesarean section rate is high. 

Developing countries 

It was felt that improving the standard 
of women's education was as important 
as improving health services. The latter 
required improvement in community 
health services, better transportation for 
emergencies and improved referral 
centres. Women should not be left to 
give birth alone and birth attendants 
with training in at least basic hygiene 
should be present This forms the basis 
of the WHO Safe Motherhood initiative. 

Audit of progress has shown that 
the training of traditional birth 
attendants does not have an impact on 
maternal mortality unless it is 
combined with accessible 
units/hospitals where essential 
obstetric services are available. The 
attendants must learn to take an 
obstetric history to assess risk factors, 
to be alert to complications and to 
advise women to stay near basic 
obstetric centres. 

Specific models of care 

The Domino scheme 

The same midwife who saw the 
patient in the community setting 
delivers the baby in the hospital 
maternity unit, and if all goes well 
mother and baby go home within 
G hours. 

Midwifery-run delivery units 

These units (Fig. 4) offer women a less 




Fig. 4 Low-risk midwife-run delivery unit. 



technological, more relaxing 
environment located near the 
communities most likely to use them. 
The women must be assessed as being 
low risk. The unit must have a 
minimum of two midwives as core staff 
No delivery should take place without 
two trained professionals being present 
Despite screening, statistics are fairly 
constant across a number of studies: 

■ 28-34% of women booked will 
develop antenatal complications, 
which will necessitate transfer to the 
local maternity unit 

■ 12-16% are transferred intrapartum, 
of whom approximately one-third 
will deliver by caesarean section 

■ 12% of breeches are not diagnosed 
until labour. 

Consequently, the numbers of women 
delivering in these units are always less 
than the projected figures. Midwife- 
managed intrapartum care for low-risk 
women appears to result in more 
mobility and less intervention with no 
increase in neonatal morbidity. 

Needs-based community services 

Targeting women with needs means 
developing innovative ways of dealing 
with maternity care: 

■ extending services offered in local 
clinics, e.g. sickle cell support 
services 

■ ensuring that advocacy and language 
services are readily available 

■ providing culturally sensitive services 

■ allowing time for the complexity of 
the health needs 

■ ready access to housing and social 
benefit services. 



Maternity care 






I Severely high maternal mortality rates in underdeveloped countries have prompted the WHO Safe Motherhood initiative. 

i The introduction of birth attendants trained in basic hygiene must be complemented by efficient access to obstetric units. 

i In the UK the Cumberlege Report stressed the need for women-centred care. 

i The woman should have a choice of carer and place of delivery and be offered continuity of care. 

i The Domino scheme offers continuity of midwife and 6-hour discharge from hospital. 

i The low-risk midwifery-run delivery unit offers an alternative venue for delivery. 



74 OBSTETRICS 

Drug misuse and physical abuse 



Drug misuse 

The prevalence of drug misuse is on 
the increase, particularly in women of 
childbearing age. Serious problem 
misuse (especially i.vO and poly-drug 
misuse are associated with socio- 
economic deprivation and an increase 
in obstetric complications including 
miscarriage, antepartum haemorrhage 
[APH], intrauterine growth restriction 
[IUGR], intrauterine death (IUD] and 
preterm labour. Care must usually be 
directed firmly towards social factors 
before any impact on obstetric 
problems can be achieved. Pregnancy 
may provide a window of opportunity 
to provide real help, often breaking a 
cycle of poor parenting leading in turn 
to further problems in the next 
generation. 

The history should cover: 

■ type of drugCs] (see Table 2) 

■ street drugs, e.g. heroin, 
amfetamines 

■ pharmacological preparations 
(usually illicitly obtained), e.g. 
benzodiazepines, buprenorphine and 
analgesics, particularly DF118 and 
other codeine compounds 

■ prescribed preparations, usually 
methadone 

■ pattern of use, dose, route, frequency 
and method of financing supply 

■ available social support, the other 
children, partner, family, friends, 
social work involvement, clothing, 
food, shelter and transport 

■ impending legal problems 

■ risks of infection including HIV, 
hepatitis B/C counselling + testing 



* domestic violence - a common 
occurrence with all groups of 
pregnant women. All women should 
be asked about this (surprisingly, it 
is not any more common with 
socio-economic deprivation). Female 
drug misuse is often a consequence, 
rather than a cause, of violence. 

There may be poor self-esteem 
following a lack of trusting 
relationships, loss of positive body 
image and concerns about their own 
abilities to be a parent. 

Management 

Social factors 

Illegal drugs are expensive and addicts 
are often forced into theft (and 



therefore problems with the police and 
courts) or prostitution (with its risks of 
violence and sexually transmitted 
diseases including HIV). In addition, 
lifestyle may be erratic and pregnancy 
outcome is compounded by various 
additional nutritional and social 
factors. Attendance for antenatal care 
may often compete with more 
immediate problems (e.g. seeing the 
social worker, lawyer, or getting 
money/drugs, etc.) but if such care can 
be delivered locally with truly flexible 
access and be combined with 
confidentiality, non-judgmental 
consistency, access to social workers 
and legal aid, then fuller and more 
holistic care can be achieved. 



Table 2 Drugs of misuse in 


pregnancy 


Drug 


Effect on fetus 


Alcohol 


There is nn clear dose relationship Fetal alcohol syndrome is rare [IUGR 




microcephaly, craniofacial abnormalities and mental retardation) Consumption of 




even small amounts of alcohol hss been associated with a reduction m 




birthvveiflhl and inlellecrual impairment 


Amfetamines 


No increased risk has been demonstrated 


Benzodiazepines 


'Fluppy infant syndrome' may occur if high doses have been given within the 1 5 




hours pnoi to delivery Neonatal withdrawal occurs following prolonged use 


Ecstasy 


No increased risk has been demonstrated 


Cannabis [hash, marihuana) 


There have ueen no demonstrable teratogenic effects hill There is an association 




pmdircct) with IUGR 


Opiates/ opioids 


There are associations with anovulation. IUGR, preterm Isbou' Inwer Apgar 


[e.g. heroin, methadone. DP1 13. 


scores, and neonatal withdrawal difficulties 


buprenorphine) 




Cocaine and crack 


Cocaine has been associated (rarely) with genitourinary. Iimb.'botty and brain 




abnormalities [probably because of vasoconstrictive vascular accidents; 


Nicotine 


There is an association with IUGR, preterm labour, perinatal death ann delayed 




development. Tobacco use. if heavy, may lead to neonatal withdrawals 


LSD 


No increased risk has been demonstrated 



Table l Therapeutic drugs in pregnancy 
Class of Drug Risk to fetus 

General a naestnetics Any risks aie piobaijly rcl^tod to risks ct hypoxia itself 

Analgesics Low-dose aspirin use OK. but analgesic doses may lead to impaired platelet function and an increased risk of haemorrhage. 

Indomctacir, causes impaired renal function Paracetamol is thought to he safe 
Antacids Are thought to be safe. Qmetidme may have ami androgenic effects 

Antibiotics Aminoglycosides carry a risk of fetal ototoxicity. Chloramphenicol is potentially harmful and The sulfa component of co-tnmoxazole may displace uilnubm and 

cause kernrcterus Tetracyclines cause dental discolouration Erythromycin, the penicillins, metronidazole and the cephalosporins are thought to he safe 
Anticonvulsants All carry risks of [era [agenesis, though data are limited on the newer preparations (gabapeniin, lamotnyme and vigabatnn] 

Antidepressants Lithium shouEd be avoided if possible but, af used, monitor serum levels closely The risks a re probably low witnSSR I and tricyclic antidepressants 

Antihypertensives Methyldopa and (i-biockers probably safe ACE mnibitors and diuretics should be avoided 

Aniihisiamtnes Chlorphenamme [chlorpheniramine) is thought to he safe in pregnancy. There is little experience with the newer preparations 

Antimalanals For prophylaxis, chloroqume is preferred. In treatment of malarial infection, benefits far outweigh ihe risks 

Antipsychotic dujgs No consistent teratogenic elfea has been demonstrated 

Bronchodilators All inhaled preparations, rncludmg inhaled steroids, are considered safe m pregnancy 

Retinoids High risk oMei a I malformation $ulfic*ent to consider TOP 

Stesoids No consistent teratogenic effects demonstrated in humans 

Vaccines There is a theoretical risk ol teratogenic problems from vaccnes but on nrmciple. avoid 



Drug misuse and physical abuse 75 




Fig. 1 Ventricular septal defect CVSD) associated with anticonvulsants. Note the Doppler 
flow across the interventricular septum. 



Transfer to methadone 

Consideration should be given to 
transfer to methadone (slower 
metabolism therefore more stable 
levels and less prone to the risks of 
fetal distress and preterm labour 
associated with sudden withdrawals or 
fluctuations in serum opiate levels). 
Those stabilized on methadone alone 
probably have a lower neonatal 
mortality than those still taking heroin 
(Fig. 2). There may also be improved 
antenatal attendance. 

Detoxification 

There are theoretical fetal risks from 
very rapid detoxification but in practice 
the true fetal risks from even 'cold 
turkey detoxification are relatively 
small. It has been suggested that the 
risks of detoxification (whether rapid 
or gradual) may be higher in the first 
and third trimesters, but practical 
experience does not bear this out. The 
goal should be to reduce drug use to a 
level compatible with stability (e.g. 
with methadone), not necessarily 
aiming for abstinence. It is more 
acceptable for the mother to top up 
with more of the same substance (e.g. 
smoking heroin) than adding 
additional preparations (especially if 
the addition is with benzodiazepines or 
codeine compounds). Patients should 
ideally be managed on an obstetric 
unit, or at least under the close 
supervision of an obstetrician. 

Neonatal complications 

There is an increased incidence of 
IUGR, meconium aspiration and 



sudden infant death syndrome (SIDS). 
Withdrawal is particularly associated 
with benzodiazepines, and is worse if 
they have been used in conjunction 
with other drugs. Severity is dose 
related and timing depends on the rate 
of drug metabolism, e.g. heroin and 
morphine are metabolized rapidly and 
signs develop within 1-2 days, whereas 
methadone is metabolized more slowly 
and signs occur between 5-7 days. 
Babies are classically hungry, but feed 
ineffectually. There is CNS 
hyperexcitability (increased reflexes 
and tremor), gastrointestinal 
dysfunction (finger sucking, 
regurgitation, diarrhoea) and 
respiratory distress. Treatment options 
include replacement (e.g. with 
methadone or oral morphine). 

Physical Abuse 

Violence against women can take the 
form of physical or sexual abuse. 
In some cultures, violence against 
women is accepted and societal norms 
blame the woman for the violence 
perpetrated against her. These attitudes 
may also occasionally be held by 
healthcare workers, sometimes 
resulting in an inadequate or 
inappropriate response to women who 




Fig. 2 Those stabilized on methadone 
alone probably have a lower neonatal 
mortality than those still taking heroin. 



seek help. In most other cultures, 
where violence against women is not 
considered to be acceptable, there is 
still a surprisingly large problem. 

Around 1 in 4 women worldwide 
will suffer from domestic violence at 
some stage in their lives and, in many 
countries, statistics suggest that more 
than 50% of women who are 
murdered are killed by their intimate 
partner. In other studies, more than 
95% of women who are raped already 
know their assailant. In addition, 
violence against women can have both 
short- and long-term health 
consequences including sexually 
transmitted infections, and unwanted 
pregnancies which may in turn lead to 
unsafe abortions. Women living with 
partners may not feel able to make their 
own decisions about contraceptive 
issues, or even about staving or leaving 
the relationship, and the psychological 
implications are immense: victims of 
rape are 11 times more likely to 
experience clinical depression and are at 
greater risk of drug- and alcohol-related 
problems, and suicide. 

It is important to bear in mind these 
issues when meeting patients. A 
history of such problems is unlikely to 
be volunteered spontaneously and 
considerable tact may be required to 
explore these areas. 



Drug misuse and physical abuse 

i All drugs are potential teratogens, 
i Drug misuse iseommon. 



■ Serious problem misuse may be the end-point of multiple social factors which must be 
addressed. 



76 OBSTETRICS 

Common problems in pregnancy 



Most women feel well during 
pregnancy. 

Minor ailments do occur [Table 1) 
and symptomatic relief is occasionally 
possible. Women should be 
encouraged to discuss these ailments 
with their health care professionals as 
apparently minor symptoms may be 
symptomatic of more serious 
conditions, e.g. pruritus of acute 
cholestasis of pregnancy, or leg 
oedema of venous thromboembolism. 

Varicosities 

Varicose veins may appear for the first 
time in pregnancy and if already 
present they are likely to deteriorate. 
Varicosities may appear in the legs, 
vulva, abdominal wall and also as 
haemorrhoids. They are probably due 
to impaired venous return secondary 
to back pressure from the expanding 
gravid uterus. Varicose leg veins can 
ache and itch intensely, especially by 
the end of the day. They are best 
helped by elastic support tights or 
stockings. These may be 
uncomfortable, particularly in high 
temperatures and the only alternative 
may be to sit down whenever possible 
with the legs elevated. 

Anterior abdominal wall varicosities 
are unsightly but do not cause any real 
problem. They always disappear after 
delivery. Very rarely a patient may 
present with a large groin swelling in 
the third trimester which is a 
varicocele of the round ligament of the 
uterus. This may be misdiagnosed as 
an inguinal hernia. 

Vulval varicosities can be very 
dramatic in their appearance and can 



cause considerable discomfort. There is 
unfortunately no useful intervention 
other than suggesting that the area is 
kept dry and well aerated to minimize 
itching. Controlled delivery minimizes 
bleeding. Vulval varicosities almost 
always disappear postnatally 
Haemorrhoids can be very 
troublesome and may cause 
considerable discomfort and even 
bleeding. Steps must be taken to avoid 
constipation. Local anaesthetic-steroid 
combination creams may be applied 
during the day and suppositories used 
for night-time relief Application of ice 
packs may be helpful. A thrombosed 
pile may need incision and clot 
evacuation under local anaesthetic but 
a local anaesthesic gel may provide 
some relief. 

Constipation 

Constipation is common in pregnancy 
because of reduced bowel motility and 
increased colonic absorption of water. 
It can be helped by increasing dietary 
fibre and fluid intake. Regular exercise 
may also help. Bulking agents and a 
stool softener may be prescribed. 
Some iron preparations exacerbate 
constipation. 

Dyspepsia 

Dyspepsia ('heartburn') is due to a 
combination of reduced peristalsis and 
relaxation of the gastric smooth 
muscle sphincter predisposing to 
regurgitation of gastric content into 
the lower oesophagus. Women should 
be encouraged to eat regular small 
meals and may find relief from 
sleeping propped up at night rather 



Table l Common complaints in pregnancy 


Complaint 


Cause and management 


Vomiting 


Common in first trimester especially, but often persists through pregnancy 


Constipation 


Due to progesterone effect relaxing the gut- managed with mild laxatives and 




increased fluid intake 


Heartburn 


Also thought to be due to progesterone relaxation of the gut - managed with 




antacids 


Backache 


Due to the effect of relaxm on ligaments causjng abnormal strain with lumbar 




lordosis - managed with physiotherapy 


Abdominal pain 


Otten due to stretching of the round ligament - analgesia if severe 


Fainting 


Due to postural hypotension - advise standing up sfowly and possibly ihe use of 




support stockings 


Varicose veins 


Due to pressure on the venous side by the gravid uterus - managed with support 


Haemorrhoids 


stockings tor veins, anaesthetic steroid creams for haemorrhoids 


Carpal tunne? syndrome 


Due to oedema causing pressure on the median nerve as it passes under the 




flexor retinaculum - managed with splints and postural rjrainace of the hands. 




possibly surgery - usualfy postrrelivery 



than lying flat. Antacids may prove 
helpful. 

Nausea and vomiting 

Nausea and vomiting are very 
common in early pregnancy. The 
symptoms usually diminish by the 
lGth week but can occasionally 
continue throughout pregnancy. 
Vomiting is usually worse in the early 
morning but it can occur throughout 
the day. The majority of women 
respond to simple measures such as 
eating frequent small, non-fatty, dry, 
high-calorie meals and avoiding spicy 
food. 

Severe excessive vomiting in the first 
trimester is termed hyperemesis 
gravidarum. Hospital admission is 
necessary if there is dehydration, 
persistent ketosis, profound weight 
loss or impaired renal or liver 
function. Rehydration by intravenous 
infusion is the most effective therapy. 

The majority of cases of 
hyperemesis are idiopathic but urinary 
tract infections, multiple and molar 
pregnancies should be excluded. If the 
symptoms do not settle with 
rehydration and dietary adjustment 
medication should be considered Can 
antiemetic or phenothiazine 
preparation). 

Recurrent or prolonged hyperemesis 
may indicate an underlying 
psychosocial problem [see p. 44). 
Unresolved hyperemesis may lead to 
Wernicke's encephalopathy, due to 
vitamin Bl deficiency, or pontine 
myelinosis, due to sodium depletion. 

Urinary symptoms 

Most women develop increased 
frequency of micturition in early 
pregnancy, related to vascular 
engorgement and the progestogenic 
effects on urinary tract smooth muscle. 
Frequency usually diminishes by the 
12th week but recurs towards the end 
of pregnancy due to the pressure of 
the presenting part on the bladder. 
Urinary tract infections are more 
common in pregnancy. Asymptomatic 
bacteriuria may be found in 10% of 
pregnant women and of these, 20-30% 
will develop ascending pyelonephritis 
if left untreated. Regular urine analysis 
is important throughout the antenatal 
period and asymptomatic bacteriuria 
should be treated with antibiotics. 



Common problems in pregnancy 77 



Vaginal discharge 

Normal physiological vaginal discharge 
increases during pregnancy. If the 
discharge is clear and non-offensive the 
woman can be reassured. Fungal 
infections (particularly candidiasis), 
Trichomonas vaginalis and bacterial 
vaginosis are more common in 
pregnancy. The treatment can be 
difficult as clinical response tends to be 
slower and recurrences are common. 
Topical antifungal treatment with 
imidazoles or nystatin can be given as 
either a vaginal pessary or a cream. 

Bacterial vaginosis carries a five- to 
seven-fold increased risk for late 
miscarriage and preterm labour. 
Treatment is with metronidazole or, 
preferable in pregnancy, topical 
clindamycin. 

Backache 

The commonest cause of backpain is 
the increasing lumbar lordosis adopted 
to prevent toppling forward [Fig. 1). 
Pregnancy can exacerbate pre-existing 
back problems, particularly disc 
prolapse. A support corset may be 
helpful and flat shoes should be 
advised. It is advisable to keep the 
woman as mobile as possible in 
labour. Consideration should be given 
to route of delivery and types of 
analgesia. 

Pregnant pelvic arthropathy 

Normally the pubic symphysis and 
sacroiliac joints are fixed (Fig. 2). In 
pregnancy the ligaments become more 
lax and the symphysis pubis will 
separate to some extent. This is 
desirable as it allows the antero- 
posterior diameter available for the 
fetus to increase but in extreme 
situations the hemi-pelvices can be 
widely separated causing severe pain. 
Walking can be very difficult. Milder 
cases can be treated with analgesia and 
the use of a tight girdle or orthopaedic 
belt. In severe cases a zimmer frame 
and bed rest may be necessary. The 
condition is self-limiting and slowly 
improves after delivery. 

Carpal tunnel syndrome 

Pain may radiate up the forearm. The 
patient is often woken in the early 
hours of the morning with severe pain. 
Her fingers feel stiff and useless and 
she will often drop things. 

Explanation and reassurance are 
usually all that are needed. In more 
severe cases the woman is advised to 
sleep with her hand slightly elevated 
and may be fitted with night splints to 





Centre of gravity in a 
non-pregnant woman 
goes through the knees 



Centre of gravity in a 
pregnant woman is in 
front of the knees - 
uncorrected she will 
fall over 



Lumbar lordosis 
corrects situation - 
centre of gravity 
now re-established 




In the non-pregnant state 
the pubic symphysis and 
sacro-iliac joints are rigid 
and fixed 



Fig . 1 Lumbar lordosis in response to the body's change in centre of gravity. 



dorsiflex the wrist and reduce the 
pressure on the median nerve. 

Other aches and pains 

Pain in one or both groins is common. 
Aetiology is unproven but has been 
attributed to stretching of the round 
ligaments of the uterus. Analgesia and 
reassurance are appropriate. 

Tenderness over the intercostal 
muscles can occur in late pregnancy 
due to the enlarged uterus elevating 
the diaphragm and the subsequent 
alteration in the shape of the rib cage. 

Abdominal pain 

There are many causes of abdominal 
pain in pregnancy ranging from 
something as mild as viral 
gastroenteritis to acute fatty liver of 
pregnancy, a condition that is more 
severe. 

Acute appendicitis is often higher 
and more lateral in pregnancy and 
localizing signs are reduced. Red 
degeneration of a fibroid can cause 
severe pain. Maximum tenderness is 
over the fibroid but, if right-sided, can 
be confused with appendicitis. 




In the pregnant state ligaments 
are lax, sheering movements of 
one hemi-pelvis against the 
sacrum or the opposite half can 
occur 

Fig. 2 The pubic symphysis in pregnancy. 



; 



Common problems in pregnancy 

1 Most women feel well during pregnancy. 

1 A number of minor ailments do occur, for which symptomatic relief may be possible. 

1 Women should be encouraged to discuss minor symptoms with their health care professionals as. 
they might indicate a more serious condition. 



78 OBSTETRICS 

Vital statistics 




Maternal mortality 

Audit of clinical practice is important 
in the identification of areas for 
improvement The maternal mortality 
report run in the UK is a good 
example of clinical audit. Data have 
been collected since 1952 and reports 
are produced every 3 years. The last 
four reports cover the UK as a whole. 
The maternal mortality rate has 
officially been approximately 10 per 
100 000 maternities for the past decade 
but may have been ~ 12/100 000 due to 
missed cases. The major causes of 
death are thromboembolism, 
pregnancy-induced hypertension, 
amniotic fluid embolism, early 
pregnancy complications and sepsis. In 
the 1994-1996 report these accounted 
for 85% of direct maternal deaths 
[Fig. 1]. 

The problem globally is much 
bigger with the annual pregnancy- 
related death rate at 585 000. The 



estimated maternal mortality in each 
continent [Fig. 1) shows wide variation: 

■ Africa G4 0/100 000 

■ Asia 420/100 000 

■ Latin America 270/100 000 

■ all developed countries 30/100 000 

■ Northern and Middle Europe 
-10/100 000. 

Figure 3 shows the main causes of 
maternal mortality worldwide. An 
assessment of the causes of maternal 
mortality makes it clear what steps are 
needed to reduce the mortality: 

■ oxytocic drugs and blood 
transfusion 

■ antibiotics 

■ anticonvulsants 

■ partograms 

■ contraception. 

Comparison of the causes of maternal 
death between the worldwide list and 
that in the the UK report reveals that 



Haemorrhage 



Amniotic fluid embolism 
Hypertension 

Ectopic 

Sepsis 

Suicide 
Fig. 1 Causes of maternal deaths in the UK 1997-1999. 




Thromboembolism 



Cardiac 




CZ1 <29 
I I 30-99 
CZ1 100-199 
CZl 200^t99 
CTJ 500-999 

rzzt >iooo 

I I Not available 



Fig. 2 Worldwide maternal mortality rates in 1990. 



haemorrhage and obstructed labour do 
not feature as major causes of death in 
the UK. Looking back to the figures 
from the 1950s (Fig. 4), it is obvious 
that deaths from haemorrhage have 
reduced considerably due to the use of 
oxytocic drugs and blood transfusion 
and an awareness of this as a major 
problem. Tackling the issues posed by 
maternal mortality globally will 
require health care provision and effort 
directed specifically at the areas of 
major concern. The loss of a mother in 
childbirth leaves the child orphaned 
and the other children of the family 
needing care. Money directed at the 
problem of maternal mortality would 
thus be well spent and might reduce 
money needed in other areas. 

In 1987 the 'Safe Motherhood' 
initiative called for a halving of 
maternal deaths within a decade. 
Fifteen actions were suggested, mostly 
multifaceted approaches to problems 
identified as contributing to the high 
maternal mortality in developing 
countries. Ten years later the reduction 
had not been achieved, with obstetric 
disorders still a leading cause of death. 
The relationship between 
discrimination against women and 
maternal morbidity and mortality has 
been questioned, since countries that 
do discriminate do not have the 
highest mortality rates. 

Promotion of family planning to 
reduce maternal mortality is 
questionable when most maternal 
deaths occur after wanted pregnancies. 
Antenatal care is also unlikely to offer a 
major reduction in deaths when most 
complications of childbirth arise in low- 
risk pregnancies. Training of traditional 
birth attendants has not shown any 
effect on the mortality rate. Further 
advances will necessitate the provision 
of accessible care for obstetric 
emergencies by trained staff with 
appropriate facilities - a cosdy necessity. 

Perinatal mortality 

This is another indicator of the level of 
health care provision and annual 
figures are available for many 
countries (Fig. 5). In the UK the 
perinatal mortality rate (PMR) is 
defined as the number of stillbirths 
plus the deaths in the first week of life 
per thousand births (live and still), but 
variations in other countries include 
stillbirths from 20 weeks and loss for 



Vitaf statistics 79 



Other causes 
27.6% 




Haemorrhage 
24.8% 



Sepsis 
14.9% 



Obstructed 
labour 6.9% 



Fig. 3 Main causes of maternal deaths worldwide 1990. 



s 
£ 



8 

o 
o 
S 



- 

rx 



m 




70- 


D 

a 


60- 


□ 


50 


England and Wales 




n n 


40 


■■ 




o n 


30- 


a 


20- 


nao D 

a United Kingdom 




D ° aa 


10- 

n 


° da 

O OOOODQDD 
D 



52 56 60 64 68 



72 75 

Years 



79 83 87 91 



Fig. 4 UK maternal mortality rates 1952-1993. 



■c 

O 

c 
c 






60- 




— West Germany 

— Scotland 


50- 


^ 


Japar 
— England and Wales 
United States 


40- 


^r^ 


— Sweden 
^^ — Norway 


30- 


^^^ ^*-^ 


=bk. 


20- 




^* , ^~v^^~^>i^ 


10- 













III 


i i i i 



1945 1950 1955 1960 1965 1970 1975 1980 



Fig. 5 Perinatal mortality rates 1945-1982. 

up to the first month of life. Differing 
definitions hamper direct comparisons 
between countries. A dramatic 
reduction in the rates noted in the UK 
over the past five decades is seen with 
62.5/1000 in 1930-1935 compared to 
12-14/1000 during the 1990s. 

Again, audit of the figures, by 
making an assessment of the factors 
leading to death in each case, can 
contribute to changes in clinical 
practice that may lower the PMR. 

Numerous attempts have been made 
to classify the causes of perinatal death 
to improve preventive measures. The 
Wigglesworth classification centred on 



division into the time when preventive 
action might be taken - congenital 
abnormality and antepartum stillbirths 
have factors present in the antenatal 
period, asphyxia occurs during labour 
and delivery, whilst immaturity must 



I 



Vital statistics 



be active in the neonatal period. 
Factors associated with a raised 
perinatal mortality rate are: 

■ preterm delivery - 5°/o of babies 
deliver preterm but this accounts for 
70% of perinatal deaths 

■ congenital abnormality 

■ small for dates 

■ social class - IV and V rates are 
higher than I and II 

■ teenage and older (> 40) mothers 

■ multiple pregnancy. 

Prevention of preterm delivery could 
dramatically affect the PMR but depends 
on a better understanding of the process 
of initiation of labour. Current methods 
of arresting labour are ineffective and the 
diagnosis of preterm labour is also 
difficult (see p. 18). Congenital 
abnormality can sometimes be detected 
antenatally with ultrasound but litde can 
then be done if the condition is known 
to be lethal Prevention of the small for 
dates infant is again dependent on a 
better understanding of what controls 
fetal growth. 

The factors active in social class 
discrepancy are known but require 
great social change and are unlikely to 
undergo dramatic improvement 
without major funding. The incidence 
of multiple pregnancy is increased in 
association with assisted conception 
techniques. Management includes feto- 
reduction to try to improve the 
chances of the surviving infant(s) but 
this raises ethical questions. 

The role of audit 

The major 'vital statistics' are maternal 
and perinatal mortality but, in 
developed countries, every hospital 
audits their obstetric figures looking at 
the mode of delivery, complications 
including deaths, how analgesia is 
given, and many other factors. This 
allows changes to be made in the 
delivery of care to ensure best 
outcomes. In less-developed countries 
basic levels of health care need to be 
introduced but audit infrastructure 
must be added to ensure that the local 
community can continue to detect 
where to direct their efforts for 
maximum benefit 



Maternal mortality has reduced in developed countries due to use of blood transfusion, 
medication to control haemorrhage and antibiotics for sepsis. 



; Worldwide reduction in maternal mortality requires adequate health care provision ■ 
necessity. 

i Perinatal mortality fate is not uniform in its definition. 

i Prematurity accounts for 70*b of perinatal mortality in western countries 



a costly 



80 OBSTETRICS 

The newborn 



Separation of the placenta means the 
infant must adapt to extrauterine life. 
The physiological changes are many 
and need to be immediate as the infant 
takes over oxygen exchange for itself 
Acidosis in the baby and a fall in pa0 2 
will result in failure to breathe - if of 
short duration there is usually a rapid 
response to resuscitation; a slower 
response suggests anoxia of longer 
duration. The newborn has large 
glycogen stores in the brain, liver and 
heart which enable survival up to 
20 minutes with no oxygen. Thus 
resuscitation is always worthwhile. 

Adequate equipment (Fig. 1) in the 
delivery room to deal with infant 
resuscitation includes: 

■ radiant warmer 

■ resuscitation bags and masks 

■ endotracheal tubes 

■ laryngoscope 

■ stethoscope 

■ oxygen source and suction 

■ naloxone. 

All high-risk deliveries should be 
attended by someone skilled in infant 
resuscitation but it is recognized that 
in approximately half of all cases 



Table 1 Assessing 


the 


Apgar score 











Score 
1 


2 


Calaur 
Respiratian 

Heart rate 




Pale 

Nil 

Absent 


Blue 
Gasps 
< 100 

Presenr 
Presenr 


Pink 
Regular 
> 100 

Good 
Brisk 


Tone 

Response to stimulat 


On 


Flaccid 
Nil 



requiring resuscitation the need for 
resuscitation is not recognized prior to 
delivery. It thus is necessary for those 
involved in delivery to be able to initiate 
and continue infant resuscitation. 

Assessment of the infant 
immediately after delivery is usually by 
means of the Apgar score (Table 1]. 

Resuscitation 

Most infants require only removal of 
mucus from the oropharynx, drying 
and handing to the mother or, 
preferably, delivery straight onto the 
mother's abdomen. The ambient 
temperature in a delivery room is high 
to ensure that there is minimal cooling 
of the infant Neonates maintain their 
body temperature in a cool 
environment at the metabolic cost of 
increased energy expenditure. Ways to 




Tabi e 2 Ad van ta g e s an d d is a d va ntag es 
if nasopharyngeal suction 


Advantages 


Disadvantages 


Improved air exchange 
Decreased likelihood of 
aspiration ol secretions 
Less acquisition of 
pathogens from amniotio 
(hurl or birth canal 


Bradycardia 

Laryngospasm and pulmonary 

artery vasospasm 



Fig. 1 Resuscitation equipment. 



reduce the postnatal fall in 
temperature include: 

■ skin-to-skin contact with the mother 

■ drying the neonate 

■ radiant heater 

■ covering the head ± body with 
insulated material. 

The indications for resuscitation are: 

■ heart rate < 100 bpm after birth - 
needs oxygen administration 

■ generalized cyanosis - needs oxygen 
administration 

■ inadequate chest excursion and poor 
breath sounds - bag and mask 

■ poor response to bag and mask 
ventilation - needs endotracheal 
intubation. 

Proper ventilation of the infant is the 
single most important aspect of 
neonatal resuscitation. Observation of 
the chest distending with squeezing the 
bag indicates a proper head position 
and a clear airway. A rise in the heart 
rate is an indicator of the success of the 
resuscitation. Enough pressure on the 
bag to produce chest excursion is 
needed as well as an adequate inspired 
oxygen concentration. 

Nasopharyngeal suction has benefits 
and risks (Table 2) but in a delivery 
complicated by passage of meconium, 
nasopharyngeal suction before delivery 
of the chest may be useful. The use of 
routine intubation in these cases is 
accompanied by the risks of hypoxia, 
bradycardia and increase in 
intracranial pressure. 

Medication 

Routine administration of certain 
medications to the neonate is standard 
practice. Vitamin K is offered routinely 
for all newborns to prevent 
development of haemorrhagic disease 
of the newborn (HDN) which has an 
incidence of 0.25-0.5%. The vitamin K 
level in breast milk is considerably 
lower than in infant formula feeds and 
puts the infant at risk of serious 



The newborn 81 



bleeding (e.g. intracranial 
haemorrhage). Thus a policy of 
giving routine vitamin K to all breast- 
fed babies seems reasonable. Recent 
work comparing vitamin K 
administered orally with that given 
intramuscularly (i.m.) suggested an 
increased rate of childhood cancers in 
the group who had had i.m. 
administration of the vitamin. This has 
subsequenuy been disproved but some 
parents may refuse i.m. vitamin K and 
thus oral doses should be administered. 

Surfactant 

The immediate postnatal 
administration of surfactant can reduce 
morbidity and mortality of infants 
born before pulmonary maturation 
has occurred. Administration decreases 
the likelihood of moderate or severe 
respiratory distress syndrome (RDS), 
pneumothorax and periventricular 
haemorrhage. 

Naloxone 

This narcotic antagonist may be given 
to a neonate who is slow to establish 
spontaneous respiration when this is 
thought to be due to narcotic 
analgesics given to the mother before 
delivery (see p. 71). As the role of 
endogenous opiates in the newborn is 
unclear, but thought to be important, 
it seems wise to restrict the use of 
naloxone to infants exposed in utero 
to narcotic analgesia who also require 
active resuscitation after delivery. 

Examination 

The examination of the newborn is 
important to establish normality and 
to allow the parents to discuss any 
worries they may have. In order to 
avoid missing anything it is important 
to have a clear plan which is followed 
during every examination [Table 3). 
The examination plan should be: 

■ colour 

■ tone 

■ head - fontanelles, eyes, ears, palate 

■ chest - heart, breasts 

■ abdomen - cord insertion, femoral 
pulses 

■ genitalia and anus 

■ hips 

■ feet 

■ neurological responses. 

The skin colour will vary with the 
maturity of the infant, that of the 
premature baby being more red as the 
skin is more translucent. Peripheral 
cyanosis is common at delivery. Tone 
can readily be assessed by ventral 



Table 3 Checklist for neonatal examination 


Examine 


Signs to look lor 


Comment 


Colour 
Cranium 
Face 
Eyes 


Cyanosis, plethora 


Examine in goad light - cyanosis is easy to miss 


Large'smal head circumference 

Dysmorphism 

Red reflex 


Hydrocephalus/microcephary 

Try to identify the specific abnormal features 

Use ophthalmoscope - red reflex is absent if cataract or retinal 

disease is present 


Mouth 


Cleft palate 


Use little finger to feel the hard and soft palate 
Head movement may be restricted 


Meek 


Sternomastoid "tumour' 


Pulses 


Brachials and femorals 


Absent femorals represent possibility of coarctation 


Hands 
Chest 


Shape, creases, nails, accessory digits 
Shape, resp. rate, recession, auscultation 


Heart murmurs 


Abdomen 


Palpable masses 


Liver is always palpable and kidneys usually 


Umbilicus 
Genitalia 


Discharge, flare around 

Boys: testes 

Girls: labia and vaginal orifice 


Suspect cord sepsis 

Cremasteric reflex may be very brisk 


Anus 


Check that it is present 


Recto -vaginal fistula may allow the passage af meconium 
without an anus 


Hips 


Sub luxation/dislocation 




Feet 


Mobility 




Reflexes 


Mora, grasp, sucking 




Tone 


Posture during sleep 
Posture on ventral suspension 





After Field. D.etal. 1997 Paediatrics An Illustrated Colour Text, Churchill Livingstone, Edinburgh, p. 5. 



suspension of the infant; normal tone 
is associated with arching of the back. 
This also allows examination of the 
spine. Normal head circumference in a 
term infant is 33-37 cm. The 
fontanelles should not be bulging or 
abnormally sunken. The eyes need to 
be opened to look for cataract and to 
elicit a red reflex. Examination of the 
ears and palate for normality and 
observation of the scalp for signs of 
trauma from a scalp electrode or 
ventouse delivery complete the 
examination of the head. 

Listening to the heart sounds may 
elicit a heart murmur but this is 
common in the newborn so further 
assessment at a later stage is 
appropriate (Fig. 2). The breasts may 
appear engorged from the effect of 
stimulation due to the mother's 
hormone levels or vaginal discharge 
may be noted. Inspection of the cord 
insertion will exclude exomphalos. The 
femoral pulses are palpated to rule out 
coarctation of the aorta and the 
abdomen palpated for presence of 
masses. The genitalia should be 
inspected, looking especially for 
hypospadias or bifid scrotum which 
may call into doubt the allocated 
gender of the infant Patency of the 



anus should be confirmed, then the 
hips examined to exclude congenital 
dislocation (Fig. 3). The feet are 
inspected and their mobility assessed. 
Finally, neurological response may be 
checked by tapping the cot and a Moro 
reflex is usual - startle response. 




Fig. 2 Auscultation of the heart. 




Fig. 3 Examination of thehipsof a 
newborn infant 



J 



The newborn 



The need for resuscitation of the neonate is not predictable in approximately half of all cases. 
Keeping the newborn warm after delivery improves survival, especially in the preterm infant. 
Adequate ventilation should move the infant's chest. 
The first routine examination of the newborn is to exclude identifiable abnormality 



82 OBSTETRICS 

Problems in the first week of life 



A newborn baby must adjust very 
rapidly to extrauterine life. While 
cardiorespiratory changes are the most 
obvious, the thermoregulatory, 
gastrointestinal, and immune systems 
are also important. 

Prematurity-related problems 

Survival increases from approximately 
5% at 23 weeks' gestation to 95% at 
31 weeks. About 25% of these 
survivors have some disability - 
including cerebral palsy, short stature, 
respiratory difficulties, visual 
impairment and poor school 
performance. It is now well established 
that corticosteroids given to mothers 
who subsequently deliver preterm are 
effective in reducing the incidence of 
respiratory distress syndrome (RDS) 
by around 50% as well as the risk of 
periventricular haemorrhage. Whether 
or not to start resuscitation with an 
extremely premature (less than 
24 weeks) infant can sometimes be a 
difficult question and, ideally, 
discussions with the prospective 
parents should have taken place 
beforehand in order to be able to 
gauge their wishes. 

Heat loss 

Preterm infants have a very high 
surface area to mass ratio and thin 
skin, and are extremely liable to 
hypothermia. This means that it is 
vitally important to deliver in a warm 
room with heated towels for drying 
and some method to keep the baby 
warm during resuscitation, e.g. an 
overhead heater. Survival is directly 
related to the temperature of the infant 
on admission to the neonatal intensive 
care unit. 

Respiratory support 

At 23-24 weeks the respiratory 
epithelial cells start to differentiate into 
type 1 (gas exchange) and type 2 
(surfactant production) pneumocytes. 
Surfactant levels are very low but can 
be increased by antenatal 
glucocorticoids. Support at this 
gestation is often by mechanical 
ventilation, either conventional 
ventilation or with high-frequency 
oscillation. Exogenous surfactant can 
be administered via the endotracheal 
tube. A large proportion of extremely 
preterm infants develops chronic lung 
disease of prematurity (or 



bronchopulmonary dysplasia) with 
continuing requirements for 
respiratory support. 

Central nervous system 

The subependymal germinal matrix 
lies close to the ventricular space and 
contains the developing brain cells of 
the premature infant. Bleeding from 
this very vascular area may occur with 
preterm delivery, giving rise to 
periventricular haemorrhage, cortical 
damage and hydrocephalus. The 
extremely preterm infant is also prone 
to ischaemic brain injurs' from low 
arterial oxygen tension, hypotension, 
or reduced cerebral blood flow. 
Subsequent periventricular cysts 
(periventricular leukomalacia) may 
form and long-term neurological 
sequelae are common. 

The gastrointestinal system 

Structurally, the bowel is well 
developed by the end of the second 
trimester but there is functional 
immaturity. Motility and food 
absorption are both reduced and early 
enteral feeding may not be tolerated. 
Parenteral nutrition may be needed 
during the early days and weeks, but 
this may lead to numerous problems, 
from both the need to maintain 
adequate venous access and the 
tolerability of the amino acid and lipid 
solutions. 

Sepsis 

Sepsis is a major problem in the 
extremely preterm baby. Relative 
immunocompromise and frequent use 
of multiple, broad-spectrum antibiotics 
render the tiny baby prone to 
infection, particularly with sub- 
pathogenic bacteria, such as 
Staphylococcus epidermidis, and fungi, 
especially Candida albicans. 

Retinopathy of prematurity 

Early vasoconstrictive damage to the 
retina occurs as a result of high 
oxygen pressure and other factors. The 
incidence of this is reduced by using 
ventilation at lower pO, levels. 
Secondary proliferation of weaker, 
potentially haemorrhagic, vessels 
occurs. Regular ophthalmological 
review is vital as early laser or 
cryotherapy treatment of these new 
vessels can preserve vision. 



Cerebral damage 

Although commoner in premature 
infants, cerebral damage may be found 
in term infants and may lead to 
mental impairment and/or cerebral 
palsy (a non-progressive motor deficit). 
Probably less than 10% of cerebral palsy 
is related to intrapartum problems, the 
remainder being caused by some often 
unidentifiable antenatal event. 

Apgar scores are a reflection of the 
level of resuscitation required but are a 
very poor predictor of long-term 
outcome. Neonatal encephalopathy 
grading is a better guide to long-term 
outlook: 

■ Grade 1 : hyper-alert, reduced tone, 
jittery, dilated pupils: usually 
resolves in 24 hours 

■ Grade 2: lethargic, weak suck, fits: 
15-27% chance of severe sequelae 

■ Grade 3: flaccid, no suck, no Moro 
reflex, prolonged fits: nearly 100% 
chance of severe sequelae. 

The prognosis is generally good if the 
baby does not develop grade 3 
encephalopathy, or if grade 2 
encephalopathy lasts < 5 days. Further 
clinical evaluation may be available 
from electroencephalography (EEG; 
incidence of death or handicap low if 
normal or near normal), computed 
tomography (CT; good prognosis if 
normal or only patchy hypodensities) 
or ultrasound scan (USS; incidence of 
impairment correlates with 
intracerebral hypoechogenic areas of 
necrosis). Intracerebral haemorrhage is 
also an adverse sign (Fig. 1). 

Congenital anomalies 

The incidence of major anomalies in a 
low-risk unscreened population is 




Fig. 1 Spontaneous intracerebral bleed 
following preterm delivery, occluding the 
lateral ventricle on the right. 



Problems in the first week of life S3 



around 2%. The incidence is higher in 
those exposed to potential teratogens 
[e.g. anticonvulsants) and with certain 
medical conditions (e.g. pre-existing 
diabetes). The incidence of live births 
with severe anomalies is lower in those 
countries which have some form of 
screening programme and which allow 
the option of pregnancy termination. 

Trauma 

Caput succedaneum (oedema caused 
by pressure over the presenting part) is 
common and resolves within a few 
days. Cephalhaematoma (a 
subperiosteal haematoma) is much 
rarer, but is significantly commoner 
following vacuum extraction compared 
to forceps delivery. Subgaleal 
(subaponeurotic) haemorrhage occurs 
when there is bleeding into the 
potential space beneath the aponeurosis 
of the scalp - this is a large space and 
can accommodate a large volume of 
blood. Although rare, it can be life- 
threatening (Fig. 2). Forceps are more 
likely to cause craniofacial injuries, 
including bruising, linear skull fractures 
and facial nerve palsies. 

Fractured clavicle and brachial 
plexus injuries are more common 
following shoulder dystocia. Erb's palsy 
is a C5-6 lesion in which the arm is 
held loosely at the baby's side with 
internal rotation of the shoulder and 
extension of the elbow (waiter's tip). In 
Klumpke's palsy there is impairment 
of C8-T1. There is often very good, if 
not necessarily complete, recovery of 
palsies within the first few months, 
and physiotherapy may be offered to 
prevent contractures. A fractured 
clavicle will heal spontaneously. Other 
orthopaedic injuries, including spinal 
injur}', are rare. 





Fig. 3 Respiratory distress syndrome 
following emergency caesarean section. 

The mother had diabetes which predisposes to 
respiratory distress syndrome. Note the ground 
glass appearance of the lungs. 



Scalp damage may occur from a 
scalp ECG clip. Rarely this can be 
severe and associated with secondary 
infection and long-term scarring. 

Respiratory distress syndrome 
(RDS) 

This is caused by a deficiency of 
surfactant and is commoner in 
preterm infants (0.1% at term vs 30% 
at 28 weeks). Surfactant, a complex 
lipoprotein consisting largely of 
phosphatidyl choline, is synthesized by 
type II pneumocytes within the alveoli 
and is important in allowing the 
alveolus to expand. Hypoxia, acidosis 
and hypothermia reduce surfactant 
production; antenatal steroids increase 
production and thereby reduce the 
incidence of RDS. Clinically, there is 
tachypnoea, grunting and intercostal 
recession commencing within the first 
4 hours of life, and the chest X-ray 
demonstrates a generalized 
reticulogranular appearance referred to 
as like 'ground glass' (Fig. 3). 
Treatment is with oxygen ± supportive 
ventilation and often includes giving 
artificial surfactant through an 
endotracheal tube. 

Meconium aspiration syndrome 

In utero, meconium is usually retained 
within the colon. Although it may be 
passed through the sphincter under 
physiological conditions, particularly 



Fig. 4 Meconium aspiration syndrome. 

Note the widespread patchy shadowing in both 
lungs. 



after 40 weeks, it also has an 
association with fetal hypoxic stress. 
Meconium is irritant to the neonatal 
lungs and may lead to a pneumonitis, 
the meconium aspiration syndrome 
(Fig. 4). Clinical features range from 
mild neonatal tachypnoea to severe 
respiratory compromise. Treatment is 
with oxygen, mechanical ventilation 
and, if very severe, extracorporeal 
membrane oxygenation. 

Seizures 

The immature central nervous system 
is particularly prone to seizure activity, 
which is the brain's common response 
to differing pathologies. They may be a 
feature of neonatal encephalopathy 
(see above) but can also occur with 
focal cerebral infarction, cerebral 
malformation, meningitis (e.g. with 
group B (3-haemolytic streptococci), 
hypoglycaemia, hypocalcaernia, 
maternal drug misuse and inborn 
errors of metabolism. 

The commonest timing of onset is 
between 12 and 48 hours. The 
resulting membrane damage of seizure 
activity releases excitotoxic substances 
such as glutamate, which can trigger 
further seizure activity, and 
investigation and treatment are 
therefore of great importance. In 
particular, prolonged fits can cause 
cerebral hypoxia and cerebral oedema. 



Problems in the first week of life 



Fig. 2 Cephalhaematoma (a) and 
subgaleal (subaponeurotic) haematoma 
(b). Note that the potential subgaleal space can 
hold a much greater volume of blood than the 
smaller potential space under the periosteum. 



Prematurity is the commonest cause of fetal morbidity and mortality. 

Probably less than 1 0% of cerebral palsy is related to intrapartum' problems, 
i Neonatal encephalopathy is a better guide to long-term prognosis than Apgar scores. 
i Respiratory distress syndrome responds well to surfactant administration. 



84 OBSTETRICS 



Bereavement in obstetrics and gynaecology 



There are few harder things to come 
to terms with than the loss of one's 
child at whatever gestation. 

Obstetric bereavement shares many 
of the features of the mourning 
process common to other situations: 

■ accept the reality of the loss 

■ experience the pain of grief 

■ adjust to the environment 

■ reinvest in the future. 

During the first two phases there are 
issues of blame, disbelief, acute sadness 
and an attempt to search for 
explanations. These negative emotions 
gradually disappear with time but 
levels of distress are higher in 
situations where there is a lack of 
opportunity to discuss the events 
surrounding the loss. Older women 
and particularly those who have had 
previous children are less likely to 
suffer depression. 

It is a mistake to rush into another 
pregnancy to try to compensate for the 
loss of a previous child. The grieving 
process must be worked through in its 
entirety before the couple is 
emotionally and psychologically strong 
enough to undergo another pregnancy, 
and to be able to deliver the quality of 
bonding and parental care required by 
the new offspring. 

Miscarriage 

There is a risk that the miscarriage, or 
early pregnancy loss, is managed only 
medically with a failure to recognize 
that for the woman concerned, and her 
partner, the grief of a lost early 
pregnancy can be as real as the loss of 
a child at term. 

The most appropriate care is in an 
early pregnancy assessment unit or 
gynaecological ward. The woman 
should be admitted and treated 
promptly, as long waits may enhance 
anxiety. 

Parents should be given the 
opportunity to discuss the miscarriage 
with a counsellor and a suitable clinic 
appointment should be made. 
Information leaflets and contact 
numbers should be available. They 
may well wish to involve a religious 
adviser even at this early gestation. A 
Certificate of Non Viability will need to 
be completed together with a 
Notification of Miscarriage Form in 
England. This is sent to the antenatal 
clinic to avoid the distress of an 




Fig. 1 Memento birth document with 
name, photo, footprint, etc. 

inappropriate appointment being sent. 
Under 1G weeks the fetus will be sent 
to the histopathology laboratory. Anti- 
D should be prescribed, as appropriate, 
to the mother. 

In the case of late second trimester 
miscarriages, i.e. those > 1G weeks' 
gestation but under 24 weeks' gestation, 
the mother might wish to see the baby 
or have a photograph (Fig. 1). This is 
not always the case and her wishes 
must be respected. It is also important 
to discover whether she would like a 
visit from the hospital chaplain or a 
blessing or naming ceremony for her 
baby. Gathering of mementoes, etc may 
also be important 

When a histopathology examination 
is required in these later miscarriages a 



consent form should be signed. If the 
family do not agree to a full autopsy, a 
limited autopsy may be performed. In 
order to help parents make a decision, 
the government leaflet entitled 'Guide 
to the Post Mortem Examination' is 
available in many different languages. 
A Certificate of Non-Viability and a 
clinical information form must be 
completed. 

Intrauterine death (IUD) and 
stillbirth (SB) 

When an IUD is diagnosed the 
parents should be offered a choice of 
admission for induction immediately 
or they may prefer to wait a day or 
two which will allow them the chance 
to mourn in private. It is important to 
keep the number of midwifery and 
medical staff to a minimum to provide 
continuity of care. 

If the evidence suggests that the 
baby has been dead for longer than 
4 weeks a clotting screen is performed, 
as disseminated intravascular 
coagulation can occasionally intervene. 
Induction of labour during the third 
trimester is usually undertaken with 
prostaglandin pessaries or gel similar 
to a normal induction (see p. 48). 
Cervagem or extra-amniotic 
prostaglandin infusions can be used 
for second trimester IUDs. Many units 
now use mifepristone. 

Most hospitals will have an active 
policy for the management of 



Table l Checklist for intrauterine deaths, stillbirths and neonatal deaths 

■ Mother and partner informed ol death 

■ Parents offered a chance :o see and hold their baby 

■ Other relatives requesting trj see and told baby with parents' consent 

■ Photograph ol baby, two lot parents it warned one for notes 

■ Memento oflered. cot card, name band, footprints, locks ol hair 

■ Religious leader notified if wished after discussion with parents 

■ Father given the opportunity to stay in hospital overnight 

■ Postmortem discussed and requested, consent obtained or refused 

■ Clinical information and postmortem form completed 

■ Certificate of Non-Viability (< 24 weeks) or stillbirth certificate completed 

■ Consultant obstetrician informed 

■ Consultant paediatrician informed, il neonata I d eai h 

■ Genera I practit inner mtot med 

■ Patients Officer informed regarding f uneral/dsposal arrangements and birth registration 

■ Parents given appropriate bookJets'access to videos 

■ Any special clothing or items to be placed on baby 

■ Discussion on suppression of lactation 

■ Fa in ity plan m n g advi ce offered 

■ Commu any m idwife informed 
■: Health visitor informed 

■ Medical social worker informed if necessary 

a Appointment made lor appropriate consultant's clime 

■ Paiem education classes cancelled 

■ An tenatal appo ml ments cancetl ed 

■ Counselling oflered 



Bereavement in obstetrics and gynaecology 85 



Fa I > e 2 Investigationsforlatefetalloss 
(intrauterine deaths and stillbirths) 

Maternal 

■ TORCH screen [check if done antenatally) 

■ Kieitnauer tesi 

■ Lupus anticoagulant test 

■ Antica rdiolipan antibodies 

M Syphilis serology screening [check if done 
antenatally) 

■ Random blood glucose 

■ Thyroid function tests 

■ Rh esus a n tibody titre (if moth er is Rhesu s nega tive) 

■ High vaginal swab and endocervical swab 

■ Parvovirus titre [if ultrasound evidence of hydrops] 

■ Genetic studies [if indicated) 

Placental 

■ Histology 

■ Swab - or culture 



Felal 

■ Photograph : 

■ Postmortem 

■ Chromosomal analysis 



: X-ray 



bereavement. A checklist (Table 1) is 
usually helpful for the midwifery and 
medical staff involved, who are often 
distressed themselves. Some mothers 
regard lactation as a tangible link with 
the child they have lost, others are 
horrified by the prospect and 
bromocriptine should be prescribed 
immediately to prevent lactation 
occurring. Advice regarding family 
planning should be offered as soon as 
is practicable. 

Often no satisfactory cause is found 
but every attempt should be made to 
do so (Table 2) and consent to a 
postmortem may be useful. If this is 
refused, clinical photographs and 
X-rays of the baby can be substituted. 
Genetic counselling may be indicated 
when fetal malformation is detected. 
Chromosomal analysis on fetal 
material is required. Most areas run a 
regional congenital malformation 
register and a Notice of Malformation 
should be completed and sent 
appropriately. For gestations less than 
24 weeks a stillbirth certificate will 
need to be completed. 

Neonatal deaths 

It is important to recognize the family 
as a unit and to involve the parents as 
much as possible in the care of the 
terminal baby. They should be 
encouraged to handle their child and 
to have photographs of the baby whilst 
alive. In the case of twins, photographs 
of the two babies together should be 
encouraged. Children need to grieve 
for their lost brother or sister and this 
process is facilitated if the sibling is 
actively involved from the beginning. 



Parents must never be left to feel 
that they alone made the decision to 
withdraw intensive care support. 
Adequate provision of privacy for the 
parents to be with their child to allow 
them to say goodbye is very important. 

Arrangements for cremation and 
burial 

There is no legal requirement to bury 
or cremate a baby lost before 24 
weeks' gestation, as it was non-viable, 
and no legal requirement for the 
parents to be involved. However, staff 
should be aware that parents could, if 
they so wish, take the body away for 
burial. Usually, they prefer the hospital 
to make appropriate arrangements. A 
book of remembrance is often kept in 
the hospital chapel and parents can 
enter their baby's name and an 
inscription of their choice regardless of 
the gestation. Often chapels will hold 
an annual service of remembrance for 
all bereaved parents. 

In the case of stillbirths and 
neonatal deaths, there is a legal 
requirement for the baby to have a 
proper burial or cremation. Parents 
may make their own private 
arrangements or the hospital can 
arrange for a funeral. It is vitally 
important that carers are sensitive to the 
religious and cultural needs of the 
bereaved relatives. For members of the 
Jewish and Muslim faiths it is important 
that burial takes place, if possible, within 
24 hours of the baby's death. 

Continued support 

Most units now have a special 
bereavement suite where the couple 
can stay overnight Usually the mother 
is inclined to go home as quickly as 
possible after delivery. Counselling 
should be continued and often a 
counsellor will offer to call on the 
mother at home. She will not have 
worked through all the bereavement 
issues prior to leaving hospital. There 
are a number of useful support 



agencies (Table 3) and there are 
excellent information leaflets, books 
and videos available (Fig. 2). 



Table 3 Chromosome analysis 

Indications 

■ Malformed or dysmorphic baby 

■ Any ba by si gn if i ca ntly small for dates 

■ Significantly macerated stillbirths [although may Be 
difficult to obtain karyotype) 

Specimens required 

■ Blood sample by cardiac puncture [2-3 ml of blood 
in lithium heparin suitable from fresh stillbirth and 
early neonatal deaths) 

> Skin biopsy [a full thickness 0.5 cm ellipse from the 
lateral border of the thigh if blood sample difficult) 

■ Placental tissue [sample of membranes and placental 
disc sent dry in a universal container if maceration is 
significant) 




Fig. 2 'When our Baby Died' video and 
'Grieving after the Death of your Baby' 
accompanying booklet. 



Table 4 Useful support agencies 

■ The Miscarriage Association 

■ Stillbirth and Neonatal Death Society (SANDS) 
(Jewish Baby Bereavement Support affiliated to 
SANDS) 

■ ARC (Antenatal Results and Choices) 
(formerly Support Around Termination for 
Abnormality. SATFA] 

• The Compassionate Friends 

■ The Asian Bereavement Counselling Service 

■ Bereaved Parents Mutual Support Group 

■ The Twi n s and M u Itiple Births Associa tion (TAM 8 A) 

■ The Bereavement Clinic. The Lone Twin Network 
from the Multiple Birth Foundation 

■ Foundation for Study nf Infant Deaths (FSID) 
(Cot Death Helpline 2*-h service - run by FSiD] 

■ Child Death Helpline 

(run by Great Ormond Street & Alderhey Children's 
Hospitals) 

■ The Child Bereavement Trust 



Bereavement 



■ Couples often feel the loss of a miscarriage as greatly as the toss of a baby. 

■ A longstanding intrauterine death may result in dotting abnormalities and a clotting screen 
should be taken on admission. 

■ Even if a postmortem is refused, clinical photographs and X-rays of the baby can be useful to 

identify the cause of death. 

■ The parents should be encouraged to be involved in nursing a terminal baby. 

■ It is unwise to rush into another pregnancy to compensate for a lost child due to the greater risk 
of depression. 



86 GYNAECOLOGY 




Gynaecological assessment of the patient 



Basic facts about the patient are usually summarized in one 
sentence which is given at the start and at the end of the 
gynaecological history presentation, e.g. Mrs Jones is a 33- 
year-old with pelvic pain and deep dyspareunia. History 
starts with the patient's presenting complaint first, going 
thoroughly into such gynaecological details as may be 
relevant to this particular complaint. Whatever the 
complaint, it is usual to ascertain the length of the history, 
salient features such as the nature of pain, location and 
character of a mass, the timing of bleeding history, or length 
of infertility suffered. Thus many aspects of the 
gynaecological history may be covered under presenting 
complaint and further history discussed later. 

Patient history 

Menstrual history 

Table 1 outlines the history to be elicited. The volume of 
blood lost during menstruation is usually gauged from the 
amount and type of sanitary protection, passage of clots and 
flooding bedding and outer clothes. 

Vaginal discharge 

Physiological discharge is usually off-white and varies in 
amount. This increases in mid-cycle when the nature also 
changes to that of a stringy mucous discharge at the time of 
ovulation. Questions concerning the volume of the 
discharge, the timing of it in relation to the menstrual cycle, 
the association with pruritus, and the odour of the discharge 
all need to be determined. 

Non-physiological discharge may be associated with intense 
itching as caused by candidiasis, where the discharge would be 
thick and curdy. A frothy yellow/ green offensive discharge 
might be caused by Trichomonas [see also p. 104). 

Pain 

Dysmenorrhoea may be primary, noted at the onset of 
menses and relieved with the establishment of flow, or 
secondary, associated with other pelvic pathology (see 
p. 123). Dyspareunia is pain during sexual intercourse which 
may be experienced superficially (at the introitus - look for 
obvious cause) or be deep (within the pelvis - may be 
associated with endometriosis or pelvic infection). Pelvic pain 
may be colicky, due to uterine contractions, or more constant 
Unilateral pain may suggest an adnexal problem but infection 
causes bilateral pain. Vulval pain is intense with an initial 
herpetic attack - look for blisters. Vulval itching in 
postmenopausal women is found with vulval dystrophies. 

Sexual intercourse 

A detailed history is appropriate in infertility patients 
(seep. 130). 

Urinary symptoms 

The five classic symptoms to enquire about are stress 
incontinence, urgency, urge incontinence, frequency, and 
nocturia. A detailed urinary history is appropriate if the 
presenting complaint is vaginal prolapse. Usually described as 
a lump in the vulval region, it may be associated with pain or 
difficulty in defecation. In some gynaecological complaints, 
subspecialty interest clinics have been developed where a 
specialised history is used - for example, infertility (see p. 130) 
and urogynaecology. 



Table 1 History taking 






Term used 


Meaning 




Menarche 


Age at first menstruation 




Amenorrhcea 


Absence of menses 




Last menstrual period (IMP) 


Date of first cay of bleeding 




K7-10/2S 32 


Menstrual cycle length 28 to 32 days 
with 7 to 10 days of bleecmg 




Menopause 

Olignmenorrhoea 


Trie last menstruation 




Inlrequeut menstruation 




Menorrhagia 


Regular heavy menses 




Intermenstrual bleeding [1MB] 


Bleeding between menses 




Postcoital bleeding (PCBj 


Bleeding after intercouse 




Dysmenorrhoea 


Pain associated with mertstruatEon 





; 



\ Liver 


4 

Middle lobe 
of liver 


> / 

Spleen / 


/ 8 

/ Kidney 


5 

Aortic 
aneurysm 


A 

Kidney \ 


7 

Colon 


6 

Pelvic masses 
or bladder 


1 

Descending 
colon 



Fig. 1 Abdominal palpation of the nine areas of the abdomen. 

Past obstetric history 

The level of detail required of the past obstetric history is 
dependent on the presenting gynaecological complaint with 
more details being relevant in someone complaining of 
recurrent spontaneous miscarriage or infertility than in an 
older patient complaining of urinary symptoms or prolapse. It 
is usual to record the number of pregnancies and the outcome, 
the mode of delivery, the weight of the heaviest baby and any 
complicating factors during or after the pregnancies. 

Contraception 

Record the method used, satisfaction with the method, any 
side effects or problem with compliance and the consistency 
of use of the method. 

Examination 

After performing a general systems examination, breast and 
abdominal examination precede the pelvic examination. 

Breast examination 

Using the palmar aspect of the fingers palpate for lumps in 
the breast using circular motions starting over the nipple and 
radiating outwards, finishing with palpation of the axilla and 
supraclavicular areas for palpable lymph nodes. 

Abdominal palpation 

The nine areas of the abdomen are examined [Fig. 1), the 
right-handed examiner usually commencing in the left iliac 



Gynaecological assessment of the patient 87 



Shifting 

cLiI ness 



<») 



O 

(a) 



Examining 
fingers 



Thumb out of contact 
with clitoris 




Fig. 3 The correct hand position for 
vaginal examination. 



(a) Dullness on percussion over fibroid 
uterus or ovarian cyst is noted centrally 

(b) Dullness on percussion in the flanks is 
associated with ascites. 

The level rises as the patient rolls to her side 

Fig. 2 Difference in percussion findings in cysts/fibroids versus 
ascites. 



fossa progressing up towards the spleen, down the centre of 
the abdomen towards the pelvis and up the right hand side 
of the abdomen towards the liver. Superficial then deep 
palpation should be performed looking for tenderness and 
masses, which would be delineated by percussion. 

If tenderness is present, peritonism is then sought - 
rebound tenderness or guarding. A check of hernial orifices 
and femoral pulses is usual and, if ascites is thought to be 
present, it may be confirmed with a check for 'shifting 
dullness' (Fig. 2). Auscultation for bowel sounds completes 
the examination. 

Pelvic mass 

A mass arising from the pelvis will have free lateral and 
upper borders but the examining hand cannot go between 
the symphysis pubis and the lower border of the mass. To 
determine whether the mass is cystic or solid use a ballotting 
motion. The regularity, mobility, firmness and tenderness 
are assessed during the examination. Percussion would elicit 
central dullness over a large ovarian cyst or fibroid uterus; 
the dullness would be in the flanks if the abdominal 
distension is due to ascites. 

Pelvic examination 

The vulva should be inspected for any lesions as indicated 
from the history. The oestrogen status of the patient can be 
determined by the degree of atrophy of tissues and white 



plaques (leucoplakia) or ulcerated areas may be noted. The 
labia are parted with the left hand, inspecting the introitus 
and noting any discharge and its nature. The external 
urethral meatus is observed, noting urethral caruncles and 
urinary incontinence. 

Speculum examination 

A Cuscoe bivalve speculum is introduced with a 90 degree 
rotation allowing comfortable insertion. The use of 
lubricants [KY jelly] does not disturb the taking of a smear. 
Once the speculum has achieved its full length the jaws are 
fully opened revealing the cervix, noting any discharge or 
ectopy (see p. 134). A cervical smear and bacteriological swabs 
are obtained as required. 

A Sims' speculum examination may be performed in cases 
of prolapse or urinary symptomatology (see p. 154). 

Bimanual examination 

Two fingers of the gloved hand are introduced into the 
vagina keeping the thumb off-centre to avoid the clitoris, 
which is tender to palpation (Fig. 3). With the fingers in the 
posterior fornix, the other hand is placed on the lower 
abdomen and is the working hand during the pelvic 
examination. Downward pressure on the abdominal hand 
should trap the uterus between the hands allowing a 
determination of its size, regularity, whether it is ante- or 
retroverted, presence of tenderness and the mobility of the 
uterus. 

Palpation for the adnexa commences at the anterior 
superior iliac spine on each side, using downward pressure 
to trap the adnexa between the examining hands. The ovary 
is small and firm, often described as like a walnut, thus only 
in slim patients would you expect to feel a normal ovary, but 
masses should be palpable and tenderness would be elicited. 

To check for cervical excitation pain the cervix is pushed to 
the right, checking right adnexa and then to the left, checking 
for pain on the left side. This puts the parametrium on each 
side in turn on the stretch and, indirectly, tests for 
inflammation and tissue oedema. 



Gynaecological assessment 



i The patient history starts with the presenting complaint. 

i This is followed by menstrual history, any pains, urinary symptoms 
and details of past history. 

i Physical examination begins with general systems, followed by 
breasts, abdomen then pelvis. 



88 GYNAECOLOGY 



Developmental and paediatric gynaecology 



(See also Puberty and its abnormalities, p. 90, and 
Amenorrhoea, p. 112.) 

Those with an XY karyotype require both testosterone and 
Miillerian inhibiting factor to develop normal genitalia. 
Testosterone masculinizes the otherwise female external 
genitalia and stimulates the mesonephric (Wolffian) system 
to develop. Miillerian inhibitory factor inhibits the 
paramesonephric (Miillerian) system, which would 
otherwise form female internal genitalia. 

Intersex disorders and ambiguous genitalia 

Early multidisciplinary sub-specialist involvement is essential, 
particularly surrounding the issues of genital surgery and 
gender assignment. There will be initial parental shock at the 
diagnosis, with possible subsequent depression, doubts of 
gender, concerns over fertility, issues of sexuality, cultural 
problems and a sense of worthlessness. Peer support from 
those with similar problems is essential. 

XY but look female (male pseudohermaphroditism) 

Testicular feminization syndrome (androgen insensitivity). 
This is an X-linked recessive disorder caused by an absence 
of androgen receptors. Although testosterone is present, it 
has no effect on the external genitalia and these individuals 
appear female. Miillerian inhibitory factor is also still present 
and therefore no internal genitalia form. Presentation is 
usually after puberty with amenorrhoea in the presence of 
normal breast development, scanty pubic and axillary hair, a 
blind-ending vagina, absent uterus and female habitus and 
psychosexual orientation. Gonadectomy is essential because 
of the risk of malignant change. 

There is a small phallus, some degree of hypospadias, a 
bifid scrotum and a blind vaginal pouch. 

5a-reductase deficiency. There is an autosomal recessive target 
enzyme defect of 5a-reductase. This converts testosterone to 
dihydrotestosterone in the target organs, and is therefore 
important for male development At puberty considerable, but 
still incomplete, virilization occurs with male body habitus, 
psychosexual orientation and gender conversion. 

XX but look male (female pseudohermaphroditism) 

Congenital adrenal hyperplasia (accounts for 70% of 
ambiguous genitalia). There is an autosomal recessive 



enzyme defect in aldosterone synthesis that leads to reduced 
aldosterone production and an increase in androgen 
production (Fig. la). In the commonest form, 21 -hydroxylase 
deficiency, two-thirds have a salt-losing crisis, often within 
the first 4 weeks of life, which requires long-term 
mineralocorticoid replacement. There are ambiguous 
genitalia (Fig. lb), which may require a reduction 
clitoroplasty, although there is an argument against such a 
procedure as future sexual sensation may be reduced. 

Exogenous administration of androgens (e.g. danazol). This 
may lead to virilization of a female fetus. 

Other rare abnormalities 

These may occur with XO, XX or XY chimerism. True 
hermaphroditism (i.e. the presence of male and female 
gonadal tissue) is also rare. 

Abnormal genital tract development 

Vagina (Fig. 2) 

There may be horizontal septae, vertical septae or the vagina 

may be absent. 

Horizontal septae. There may be cryptomenorrhoea with 
cyclical pain and a haematocolpos. If obstruction is caused 
simply by the hymen (blood looks blue behind it) then a 
cruciate incision, usually under anaesthesia, is all that is 
required. If the septum looks pink rather than blue the 
situation is potentially more serious and should be referred 
to a specialist surgeon. If the septum is in the low or 
midportion of the vagina, total excision and resuturing is 
necessary. If the septum is high, a combined abdominal and 
vaginal approach may be required. Pregnancy rates are 
excellent with low septae, but only around 25% for those 
higher in the vagina. 

Vertical septae. These may be associated with abnormal 
uterine development. Although presentation may be with 
dyspareunia or infertility, they may occasionally present in 
advanced labour. They can be surgically removed. 

Vaginal atresia. This is associated with an absent, or only a 
rudimentary, uterus and is known as the Rokitansky 
syndrome. Presentation is at puberty with amenorrhoea (or 



Cholesterol 



_±_ACTH 



Pregnenolone 



1 7-hydroxypregnenolone 



Dehyd roe pi andrasterone 



Progesterone 17-hydroxyprogesterone Androslenedione 



21 -hydroxylase 



Testosterone 



Aldosterone 



Cortisol 



(a) 

Fig. 1 Congenital adrenal hyperplasia, (a) Steroid pathway. 

(b) Ambiguous genitalia. 




Developmental and paediatric gynaecology 89 





(a) (b) 

Fig. 3 Hymens, (a) Acute tearing, (b] Partial thickness tear at the posterior margin, (c] Concavities in the hymen. 



cryptomenorrhoea) in the presence of 
normal secondary sexual 
characteristics. It is possible to create a 
vagina with regular use of vaginal 
dilators; or by one of a variety of 
surgical techniques. Surrogacy is an 
option for childbearing. 

Uterus (Fig. 2) 

Abnormal uterine shapes are usually 
asymptomatic but may present with 
primary infertility, recurrent pregnancy 
loss or menstrual dysfunction 
Coligomenorrhoea, dysmenorrhoea or 
menorrhagia). In pregnancy, there may 
be miscarriage (p. 92), preterm labour 
or an abnormal fetal lie. 

Unicomuate uterus. With this there is 
a higher miscarriage rate and risk of 
preterm labour. 





Unicomuate uterus Bicomuate uterus 




Double uterus 



Septate uterus 





Vertically septate Horizontally septate 
vagina vagina 

Fig. 2 Common genital tract abnormalities. 



Bicornuate uterus. This may often carry 
a pregnancy to an adequately advanced 
gestation, and the chance of this 
probably increases with subsequent 
pregnancies. A 'Strassman' procedure 
will correct the defect, but the benefits 
for pregnancy are unproven. A 
bicornuate uterus may be asymmetrical 
with one side hypoplastic Pregnancy in 
the hypoplastic horn carries a risk of 
rupture. 

Septate uterus. If appropriate to 
remove the septum, a hysteroscopic 
approach is probably the most 
appropriate. 

Prepubertal problems 

Sexual abuse 

This is the involvement of dependent 
sexually immature children and 
adolescents in sexual activity they do 
not truly comprehend, and to which 
they are unable to give informed 
consent, and which violates social 
taboos or family roles. The abuser is 
usually male and well known to the 
child and family. It may present 
acutely, following injury or allegation, 
or may be suggested by 
precociousness and other behavioural 
disorders. 

There are numerous pitfalls to the 
clinical examination, and a depth of 
experience is required for an 
examination to stand up in court Early 
senior multidisciplinary help is 



essential in this highly emotive area 
where incorrect interpretation of the 
signs may have major consequences. A 
colposcopic examination is helpful and 
photographic records are extremely 
useful. 

The history should be carefully 
taken and documented, and the social 
work team involved if appropriate. 
Swabs (which may include swabs for 
DNA analysis) should be taken with a 
'secure chain of evidence' in case they 
are required for a later legal action. 
Particular attention should be paid to 
bleeding, bruising or any other area of 
injury, particularly lacerations at the 
posterior fourchette and perineal 
abrasions. 

A normal hymen has a number of 
different shapes (annular, crescentic, 
fimbriated, septate, sleeve- or funnel- 
shaped). Notches and clefts can be 
highly suggestive of penetrating injury, 
but may be normal if associated with 
an intravaginal ridge above them; they 
are very rare in the posterior segment 
in non-abused girls (Fig. 3). Straddle 
injuries very rarely affect the hymen, 
and there is much more likely to be 
bruising anterior to the vagina or 
laterally (e.g. labia majora). It is also 
rare for tampon use to cause hymenal 
injury (although it may increase the 
diameter slightly), and there are no 
reported cases of congenital absence of 
the hymen. A normal pre-pubertal 
hymen does not exclude abuse. 



J Developmental and paediatric gynaecology j 



i Early multidisciplinary sub-specialist involvement is essential in ambiguous genitalia and 
suspected sexual abuse. 

i The commonest farm of ambiguous genitalia is congenital adrenal hyperplasia. 

i Uterine abnormalities do not necessarily require surgical treatment 




GYNAECOLOGY 



Puberty and its abnormalities 



Puberty is the time during which there 
is development of secondary sexual 
characteristics and attainment of 
sexual maturity. There is some form of 
hypothalamic trigger which leads to 
pulsatile release of luteinizing 
hormone (LH) and follicle-stimulating 
hormone (FSH) between 5 and 10 
years of age, with ovarian release of 
oestrogen usually from the age of 8. 
This oestrogen mediates the pubertal 
changes. The sequence starts with a 
somatic growth spurt followed by 
breast development, then development 
of pubic hair followed by axillary hair 
and finally the menarche [first period) 
(Fig. 1). 

Normal puberty 

Growth spurt 

The somatic growth spurt is the first 
notable change due to oestrogen 
stimulation. After the menarche 
somatic growth will continue for 
approximately 2 years until fusion of 
the epiphyses, after which no further 
growth is possible. Precocious puberty 
may lead to premature epiphyseal 



closure and the child may fail to attain 
its full height potential. 

Breast development (Ihelarche) 

This is the next stage in pubertal 
development with four stages of breast 
development (Fig. 2). The breast bud is 
followed by breast and areola 
enlargement. The nipple and areola 
then enlarge further and the final stage 
is development of the adult breast 

Hair growth 

Pubic hair precedes axillary hair 
development and also shows four 
stages. Initially there is sparse hair on 
the labia; this then grows centrally and 
advances onto the mons pubis. The 
next stage is for the hair to spread 
laterally a little, with the full adult 
triangular distribution as the final 
stage. 

Menarche 

The first menstrual period is the final 
stage in pubertal development, and 
occurs in 95% of girls between the 
ages of 11 and 15 years. The average 
age of the menarche in the UK is 



Female 



Height of growth spurt 




1 2 years 



Age of menarche 



Breast stage 




Pubic hair stage 



Years 




Fig. 2 The four stages of breast 
development. 



13 years, a fall in the age of menarche 
being noted in children in developed 
countries. This is thought to be a 
reflection of improved nutritional 
status - some researchers believing 
that a critical body weight must be 
reached before menarche is achieved. 
This theory has some merit as it is 
noted that moderately obese girls have 
an earlier menarche than those of 
more normal weight. Conversely, girls 
with anorexia or adhering to an 
intensive exercise programme may 
show delay in the age of menarche. 

Abnormalities of puberty 

Precocious puberty 

Signs of pubertal development before 
the age of 8 are accepted as precocious 
puberty which in three-quarters of 
females has an idiopathic aetiology. 
However, before allocating a child to 
this category, it is important to rule 
out treatable causes (Table 1). 

The idiopathic group includes girls 
with constitutional sexual precocity due 
to premature maturation of the 
hypothalamic-pituitary-ovarian axis. 



Fig. 1 The timing of pubertal changes. 



Tabic 1 Causes of precocious puberty 


Cause 


Percentage 


Idiopathic 


74^ 


Ovarian hormone production 


""■ 


Intracranial pathology 


7ii 


McCurte- Albright syodramc 


5% 


Adrenal problem 


2% 


Ectopic yonadotrcphm product or 


Lessthsr ' '■; 



Puberty and its abnormalities 91 



This tends to run in families and tends 
to occur around the cut-off age of 8 
years. Intracranial pathology includes 
cranial trauma, encephalitis, cysts or 
tumours - the mechanism by which 
they produce precocious puberty being 
uncertain. Ovarian hormone production 
is usually associated with an ovarian cyst 
which should be diagnosable by 
ultrasound scanning, but is often 
present as a palpable mass in the 
abdomen. The McCune- Albright 
syndrome (polyostotic fibrous dysplasia) 
presents with cystic bone lesions which 
easily fracture, cafe-au-lait patches and 
sexual precocity. The cause is uncertain. 
Referral to a paediatric endocrinologist 
ensures everything is addressed. 

Delayed puberty 

Delayed puberty (Table 2) is rare with 
only 1% of females not having had 
menarche by the age of 18. If there are 
no secondary sexual characteristics by 
the age of 14 delay is diagnosed and 
investigation is appropriate. The largest 
group are those with ovarian failure, 
more than half of whom have 
chromosomal anomalies. 

In girls with hypergonadotropic 
hypogonadism the ovarian failure may 
be associated with an abnormal 
karyotype, particularly Turner's 
syndrome. In those with a normal 
karyotype it may be that there is 
gonadal dysgenesis (the external 
genitalia are usually of infantile female 
type) or the resistant ovary syndrome 
with normal appearance of external 
genitalia (where the ovary fails to 
respond to the increased levels of LH 
and FSH) but where there can be 
spontaneous ovulation and obviously 
pregnancy can thus occur, though 
prognosis with respect to future 
pregnane}' in these cases should be 
guarded. 

With hypogonadotropic 
hypogonadism (low levels of LH and 
FSH) the delay may be constitutional - 
particularly when short compared to her 
family but appropriate for the stage of 
puberty and bone age - or due to a 
chronic medical condition or anorexia 
nervosa. 

In the eugonadotropic group (normal 
LH and FSH) congenital absence of the 
uterus (Rokitansky syndrome) or vaginal 
developmental obstruction should be 
considered. 

Treatment of delayed puberty 

Initial management 
First exclude pregnancy. 



Table 2 Causes of delayed puberty 

Cause Percentage Underlying cause 

Hypergonadotropic hypogonadism 43% Gonadal dysgenesis, e.g. Turner's syndrome 

Hypogonadotropic Hypogonadism 3 1 * Constitutional, chronic medical illness, anorexia 

Eugonadism 26* Abnormal genitalia, s,g, absent uterus, vaginal septum 



Ask about chronic illnesses, 
anorexia, excessive physical exercise or 
family history of delayed puberty. 
Heart problems may be found with 
chromosomal disorders, urinary or 
bowel disorders with anatomical 
disorders of the genital tract, hernia 
repairs may suggest gonadal disorder 
and slow general development is 
associated with hypothyroidism. 
Examination should include 
measurement of height, weight and 
visual fields; check for secondary 
sexual characteristics, virilization and 
hirsutism. Vaginal examination is 
inappropriate unless the girl is sexually 
active. Check for stigmata of Turner's 
syndrome (short stature, webbed neck, 
and wide carrying angle). 

Investigations include sending 
serum for LH and FSH (low with 
constitutional delay), testosterone 
(increased in polycystic ovarian 
syndrome), free T4, TSH (increased in 
primary hypothyroidism) and 
prolactin (ideally measured under non- 
stressed conditions). Karyotype is 
needed if a chromosomal problem is 
suspected; if an XY chromosomal 
pattern is found, it is usual to suggest 
gonadectomy due to the 25% risk of 
tumour in the gonad. X-ray for bone 
age would confirm constitutional delay. 
Assessment of 17-hydroxyprogesterone 
when congenital adrenal hyperplasia is 
suspected, pelvic ultrasound to assess 
pelvic anatomy and skull X-ray if 
prolactin is raised are appropriate. 

Causes and further management 
Normal secondary sexual characteristics 
but with primary amenorrhoea. This 
is most commonly caused by an 
imperforate hymen and is 
characterized by cyclical pain and a 
haematocolpos (see p. 88). A 



progesterone challenge test will 
identify constitutional menstrual delay, 
i.e. will result in bleeding only with an 
adequate estradiol level and normal 
genital tract. Give 5 days of oral 
progesterone and there should be a 
withdrawal bleed within 10-14 days of 
stopping. 

Poor or absent secondary sexual 
characteristics. These comprise: 

1. Constitutional delay. The 
diagnosis is likely in a healthy 
adolescent who is short for the family 
but appropriate for the stage of 
puberty and bone age. There is often a 
family history and it may be associated 
with chronic systemic disease (rare, 
but consider hypothyroidism and 
malabsorption). If the bone age on 
X-ray is less than the chronological age 
than it is reasonable to adopt a 
conservative approach. Anorexia 
nervosa should also be considered. 

2. Ovarian dysfunction. This may 
be due to gonadal agenesis with 
Turner's syndrome or Turner's mosaic. 
Treatment is specialized as oestrogen 
treatment may predispose to short 
stature b\ 7 premature epiphyseal 
closure. Therapy is with low-dose 
ethinylestradiol initially, increasing 
over the next 18 months. A 
progestogen is then added for 5 days 
every 4 weeks. The dose of oestrogen 
is increased if response is adequate 
and the contraceptive pill substituted. 

3. Hypothalamopituitaiy disorders. 
Hypogonadotropic hypogonadism is 
usually associated with pituitary 
tumours and other pituitary 
deficiencies. In Kallmann syndrome 
there is a congenital deficiency of 
luteinizing hormone-releasing 
hormone (LHRH) and absent olfactory 
sensation. Hypothyroidism is likely to 
cause pubertal delay. 



Puberty and its abnormalities 



i For puberty to occur there must be oestrogen production from the ovaries. 

i Thelarche and sexual hair growth follow the somatic groyyth spurt. Menarche is the final stage of 
puberty. 

i Precocious puberty is associated with failure to achieve full adult height so must be treated. 

i Delayed puberty is only found in l %. 



92 GYNAECOLOGY 






Miscarriage 



Spontaneous miscarriage 

■ Spontaneous miscarriage is the loss of a pregnancy before 
24 weeks' gestation. It is most common in the first 
trimester and is said to occur in = 25% of all pregnancies. 

■ The word 'abortion' has connotations of induced abortion 
and should not be used for miscarriage. The term 'blighted 
ovum' used to describe an anembryonic pregnancy should 
be discarded. 

■ Extreme care must be taken not to advise uterine 
evacuation if there is any possibility of viability. 

■ It should not be assumed that the pregnancy is non-viable 
simply because the gestation does not agree with the 
expected dates. 

■ There should also be a low threshold of suspicion for 
ectopic pregnancy. 

■ Approximately 50% of miscarriages occurring early in the 
first trimester are associated with chromosomal 
abnormality [trisomy, monosomy, polyploidy), although 
this becomes less with increasing gestation. 

Presentation 

There is usually a history of bleeding per vagina and lower 
abdominal pain, although an empty gestational sac Cor fetal 
pole with absent fetal heartbeat) may be an asymptomatic 
finding at booking scan ('missed'). Miscarriage is 'inevitable' 
if some products of conception (not clots') are passed. Rarely, 
products of one twin may be passed, with the other twin 
being viable, justifying an ultrasound scan in every case. The 
miscarriage is said to be 'threatened' if the pregnancy is still 
viable, and 'incomplete' if there is residual tissue within the 
cavity (Fig. 1). 

Management 

This is based on USS findings. 

Viable intrauterine pregnancy. The prognosis is good and the 
parents can be offered reasonable reassurance. 

Empty gestational sac. A true gestational sac usually has a 
double decidual ring, unlike a pseudosac which is suggestive 
of ectopic pregnancy. If there is an empty gestational sac 
greater than 25 mm maximum diameter, the pregnancy is 
very likely to be non-viable (Fig. 2). 




Threatened miscarriage 



Incomplete miscarriage 




Inevitable miscarriage Missed miscarriage 

Fig. 1 Different types of miscarriage. 

Pseudosac. See Ectopic pregnancy, page 98, and Figure 3. 

Fetal pole with no fetal heartbeat (FH). An FH is usually seen 
on transvaginal (TV) scan if the fetal pole is > 2-3 mm in 
diameter, but will always be seen by G mm diameter (Fig. 4). 
A similar cut-off of 15 mm diameter is appropriate for a 
transabdominal (TA) scan. If in doubt, rescanning should be 
arranged in 7-10 days. 

Empty uterus. Either there has been a complete miscarriage 
(tissue may have been passed), or the pregnancy is very early 
(e.g. < 5 weeks), or there is an ectopic pregnancy. Ectopic 
pregnancy must be excluded. An intrauterine sac will usually 
be seen on TV scan if the human chorionic gonadotrophs 
(hCG) is > 1000 IU f> G500 IU for a TA scan) and its absence 




Fig. 2 35-mm empty gestational sac. If the 
mean sac diameter is greater than 25 mm, the 
pregnancy is almost certainly non-viable. 



Fig. 3 Pseudosac, with intrauterine 
contraceptive device (IUCD) in situ, in a 

patient with a 6-week, right-sided tubal ectopic 
pregnancy. 




Fig. 4 A-mm fetal pole with no fetal 
heartbeat on transvaginal scan. Viability is 
unlikely but the patient should be rescanned in 
7-10 days. 



Miscarriage 93 



raises the possibility of an ectopic 
pregnancy. Serum levels of hCG should 
double in 48 hours if the pregnancy is 
viable and intrauterine; less suggests an 
ectopic pregnancy [although by using 
this method in isolation, 15% of 
intrauterine pregnancies would be 
diagnosed as ectopics and 13% of 
ectopics as intrauterine). If the level 
doubles and the patient remains well, 
the ultrasound scan should be repeated 
in 1 week to ensure that the pregnancy 
is ongoing. If less than doubling, 
steady, or only slightly reduced, a 
laparoscopy should be considered to 
exclude ectopic pregnancy. 

Retained products. Evacuation of 
retained products of conception 
(ERPOC) has become the established 
management for miscarriage with 
retained products. For those with 
heavy bleeding this remains 
appropriate, although it is occasionally 
possible to remove retained products 
from the cervical os at speculum 
examination and save the need for 
further intervention. While ERPOC 
may still be offered to those with little 
bleeding, there is evidence that if the 
diameter of retained products is small 
Ce.g. < 40 mm), ERPOC may not be 
necessary. An additional option is also 
available to give mifepristone and 
misoprostol for a 'medical' evacuation 
of retained products (see p. 94). 

Adnexal mass or ectopic. Possible 
adnexal findings with an ectopic 
pregnane}' are of a sac [30%), a sac 
containing a yolk sac (15%) and a sac 
with a fetal pole and FH (15%). The 
absence of adnexal findings on USS 
therefore does not exclude an ectopic 
pregnancy. 

After the miscarriage 

There has been a bereavement and the 
parents have lost 'a baby. They should 
be reassured that they did nothing 
which might have caused the 
miscarriage and given time to grieve. 
There is no medical indication to wait 
before trying again, but they may 
require contraception to allow time to 
grieve. There is often further upset 
around the date the baby would have 
been born. 

Septic abortion 

This is rare unless after illegal 
terminations with inadequate asepsis, 
and therefore more common in 
countries with anti-abortion policies. 




Rg. 5 Cervical incompetence. Ca} Normal cervix, (b) Incomplete cervix, [c) Cerclage with a non- 
absorbable suture. 



There is usually raised temperature 
> 38°C, tachycardia, malaise, 
abdominal pain, marked tenderness 
and purulent vaginal loss. Endotoxic 
shock may develop and there is a 
significant mortality. The usual 
infecting organisms are Gram-negative 
bacteria, streptococci (haemolytic and 
anaerobic) and other anaerobes (e.g. 
Bacteroides). 

Recurrent spontaneous 
miscarriage 

This is the consecutive loss of three or 
more fetuses weighing < 500 g 
(incidence 0.5-1%). Those who have 
had three consecutive miscarriages still 
have a 70% chance of a normal 
outcome in their next pregnancy. 

Investigation 

■ Karyotype from both parents. 

■ Maternal blood for lupus 
anticoagulant and anticardiolipin 
antibodies. 

■ Possible hysterosafpingogram and/or 
pelvic ultrasound examination 
(uterus and ovaries) to look for 
uterine abnormalities (see p. 89). 

Causes and management 

Antiphospholipid syndrome (« 15%). 
Miscarriage is more likely to occur in 
the presence of lupus anticoagulant 
and raised anticardiolipin antibodies. 

Chromosomal abnormality i~ 5%). This 
is usually a balanced reciprocal or 



Robertsonian translocation, and the 
finding of such an abnormality should 
prompt genetic referral. 

Cervical incompetence. This is a cause 
of mid-trimester miscarriage, and 
cervical cerclage should probably only 
be considered when the miscarriage 
has been preceded by spontaneous 
rupture of membranes or painless 
cervical dilatation (Fig. 5). Use of such 
a suture probably provides a small 
improvement in the prognosis in the 
next pregnancy, but at the risk of 
infection developing after insertion. 
Transabdominal cerclage has also been 
used but is not without risk and 
should be considered a sub-specialist 
procedure. 

Thwmbophilic defects. Retrospective 
studies have indicated an increased 
incidence of thrombophilic defects in 
those with recurrent miscarriage 
(activated protein C resistance, 
antithrombin III, protein C and 
protein S deficiency + 
hyperhomocystinaemia). Evidence for 
the efficacy of treatment in this group 
is lacking. 

Anatomical uterine abnormality (see 
also p. 89). 

It is very difficult to estimate the 
significance of anatomical 
abnormalities and great caution is 
required before undertaking significant 
surgical procedures. 



Miscarriage 



i Extreme care must be taken not to advise uterine evacuation if there is any possibility of viability. 

i A positive pregnancy test and an empty uterus should be considered as an ectopic pregnancy 
until proven otherwise. The absence of adnexal findings does not exclude an ectopic pregnancy. 

i Ttiose with recurrent spontaneous miscarriage associated with lupus anticoagulant or raised 
anticardiolipin antibodies should be given aspirin and heparin in the next pregnancy. 



94 GYNAECOLOGY 






Induced abortion (termination of pregnancy) 



Termination of unwanted pregnancies, 
or abortion, has been carried out for 
thousands of years. Both Aristotle and 
Hippocrates favoured its selective use, 
and yet its provision in a legal, medically 
supervised and safe framework is still 
one of the most contentious issues in 
medicine. Strictly speaking, the term 
'termination' is used here to refer to any 
pregnancy induced at < 24 weeks' 
gestation (UK) or with a fetal weight of 
< 500 g, but as neonatal survival has 
been achieved below these parameters, 
the definitions are debatable. The term 
'abortion' here refers to induced abortion, 
and the expression 'miscarriage' is 
reserved for spontaneous loss. 

Ethics 

Many people have an opinion, often 
strongly held, about abortion (Table 1). 
Those who are pro-abortion argue they 
are 'pro-choice' and believe in the right 
of individuals to make their own 
decisions. They focus on the potential 
problems of bringing an unwanted baby 
into the world, and of the surrounding 
social difficulties the child might face. 
Those who are anti-abortion, 'pro-life', 
argue that the fetus is more than just 
part of the mother, but a life in itself 
and should be protected as such, even to 
the extent of limiting the mother's own 
actions. 

Worldwide, unsafe abortion is a major 
public health issue. At least 
20 million women undergo unsafe 
abortion each year and some 67 000 
women die as a result with many others 
suffering chronic morbidities and 
disabilities. Unsafe abortions may be 
induced by the woman herself, by non- 
medical persons or by health workers in 
unhygienic conditions. Such abortions 
may be induced by insertion of a solid 
object (usually root, twig or catheter) 
into the uterus, an improperly 
performed dilatation and curettage 
procedure, ingestion of harmful 
substances, or exertion of external force. 
The complications of sepsis, 



Table 2 The five sections of the UK 
Abortion Act 

A To save the mother's life 

B To prevent grave permanent injury to the mother's 

physical or rnantal health 
C If < 24 weeks, re avoid injury to the physical or 

mental health of the mother 
D If < 24 weeks, to avoid injury to the physical or 

menial health of the existing children) 
E It th e ch i Id <s I ikely to b e severely p hys ica I ly or 

mentally handicapped 



haemorrhage, genital and abdominal 
trauma, perforated uterus or poisoning 
may be fatal if left untreated. Death may 
also result from secondary 
complications such as gas gangrene and 
acute renal failure. The mortality from 
an appropriately conducted abortion, 
however, is minimal, and the morbidity 
small. In the United States, for example, 
the death rate for abortion is now 0.G 
per 100 000 procedures, compared to 
perhaps several hundred times this rate 
for an unsafe abortion. The abortion 
rate is also much higher in those 
countries with limited access to 
contraception. Where abortion is 
permitted by the law, the large majority 
of abortions (typically > 90%) take place 
before the end of the 12th week of 
pregnancy. 

Abortion is legal in the UK under the 
Abortion Act 1967 amended by the 
Human Fertilisation and Embryology 
Act 1991 (Table 2). Two doctors are 
required to sign a form, and if a doctor 
does not wish to sign he or she has a 
duty to refer to another doctor who 
would. There is also a duty to treat 
complications in an emergency 
situation. 

In practice, Section 'C can be 
interpreted in such a way as to support 
termination of pregnancy, as it could be 
argued that continuing an unwanted 
pregnancy might be injurious to the 
mother's mental health. The risk of 
psychiatric morbidity is significantly 
greater after delivery of a baby than after 
a termination. Furthermore, women 



Table 1 Induced abortion 


Advantages 


Disadvantages 


■ Reduces illegal abortions and their complications 


■ Moral, ethical and religious objections 


(particularly sepsis and uterine perforation) 


■ May be inappropriately looked upon as a form of 


■ Allows an opportunity to screen for sexually 


contraception 


transmitted diseases fSTDs). discuss 




contraception and support the patient 




through difficult circumstances 




■ Reduces the births of unwanted children 





with an unwanted pregnancy may 
display evidence of an anxiety state or 
reactive depression. Categories A, B and 
E do not specify a gestation limit and 
category E only allows termination of a 
major potentially serious anomaly. If 
abortion is required to save a women's 
life in emergency circumstances, one 
doctor may act alone. 

Counselling for Section 'C 
terminations 

Counselling needs to explore many 
areas. It is often helpful to start by 
acknowledging that this is a difficult 
situation, e.g. 'This must have been a 
very difficult week or two for you', and 
then follow with an open question: 'Tell 
me what has been happening.' It is 
important to find out the patient's own 
views and to ensure that she is not 
being forced against her will. If a parent 
is present, it is often useful to see the 
patient alone for at least part of the 
time. 

It is also important to find out 
whether the baby's father knows, how 
he and the baby's mother get on 
together, who else knows and what they 
all feel. The counsellor should try to 
explore how they might cope afterwards, 
or how they would feel if they went 
ahead with the pregnancy. They should 
also consider whether there are plans to 
have children in the future, whether 
they have considered adoption and what 
the plans for contraception are 
afterwards. 

The woman should be aware that 
there is a possibility, albeit rare, that 
infection following termination of 
pregnancy (TOP) may lead to tubal 
occlusion and second-degree infertility. 
There is also a small procedure failure 
rate, and either a clinical follow-up or 
pregnancy test 2-6 weeks post- 
termination is important (note: the 
pregnancy test may remain positive for 
up to 4 weeks despite successful TOP). 
It is important to either screen for and 
treat infections (including chlamydia), or 
treat all prophylactically, e.g. with oral 
metronidazole and azithromycin. 

Method 

In general, the complication rate is 
lower the earlier the procedure is 
carried out. The risk of major 
complications from termination at 15 
weeks' gestation is double the risk from 
termination at 8 weeks' gestation. 



Induced abortion (termination of pregnancy) 95 



It is important to confirm that the woman is pregnant and 
to establish the gestation either clinically or by USS. Blood 
should be sent for grouping and testing for antibodies, and 
anti-D should be given post-termination to Rhesus-negative 
women. Options (if available) should be explained and the 
woman given the choice as outlined below: 

■ less than 9 weeks: suction evacuation or medical 
termination 

k 9-12 weeks: suction termination only 

» more than 12 weeks: medical termination only. 

(Note: some experienced practitioners will consider surgical 
dilatation and evacuation up to 18 weeks' gestation.) 

The pros and cons of medical vs surgical termination at less 
than 9 weeks' gestation are as follows: 

■ Medical TOP avoids a general anaesthetic. 

■ There is probably little to choose in terms of the infection 
risk, pain, post-procedure bleeding and subsequent fertility. 

■ Those that choose either method are usually satisfied with 
their choice. 

■ Medical termination may be more effective at earlier 
gestations, and surgical better closer to 9 weeks. 

Surgical termination (Fig. 1) 

Prostaglandin pessaries 4 hours prior to the operation are 
useful to soften the cervix and minimize trauma from the 
dilatation, particularly if the woman is a primigravida or at a 
gestation of > 10 weeks. Surgery is usually carried out under 
general anaesthetic (local anaesthesia is occasionally an option) 
and cervical dilators are used to dilate the cervical os. A rigid or 
flexible suction curette is then used to remove the pregnancy. It 
is important to check and document that definite products of 
conception are seen to be coming away at the time of surgery. 

Medical termination 

First trimester 

Mifepristone is given orally and the patient admitted to 
hospital 3G-48 hours later for a prostaglandin pessary. Eighty 




per cent will pass products of conception in the following 
4 hours and this should be confirmed by clinical inspection 
and speculum examination before discharge. Ninety-four per 
cent will abort spontaneously and most will bleed for a total 
of 10 days. Follow-up should be arranged for 2 weeks to 
ensure that bleeding has settled and to confirm complete 
abortion by bimanual examination. If in doubt, an ultrasound 
scan is useful. Retained products can almost always be 
managed conservatively unless bleeding is particularly heavy. 
Less than 5% require uterine evacuation. 

Second trimester 

Mifepristone is given orally and the patient admitted to hospital 
3G-48 hours later for a prostaglandin pessary. She is then fasted 
until abortion occurs, and an intravenous infusion is set up if 
more than G hours pass. Further prostaglandin pessaries are 
inserted 6-hourly to a maximum of 24 hours (nearly all will 
abort by 24 hours, average 8 hours). During this time analgesia, 
emotional and sympathetic support are required. It is important 
to ensure that the placenta appears complete and that the 
uterus is well contracted on bimanual examination. 
Approximately G°/o will require a uterine evacuation. 

Risks of termination 

Although early termination of pregnancy is a relatively safe 
procedure, there are risks which, generally, increase with 
advancing gestation. The first possibility is of failure to 
terminate the pregnancy, which is greater at the earlier stage 
when the gestational sac is smallest. With suction termination, 
there is a risk of uterine perforation with damage to the 
abdominal viscera, and possible longer-term consequences of 
cervical trauma which might lead to cervical incompetence. 
Postoperative pelvic infection may occur with either method 
and may lead to tubal occlusion. With pregnancy tennination 
overall, however, there seems to be little statistical impact on 
the outcome of subsequent pregnancies. 

Follow-up 

After termination, anti-D should be given to those who are 
Rhesus-negative and the results of any infection screens 
should be assessed. Follow-up can be in either the hospital or 
community setting, and it is important to ensure that it is 
organized. This is to check that the TOP is complete, that 
contraception has been arranged and to discuss the emotional 
aspects. 

Psychological problems after termination 

Most women feel tearful and emotional a few days after 
termination of pregnancy, but there is good evidence that 
most feel psychologically much better 3 months later when 
compared with their feelings before the procedure. There is 
no evidence that termination causes serious psychiatric 
morbidity, although relapse of existing psychiatric problems 
can occur. On the other hand, the incidence of depression, 
suicide and child abuse is higher in women who have 
continued with the pregnancy because termination was refused. 



Fig. 1 Surgical TOP is performed in the same way as this 
evacuation of retained products of conception. 



j Induced abortion 

■ Unsafe abortion is a major worldwide public health issue, 
a There is strong 'pro-life' and 'pro-choice' support, 
a Termination can be either medical or surgical. 



96 GYNAECOLOGY 



Trophoblastic disorders 



Trophoblast is naturally invasive, but the 
invasion normally ceases after 
placentation has occurred. Gestational 
trophoblastic disorders represent an 
abnormal proliferation of trophoblastic 
tissue, leading to often massive placental 
overgrowth, occasional invasion and 
rarely even metastases. Malignant change 
can also occur with transformation to 
choriocarcinoma. Trophoblastic disorders 
occur in approximately 1 : 1000 UK 
pregnancies. Large differences in 
incidence between different racial groups 
have been reported [e.g. 1 : 85 in 
Indonesia, 1 : 1700 in USA) but are not 
confirmed by all authors. All secrete 
human chorionic gonadotrophin (hCG), 
making it a very useful tool to monitor 
treatment and screen for recurrence. In 
the UK, management of post-uterine 
evacuation is confined to one of the 
three centres: Charing Cross, London; 
Ninewells, Dundee; Weston Park, 
Sheffield. 

Hydatidiform mole 

This is the commonest type of 
gestational trophoblastic disease. 

Partial hydatidiform mole 

This is triploid with one set of maternal 
and two sets of paternal chromosomes, 
usually 69 XXY (Fig. 1). There may 



initially be a fetus, but it often dies early 
in the first trimester. Although 1% invade 
('invasive mole') and a few of these can 
develop metastases, they virtually never 
become choriocarcinoma. Only 0.5% 
require treatment following uterine 
evacuation. 

Complete hydatidiform mole 

This is the 'classical' molar pregnancy. It 
is androgenetically diploid; in other 
words, although there are the normal 
number of chromosomes, all are 
paternally derived and the female 
nuclear DNA is inactivated (Fig. 1). In 
90% there is duplication of one haploid 
sperm (XX) and the rest are from two 
spermatozoa, i.e. dispermic (and usually 
XY). There is never an embryo and the 
patient usually presents at 8-24 weeks' 
gestation with vaginal bleeding (+ the 
passing of grape-like tissue). The uterus 
may be soft, doughy and large for dates. 
There may also be pre-eclampsia, 
hyperemesis, cardiac failure and 
thyrotoxicosis, probably related to the 
very high levels of hCG (hCG and 
thyroid-stimulating hormone share a 
common structure and a subunit). 
Ultrasound is said to show a 'snowstorm 
appearance' but this describes the older 
B-scan pictures. On a real-time scan it 
more correctly looks as if the cavity is 



filled with relatively homogeneous solid 
tissue with a vesicular appearance (Fig. 
2). There may also be multiple luteal 
cysts on the ovaries from stimulation by 
the very high hCG levels. Ten per cent 
invade through the uterus ('invasive 
mole' - Fig. 3) and can metastasize to 







<z ;. ... , 


. ^ 

- 






V 




* 



Fig. 2 Ultrasound scan of hydatidiform 
mole. 




Fig. 3 Invasive mole. 



Size (bps) 160 170 180 190 200 



220 230 240 250 260 



S 
e 

3 
LL 




I Lll Partner 



I I If Partner 



Fig. 1 Fluorescently labelled products of conception. In the complete hydatidiform mole 
(CHM; left) the genetic material is of paternal origin following duplication of one haploid sperm. On the 
right, the partial hydatidiform mole (PHM) is triploid with two different sets of paternal chromosomes 
and one maternal haploid set. bps, base pair size. 




Fig. 4 CT scan of pulmonary metastases 
with choriocarcinoma. 




Fig. 5 CT scan of pelvis in the same 
patient showing a large vascular mass. 



Trophoblastic disorders 



lung, vagina, liver, brain and the 
gastrointestinal tract (Figs 4 and 5). 
These may occasionally regress 
spontaneously. Approximately 15% of 
complete moles require chemotherapy 
after uterine evacuation. The incidence 
of choriocarcinoma is 3%. 

Gestational choriocarcinoma 

Gestational choriocarcinoma contains 
both syncytiotrophoblast and 
cytotrophoblast and is histologically 
different from a hydatidiform mole 
[absence of villi). It may arise from a 
hydatidiform mole (50%) or follow a live 
birth, stillbirth, miscarriage or ectopic 
pregnancy de novo. It contains maternal 
and paternal chromosomes, unlike 
choriocarcinoma of ovarian origin. 

Placental site trophoblastic 
tumour 

This contains largely cytotrophoblast 
(therefore it has lower hCG) and occurs 
almost exclusively following a normal 
pregnancy. It is much rarer than 
gestational choriocarcinoma and 
presents with amenorrhoea or irregular 
bleeding. 

Clinical presentation 

Partial and complete mole 

Molar pregnancy becomes clinically 
apparent because of its 
pathophysiological features. Most 
molar pregnancies will miscarry 
spontaneously and the commonest 
clinical presentation, therefore, is pain 
and vaginal bleeding. It may also be 
asymptomatic and discovered at a 
routine early pregnancy ultrasound scan. 
The uterus is often large for dates. 
Excessive production of hCG maybe 
one of the reasons why a molar 
pregnancy may present with 
hyperemesis gravidarum or even (very 
rarely) with extremely early-onset pre- 
eclampsia. 

Gestational choriocarcinoma 

An invasive mole is usually identified 
because of persistent hCG levels or 
ongoing bleeding after surgical 
evacuation of the uterus. 
Choriocarcinoma may present either 
because of the primary intrauterine 
lesion, in which case the pathology after 
surgical evacuation will confirm the 
diagnosis, or because of a metastasis. 
Metastases may be to: 

■ the lung, causing haemoptysis 

■ the brain, leading to neurological 
abnormalities 



Table 1 Prognostic factors in gestational trophoblastic disease. 

chemotherapy are used for differing risk groups: low risk is < 4. medium 4 


D life ring forms of 
-8 and high > 8 




Score o 


1 


2 


4 


Age < 39 


>39 






Previous pregnancy Mole 
Interval from previous pregnancy (months] a 


Miscamage 


Term pregnancy 




4-6 


7-12 

io ooo- ioo ooo 


>12 

> 100 000 


KCG < 1000 


1000- 10 ODD 


Parental blood group 


OorA 


BorAB 




Sizeollumour 


3-5 cm 


>5cm 


Brain 


Metastasis site 


Spleen, kidney 


Gl tract, liver 


Metastases number 


1-4 


4-8 


>8 


FVevious chemotherapy 




Single drug 


> 2 drugs 



■ the GI tract causing chronic blood 
loss or melaena 

■ the liver, leading to jaundice 

■ the kidney, causing haematuria. 

Initial management 

If gestational trophoblastic disease is 
suspected, then an ultrasound scan and 
chest X-ray should be arranged. Blood 
should be sent for measurement of 
hCG, thyroid function tests and cross- 
matching prior to undertaking the 
uterine evacuation. The risk of bleeding 
with or without perforation is significant 
but uterine evacuation for a complete 
mole is superior to both medical 
evacuation of the uterus (may lead to 
increased risk of dissemination) and 
hysterectomy. Medical evacuation may 
be appropriate for a partial mole, 
particularly if a larger fetus is present, 
but should be followed with a surgical 
evacuation of any retained products of 
conception. It is recommended that 
oxytocics be avoided until after the 
uterine evacuation, and used 
preoperatively only if they are necessary 
to control severe haemorrhage, as 
uterine contractions may precipitate 
distant spread. Mifepristone and 
prostaglandin analogues should also be 
avoided unless clinically essential. 

Management after uterine 
evacuation 

■ The patient should be registered with 
a regional centre. 

■ Urinary hCG levels should be checked 
fortnightly until undetectable, then 
monthly for 

G months and 3-monthly for the 
second year. This may be best 
achieved by the patient posting 



specimens directly to the regional 
centre. Following a complete mole, 
the patient must wait at least 
G months from the hCG returning to 
(or for 1 year following 
chemotherapy) before trying for a 
further pregnancy to minimize the 
risks of recurrence. Condoms or an 
intrauterine contraceptive device may 
be used. The combined oral 
contraceptive can only be taken when 
the hCG has returned to zero, 
although some advocate waiting an 
extra 6 months beyond this time, 
again to minimize recurrence risk. 
■ Chemotherapy may be required if the 
hCG rises progressively following the 
uterine evacuation, or is > 20 000 U at 
4 weeks, or if the pathology is 
reported as choriocarcinoma. Of those 
patients who develop persistent 
trophoblastic disease, approximately 
80% are low risk and 20% high risk 
on the scoring system shown in Table 
1. Of the low-risk group, 80% respond 
to low-dose methotrexate but 20% 
need additional chemotherapy 
because of methotrexate resistance. 
All low-risk patients are cured. High- 
risk patients are usually given 
chemotherapy over several cycles. 
Chemotherapy is always given if the 
diagnosis is choriocarcinoma, or if 
there are metastases to liver, brain 
and gastrointestinal (GI) tract (80% of 
high-risk patients are cured). 

Of long-term survivors, 85% have 
normal pregnancies, but if a patient has 
had one hydatidiform mole, the risk of a 
second mole is 2% and a third 20%. 
Follow-up with checking of hCG levels 
must be undertaken after any 
subsequent pregnancy. 



Trophoblastic disorders 



Gestational trophoblastic disorders represent an abnormal proliferation of trophoblastic tissue. 

It is important to track urinary hCG after uterine evacuation to ensure that there is no residual 
tissue and that there is no invasion. 

There is an increased recurrence risk in subsequent pregnancies. 



98 GYNAECOLOGY 

Ectopic pregnancy 




An ectopic pregnancy is one which implants outside the 
uterine cavity. It occurs in about 1 in 200 pregnancies in the 
United Kingdom, 1 in 30 in the West Indies arid in the 
United States is found twice as commonly in the non-white 
as in the white population. The incidence has been rising 
slightly, but the death rate of about 1 per 1000 ectopic 
pregnancies has been falling due to earlier diagnosis and 
treatment in western societies. 

Aetiology 

The mechanism by which the fertilized ovum reaches the 
uterine cavity is dependent upon motility of the tube, the 
movement of the cilia of the fallopian tubes, and currents set up 
within the tubes. These all contribute to the sperm making 
passage upward to meet the egg which is coming down the 
fallopian tube. Three or four days after fertilization the fertilized 
ovum implants within the uterine cavity. This implantation will 
occur at the appropriate time wherever the zygote happens to 
be at that stage. The associations and possible causes of ectopic 
pregnancy are thus thought to operate by changing the motility 
of the tube or damaging the cilia and disturbing the normal 
progression of the fertilized ovum. 

Any past history of pelvic infection or ruptured appendix 
which will cause peritubular adhesions or pelvic 
inflammatory disease causing damage to the internal 
structure of the tube may predispose to ectopic implantation. 
Tubal surgery, even using microsurgical techniques, is 
unlikely to reconstruct the tube to its native form and thus 
predisposition to ectopic pregnancy remains. Reversal of 
sterilization is the tubal surgery with the lowest incidence of 
ectopic pregnancy. With other indications for tubal surgery 
the incidence of ectopic pregnancy is dependent upon the 
original damage to the tube. Where there has been 
conservative surgery for an ectopic pregnancy the chance for 
a future ectopic pregnancy is dependent upon the pre- 
existing tubal disease. 

The presence of an intrauterine contraceptive device is 
associated with a higher rate of ectopic pregnancy, thought 
to be due to the ability of the device to prevent intrauterine 
but not ectopic gestation. The presence of the device may 
also alter tubal motility which is the mechanism that has 
been proposed for ectopic pregnancy seen in association 
with progestogen-only oral contraception (see p. 108). About 
half of all ectopic pregnancies are idiopathic. 

Site of ectopic pregnancy 

The commonest site for an ectopic pregnancy is along the 
fallopian tube (Fig. 1), though ovarian pregnancy, abdominal 
pregnancy and cervical pregnancy are all reported (Fig. 2). 
Ovarian and abdominal pregnancies may be primary 
implantations on those sites or may follow a tubal abortion 
which re-implants. 

Presentation 

The patient may present with sudden onset of symptoms or a 
more gradual course. The classical, though rare, acute 
presentation is of sudden collapse in a previously well young 
woman after a period of amenorrhoea with possibly some 
brown vaginal loss. There may be a history of fainting or 
shoulder tip pain and acute abdominal pain. The patient is 
likely to be shocked and requiring resuscitation. Abdominal 




Fig. 1 A cornual ectopic (rare). This is 

dangerous as it ruptures early and bleeds heavily. 



Ampullary 



Isthmic Cornual Broad ligament 




Ovary Fimbrial 



Cervical 



Fig. 2 Sites of ectopic pregnancies. 



Slow steady leak' - 
reseating and 
rebleeding - eventually 
ruptures % 4 



Massive Secondary 

intraperitoneal abdominal 
bleed: collapse implantation 





Broad ligamenl 
bleed: contained 
unilateral bleed: 
pain 



Pelvic collection - 
may be reabsorbed 
or become infected 



Heavy vaginal bleeding 



Fig. 3 Sequelae of ectopic pregnancies. 



palpation reveals a rigid abdomen and immediate laparotomy 
is necessary to control the haemorrhage. Haemoperitoneum 
with rupture of the fallopian tube would be noted (Fig. 3). 
The subacute presentation is much more common and 
diagnosis depends on a high index of suspicion. The patient 
may complain of lower abdominal pain which may be 
central or localized to the side of the ectopic gestation. The 
period of amenorrhoea is commonly between 6 and 8 weeks 
with the history that the patient is trying to conceive or not 
using contraception. She may have frank red vaginal 
bleeding, but more commonly would have brown vaginal 
loss. Vaginal bleeding occurs as the decidua sloughs after the 
demise of the fetus. 



Ectopic pregnancy 99 



Urinary pregnancy test 



/ 



+ve 



-we 



X 



Uterus 

empty 



Diagnostic 
laparoscopy 



Pelvic ultrasound 
scan 



Gestation sac 
seen with fetal 
pole 



Book for 

AN care 



If symptoms persist 
repeat pregnancy test 
and pelvic ultrasound 



Small gestation 
ring only 



Quantitative |'.hCG 
and repeat in 
48 hours to check 
'doubling time' 



Fig. 4 Investigations in cases of suspected subacute ectopic 
pregnancy. 

Clinical examination may reveal peritonism with guarding 
and rebound on abdominal palpation, but often the findings 
are more vague with only tenderness in the lower abdomen. 
Prior to pelvic examination, if ectopic pregnancy is expected 
it is wise to site an intravenous line as rupture of the ectopic 
may occur during the examination. Gentle pelvic 
examination may reveal cervical excitation pain, because the 
tube is distorted by the enlarging ectopic pregnancy. It may 
be possible to feel a mass in the adnexal region in about 
20%. The uterus would be bulky due to the normal early 
pregnancy changes. 

Since assays have been available for the detection of the 
sub-unit of human chorionic gonadotrophin (hCG) it has 
been possible to detect this in the serum of a pregnant 
patient between 7 and 10 days after ovulation has occurred. 
Thus diagnosis of pregnancy can occur before the patient 
has missed her period. In a normally-sited pregnancy the 
doubling time for hCG levels is approximately 48 hours, so 
serial measurements of hCG may help in the diagnosis of an 
ectopic pregnancy (Fig. 4). The detection of urinary hCG is 
the standard pregnancy test and with a positive pregnancy 
test an intrauterine gestation sac would be seen from 5 
weeks onwards. 

Ultrasound examination earlier than this may reveal an 
empty uterus with a positive pregnancy test. Failure to detect 
a sac should raise the possibility of ectopic gestation. The 
thickening of the endometrium for the implantation of the 
fertilized ovum may lead to an ultrasound picture known as 
a 'pseudo-sac', which should be distinguishable from a 
normal gestation sac. An hCG discriminatory zone is 
described whereby a titre of 1000-1500 I U/ml is associated 
with the presence of an intrauterine sac on transvaginal 
ultrasound (6000-G500 IU/1 for transabdominal scan). This 
may help to increase the accuracy of the diagnosis. 

Management (Table l) 

The initial management of the acute patient involves 
correction of shock with rapid fluid replacement, cross- 
matching of blood, check on the haemoglobin and 
immediate recourse to laparotomy to stem the source of the 
haemorrhage. In the more usual subacute presentation a 
laparoscopy is performed to make the definitive diagnosis 
and to plan the type of treatment that would be appropriate. 
The laparoscopic treatment of ectopic pregnancy offers a 



Table l Management of ectopic 
pregnancy 

Conservative 

■ Inject ectopic with methotrexate or use intramuscular 
methotrexate then follow with flhCG measurements 

■ Salpingostomy 
-primary closure of tube 
■ secondary closure 

■ Pa rti a I sa Ip ingecto my 

- open procedure 

- laparoscopic procedure 

Radical 

■ Sa Ip i n g e etc my with a r w ith out oophorecto my 



quicker recovery associated with an improved rate of 
subsequent intrauterine pregnancy compared to treatment 
by laparotomy. There is also a lesser risk of recurrent ectopic 
but a higher rate of persisting trophoblastic tissue during 
laparoscopic management 

The surgery may be laparoscopic or may require 
laparotomy. Laparotomy would be indicated where access to 
the tube was limited by adhesions or in a patient with 
haemorrhagic shock, but ectopic pregnancies are commonly 
managed laparoscopically. The tube may be removed 
(salpingectomy) or conserved (salpingostomy). 
Salpingectomy is associated with a lower rate of persisting 
trophoblast and subsequent repeat ectopic, whilst having a 
similar intrauterine pregnancy rate to salpingostomy. The 
advent of laparoscopy has reduced laparotomy rates during 
ectopic pregnancy by at least 40°/o and as conservative 
management down the laparoscope proceeds man}' fewer 
laparotomies need be performed. 

The ultimate conservative management would be to cause 
tubal abortion by ensuring death of the ectopic tissue - 
attempts have been made to inject the ectopic with 
methotrexate or with high-dose potassium, a risky procedure 
due to the possibility of intravascular injection and harm to the 
mother. Follow-up with hCG levels to ensure non-continuation 
of the trophoblastic tissue is essential. 

The future 

Most patients will wish to discuss the recurrence risk for 
ectopic pregnancy - this being highly dependent upon the 
reason for the current ectopic pregnancy. The usually quoted 
risk of ectopic pregnancy after surgery is approximately 
5-15%, depending on whether management is laparoscopic 
or open. Some patients will not wish further conception after 
an ectopic pregnancy but of those who do, approximately 
50% achieve a live birth. 



Ectopic pregnancy 



■ Ectopic pregnancy is a diagnosis easily missed unless a high index of 
suspicion is maintained. 

■ The fallopian tube is the commonest site for ectopic implantation. 

■ Slow rise in hCG levels may indicate an ectopic pregnancy. 

■ On ultrasound examination beware the pseudo-sac and look for free 
peritonei fluid or an adnexal mass. 

■ There is decreased fertility after ectopic pregnancy. 



100 GYNAECOLOGY 



Pelvic inflammatory disease 



There is a broad spectrum of disease 
included under the term pelvic 
inflammatory disease (PID), ranging 
from an acute, life-threatening 
presentation to a more chronic but 
disabling disorder. In many instances it 
may be that the disorder is completely 
asymptomatic, which means that the 
incidence is usually under reported. 

The term covers ascending infection 
of the genital tract and usually includes 
an endometritis and salpingitis - though 
parametritis, salpingo-oophoritis, pelvic 
peritonitis and pelvic abscess may all be 
found (Fig. 1). It is a disease of the 
reproductive years so most patients are 
young (75% of cases are under 25 years) 
and are sexually active (90% of 
infections are sexually acquired). Pelvic 
infection may follow childbirth or 
instrumentation (insertion of 
intrauterine contraceptive device, 
hysterosalpingography) of the uterus in 
10%. The reported incidence varies 
geographically (Table 1). 

Acute PID 

Presentation and diagnosis 

The clinical presentation may be very 
varied but low, bilateral pelvic pain with 
associated fever is suggestive of the 



Chronic infection can 
blunt the villi 















sJ/njS 













Table 1 Incidence of pelvic inflammatory 
disease 

Country Incidence 

USA 1CM 

Sweden 0.27% 

Africa 1 5-20% incidence cf gonorrhoea 

Uganda 6-18* PID 



Table 2 Diagnosis of pelvic inflammatory 
disease 



All three of: 

■ Abuurriina: tenderness 

■ Cervical excitation 

■ Adnexel tenderness 



And at least one of: 

■ Temperature >38°C 

■ WBOlOxirjVl 

■ ESR> 15 mm/hour 



diagnosis. It is important to question 
about the time of the last menstrual 
period and use of contraception as the 
differential diagnosis includes ectopic 
pregnancy, threatened abortion, 
menstrual pain (dysmenorrhoea) and 
endometriosis. Vaginal discharge may be 
profuse, purulent and offensive, blood- 
stained or minimal. Onset of symptoms 
is likely to have been over a few days 
with possibly deep dyspareunia and 
general malaise. 

If the diagnosis is based on Table 2, 
then laparoscopic findings will be 70% 
with salpingitis, 30% with adhesions and 
G°/o with tubal occlusion. 




Transverse section of 
normal fallopian tube 




Inflammation clearly shown 
affecting the fallopian tube 




Histology of healthy 
fallopian tube mucosa 



Tuberculosis infection of the 
fallopian tube - a rare cause 

of infertility 

Fig. 1 Changes to fallopian tubes resulting from pelvic inflammatory disease. 



PID may be caused by a variety of 
organisms. As they are known to have 
ascended from the lower genital tract 
this may explain why swabs taken from 
the high vagina or endocervix are 
frequently unhelpful in isolating the 
cause of symptoms. The natural history 
of the disease is incompletely 
understood, though the relationship 
with sexually transmitted disease raises 
the possibility of damaged mucosal 
surfaces being more prone to ascending 
infection. Proposals as to how organisms 
ascend the genital tract include being 
swept upwards during retrograde 
menstruation, which might explain why 
the onset of PID is often associated with 
menstruation. 

The two organisms most commonly 
associated with PID (60% of cases) are 
Chlamydia trachomatis and Neisseria 
gonorrhoeae. They have changed in 
prevalence over the past 30 years - 
Chlamydia increasing whilst gonorrhoea 
is less prevalent. Chlamydiae are 
obligate intracellular parasites and 
appear to be able to influence the host's 
immune response in ways beneficial to 
their survival. It may be the immune 
response to the chlamydiae which 
determines the extent of tubal damage. 
The necessary investigations in 
suspected cases are: 

■ FBC (full blood count) - looking for a 
raised white blood cell count as 
response to infection 

■ ESR > 15 mm/hour 

■ temperature - raised in response to 
infection 

■ triple swabs - from high vagina, 
endocervix, urethra 

■ diagnostic laparoscopy - may be 
considered for a definitive diagnosis, 
investigation of a pelvic mass, or 
failure to respond to treatment. 

Related factors 

Sexual history. An increased risk of PID 
has been noted in association with a 
young age at first sexual intercourse, a 
high frequency of sexual intercourse and 
multiple sexual partners. 

Contraception. Use of the oral 
contraceptive has a lower risk of PID, 
possibly due to the changes in the 
cervical mucus making this 
impenetrable to ascending organisms. 
On the other hand, there is an increased 
chance of PID in association with the 



Pelvic inflammatory disease 101 



use of the intrauterine contraceptive device (IUCD). This may 
be due to the introduction of organisms at the time of coil 
insertion or the presence of the thread leading from the 
endometrial cavity down to the vagina - which may allow 
organisms to ascend. 

Smoking. Smoking is also noted to be associated with an 
increased risk of PID. 

Treatment of acute PID 

This illness is polymicrobial in nature and thus requires the 
use of broad-spectrum antibiotics. With GO°/o of cases due to 
Chlamydia trachomatis or Neisseria gonorrhoeae it seems 
prudent to base treatment around coverage of these organisms. 
A single oral dose of azithromycin and a course of 
metronidazole should be given. In the unwell patient the 
addition of cefuroxime or gentamicin will be necessary. In those 
with excessive vomiting, intravenous fluids will also be helpful. 

Treatment regimes should include treatment of the sexual 
partner(s) as more than 50% will have evidence of genital tract 
infection. Contact tracing is thus important and it may be wise 
to call on the services of the genitourinary medicine team who 
have this facility set up already. 

If after 48 hours of antibiotic therapy there is no 
improvement in the patient's condition, laparoscopy can be 
considered to exclude the possibility of a developing pelvic 
abscess, which would require surgical incision and drainage. 
Recurrent episodes of acute PID are associated with increasing 
chance of tubal blockage - after one episode 17%, two 
episodes 35% and three episodes 70%. 

Chronic PID 

This follows inadequately treated acute PID or may follow 
cases where low-grade symptoms mean the patient did not 
seek help. It can also occur even with good treatment of the 
first infection in the presence of tubal damage or reinfection 
with Streptococcus, Staphylococcus, anaerobes or Actinomyces. 
Inflammation leads to fibrosis and adhesions develop between 
pelvic organs with, in severe cases, obliteration of the pelvis with 
a matted mass of bowel loops above the pelvic organs. 

The tubes may be distended with pus (pyosalpinx) or fluid 
(hydrosalpinx, Fig. 2). They become distorted and form a 
characteristic retort shape round the ovary. The function of the 
tube in transporting eggs and sperm is disrupted, leading to 
infertility. The management of pain may require frequent 
hospital admissions. Treatment of the infectious cause is often 
unsatisfactory as scarring means an inadequate blood supply 
with poor delivery of antibiotics to the affected area. Surgical 
clearance of the pelvis may be the final step in a long line of 
treatments - there is a 10-fold increase in hysterectomy rates 
following PID and 7-10-fold increased rate of ectopic 
pregnancy. 

Presentation and diagnosis 

Pelvic pain may be associated with menstruation [secondary 
dysmenorrhoea), deep dyspareunia, or be present constantly 
with disruption of lifestyle. Heavier menstrual loss is seen 
which may be due to increased blood flow to the uterus 
associated with infection or may result from interference with 
the function of the spiral arterioles which normally control 
volume of blood loss. 

Vaginal discharge is usually minimal in chronic cases but may 
be increased and offensive. 

Infertility may be noted in a patient who has had numerous 







Fig. 2 Bilateral hydrosalpinges on hysterosalpingography. 

treatments for PID or the findings at laparoscopy during 
fertility investigations may be consistent with a diagnosis of 
PID. If investigation of infertility includes 
hysterosalpingography (Fig. 1) there may be a flare-up in cases 
due to chronic PID. 

The definitive test is laparoscopy when pelvic adhesions may 
be seen. Culture of organisms from fluid obtained from the 
pouch of Douglas is more likely to direct antibiotic prescribing 
correctly but is frequently unhelpful. 

Treatment 

Analgesia in increasing strengths may be necessary to control 
pain. Antidepressant medication may potentiate the effect of 
analgesics, and short-wave diathermy may have a role. If a 
desire for fertility is not a consideration then removal of 
infected tissue may be the only way to get pain relief. This 
may involve total abdominal hysterectomy with bilateral 
salpingo-oophorectomy as leaving the ovaries behind at 
hysterectomy results in continuing pain in a number of 
patients. Resolution of symptoms is usual after the menopause 
though it may be unrealistic to expect the patient to wait until 
this stage. 

If menstrual problems predominate and are not amenable 
to non-steroidal anti-inflammatory therapy or antifibrinolytics 
then hysterectomy may be necessary. 

For treatment of infertility see page 132. 



Pelvic inflammatory disease 



■ Early and vigorous treatment of acute PID should decrease the 
incidence of secondary complications. 

■ Triple swabs are frequently negative. 

■ Antibiotics should be broad -spectrum and cover N. gonorrhoeae. 
C. trachomatis and anaerobes, 

■ Infections are usually sexually transmitted and contact tracing is an 
essential part of therapy. 

■ Chronic pain management may require hysterectomy with bilateral 
salpingo -oo ptiorectomy 



102 GYNAECOLOGY 

Genital infections 



Introduction 

The World Health Organization [WHO) estimated that, in 
1995, there were over 333 million cases of curable sexually 
transmitted infections (STIs) in adults aged 15 to 49 
throughout the world. Many of the STIs can cause long-term 
morbidity, particularly in females. Untreated, some infections 
can lead to infertility or cause miscarriage, premature birth, or 
infection of the newborn. Prompt diagnosis and appropriate 
management are crucial in reducing these complications. This 
may be difficult as some infections, for example, for example 
Chlamydia trachomatis, are often asymptomatic until 
complications arise. 

Certain demographic features increase the likelihood of 
someone having an STI. There are: 

■ age under 25 years 

■ lack of barrier contraception use 

■ being single, separated or divorced 

■ having an occupation involving staying away from home. 

Women undergoing termination of pregnancy and those with 
an infection such as genital warts are at increased risk of STIs. 
In reality, these factors are surrogate markers of sexual activity 
and rates of partner change, as it is these factors mainly that 
determine the risk of transmission and acquisition of an STI. 
To be able accurately to assess someone's risk of having an 
STI, therefore, it is necessary to take a good sexual history. 

History 

A good history should be taken in a relaxed, communicative 
and non-judgmental way with reassurances about 
confidentiality. Choice of words, appropriate facial expressions 
and appropriate body language by the questioner are 
extremely important. There is never a 'routine' way to take a 
history, but the questions will need to cover: 

■ Symptoms 

- vaginal discharge - is it offensive (vaginosis) or does it 
cause irritation [Candida)? 

- dysuria - suggestive of gonorrhoea or chlamydial infection 

- genital ulcers - timing, prodromal symptoms (e.g. before 
herpes), painful (also genital herpes) 

- abdominal pain or dyspareunia - suggestive of pelvic 
inflammatory disease (PID) (see p. 100) 

■ The place and time of recent sexual contacts 

■ Whether the contact was penile-vaginal, or anal, or oral 

■ Sexual orientation and whether the contacts were with a 
man or a woman 

■ Foreign travel and sexual contact 

■ Contraceptive precautions, and the requirement for 
postcoital contraception 

■ Risk factors for HIV, especially: 

- unprotected sexual activity with others at high risk for 
HIV, or in areas of the world where HIV is endemic 

- injected drug misuse by the patient or partner 

■ A gynaecological history to exclude the possibility of 
pregnancy and to check cervical smear test results. 

Physical examination 

The skin and mouth should be examined and the abdomen 
palpated looking especially for tenderness (PID) or for 
evidence of lymphadenopathy. The external genitalia should 



be examined for skin lesions, particularly genital warts, genital 
herpes and ulceration. The commonest cause of genital 
ulceration in the UK is herpes; syphilis is rare. The urethra 
should be inspected for inflammation urethritis. Where 
appropriate, the anal area needs to be inspected. 

On speculum examination, the posterior fornix should be 
inspected for discharge, and the cervix examined for discharge, 
ulceration, bleeding, polyps, tumours or the threads of an 
intrauterine contraceptive device. A bimanual pelvic 
examination should also be performed to detect tenderness of 
the cervix or adenexa. 

Swabs should be taken from the urethra, vagina and 
endocervix. Although chlamydia is readily identified from 
appropriate endocervical swabs, the ligand chain reaction 
(LCR) or the polymerase chain reaction (PCR) testing of urine 
is also an extremely sensitive test. Immediate microscopy of 
vaginal swabs can detect yeasts, Trichomonas vaginalis and 
'clue cells' - vaginal epithelial cells covered with large numbers 
of Gram-positive and Gram-variable bacilli, characteristic of 
Gardnerella vaginalis. Measurement of vaginal pH maybe 
useful. It is normally < 4.5 but will be > 4.5 in bacterial 
vaginosis and trichomona! infection. 

(See also HIV infection, p. 1G.) 

With the possible exception of PID, genital infections are 
best managed in an STD clinic with facilities for counselling, 
contact tracing and on-site Gram staining and microscopy. 

Actinomycosis 

Actinomyces are Gram-positive bacteria which only rarely 
cause salpingitis (often unilateral, more often on the right), 
chronic tubo-ovarian abscesses and fistulae. Actinomycosis 
may occur secondary to appendicitis or with use of an 
intrauterine contraceptive device (IUCD). It is not sexually 
transmitted and is treated with long-term high-dose oral or 
parenteral penicillin. 

Bacterial vaginosis 

This is very common and occurs when lactobacilli are replaced 
by anaerobes, particularly Bacteroides species (Fig. 1). It is not 
sexually transmitted and many women are asymptomatic, but 
it can cause an offensive green or grey discharge (the pH is 
raised to ~ 5.5 and bacterial metabolites produce volatile 
amines with a 'fishy' odour), particularly after intercourse. On 




WwBRmmm 



MHr 



Fig. 1 Gram-stained smear of bacterial vaginosis. 



Genital infections 103 



wet microscopy, there are 'clue' cells (see 
above). If symptomatic, it is treated with 
oral or vaginal metronidazole or with 
vaginal clindamycin cream (if the 
woman is pregnant, ampicillin may be 
more appropriate). There is no benefit 
in treating the partner or in using 
condoms. 

Bacteroides spp. 

These are commensals but may cause a 
vaginal discharge (see 'Bacterial 
vaginosis', above) or complicate pre- 
existing PID (leading to chronic 
infection). They are not sexually 
transmitted. Treatment is with 
metronidazole or with clindamycin cream. 

Candida or thrush [Candida 
albicans) 

This presents with a whitish discharge 
and pruritus and is not sexually 
transmitted (Fig. 2). The vulva and 
vagina may be fissured and painful. It 
occurs more commonly in the sexually 
active, the pregnant, the 
immunocompromised, the diabetic and 
after antibiotic treatment The combined 
oral contraceptive (COC) probably 
makes no difference. Microscopy reveals 
yeasts and pseudohyphae, and a high 
vaginal swab may be cultured on 
Sabouraud's medium. Treatment is with 
clotrimazole (e.g. Canesten) pessaries 
and cream. Oral fluconazole (Diflucan) 
given immediately is also effective, but 
may have systemic side effects, and 
should not be used in pregnancy. If 
proven infection is recurrent, there is no 
benefit from treating the partner. 




Prophylactic treatment, however, may be 
of benefit, e.g. if the patient's symptoms 
are particularly troublesome 
premenstrually, a single pessary may be 
inserted midcycle. Alternatively, a 
weekly pessary may be used. Natural 
yoghurt on a tampon for 3 nights, acetic 
acid jelly, wiping the anus front to back, 
and cotton underwear may also be of 
help. 

Chlamydia 

This is the commonest bacterial sexually 
transmitted infection in the UK 
(0.5-15% depending on the sample 
selected), and is a much commoner 
cause of infection than the gonococcus 
(Neisseria gonorrhoeae). In the female it 
is often asymptomatic, but may cause 
PID, bartholinitis, spontaneous abortion, 
premature labour, neonatal 
conjunctivitis (5-14 days postnatally, 
Fig. 3) and neonatal pneumonia. PID 
with associated perihepatitis is known as 
the Fitz-Hugh- Curtis syndrome 
(Fig. 4). Reiter's syndrome (arthritis, 
mucosal ulceration and conjunctival 



symptoms) is very rare in women. In the 
male, C. trachomatis infection may cause 
urethral discharge, dysuria, epididymo- 
orchitis and Reiter's syndrome. 
Diagnosis in the female is by 
endocervical swabs, urethral swabs or 
first-void urine sent in a specific 
transport medium for investigation via 
the LCR or the PCR. Uncomplicated 
infection may be treated with an 
immediate oral dose of azithromycin or 
with doxycycline for 7-10 days or 
erythromycin for 7-10 days. Increased 
doses plus the addition of metronidazole 
are employed for complicated infection. 
Contact tracing is important and 
individuals should avoid unprotected 
intercourse for 2 weeks. 

The main concern with chlamydial 
PID is its association with tubal damage 
and infertility. As infections may be 
subclinical, it has been suggested that at- 
risk groups should be screened - 
particularly as this can now be achieved 
simply through LCR/PCR testing of 
urine. Those at greatest risk are those 
aged < 25 years, particularly those with 




Fig. 3 Chlamydial conjunctivitis occurs in 50% of neonates born 
to an infected mother. 




Fig. 2 Candidal vaginitis. 



Fig. 4 Fitz-Hugh-Curtis syndrome. 









104 GYNAECOLOGY 



two or more sexual partners in the 
preceding year or who are presenting 
with a request for termination of a 
pregnancy. It has also been argued that 
all women under 25 years old should be 
regularly screened. 

Genital warts [Fig. 5] 
These are usually caused by human 
papilloma virus (HPV) types G and 11, 
though types 16 and 18 are occasionally 
implicated. Most patients with genital 
HPV have no visible warts but the virus 
can be transmitted to sexual partners 
who may then develop visible lesions. 
Twenty-five per cent of those with warts 
have other demonstrable STIs. 
Podophyllin paint can be applied weekly 
to the non-pregnant patient by medical 
staff, with advice to wash the solution 
off G hours later. Self-treatment is also 
available with podophyllotoxin solution 
- this is applied twice a day for 3 days, 
and the treatment repeated on a weekly 
cycle for four cycles. For patients with 
multiple or large warts, treatment with 
cryotherapy using liquid nitrogen, or 
laser treatment, or diathermy under 
general anaesthetic is appropriate. 
Annual cervical screening is not 
required but those with visible cervical 
warts or abnormal cytology should be 
colposcoped. 

Gonorrhoea (.Neisseria 
gonorrhoeae") 

The incubation period is 2-5 days for 
men. The vast majority of women are 
asymptomatic but infection may cause 
PID (often at the time of menstruation), 



urethritis, polyarthralgia, miscarriage, 
premature labour and neonatal 
ophthalmia (2-7 days postnatally). Most 
men have symptoms of urethritis and 
penile discharge (Fig. 6). Swabs should 
be taken from the urethra and cervix 
and placed in Amies transport medium. 
A Gram stain of an endocervical swab 
shows Gram-negative intracellular 
diplococci in only 50% so that definitive 
diagnosis is by culture on NYC (New 
York City) medium. Treatment is with 
ampicillin orally stat. together with 
probenecid. Ciprofloxacin orally stat. is 
used in penicillin allergy and for 
infections acquired in regions where 
resistance is common. 

Herpes (herpes simplex virus, 
HSV) 

This infection classically occurs 
secondary to the sexually transmitted 
Type II virus, but infection with Type I 
from cold sores is increasingly common. 
The incubation is 2-14 days with itch 
and dysuria prominent early symptoms. 
The vulva becomes ulcerated (Fig. 7) and 
exquisitely painful and, in the first attack 
(which may last 3-4 weeks), there may 
be systemic flu-like symptoms with or 
without secondary bacterial infection. 
Autoinoculation to fingers and eyes can 
occur and there may be a sacral 
radiculopathy giving a self-limiting 
paraesthesia to the buttocks and thighs. 
Only very rarely is there an associated 
meningitis or encephalitis. Strong oral 
or intramuscular analgesia and advice to 
micturate while in the bath may be of 
help (lidocaine (lignocaine) gel is 



painful to apply and may lead to 
hypersensitivity reactions). Aciclovir 
orally shortens the duration of 
symptoms and lessens infectivity 
(famciclovir and valiciclovir are 
alternatives). Recurrent infections are 
shorter (lasting 5-10 days) and usually 
less severe. Ninety-five per cent of Type 
II and 5% of Type I infections recur in 
the first year. Aciclovir cream should be 
used at the start of subsequent 
infections. Prophylactic oral aciclovir 
should be reserved for those with 
frequent incapacitating infections (e.g. 
> 10/year) and should be continued for 
at least 12 months. There is no necessity 
for annual cervical cytology. (See p. 15 
for 'infections in pregnancy*.) 

Syphilis (Treponema pallidum) 

(Table 1) 

A primary chancre (raised, round, 
indurated usually painless ulcer; Fig. 8) 
resolves in 3-8 weeks and may be 
followed by secondary fever, headaches, 
bone and joint pain, generalized rash, 
flat papules known as condylomata lata 
and generalized painless 
lymphadenopathy. Following the latent 
phase, there may be tertiary gummas 
(Fig. 9) or quaternary neurological and 
cardiovascular disease. Congenital 
syphilis may lead to intrauterine death 
or midtrimester loss. Survivors may be 
premature, have intrauterine growth 
restriction, and failure to thrive as well 
as bone, joint, liver and kidney disease. 
The diagnosis is made serologically, 
ivith most laboratories using the 
Venereal Disease Research Laboratory 




Extensive vulval warts. 



most women are asymptomatic. 



Fig. 7 Herpetic ulceration of the vulva. 



Genital infections 105 



Table l Syphilis 


Stage 


Timing 


Features 


Primary 


Usually u-ZSdays 
ircm conlacl 


Chancre 


Secondary 


Approx. 6 weeks after 

Chancre 


Rash, condylomata lata, lymphadenopathy 


Ternary 


More itian 1 years after 


Gumma m skin, mucous membranes. 




infection 


long bones 


Quatcnary 


Late 


Cardiovascular an rj neurosyphilis 





Fig. 9 Gumma of the leg. 'Punched-out' ulcers classically occur in the 
leg, scalp and sternoclavicular area. 



Fig. 8 Vulval chancre. 




(VDRL), T. pallidum haemagglutination (TPHA) and 
fluorescent treponemal antibody (FTA) tests. Many 
laboratories now screen with an anti-treponemal IgG enzyme- 
linked immunosorbent assay (ELISA) that is highly sensitive 
but does give false-positive results. True positives are 
confirmed by the more traditional tests. Treatment is with 
procaine benzylpenicillin (procaine penicillin) i.m. for 
10-21 days depending on the stage of the disease. 

Trichomonas vaginalis 

This is usually sexually transmitted. There is a foul-smelling, 
purulent vaginal discharge with accompanying symptoms of 
dysuria and vulval soreness (Fig. 10). Diagnosis is by 
identification of the flagellate organism on a wet film. 
Treatment is with metronidazole as for bacterial vaginosis. 

Vaginal discharge 

History 

Physiological vaginal discharge changes throughout the 
reproductive life, increasing as the oestrogen level increases 
(e.g. at puberty, in pregnancy or with the COC). An itchy 
discharge suggests Candida, an offensive one a foreign body, 
Trichomonas vaginalis or bacterial vaginosis. Ask whether 
there is pain or fever (PID causes abdominal pain, HSV causes 
vulval pain). A sexual history should also be obtained. 

Management 

Perform a speculum examination to see whether the discharge 
is vaginal or cervical. 



Fig. 10 Trichomonal vaginitis. Note that the classical 'frothy yellow' 
discharge is found in only a third of cases. 



If the history is one of pruritus vulvae, the patient is well 
and the discharge is white, prescribe antifungal preparations 
(swabs for culture are optional). See 'Candida' above. 
The treatment of bacterial vaginosis is described above. 
If there is no response to the above, or there are concerns 
about STIs, or there is an endocervical discharge, swabs 
should be taken for N. gonorrhoeae and C. trachomatis (or 
first-pass urine for PCR/LCR if available) and a fresh wet 
smear examined for Trichomonas vaginalis. 
If there has been no response to the above measures and 
there are no identifiable organisms, it is worth formally 
calling a halt to investigations and reviewing the original 
history. Discussion about the changing nature of a 
physiological discharge and reassurance about the absence 
of infection is often reassuring. Treating a cervical ectropion 
to cure vaginal discharge is frequently unrewarding. Topical 
or systemic oestrogen treatment for recurrent vaginal 
infections may be of help in atrophic vaginitis (e.g. 
postmenopausally or in those on depot progestogens). 



J 



Genital infections 



i Chlamydia and gonococcal infections are often asymptomatic in the 
female, but may cause tubal damage and infertility. 

i Active herpes simplex virus infection may lead to serious neonatal 
infection. 

i Contact tracing is very important 



106 GYNAECOLOGY 




Oestrogen-dependent hormonal contraception 



The combined oral contraceptive pill is 
still the commonest form of 
contraception used in the UK, and is 
highly effective, with a failure rate of 
0.1 per 100 woman-years (i.e. if 100 
women took the pill for 1 year, one 
woman would conceive]. 

The combined oral contraceptive 
pill (the 'pill') 

The pill is a combination of synthetic 
oestrogen and progestogen (synthetic 
progesterone). The main oestrogen is 
ethinylestradiol, although mestranol is 
used in two products. The 
progestogens are all C19 nor- 
testosterone derivatives, apart from 
cyproterone acetate (used in Dianette) 
which is a pregnane-type anti- 
androgen. The majority of pills contain 
second generation progestogens. 

More recent pills contain third 
generation progestogens. The latter 
display higher binding affinity for 
progesterone than for androgen 
receptors, and therefore produce fewer 
side effects, e.g. acne, weight gain and 
premenstrual tension. They have better 
carbohydrate and lipid metabolism 
profiles and, despite recent 
controversy, probably have no 
increased risk of venous 
thromboembolism compared to their 
second generation counterparts. 

Most contraceptive pill packets (Fig. 1) 
contain 21 tablets, allowing 7 pill-free 
days for the withdrawal bleed. 'Everyday* 
packs including seven dummy pills are 
available. This may enhance compliance 
in certain groups, e.g. adolescents. 

■ The monophasic pills contain the 
same dose of oestrogen and 
progestogen in all 21 tablets. 

■ Biphasic pills maintain the same 
dose of oestrogen, but vary the 
progestogen so that there is a lower 
dose in the first half as compared to 
the second half of the cycle. 



7 pill-free days 1 tablet taken daily, 
for 21 days 



® 

® 



® 
® 



Tabic ' Benefits of combined 


pill use 




Menstrual related 

■ Regular cycles 


■ Ovarian cysts 


■ Reduction in acne 


■ Reduction of blood loss 


a Ovanan cancer 


■ Reduction In hirsutism 


■ Less anaemia 


■ Endometriosis 


[in certain circumstances] 


■ Reduction of dysrncnorrhoea 


■ Endometrial cancei 


■ Reduction in anxiety 


■ Control oi premenstrual syndrome 


■ Benign breast disease 


[reliable contraception) 




■ Pelvic inflammatory disease 


■ Seizure control improves with a steady 




■ ? Rheumatoid arthritis 


hormonal environment 



■ In triphasic contraceptive tablets the 
dose of oestrogen varies slightly to 
mimic the mid-cycle surge and there 
are three phases of progestogen doses. 

When prescribing the oral 
contraceptive pill consider: 

■ benefits (Table 1} 

■ disadvantages (Table 2) 

■ risk factors or contraindications to 
pill prescribing 

■ any concurrent therapy that might 
interact with the pill 

■ whether or not the individual will be 
a reliable pill taker 

■ whether or not she might exhibit 
oestrogen or progestogen sensitivity. 

Absolute and relative 
contraindications 

The ideal pill user is fit thin, and a non- 
smoker with no personal or family 
history of venous thromboembolism. 
This ideal category may be allowed to 
continue to take a low-dose third 
generation progestogen pill until the 
menopause. Contraindications include 
the following: 

■ cigarette smokers - advised to stop 
the pill at age 35 

■ previously existing hypertension, 
obesity and diabetes mellitus (in the 
presence of other risk factors, 
diabetes is a contraindication, 
especially if there is evidence of 
microvascular disease, or if there is 
retinopathy or nephropathy) 

■ as sickle cell disease is associated 



@®@®©©®©® 



Fig. 1 Combined oestrogen/progestogen 
pill. 



Table 2 Possible side e 


fleets of 


oestrogen and progestogen pills 


Oestrogen 


Progestogen 


■ Breast enlargement 


■ Acne 


and tenderness 


■ Hirsutism 


■ Bloating 


■ Wei ght gam due to 


■ Weight gain due to fluid 


mcreaseri appetite 


retention 


■ Depression 


■ Carpal tunnel syndrome 


■ Vaginal dryness 


■ Headaches 


1 Greasy nair 


S Vaginal moisture 


■ Decreased libido 


■ Nausea 




■ Chloasma 





with thrombotic episodes the pill is 
contraindicated in homozygotes 
(heterozygous carriers may use the 
pill) 

■ coronary artery disease, 
cardiomyopathy and pulmonary 
hypertension are all absolute 
contraindicators to the pill due to an 
increased risk of myocardial infarction 

■ inflammatory diseases are relative 
contraindications (ulcerative colitis 
and Crohn's disease) 

■ focal, crescendo and severe migraine 
requiring ergot treatment are 
contraindications because the 
vasoconstriction associated may add 
to the thrombotic risk of the pill. 
Some women, however, have so- 
called menstrual migraines and 
these improve if the cycles are 
ablated by running three packets of 
the pill together before having a 
withdrawal bleed, i.e. tricycling. 

Breast disease and the pill 

Controversy surrounds the issue of 
breast disease. The use of the 
contraceptive pill appears to reduce the 
incidence of benign breast disease 
(Table 1). The incidence of breast 
cancer is slightly higher in women 
who began taking the pill before the 
age of 20. Against this the benefits of 
the pill must be considered. 

Practical prescribing 

The current advice is to start the 
contraceptive pill on the first day of a 
period. This provides immediate 
contraception. It is important to link 
taking the pill with an everyday activity 
to reduce the likelihood of the pill 
being forgotten As there are seven pill- 
free days each packet is always started 
on the same day of the week. New 
patient guidelines have been issued for 
cases of missed pills (Table 3). 

Drug interactions 

Although anticonvulsants can reduce 
the contraceptive effect of the pill 
(Table 4), seizure control is improved 



Oestrogen-dependent hormonal contraception \ 07 



Advice to be 


given 


to 


women who 


miss the combined contraceptive pill 


Omission 










Advice 


■ pull omissions of less than 


"i 


iOl,rs 




T= 


ie me pi 1 immediately and Furtlior nil Is as usual 


Fre one. or more, pill omissions, nore man 12 hoi 


,rs l3ie 






- m week ! ol p»l pacitet 










■ 
■ 
■ 

■ 


lake the p-ll immediately 

Continue the packet as usual 

If intercourse has net occurred for 7 days - use 

sheath in addition fur 6 days 

It intercourse has occurred - see a doctor [consider 

emergency contraception] 


- in week 2 of pill packei 










■ 
■ 
■ 


Take the last pi u immediately 

Continue with the packei as usual 

If four, or mare, pills are missed - use sheath for 

7 days as well 


mwccKSol pill packet 










■ 
■ 
■ 


Tate the pill immediately 

Continue with the packet as usual 

At tne end ol the packet continue with the next 

packei wttmuta break [breakthrough bleeding 

may occur) 



After Korver. Tet al. 1995. Br J. Obstet Gynaecol. 102: 601-7. 



Iahte A Drug interactions with the combined contraceptive pill 


Drug category 


Example 


Drug effect 


Notes 


Drug Interactions tfi at 


may lead to contraceptive failure 




■ 6 road -spectrum 


Arnpicillm, tetracycline. 


Disturb bowel flora and 


- 


antibiotics 


cephalosporins 
(? erythromycins] 


affect absorption 




■ Rslarrpcin 




Potent enzyme inducer 


Used to ileal tuberculosis. 






[even bnef exposure can 


but more commonly 






interfere with contraceptive 


encountered as prophylaxis 






cover for 1 month] 


following meningococcus 
exposure 


■ Antifungal agents 


Gnseofulvin (Voraf 




Anecdotal reports of pill 




imidazoles. 




failure with oral imidazoles 




fluconazole. 








kelQconazo-le. 








itraconazole] 






■ Anticonvulsants 


Barbiturates, phenytoih. 


Enzyme-inducing agents 


The newer anticonvulsants 




primidone. 




are ssfe to use with the pill - 




carbamazepine 




sodium valproate, 
clonazepam, vigabatrm 


The contraceptive pill may interfere with drug action: 




■ Antihypertensives 


Ace- inhibitors, beta blockers 


Oestrogen antagonizes 

hypotensive effect 


- 


■ Anticoagulants 




Effects antagonized 


- 


■ Antidepressants 




Effects antagonized 


- 


■ Gral hypoglycemics 




Effects antagonized 


- 


■ Diuretics 




Effects antagonized 


- 



with a steady hormonal environment. 
Monophasics are recommended in 
epileptics. A stronger pill is normally 
prescribed, often tricycling three 
packets (to minimize risks from the 
pill-free week). The pill itself may 
interact with pre-existing medication. 

Surgery and the pill 

The pill should be stopped at least 4 



weeks before major surgery and before 
minor surgery where immobilization 
follows. For emergency (Le. unplanned) 
surgery the pill should be stopped and 
heparin prophylaxis provided. The pill 
should be recommenced 2 weeks after 
full mobilization. 

Breast feeding 

The pill is contraindicated in breast 



feeding as it inhibits breast milk 
production. Women who plan to bottle 
feed their baby may start the pill 3 
weeks after delivery. The relative 
thromboembolic risk is high in the 
immediate postpartum period. Most 
postpartum regimens would advise 
waiting until the sixth postnatal week 
Csee p. G5). 

Emergency contraception 

There is still a problem with the 
under-utilization of emergency 
contraception due to a lack of 
awareness. The much used misnomer 
'the morning after pill' is confusing: 

■ progestogen-only emergency 
contraception (Levonelle-2) - can be 
used for up to 72 hours post 
unprotected intercourse 

■ the intrauterine device (a copper 
coil) - may be fitted up to 5 days 
after unprotected intercourse. 

The Levonelle-2 pill is very effective, 
preventing four out of five potential 
pregnancies with few side effects. 

Adolescent contraception 

Many adolescents are mentally and 
emotionally unprepared for early 
sexual experience. There is a risk of 
unwanted pregnancy, sexually 
transmitted diseases, pelvic 
inflammatory disease, and cervical 
dyskaryosis. 

It is important that any service for 
young people is user-friendly, 
confidential, approachable and offers a 
full range of options. The pill is the 
most popular choice, but other 
methods including the sheath are 
frequently used - the latter because it 
is easy to obtain. 

Controversy surrounds treating 
under 16-year-olds. Since 1985 in the 
UK there are strict guidelines covering 
these circumstances, including that the 
girl fully understands the doctor's 
advice and that the doctor tries to 
persuade her to inform her parents or 
guardian - but obviously will respect 
her confidentiality if she decides she 
does not wish to do so. 



Oestrogen-dependent hormonal contraception 



i The contraceptive pill is the most widely prescribed con [reception available with a safety rate of approximately 0.1 per 100 woman -years 
i The major side effects include venous thromboembolism, arterial thrombosis, hypertension and subarachnoid haemorrhage. 

• Antibiotics, antifungal agents, antiepileptics and rifampicin can reduce the pill's contraceptive effect. 

i Progestogen-only emergency contraception may be used for up to 72 hours after unprotected intercourse, 

i Adolescents must be treated as a special category in an approachable and confidential manner. 



108 GYNAECOLOGY 



Progestogen-dependent hormonal 
contraception 



It is in this area that contraception has 
made the most advances in recent 
years. Oral, depot and intrauterine 
treatment modalities are now available 
with the length of activity ranging 
from 24 hours to 5 years, allowing the 
clinician to pick the contraception that 
is most suitable to the individual 
woman's needs. 

Progestogen-only pill (POP) 

The progestogen-only pill contains 
norethisterone, levonorgestrel or 
norgestrel. There are three possible 
modes of action: 

■ cervical mucus changes 

■ ovulation either prevented or 
interrupted [in 60% of cases) 

■ some antinidatory action on the 
endometrium [producing an 
atrophic endometrium). 

Some women bleed regularly, 30-50% 
have irregular bleeding, and the rest 
become amenorrhoeic Prolonged 
amenorrhoea, e.g. for up to 5 years, 
especially in a woman who smokes, 
should prompt an assessment of bone 
mineral density. Being oestrogen free, 
the POP may be used in certain 
medical conditions where the combined 
pill is contraindicated (Table 1). 

However, it should still not be 
prescribed in pregnancy, undiagnosed 
abnormal vaginal bleeding, severe 
arterial and ischaemic heart disease 
and previous ectopic pregnancies. The 
incidence of ovarian cysts is more 
common in POP usage. Older users 
appear to be more at risk. 

The failure rate with the POP varies 
with age. It can be as high as 3.1 per 
100 woman-years in women aged 
25-29 and drop to 0.3 per 100 woman- 
years for women over 40 years of age. 
It is therefore more suitable 
contraception for the older woman 



Table i Clinical situations where POP 
may be useful 

■ Older women, especially smokers, ovef the age of 35 

■,.■:■■■ 

■ Breast-feetfing women 

■ Women who suffer Side effects with (he combined 
contraceptive pill [COO 

■ Medical conditions which aw coraramdicaied to 
COC usage, e.g. sickle cell disease, past history of 
venous trnornuoemDOIism 

■ Mig-aine sufferers 



Table 2 Disadvantages of the depot progestogen injections 


1 


Menstrual cycle disturbance 


Initial irregular bleeding 
Eventual artienoirhoca 




Weighi gajn 


Often 4-5 Jbs 

Commoner in slimmer women 




Fertilty 


Slower returni to fertility than with nra' methods 
LJ b u al r>- reiur n$ by 5 month s after last i nject-O' 1 ! 
This may be a decid<r>g (actor m some women 




Qsteooarcs,s 


Conflicting evidence, certainty no noticeable rcrease in osteoporotic fractures 

tong -term users 

However, generally. no * recommended for women > ^5 years 

Amenorrhoea induced by depot could mask the onset of the menopause 


in 


General symptoms 


Tiredness 
Low mood 
Low libido 
Masraigia 





than for the young teenager. Body 
mass index also exerts an effect on the 
failure rate and in the very overweight 
two tablets per day are advised. 

Missed or late pills constitute the 
biggest cause of POP contraceptive 
failure, as it must be taken within 
3 hours of the same time each day. If 
taken late, other precautions should be 
taken for the following 7 days. 

Pills are usually started on day 1 or 2 
of the cycle. Postpartum contraception 
is usually started on day 21. 

Depot progestogen injections 

Long-term depot progestogen provides 
contraception by suppressing ovulation 
as well as exerting effects on the 
endometrium and cervical mucus. The 
injections are highly effective 
convenient contraceptives which are 
particularly useful for women who are 
unable to remember to take the oral 
contraceptive methods. 

The depot progestogens have been 
widely used in developing countries, 
and the World Health Organization 
has a vast body of literature on their 
efficacy and safety. Depo-Provera, 
lasting 12 weeks, has been used the 
longest and more extensively 
worldwide. Noristerat is active for 
8 weeks and frequently used in 
Germany. They are somewhat under- 
utilized, however, in the United 
Kingdom, where they are licensed as 
'second choice contraceptive methods, 
to be used only after counselling'. 

Overdue injections pose a risk of 
contraceptive failure. It is generally 
thought that 7 days of latitude exist. 
Longer delays should be followed by 
emergency contraceptive advice. 



Although a very safe method of 
contraception, certain disadvantages 
have been identified [Table 2). 

The Fern-ring 

The progestogen-only ring looks 
similar to a vaginal ring pessary and is 
5-G cm in diameter (Fig. 1). 

The Fem-ring releases 20 mg 
levonorgestrel locally each day, 
absorbed through the vaginal mucosa. 
The ring is effective for 3 months. 

The main contraceptive activity is to 
thicken the cervical mucus. There is a 
failure rate of 3-4 per 100 woman- 
years. Studies have demonstrated a 7% 
expulsion rate, mainly related to pelvic 
wall laxity. Continuation rates are 
between 50 and 75%. Irregular 
bleeding has been the most-cited 
problem. Asymptomatic erythematous 
vaginal wall patches have been noted. 

The Fem-ring offers certain 
advantages over Depo-Provera, the 
alternative 3 -monthly progestogen 
contraception: 




Fig. 1 The Fem-ring. 



Progestogen-dependent hormonal contraception 1 09 





Fig. 2 Site of insertion. 

■ Reversibility 

■ Much smaller risk of amenorrhoea 

■ No concern regarding osteoporosis 

■ No problem with delay in return to 
fertility. 

Progestogen implants 

Implanon is the newest progestogen 
implant pellet (Fig. 2). It is a 
biodegradable, single flexible rod 4 cm 
long x 2 mm in diameter. It contains 
G8 mg etonogestrel, an active 
metabolite of desogestrel. It is licensed 
for 3 years and has the same mode of 
action as Norplant. Being 
biodegradable, the rod does not 
require removal. Follow-up is advised 
3 months after insertion and every 
3-6 months thereafter. 

Implants have a low pregnancy rate 
of 0.2 per 100 continuing users for the 
first year, with an accumulative 
pregnancy rate of 3.9 per 100 users 
over 5 years. On removal or 
degradation, the contraceptive effect 
ceases almost immediately. 

The majority of women (GO-80%) 
will experience some change in 
bleeding pattern during the first year. 
Menstrual irregularities tend to settle 
with time. Occasionally women 
complain of headaches, mastalgia, 
dizziness or hair growth (5-10%). 

The levonorgestrel intrauterine 
system 

The levonorgestrel intrauterine system 
(LNGTUS), otherwise known as the 
Mirena coil (Fig. 3), is a major 
breakthrough in contraception. Not 
only does it provide reversible 
contraception, but it is a highly 
effective device with failure rates lower 
than those seen with the combined 
oral contraceptive pill and even 
sterilization. The failure rate is 
reported as 1 per 500 woman-years of 
use. The Mirena is licensed for 5 years' 
contraceptive cover. 



32 mm 19 mm 




Reservoir 
containing 53 mg 
of levonorgestrel 



T-shaped 
plastic frame 



Removal 
threads 



Fig. 3 The Mirena coil (LNG-IUS). 

There are added benefits to the 
Mirena coil since the direct action of 
progestogen on the endometrium is to 
produce atrophic change: 

■ menstrual blood loss is dramatically 
reduced in 70% of cases over the 
first year (now licensed in the UK 
for treatment of menorrhagia) 

■ dysmenorrhoea is greatly reduced 

■ uterine fibroids are less likely to 
grow and may indeed shrink 

■ pelvic infection is uncommon. The 
LNG-IUS may exert a protective 
effect 

■ endometrial hyperplasia and atypia 
are prevented and in established 
cases the histology appears to 
reverse 

■ there is the potential that the Mirena 
could provide the progestogen 
component of a hormone 
replacement therapy (HRT) regimen 
in conjunction with systemic 
oestrogen by providing endometrial 



protection 'at source' (awaiting 
licence). 

The expulsion rate is low (2-5%), but 
is most likely to occur in the first few 
weeks after fitment, if at all. 

Difficulties with the Mirena coil 

5-10% of women are progestogen 
sensitive and may exhibit some 
systemic side effects. 

Initially erratic bleeding or spotting 
may occur for up to 3-4 months in 
approximately 30% of cases. Very 
occasionally the problem persists. In 
most cases the woman will settle into 
light, regular cycles. Twenty per cent of 
women become amenorrhoeic by the 
end of the year, and must be 
counselled accordingly. 

Although expensive, if the cost is 
divided by its duration of action, i.e. 
5 years, then the cost per month is not 
greatly different from that of other 
forms of contraception. 

The stem is wider than those of 
most other coils. In consequence some 
women will require cervical dilatation 
to allow correct placement of the 
device with appropriate analgesia. 

The Mirena coil is subject to the 
limitations of fitting any intrauterine 
device (see p. Ill, Table 1). If the 
uterus is particularly enlarged, or the 
uterine cavity distorted, by fibroids, 
then the effect on contraception and 
menstrual loss may be inadequate. 

Contraindications to the use of the 
Mirena coil are few; the same as those 
for any other uterine device. Women 
should be checked 6 weeks following 
insertion and should be encouraged to 
check their own threads by vaginal 
examination after each period. 



Progestogen-dependent hormonal contraception 



■ There are now a considerable number of progestogen -only contraceptive methods available 

■ The progestogen- only pill may be used in situations where the combined contraceptive pill is 
considered unsafe, but must be taken within 3 hours of the same time each day. 

■ Women rendered amenorrhoeic by the POP may have a marginally increased risk of 
osteoporosis. 

■ Depot injections are safe but can produce irregular bleeding, weight gain and a slower return to 
fertility than oral methods. 

■ The Fern-ring provides 3 months* contraceptive cover and is more easily reversible than the 
Depo-Provera injection. 

■ Implanon is a biodegradable implant lasting 3 years. 

■ The Mirena coil is effective for 5 years, has both a low failure and expulsion rate and markedly 
reduces menstrual blood f owand dysmenorrrhoea. 

■ Some women will require analgesia to allow insertion of the Mirena coil. 



no OBSTETRICS 



Non-hormonal methods of contraception 



Some women do not want to commit 
themselves to a hormonal method of 
contraception. Advances have been made 
in the types of diaphragm and cap 
available, with the introduction of the 
new female condom, and in different 
types of copper-bearing coil. 

Natural methods of family 
planning 

Natural family planning has a high failure 
rate but is suitable for committed couples 
in stable relationships who may wish to 
extend their family. It requires abstinence 
from penetrative intercourse at the most 
vulnerable time of the cycle. There are 
several options available, all of which 
exploit different methods to identify the 
fertile period of the cycle. Some women 
with religious and moral objections to 
artificial forms of contraception would 
find this method ideal. 

Barrier methods of contraception 

The male condom 

Most condoms are manufactured from 
latex, with spermicides incorporated into 
the lubricant Hypoallergenic varieties 
are available. Latex can perish in hot, 
humid climates and can be damaged by a 
variety of compounds, including sun tan 
oils and some vaginal antifungal agents, 
that lead to loss of tensile strength and 
potential rupture of the sheath. 



The condom is a popular choice 
amongst young people as it is easily 
obtainable, but users must be instructed 
regarding safe application. 

There has been a resurgence of 
interest in the condom recently. Barrier 
methods protect against STDs including 
HIV. Evidence exists that adolescent girls 
are less likely to develop cervical 
dysplasia (see p. 134). This has led to the 
introduction of the 'double Dutch' 
approach to contraception, where 
teenagers are encouraged to use the 
combined oral contraceptive pill, which 
offers the most efficient method of 
contraception, in conjunction with the 
condom, which offers the protection of a 
barrier method. 

The female condom (Femidom) 

The Femidom was introduced as a 
barrier method that would be under the 
woman's control. It is a lubricated 
polyurethane sleeve sealed at one end 
(Fig. 1). The Femidom is available over 
the counter, should be fitted before 
sexual activity and can remain in place 
well after ejaculation has occurred. It has 
been reported that men find that the 
Femidom allows for more sensation 
than the male condom. 

The diaphragm 

Diaphragms stay in place because of the 



tension of the metal spring in the rim. 
Therefore the correct choice of size is 
essential and they should be fitted by a 
trained clinician. The woman must be 
taught how to insert and remove the 
diaphragm and should return for a 
follow-up appointment to check that she 
has the correct technique. The 
diaphragm may be inserted several 
hours before intercourse. Spermicidal 
cream or gel should be applied to both 
sides of the diaphragm as well as 
around the rim. Extra spermicide should 
be applied if more than 2 hours have 
elapsed from the insertion of the 
diaphragm to when coitus occurs. The 
diaphragm should not be removed for a 
minimum of 6 hours after intercourse. 
The diaphragm cannot be relied upon 
in the same way as the condom to protect 
against sexually transmitted disease. 

Caps 

Contraceptive caps are occlusive. They 
rely on suction because of the close 
application to the vaginal vault or cervix 
and because of this, they are not 
susceptible to the vaginal wall expansion 
that occurs during arousal and orgasm. 
The}' do, therefore, prevent sexually 
transmitted diseases. Unlike diaphragms, 
they can be left in place for several days, 
but 24 hours is the recommended 
length of time. Prolonged use can give 
rise to offensive discharge. 






Fig. 1 The Femidom device. 



Chemical methods 

Spermicidal agents 

Spermicides are generally advised for 
use as supplements to other methods. 
They have a mild bactericidal action. 
The active agent for most products is 
nonoxynol-9. Spermicides can be 
manufactured as foam, pessary, cream 
or gel. Use of spermicides as a sole 
method of contraception is advisable 
only in couples with very low fertility, 
i.e. perimenopausal or oligospermia. 

The contraceptive sponge 

This is a soft doughnut-shaped device 
that needs to be lubricated with water 
and inserted high into the vagina before 
intercourse takes place. The sponge is a 
delivery system for spermicide but also 
acts as a barrier and absorbs the 
ejaculate. It can be inserted into the 
vagina up to 24 hours before intercourse 
and must remain in place for at least 6 
hours afterwards. A ribbon attached to 
the sponge allows removal. 



Non-hormonal methods of contraception 



Intrauterine contraceptive 
methods 

All coils are copper bearing except the 
Mirena I US. The Nova T and the Nova 
Gard contain both silver and copper. 
These coils are licensed for 5 years' 
contraceptive use and have a failure rate 
of 1-2 per 100 woman-years. A Multiload 
Cu 250 is licensed for 3 years. There are 
two third generation copper devices, the 
Multiload Cu 375 and the Gynae T 380 
slimline. The former is licensed for 5 
years and the latter for 8 years; both have 
a failure rate as low as 0.5 per 100 
woman-years. Should pregnancy occur, 
the miscarriage rate is increased. 

Problems can be encountered when 
the coil is fitted (Table 1) which should 
only be done by a certified practitioner. 
Fitting in women with a regular cycle can 
be done from the end of the period up 
until day 19 of the cycle. Removal should 
be preceded by either 7 days' abstinence 
or the use of other contraceptive 
precautions. Ideally, devices should not 
be removed after day 19 of a 28-day cycle. 

Areas of concern 

The copper-bearing coils often produce 
menorrhagia and dysmenorrhoea. The 
coil is relatively contraindicated in a 
history of previous ectopic pregnancy, 
subfacility, immunosuppression and 
where infection would be of grave 
concern, e.g. previous tubal surgery, 
bacterial endocarditis and the presence 
of prosthetic heart valves. Fibroids are 
not a contraindication unless the uterine 
cavity is distorted. 

Previous cervical surgery resulting in 
stenosis may make insertion difficult 
and the coil should not be fitted during 
active pelvic infection. 

Actinomyces israelii is more common 
in women with an IUD. 



Tabte ' Risks associated with the fitment 


of an IUD 




Expulsion 


Most often occurs in the first 




lew weeks after fitting 


Perforation 


Most commonly occurs with 




inexperienced fitters and 




when the uterus is retroverted 


Pain 


Lidocairte (lignccame) gel 




tnay be inserted 




mtracervically 




Rarace™cai block 




Oral analgesia (NSAlDs) or 




Voftarol suppositories, grven 




prior to Mr,-™ 


Prolonged vasovagal 


Have atropine available 


bradycardia 




Bronchospasm 


Have iniubation equipment. 




oxygen and adrenaline 




(epinephrine) available 


Small risk of mleclion 







(a) ■■aHWHH^^BH (b) 

Fig. 2 Female sterilization. Ca) Operation to apply clips to tubes, (b] Clip on tube. 



Sterilization 

Sterilization offers a permanent method 
of contraception once the decision has 
been made that the couple's family is 
complete. Appropriate counselling is 
needed, and if there is any ambivalence 
alternatives should be considered. 

Male sterilization 

Vasectomy offers several advantages: 

■ It can be performed under local 
anaesthetic 

■ Significant operative morbidity and 
mortality are virtually non-existent. 

■ It is an easy procedure to perform. 

■ It is certainly cheaper than female 
sterilization as it does not require such 
sophisticated operative equipment 

■ It usually involves less disruption to 
family life than female sterilization. 

■ No inpatient stay is needed. 

The man can return to work after 1-3 
days depending on whether he is an 
office or manual worker. 

Seminal analysis should be performed 
at 12 and 1G weeks. Two negative semen 
analyses are required to confirm that the 
procedure has been effective. 
Complications are rare, but scrotal 
haematomas, wound infection or 



epididymitis may occur. Sexual activity 
may be resumed as soon as there is no 
further discomfort. 

Female sterilization 

This is a more invasive technique and 
carries the risks of any laparoscopic 
procedure. Originally the tubes were 
diathermied but this increased the risk 
of postoperative pelvic pain and 
sometimes caused ovarian dysfunction. 
Currently, the application of tubal clips 
is the most common technique (Fig. 1). 

The current failure rate stands at 1.5 
per 1000. There may be certain 
situations where a mini laparotomy will 
be required, e.g. if there are multiple 
adhesions that block access to the tubes 
or if the tubes are too thick for the 
application of the clips with guaranteed 
occlusion. 

Women can be advised that they 
may return to work within 5-7 days, 
that tubal ligation is effective at once 
and that there is no need to continue 
contraception following the procedure 
if it is performed immediately 
postmenstrually. Sterilization does not 
affect menstruation, but does increase 
the incidence of tubal pregnancy. 



Non-hormonal methods of contraception 






■ There are many approaches to the natural method of famify planning. It has a high failure rate and 
requires considerable commitment 

■ The sheath is easy to obtain but is often not used correctly by young people. It does have the 
advantage of reducing sexually transmitted disease. 

■ The double Dutch' technique utilizes the contraceptive pill for safe contraception and the sheath 
to prevent STDs 

■ The diaphragm is easy to use and does not need to be inserted immediately prior to intercourse. 
It is not particularly effective in preventing STDs. 

■ The cap is occlusive and is therefore a good barrier method to infection; it can be left in place for 
several days 

■ Spermicidal agents and the contraceptive sponge have higher failure rates and should not be 
used alone except in penmenopausal women with reduced fertility. 

■ There are several different types of copper-bearing IUD. They carry a slight nsk of infection. The 
coil should be fitted by a trained certifi ed practitioner and there should always be equipment on 
hand for the emergency situation. 

■ Sterilization should be considered as final. Female sterilization carries the risks of any 
laparoscopy. Male sterilization is under-utilized, and is cheap and safe. 



112 GYNAECOLOGY 

Amenorrhoea 



Amenorrhoea can be considered under 
two categories - physiological 
[including prepuberty, pregnancy- 
related and postmenopausal) and 
pathological (primary and secondary). 
Disorders which can lead to 
amenorrhoea are shown in Table 1. 

Physiological 

Puberty occurs between the age of 10 
and 1G years, so amenorrhoea before 
this is normal and only requires 
investigation if at age 1G no menstrual 
loss has been noted. Puberty is 
associated with a somatic growth spurt, 
breast budding and pubic hair growth. 
Menarche (the first period) is within 
2 years of breast development Any 
obvious causes for not reaching puberty 
have often been sorted out in childhood 
so with otherwise normal development 
it may be expected that menses will 
arrive. Menarche often follows a familial 
pattern - if the girl's mother had a late 
menarche it may be anticipated that 
this will occur in the patient 

Pregnancy should always be 
excluded before any investigation for 
amenorrhoea commences. The 
postpartum period will be associated 
with absence of menstrual loss for a 
variable phase, particularly in 
association with breast feeding. 

The menopause is the last 
menstrual period and can only be 
recognized in retrospect, being 
diagnosed after amenorrhoea for a 
year. This signifies the end of the 
reproductive phase of a woman's life 
and bleeding after this is abnormal, 
unless she is taking cyclical hormone 
replacement therapy. 

Pathological 

Primary amenorrhoea is defined as the 
failure of any menstrual loss by the 



age of 16 years. This requires systematic 
investigation if the correct diagnosis is to 
be reached and to ensure appropriate 
management If secondary sexual 
characteristics fail to develop it is 
appropriate to investigate earlier (age 14). 
Secondary amenorrhoea is arbitrarily 
denned as a 6-month absence of menses 
without any physiological reason. 

Investigation of amenorrhoea 

Normal secondary sexual development 
should not preclude chromosomal 
analysis as Turner's mosaic and 
testicular feminization are associated 
with normal secondary sexual 
characteristics. Measurement of follicle 
stimulating hormone (FSH), 
luteinizing hormone (LH), thyroid 
stimulating hormone (TSH), prolactin, 
estradiol and testosterone will clarify 
most other problems. A progestogen 
challenge test determines whether the 
endometrium has been exposed to 
oestrogen and is a more physiological 
method than measuring estradiol 
levels. Raised prolactin levels indicate 
the possibility of a pituitary adenoma, 
which should be further investigated 
with appropriate imaging. 

Investigations and their 
interpretation 

Blood tests 

LH - low level implies no stimulation 
from the hypothalamus; higher than 
usual levels may be found in polycystic 
ovarian syndrome (PCOS), or very 
high levels suggest ovarian failure. 

FSH - low if no stimulation from 
the hypothalamus; high levels found 
with ovarian failure. 

TSH - raised with hypothyroidism, 
an easily treatable cause of 
amenorrhoea. 



lab* ' Disorders leading to amenorrhoea 


Site of disorder 


Diagnosis 


Investigations 


■ .■ thalamus 


HypoWiaLamic hypogonadism (rate) 
Weight-related amenorrh oca 
[common) 


FSH. LH and estradiol - all low 
FSH. lh and estradiol - low 


Piluitary 


Pituitary adenoma [common) 
Sheehan's syndrome [rate) 


Prolactin • raised. FSH. LH and estradiol - low 
LH. FSH and estradiol low 
ISH - raised. T4 - low ot normal 


Endocrine - thyroid 


Hypothyroidism (tare) 


Ovsty 


Gonadal dysgenesis [rare] 

Polycystic ovarian syndrome [common] 

Premature ovarian failure (rare) 


FSH. LH - high, estradiol - low 

LH - high. FSH - normal, androgens - high notmal 

FSH, LH • high, estradiol ■ low 


Mill let ran Ira st 

Genua Ur act 


Absence of uterus [rare) 
Imperforate hymen [common] 
Asherman's syndrome or 
endometrial fibrosis [rare) 


Ulttasound and progesterone challenge 
Ultrasound and exam mat ion 
HSGandAAFBleslmg 



Prolactin - raised implies a pituitary 
adenoma; arrange a CT scan. 

Testosterone - levels at upper end of 
female range found in PCOS, levels in 
male range suggest ectopic production. 

Estradiol - low levels need to be 
interpreted with LH/FSH values as 
they can be due to no stimulation 
from the hypothalamus or pituitary, or 
may suggest ovarian failure. 

Progestogen challenge test 

Administer a progestogen for 5 days 
and within 3 days of stopping there 
will be a withdrawal bleed. This 
implies that the endometrium has 
been primed with oestrogen, that the 
uterus is present and that there is no 
outflow tract obstruction. 

Ultrasound 

Ultrasound scanning shows the pelvic 
organs. Absent uterus may be due to 
Mullerian failure or testicular 
feminization (see p. 88). A fluid-filled 
uterus and vagina implies 
cryptomenorrhoea (see p. 89). Ovaries 
showing a dense stroma and more 
than 10 follicles per field are classical 
ofPCOS(seep. 114). 

CT scan of pituitary 

Prolactinomas are classified as 
microadenomas (< 1 cm in diameter) 
or macroadenomas (Fig. 1). 

Management of amenorrhoea 

Abnormalities causing amenorrhoea 
are usually divided into anatomical 
areas to facilitate both the investigation 
of the problem and management, 
which follows logically from the 
diagnosis. 

Asherman's syndrome is caused by 
scarring of the endometrial cavity and 
synechiae are seen at hysteroscopy. It 
may follow over-vigorous surgical 
curettage or endometrial infection 
including tuberculosis. After breaking 
down these adhesions, a coil may be 
inserted to allow endometrial 
regrowth. 

'Imperforate hymen' represents one 
form of failure of complete 
canalization of the vagina (see p. 88). 

Gonadal dysgenesis occurs with 
streak gonads and is characterized by 
an infantile female phenotype from 
low levels of oestrogen. A karyotype is 
required to exclude any Y 
chromosome material necessitating 



Amenorrhoea 




Fig. 1 CT scan of enlarged pituitary fossa with double-flooring 
effect. 



gonadectomy. Development of secondary sexual 
characteristics requires slow introduction of oestrogens. The 
patient will require long-term hormone replacement therapy 
and will not become pregnant without oocyte donation. 

Testicular feminization presents with amenorrhoea in a 
phenotypically female patient who has absent uterus and 
gonads that are testes (see p. 88). 

Turner's syndrome (Fig. 2) will usually have been detected 
sooner but mosaic forms may present at puberty. Short 
stature, webbed neck, increased carrying angle at the elbow 
and sexual infantilism is found in XO females, but with 
Turner's mosaic any combination of normal and abnormal 
may result. The streak ovaries found in this syndrome are 
responsible for the low oestrogen levels and lack of sexual 
development A karyotype will confirm the diagnosis and 
management will be dependent on factors such as coexisting 
cardiac lesions. 




In PCOS [polycystic ovarian syndrome) fertility can usually 
be induced with clomifene. Treatment with combined oral 
contraceptive therapy will result in regular artificial bleeds 
(see p. 114). 

Pituitary adenomas produce high levels of prolactin and 
may present with amenorrhoea and galactorrhoea. However, 
in only a third of patients with raised prolactin will there be 
galactorrhoea and a third of patients with galactorrhoea will 
have normal menses. The high prolactin level inhibits 
pulsatile release of gonadotrophin releasing hormone 
(GnRH) from the hypothalamus but therapy with a 
dopamine agonist (e.g. bromocriptine, cabergoline) will 
lower the levels of prolactin in microadenomas enabling 
ovulation to occur. These block the prolactin receptors and 
negative feedback reduces prolactin secretion. 

Trans-sphenoidal neurosurgery achieves complete 
resolution of hyperprolactinaemia with resumption of cyclic 
menses in about 40% of patients with macroadenomas and 
80% of patients with microadenomas, but may be associated 
with cerebrospinal fluid leaks, meningitis or diabetes 
insipidus which is usually transient. The choice between 
surgical and medical treatment is not clear-cut but can be 
simplified - dopamine agonist therapy is used to shrink 
macroadenomas then reduced to a low maintenance dose 
which will need to be continued long term. This therapy 
may be used to shrink the tumour prior to surgery. Some 
patients will prefer surgery to avoid long-term therapy but 
long-term dopamine agonists will cause fibrosis, making 
surgical removal difficult. 

Agonist therapy is the treatment of choice in 
microadenomas but treatment is directed to management of 
infertility or treating breast discomfort. If the patient with a 
microadenoma only requires treatment for amenorrhoea and 
has no wish for fertility, then oestrogen therapy may be 
preferable. 

Sheehan's syndrome is panhypopituitarism and is usually 
associated with a massive postpartum haemorrhage with 
concomitant hypotension and inadequate fluid replacement 
It is rare. The pituitary blood supply is via end arteries and a 
dramatic fall in blood pressure may result in necrosis of the 
gland. After determining which hormonal deficiencies exist 
replacement therapy will be necessary. 

Hypothalamic amenorrhoea accounts for most cases of 
hypogonadotrophic amenorrhoea and is diagnosed by 
exclusion of pituitary lesions. Stress, low weight or strenuous 
exercise are the usual causes and patients will have low 
gonadotrophins, normal prolactin and will fail to respond to 
a progestogen challenge. Treatment depends on the patient's 
requirements - if pregnancy is desired then ovulation 
induction is appropriate but hormone replacement therapy 
is the better management of amenorrhoea due to low 
oestrogen. Stress management may need to be addressed. 



Amenorrhoea 



Fig. 2 Turner's syndrome. 



Exclude pregnancy before any investigation of amenorrhoea. 

i Oniy use investigations that will confirm or refute a suspected 
diagnosis: it is inappropriate to do all tests on all patients. 

Follow a logical plan of investigation and the diagnosis will become 
clear. 



114 GYNAECOLOGY 

Polycystic ovarian syndrome 



Polycystic ovarian syndrome (PCOSJ is 
so prevalent as to be a variation of 
normal - the polycystic appearance 
has been reported in 20-25% of 
ultrasound scans in a random 
population (Fig. 1). The classically 
enlarged ovaries are due to numerous 
unruptured follicles which surround a 
stroma that appears dense and gives a 
pearl necklace scan picture. The 
syndrome was first described by Stein 
and Leventhal in 1935 with obesity, 
hirsutism, oligomenorrhoea and 
infertility associated with enlarged 
ovaries seen at laparotomy. Now we 
recognize both polycystic ovaries seen 
on ultrasound scan and the above 
features with biochemical 
abnormalities - raised luteinizing 
hormone [LH) levels and low normal 
follicle stimulating hormone (FSH), 
giving a reversal of the LH : FSH ratio, 
and raised androgen levels - within 
the normal female range but 
associated with a higher free androgen 
index due to lower sex hormone 
binding globulin (SHBG) (Fig. 2). 

Both insulin resistance and 
hyperinsulinaemia are found in 
anovulatory patients with PCOS, being 
more evident in the obese patient. 
Hyperandrogenaemia is associated 
with the obesity and hence with higher 
levels of serum insulin. The 
hyperandrogenaemia and insulin 
resistance are associated with a 
characteristic atherogenic lipid picture. 
Long term there is an increased risk of 
cardiovascular disease, non-insulin- 
dependent diabetes mellitus (NIDDM), 
endometrial hyperplasia and 
endometrial and breast carcinoma, 
though there is no proven link with 
ovarian tumours. 



LH 




FSH 



Androgen production 
from cholesterol in 
the theca cell 




Aromati2ation to 
oestrogens in the' 
granulosa cell 



Fig. 1 Polycystic ovary showing dense 
stroma and multiple follicles/cysts. 



Fig. 2 Ovarian follicular steroidogenesis. 



The range of presentations is wide, 
varying from the classical scan picture 
noted in an asymptomatic patient to 
the patient with all the symptoms 
noted below. 

Symptoms 

■ Acne - found in patients whose 
sebaceous glands respond to the 
higher free-circulating testosterone 

■ Hirsutism - in these patients the 
response to the higher free 
testosterone is production of 
terminal hair in a male pattern 

■ Obesity - the reason for this is 
unclear but it is responsible for the 
suppression of SHBG production by 
the liver, giving higher free levels of 
testosterone 

■ Oligomenorrhoea - ovarian 
dysfunction with irregular ovulation 
leads to menstrual upset; there is 
also excessive production of 
androgens from the ovarian stroma 

■ Infertility - due to irregular 
ovulation. 

Hirsutism 

The extra hair growth that affects some 
women (Fig. 3) is due to the influence of 
testosterone on hair follicles in the areas 
pictured. Lanugo hair is converted to 
terminal hair in a one-way process. Fine, 
light, short hair is replaced by thicker, 
darker, longer hair. Once hirsutism has 
developed it is thus only possible to 
ensure no further conversion of lanugo 
to terminal hair and use oestrogens to 
make the hair finer, paler and less 
firmly attached. The genetic influence 
on hair growth is worth discussing, e.g. 
the Japanese have less androgen- 
sensitive hair follicles and thus seldom 
respond to raised androgen levels by 



Blood vessel 



~^v^ 





Fig. 3 Hirsutism. In this case affecting jawline, 
upper lip and sideburns. Other areas that may be 
affected include anterior abdominal wall, inner 
aspect of upper thighs, circumareolar and upper 
back. 



developing hirsutism. Africans, Asians 
and Caucasians may become hirsute. In 
some, the androgen sensitivity affects 
the sebaceous glands and excess oil 
production may result in acne with a 
similar distribution to that illustrated for 
hair growth. 

The active form of testosterone is that 
which circulates unbound to plasma 
proteins. Usually l°/o is in this form but 
this is raised in patients with polycystic 
ovarian syndrome. Oestrogen therapy 
will raise the level of SHBG and mop up 
excess testosterone. Weight loss removes 
the inhibition of SHBG production by 
the liver. 

Seventy per cent of anovulatory 
females will develop hirsutism. 

Investigations 

These will be directed towards the 
possible cause of the problem but 
need only be few and mainly need to 
exclude any tumour: 

■ check LH, FSH and the LH : FSH ratio 

■ a progestogen challenge test - see 
page 112 



Polycystic ovarian syndrome 115 



■ prolactin - raised levels suggest pituitary adenoma as a 
cause of amenorrhoea 

■ thyroid levels - altered values may be associated with 
menstrual upset 

■ testosterone - levels in the male range may be found with 
androgen-secreting tumours 

■ ultrasound scan may show characteristic appearances with 
a dense ovarian stroma, more than 10 follicles in a cross- 
sectional view, increased ovarian volume and thickening of 
the ovarian capsule. 

Treatment 

As PC OS is found in a large proportion of the female 
population, treatment is only required for the patient's 
symptoms. 

Amenorrhoea 

Either induce ovulation which will result in regular 
menstruation (see below), or protect the endometrium 
against the effects of unopposed oestrogen stimulation by: 

■ using the oral contraceptive pill which will result in 
regular menses 

■ giving progestogens three or four times per year to induce 
endometrial shedding. 

Infertility 

These patients pose problems as they are more likely to 
respond to clomifene therapy with multiple ovulation [in 
10%) and are at greater risk of ovarian hyperstimulation 
syndrome. The importance of monitoring these patients 
while using ovulation-inducing agents cannot be over- 
stressed (see p. 133). There is an 80% chance of ovulation 
using clomifene. In patients resistant to ovulation-induction 
therapies, the high androgen level within the ovary is 
thought to be detrimental and may be lowered with a 
resulting normalization of hormone levels, even if 
temporarily, by laser drilling of the ovary. Formerly wedge 
resection of the ovary was used, which would result in 
removal of some ovarian stroma and a consequent lowering 
of androgen levels. This would also result in periovarian 
adhesion formation and so is no longer used. 

Metformin has been shown to improve reproductive 
performance and reduce insulin resistance independent of 
weight loss. 

Hirsutism 

The aim is to reduce androgen levels by either turning off 
ovarian production of androgen or mopping up the free 
androgen by raising the SHBG level using oestrogen and 
weight loss (Fig. 4). The oral contraceptive pill can usefully 
achieve a decreased production of testosterone and raise the 
SHBG level. Setting out what can be achieved is important 
so that the patient does not become disheartened. 

There are many cosmetic approaches to dealing with the 
existing hair - plucking, shaving, waxing, electrolysis, laser 
treatment and using hair removal creams. These will be 
necessary in conjunction with therapy to prevent further 
new hair growth such as the antiandrogen cyproterone 
acetate (CPA) - usually given in combination with oestrogen 
(as an oral contraceptive pill) to ensure menstrual cycle 
control. Better results may be achieved initially by giving a 
larger dose of CPA daily with ethinylestradiol used for the first 
10 days of each month. Once new hair growth has been 



CAUSES OF RAISED CAUSE OF SUPPRESSION 


LEVELS OF SHB 
Oestrogen > 


G OF PRODUCTION OF SHBG 


Sex hormone J 


therapy. / 
e.g. oral 
contraceptive 1 


binding globulin , 
produced ^^y 


pil! 

Weight 

reduction 
♦ 


/-"^T Obesity — *■ f free 
— ' testosterone 

levels 

1 




Hirsutism 




and acne 




Treatments for this include 




raising SHBG levels 




1 



Fig. 4 Reducing levels of androgen will reduce hirsutism. 




Benefits of exercise: 
t BMR (basal metabolic rate) 

I Weight (results in tsex hormone binding 
globulin — *• | testosterone — *► \ hair growth 
and J acne) 



Fig. 5 The benefits of weight loss in PCOS. 



controlled then it may be appropriate to consider permanent 
removal of established hair by electrolysis. 

Obesity 

Weight reduction has many benefits for the patient but 
usually proves very difficult. Once considerably overweight, 
patients become less active and their basal metabolic rate 
(BMR) is reduced, thus they require less calories to maintain 
their body weight. The resulting frustration for them can 
mean they become very disheartened with attempts to lose 
weight - a full explanation before commencing a weight loss 
programme may avert this problem (Fig. 5). 



Polycystic ovarian syndrome 



i PCOS affects such a large proportion of the female population as to 
be a variation of normal. 

1 There are five main presenting symptoms, though many females may 
have no symptoms and will be found to have the polycystic 
appearance on ultrasound scan of their ovaries. 

1 Treatment is symptomatic as polycystic ovaries are not the primary 
disorder but a manifestation of a systemic metabolic condition. 



116 



GYNAECOLOGY 

Day care surgery 



Day surgery has been defined by the UK National Health 
Service Executive as 'an operational procedure performed on a 
particular patient who is admitted on a non-residential basis'. 
In gynaecology 60-70% of cases are now dealt with as 
outpatient or day care procedures. 

Outpatient procedures include colposcopy and cervical 
treatment modalities (see p. 135), hysteroscopy and 
endometrial sampling techniques (see p. 125), 
videocystography (see p. 154), flexible cystoscopy and, in 
some centres, suction termination of pregnancy (see p. 95) 
Periurethral injections of bulking agents can also be 
performed under local anaesthetic in suitable cases. 

Day care procedures requiring a light general or spinal 
anaesthetic routinely include suction termination of 
pregnancy, laparoscopic sterilization, cystoscopy, diagnostic 
laparoscopy, laparoscopy with dye insufflation, ovarian 
drilling, endometrial ablation, transvaginal tape (TVT) and 
periurethral injections (PUIs) (see p. 155). Cases unsuitable 
for outpatient procedures (e.g. certain cervical cone biopsies 
and hysteroscopies with dilatation and curettage) are 
performed as day cases with a light general anaesthetic 

The setting 

The ideal day surgery unit (Fig. 1) should be completely self- 
contained with its own operating theatre, ward and staff, a 
consultant director and an experienced nurse manager. 
Purpose-built units are often built onto the back of existing 
hospitals to facilitate intercommunication with the main 
theatre suite and intensive care facilities should 
complications occur. In other situations they are built as 
freestanding units, containing several operating theatres, 
consulting rooms and a medical day unit. 

Ambulatory care and diagnostic (ACAD) centre (Figs 2 
and 3) developments are substantially larger and include 
radiology suites, endoscopy units, lecture theatres and 
outpatient consulting rooms allowing for diagnostic imaging 
and interventional radiology (e.g. arterial embolectomies) on 
site. All units should be light, bright and welcoming with 
good access for the staff and patients. Some hospitals still 
nurse day surgery patients on general gynaecology wards, 
converting a 4-G-bedded bay for this purpose. The patients 
are then cycled through the main theatre suite. Children are 
usually admitted via the paediatric wards. 

Changing surgical practice 

Reasons for the increase in gynaecological day surgery are: 

■ advances in anaesthesia and pain control, particularly the 
introduction of propofol, which permits sedation and 
anaesthesia to be tailored to the patient and the procedure 

■ advances in surgical techniques, especially in endoscopic 
and laser surgery 

■ fiscal considerations - day surgery is cost effective if 
inpatient throughput and bed occupancy are reduced 

■ patient considerations (Table 1). 

Most units run audit programmes where patient satisfaction, 
efficiency and safety are constantfy evaluated. 

Preoperative evaluation 

For day surgery to be successful and safe there must be 
adequate preoperative assessment and strict patient selection 



criteria (Table 2). Problems may potentially arise if there is a 
long time interval between the outpatient clinic visit and the 
admission date for surgery, as the presenting complaint may 
have altered or the general medical condition deteriorated. 
Most units, therefore, have introduced preoperative 
assessment sessions where clerking is performed by either 




Fig. 1 The day care unit. 




Fig. 2 Ambulatory care and diagnostic centre. 




Fig. 3 Entrance foyer, ambulatory care and diagnostic centre 



Day care surgery 117 



Table 1 Advantages of day care surgery 

■ Minimal disruption lo patient's personal Me 

■ Earlier return to work rjr school 

■ Patients prefer day suigery 

■ Psychological benefits, especially lor children 

■ Sh o ner wailing I isis for admission 

■ Reduced incidence of hospital-acquired infection 

■ Reduced incidence of respiratory complications 

■ Red uced frequency of medical errors 

■ Large numbers of palients may be treated 

■ Cost effective 



junior medical staff or trained day care 
nurse practitioners. Many units have 
designed specific history proformas to 
aid clerking and have devised 
protocols for the assessment and pre- 
clerking process (Fig. 4]. 

Investigations are kept to a 
minimum and are performed at the 
outpatient appointment with results 
available on the day of surgery. All 
patients for therapeutic termination of 
pregnancy will have their Rhesus 
status and blood group checked. 
Patients of West Indian, African and 
Mediterranean origin will have their 
sickle cell status tested. In some 
centres the preoperative anaesthetic 
assessment is performed in specific 
outpatient assessment clinics. More 
usually patients are seen in the day 
unit on the day of surgery. 

The role of the nurse practitioner 

The day surgery unit (DSU) nurse 
represents a new development in the 
emerging role of the nurse 
practitioner. Some units will use the 
assessment nurse solely for 
information-giving and counselling 
and have designed excellent patient 
information leaflets. In other centres 
the assessment nurse has an 
independent and well-defined role. 
Patients will be referred directly from 
the outpatient clinic and the 
preoperative clerking will be 
undertaken by the DSU nurse, who 
will refer to medical staff only if the 
selection criteria are not met or there 
are medical concerns. These nurses 
will perform phlebotomy and 
undertake electrocardiograms if 
required. In America, anaesthetic nurse 
practitioners are now trained and 
certified to deliver straightforward 
general anaesthetics. This concept is 
being evaluated in the UK. 

Postoperative surgical findings are 
usually discussed with the patient by 
the medical team but the DSU 
practitioners will reinforce information 
and will certainly be involved with 
counselling regarding contraceptive 



Table 2 Preoperative selection guidelines for day care surgical admissions 

Surgical 

■ Operations lasting less then 1 hour 

■ Minor and intermediate procedures 

■ Exclude procedures where severe postoperative pain is likely 

■ Exclude procedures where significant postoperative bleeding rs likely 

■ Exclude procedures where significant disability is likely, e.g. bilateral aicose veins, bilateral demise, bilateral Keller's 
Social 

■ Must live within 1 5 miles or 1 hour's drive of Ihe hospital 

■ Must not go home by public transport 

a Must have responsible fit adult escort home. 

■ Must be supervised by responsible fit adult for at least 2* hours 
Medical 

■ Patient's age > 6 months and < 70 years 

■ Obesity BMI > 30 not accepted lo day unii 

■ ASA class 1 and ? only 

- ASA 1 : a normal heallhy mdiv.dual 

- ASA 2- a patient with mild systemic disease winch does not interfere with normal lite including mild medical 
condrlions which are well controlled on treatment, eg mild hypertension, asthma, osteoarthritis or epilepsy, and 
also non-insulm-dependenl diabetes. 

Antiepileptics and antihypertensives should be taken on the day of surgery 
Oral hypogfycaemic agents should not be taken on the day of surgery 



The American Society of Anesthesiologists (ASA) classification ranks patients in classes 1 to 5. Class 1 is essentially a fit 
normal individual with only localized pathology requiring treatment. Class 5 is moribund with poor chance of survival. 



Does the patient require an 


NU ,, Inpatient procedure 


operation suitable for day surgery? 






YES 
1 


1 





Does the patient fulfil the 
required selection criteria? 



YES 

Day Surgery Unit 




Fig. 4 Day care patient selection and preparation process. 



issues, hormone replacement therapy 
or other outpatient prescriptions. They 
will organize the outpatient follow-up 
visit, the documentation of the day 
care episode and the general 
practitioner (GP) discharge summary. 
Courses have now been developed 
between the British Association of Day 
Surgery (BADS) and the English 
National Board of Nursing (ENB) to 
enable training and certification of 
specialist nurses in this area. 



As, in the UK, the model for health- 
care provision increasingly emphasizes 
primary care and community settings 
for services, the day care unit could 
become an attractive interface between 
the primary and acute sectors with the 
possibility of the GP coming in to 
perform minor operations on his/her 
own patient 



Day care surgery 



i 60-70% of gynaecological surgery is now performed as outpatient or day care procedures. 
; Day care Surgery is financially effective and has reduced the waiting time for surgery, 
i Units are run with strict guidelines and protocols, 
i Preoperative assessment is often performed by specialist day unit nurse practitioners. 



lis GYNAECOLOGY 

Uterine fibroids 



Correctly known as leiomyomas, 
fibroids are benign tumours of uterine 
smooth muscle interlaced with 
connective tissue which develop within 
the wall of the uterus causing 
distortion, and disturbance of 
menstrual and reproductive function. 
Approximately 20% of women of 
reproductive age have fibroids, 
commonly presenting later in 
reproductive years with menstrual 
problems. Presentation may be earlier 
following infertility investigations. In 
Afro-Caribbeans up to 50% of women 
may have fibroids. 

Aetiology 

The actual cause of fibroids is unknown 
although it is appreciated that raised 
oestrogen levels are associated with 
increased growth of fibroids. This might 
explain the association between obesity 
and the presence of fibroids, as there is 
peripheral conversion of androgens to 
oestrogens in adipose tissue. Hormone 
replacement therapy (HRT) can be 
given to women with fibroids without 
adverse effect as the hormone levels 
achieved from standard HRT are much 
lower than in pregnancy when fibroids 
do grow. 



Intramural/ 
fibroid - 




Submucous \ 
fibroid — 



Subserous 
fibroid 



Uterus 



Cervical 
fibroid 



Fig. 1 Types of fibroids. 



Pathology 

Fibroids may be found singly within 
the uterus, but are more commonly 
multiple and may vary in size from 
seedling fibroids to enormous tumours 
filling the whole pelvic cavity and 
extending into the abdominal cavity. 
They often start intramurally (Pig. 1) 
but as they grow become more 
predominantly submucosal or 
subserosal (Table 1). The cut surface 
has a characteristic whorled 
appearance where the interlacing of 
the muscle and fibrous tissue can be 
clearly seen (Fig. 2). After the 
menopause fibroids are noted to 
shrink and regress, presumably due to 
the withdrawal of oestrogen support 
Fibroids can go through a variety of 
degenerative processes (Table 2). 

Presentation 

Menorrhagia 

Menorrhagia is the common 
presenting symptom of fibroids and is 
thought to arise due to the increased 
surface area of the endometrium 
which bleeds at the time of 
menstruation. It may also be due to 
pressure from the fibroid on venous 
drainage increasing blood flow. A 
disturbance of the balance of E and F 
prostaglandins noted within the 
menstrual effluent raises the question 
of whether a disturbance in the 
metabolism of prostaglandins is a 
contributory factor or possibly even an 
aetiological factor. Another theory is 
that ulceration of endometrium 
overlying a submucous fibroid may 
cause haemorrhage. Large fibroids can 
present with pressure symptoms on 
adjacent organs (Table 3). 

Subfertility 

This is a well recognized association, 
although whether the presence of the 



Tabic i Fibroids are predominantly submucosal or subserosal 

Site 

Submucosal 



Subserosal 



Findings 

These lie under the endometrial tiring of the ulerus and may cause distortion of the uterine cavity 

leading to monorrhagia, subfertility and late miscarriage 

If polypoid [hey may grow from [he endometrial lining and appear to develop a stalk. They may 

then be extruded by the uterus [hrough the cervix causing cramping uterine pain and often heavy 

bleeding 

Predominantly under the outer peritoneal coat of the uterus arid may cause distortion ottne pelvic 

anatomy. They grow between the leaves of the bread ligament, down towards the cervix and can 

make surgery complicated 

Fibroids under the serosal surface of the uterus may grow out on a stalk-like projection - parasitic 

fibroid, which takes blood supply from elsewhere (commonly the omentum] and becomes 

detached from the uterus 




Fig. 2 Cut surface of a fibroid showing 
fibrous tissue and whorled appearance. 



fibroids decreases successful 
implantation resulting in subfertility, 
or whether it is the lack of pregnancy 
that predisposes to fibroid growth in 
later reproductive years is uncertain. In 
patients with recurrent abortion, 
fibroids may be responsible due to the 
mechanical distortion of the 
endometrial cavity disturbing 
implantation. Pedunculated fibroids 
within the uterus may block the 
cornual region, decreasing fertility. 

Investigations 

Pelvic examination usually reveals an 
irregularly enlarged uterus of firm 
consistency and the presence of fibroids 
may be confirmed by ultrasound (Fig. 3). 
Ultrasound will clearly show intramural 
and submucous fibroids but 
distinguishing subserous fibroids from 
the ovary may not be easy. 

Submucous and intramural fibroids 
will show as a filling defect on a 
hysterosalpingogram. A 
hysterosalpingogram should be 
considered for those with infertility to 
assess tubal function and cavity structure. 
The presence of fibroids does not 
necessarily imply a causal relationship to 
subfertility - they may be coincidental. 

Management 

Medical 

Medical management is appropriate 
for patients with menorrhagia and 
small fibroids or for those with 
subfertility where fibroid size requires 
some shrinkage. Anti-prostaglandins 



Uterine fibroids lis 



Table 2 Fibroid degeneration 



Hyaline degeneration 

Cystic degeneration 
Calcification 



lors.on 



Red degeneration 



Sarcomatous change 



Th is occu rs due to a p rocess of atrophy with loss of the m uscu la r co m pon e nt a ri d hyali ne 

degeneration within the fibrous tissue element 

The centre of the fibroid becomes ischaemic and degenerates, becoming cystic 

Degeneranon may proceed to calcification at a later stage, and therefore lends to be found in 

older patients, in an extreme form it may be found as 'womb stones', the uterus containing a 

collection of stony masses 

Pedunculated fibroids may undergo torsion with pain and haemorrhage into themselves 

Rarely this subsequently becomes infected but more commonly would go on to cystic 

degeneration and possibly calcification 

this is the classic degeneration of a fibroid during pregnancy associated with rapid uterine 

growth. The cut surface would appear red but the libra id should not be surgically removed 

during pregnancy due to a very high risk ol haemorrhage Can be extremely painful requiring 

analgesia and bed rest 

Very rare [< 0. 1 Wz) hut should bo considered =f the fibroid is growing rap id ly [see p 139) 




Fig. 3 Appearance of fibroid uterus on an ultrasound scan. 



Table 3 Effects of large fibroids on 
adjacent organs 

Organ Symptoms 

Bladder Frequency, u rgency and nocturia 

Rectum Diarrhoea or constipation 

Uterus Cramping abdominal pain due to 

attempts at extrusion of fibroid 

polyp 
Acute a bdo m ma I lorsion or degeneration of fibroid 
pain 



incision. Any incision should be placed 
on the anterior surface of the uterus if 
possible to avoid adhesions involving 
the fallopian tubes. It is usual to avoid 
entering the uterine cavity at operation 
to avoid intrauterine adhesions which 
may compromise future fertility or 
necessitate caesarean section in a 
future pregnancy due to the presence 
of a full thickness scar. 

Endoscopic removal of fibroids is a 
possibility but is more commonly used 
in the treatment of menorrhagia than 
of subfertility because of the resultant 
scarring within the uterine cavity. 
Submucous fibroids may be resected 
hysteroscopically (Fig. 4) and 
subserous fibroids approached 
laparoscopically with removal by 
morcellation. 

Embolization of the blood supply to 
the fibroid will result in shrinkage but 
this can be associated with 
considerable pain. 



might be the first approach in 
menorrhagia and are associated with 
an 80% reduction in blood loss. 
Gonadotrophin releasing hormone 
(GnRH) analogues will cause 
shrinkage of fibroids, which may be 
appropriate short term either in the 
management of subfertility or prior to 
surgical removal of large fibroids - 
limiting blood loss at the time of 
operation and decreasing morbidity. 
Long-term use is limited by the loss of 
bone mineral and fibroids will return 
to the previous size after cessation of 
treatment. 

Surgical 

Hysterectomy is the definitive surgical 
approach for fibroids. A myomectomy 



is associated with greater morbidity 
than hysterectomy - so unless fertility 
needs to be conserved it is not the 
operation of choice. The patient should 
be consented for hysterectomy as well 
as myomectomy as the procedure may 
prove to be associated with excessive 
blood loss. Prior shrinkage with GnRH 
analogues may improve surgical access 
and lessen bleeding. Multiple incisions 
on the uterus may be necessary but to 
limit adhesion formation 
postoperatively, as many fibroids as 
possible are removed through a single 



Uterine fibroids 




Fig. 4 A hysteroscopic view shows a 
fibroid polyp within the uterine cavity. 






■ Leiomyomas are found in 20% of women of reproductive age 

■ Menorrhagia is the main presentation though pressure effects may also be a problem, 

■ Medical management for menorrhagia may tide a woman over to menopause when natural 

shrinkage occurs. 

■ Surgery involves either myomectomy or hysterectomy. 



120 GYNAECOLOGY 

Physiology of menstruation 



The physiology of menstruation is 
closely linked to factors controlling 
ovulation. If ovulation is regular, so is 
the menstrual cycle. 

The ovulation process 

Follicles of all stages of development 
are found within ovarian stroma. 
Folliculogenesis takes place in several 
steps - recruitment and intermediate 
follicular development. Most follicles 
are primordial and only a few are 
recruited into the 'growing' pool, the 
group designated to develop. This 
cohort of growing follicles undergoes a 
process of development and 
differentiation spanning 85 days, i.e. 
three ovarian cycles. The recruitment 
process is probably independent of 
pituitary control and may depend on 
paracrine factors. Growing follicles 
induce changes in surrounding cells, 
which differentiate into granulosa and 
theca cells. Only a fraction of these 
follicles reach a stage of maturation 
where ovulation is possible, the rest 
become atretic 

Follicle stimulating hormone (FSH) 
pushes responsive follicles into the 
final stages of the growth phase. 
Luteinizing hormone (LH) binds to the 
theca cells, stimulating androgen 
production. FSH binds to granulosa 
cells activating the aromatase enzyme 
system, enabling the conversion of 
androgens to oestrogen (Fig. 1). One 
dominant follicle responds to the high 
oestrogen milieu and ripens. 

The rising oestrogen level produces 
a negative feedback on the anterior 
pituitary to inhibit FSH secretion. FSH 
levels fall, preventing further follicles 
ripening, but the dominant follicle 
continues to grow. Once it reaches 
maturity, oestrogen levels are sufficient 
to induce a positive feedback, and a 
massive discharge of LH occurs. The 
LH surge, acting through 
prostaglandins, produces follicular 
rupture. LH then binds to granulosa 
cell receptors to stimulate 
progesterone secretion. The main 
product of the corpus luteum is 
progesterone. The lifespan of the 
corpus luteum is 12 to 14 days. As it 
degenerates, progesterone levels fall 
and menstruation occurs. 

The secretion of FSH and LH is 
controlled by luteinizing hormone 
releasing hormone (LHRH), released 
by the hypothalamus (Fig. 2). The 



Theca interna 
cells 




Ovarian vein 



Fig. 1 Action of gonadotropins on the 
theca and granulosa cells of the ovary and 
the ripening follicle. 



! Supra-hypothalamicJ + | Central CNS 




Fig. 2 Feedback control mechanism in the 
hypothalamic-pituitary-ovarianaxis. 



control of LHRH secretion is highly 
complex, depending on a number of 
inhibitory (dopamine) and excitatory 
(noradrenaline, prostaglandin) 
neurotransmitters, modulated by 
ovarian hormones. Ovarian steroids 
modulate the pattern of gonadotrophin 



pulse secretion. The positive feedback 
of oestrogen and progesterone on 
gonadotrophin secretion may involve 
alteration of the sensitivity of the 
pituitary to LHRH action. 

The normal menstrual cycle 

Most cycles are between 24 and 
32 days in length and the standard 
normal cycle is considered to be 
28 days. Some irregularity occurs at 
both ends of the reproductive 
spectrum, i.e. at puberty and at the 
menopause. Once cycles are 
established, they are most regular 
between the ages of 20 and 40 years. 

The mean menstrual blood loss in a 
healthy western woman is 
approximately 40 ml, 70% of which is 
lost within the first 48 hours. Within 
each individual the loss varies very 
little from one period to the next 
There is a considerable variation, 
however, comparing one woman to 
another. The upper limit of normal 
menstruation is taken as 80 ml per 
menses. Reported menstrual loss can 
vary between a few ml to several 
hundred. Menstrual fluid loss contains 
mucus and endometrial tissue, as well 
as blood. Uterine contractility is usually 
greatest in the first 24 to 48 hours of the 
period. This possibly aids expulsion of 
degenerating endometrium. Contractility 
is variable and can produce only a mild 
discomfort or severe cramping pain (see 
p. 123). 

Mechanisms of blood loss 

The uterine wall consists of three 
layers: the serous coat, which is firmly 
adherent to the myometrium; the 
myometrium, which contains smooth 
muscle fibres and branches of blood 
vessels and nerves; and finally the 
endometrium, which consists 
principally of glandular and stromal 
cells. The blood supply is via the 
arcuate and radial arteries (Fig. 3). The 
radial arteries develop a corkscrew-like 
appearance as they approach the 
endometrial surface, at this point 
called spiral arterioles. These arterioles 
are sensitive to changing levels of sex 
hormones. A fall in progesterone 
results in constriction of the arterioles 
with ischaemia and shedding of the 
upper two-thirds of the endometrium. 
The end arterioles are lost with the 
glands and the stroma during 
menstrual shedding. 



Physiology of menstruation 121 



Gland 




Sub-epithelial 
capillary network 

Venous lake 

Pre-capillary 

Spiral arteriole 
Lymphatic 
Basal artery 
Vein 

Radial artery 

Arcuate artery 

Uterine artery 



Oestrogen 




Proliferative phase 

a Tissue growth and 
proliferation 

• Short, straight tubular 
glands elongate and 
become tortuous 

• Mitosis present in 
glands and stroma 

• Spiral arteries are simple 
just extend into 
endometrium 



~~ Progesterone 



Ovulation 



30f 

Menstruation 



Secretory phase 

Epithelial and stromal differentiation 
Early 



• Sub-nuclear 
vacuolation 

• Presence of 
secretions 



• Growth of 
arterioles 



• Significant rise in 
PGF2« 
synthesis by 
endometrium 



Late 

• Saw -toothed 
glands appear 

• Increasing oedema 

• Glands become 
more tortuous 

• Coiling of arterioles 
due to proliferation 

and resorption 
of stromal oedema 



Fig. 3 Blood supply to the uterus - cyclical changes in structure. 



Control of menstrual blood flow 

The factors controlling blood loss include: 

■ myometrial contractility 

■ haemostatic plug formation 

■ vasoconstriction. 

Myometrial activity is probably one of 
the lesser mechanisms since drugs 
which inhibit contractions, such as 
prostaglandin synthetase inhibitors, do 
not increase menstrual blood loss. 
Menstrual fluid and endometrium 
have marked fibrinolytic activity (hence 
antifibrinolytics can be useful in 
treatment) [see p. 124). 

Vasoconstriction is probably the 
most important mechanism in 
controlling blood loss. Here the role of 
prostaglandins is central. Prostaglandin 
F2 alpha is a potent vasoconstrictor, 
whereas prostaglandin E2 and 
prostacyclin lead to vasodilatation. 
Prostacyclin is a potent inhibitor of 
platelet aggregation. Inhibitors of 



prostaglandin synthesis will therefore 
decrease blood flow to some extent 
(also dysmenorrhoea secondary to 
myometrial contractility; see p. 123). 

Excessive bleeding may be related to 
an alteration in the ratio between the 
vasoconstrictor prostaglandin F2 alpha 
and the vasodilator prostaglandin E2. 
There may also be enhanced synthesis 
of prostacyclin from the myometrium 
in women with heavier periods, which, 
by inhibiting platelet aggregation, 
reduces haemostatic plug formation. 
As yet we do not understand the cause 
of the increased synthesis of these 
vasodilator substances. 

Period pains (dysmenorrhoea) 

There are several possible aetiological 
mechanisms causing period pains. 
Both prostaglandin F2 alpha and E2 
are found in higher concentrations in 
the menstrual fluid of those with 
dysmenorrhoea. Prostaglandin F2 



alpha is a potent oxytoxic and 
vasoconstrictor and administration to 
the uterus leads to dysmenorrhoea-like 
pain. The role of prostaglandin E2 is 
less clear, but it may work by 
increasing the sensitivity of nerve 
endings. An increase in uterine 
contractility can be demonstrated in 
women with dysmenorrhoea 
compared to controls by measuring 
the intrauterine pressure. This 
contractility may be associated with a 
decrease in endometrial blood flow. 

Leukotrienes are also produced by 
the endometrium and increase 
myometrial contractility. Receptor sites 
are present in the myometrium. 
Vasopressin is also a stimulant of the 
non-pregnant uterus, and it is active at 
the onset of menstruation. The plasma 
concentration of vasopressin, which is 
known to stimulate prostaglandin 
release, is higher in those suffering 
with dysmenorrhoea. 



Physiology of menstruation 

1 LHRH controls the secretion of both FSH and LH from the anterior pituitary. 

1 Ovarian hormones modulate the proportions of gonadotrophs secretion. 

1 The control of LHRH secretion is highly complex and depends upon inhibitory and excitatory neurotransmitters, again modulated by ovarian hormones. 

1 The recruitment process promotes some ovarian follicles into the growing pool; this is probably independent of pituitary control. 

1 FSH controls maturation of the growing follicle, the LH surge produces follicular rupture to allow ovulation, 

1 Following ovulation a corpus luteal cyst is formed producing progesterone: with falling progesterone levels menstruation occurs 

1 The usual menstrual blood loss is approximately 40 ml. 

i The interaction between vasodilator and vasoconstrictor prostaglandins controls menstrual flow; an alteration in the ratio of these prostaglandins can 
produce excessive bleeding and/or pain. 



122 GYNAECOLOGY 



Disorders of menstruation I 



This chapter considers menstrual 
abnormalities - regular and irregular 
heavy bleeding and painful periods. 
Disorders of menstruation are 
common, comprising 21% of 
gynaecological referrals. 

Menorrhagia 

This is heavy, regular bleeding defined 
as a menstrual blood loss greater than 
80 ml. Women differ in their subjective 
reporting - some will describe loss as 
heavy when it is within normal limits, 
others cope stoically with excessive flow. 
A careful assessment should be made 
enquiring as to the type of protection 
(pads or tampons] used, the number of 
changes needed per day, the amount of 
clots and frequency of accidents (e.g. 
soiling of clothes or bed linen). A 
menstrual chart can be helpful (Fig. 1). 
Menorrhagia can be caused by: 

■ idiopathic 

■ fibroids (Fig. 2) 

u bleeding disorders 




Fig. 2 Multiple submucous fibroids 



■ intrauterine contraceptive devices 
(except the Mirena) 

■ pelvic infection (often heavy and 
painful menses). 

Intermenstrual bleeding 

This is bleeding occurring between 
menses. It may be physiological in 
origin, related to the sudden rise (and 
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More often it is associated with 
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cervical erosions or, occasionally, 



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Fig. 3 Hysteroscopic view of uterine 
cavity and endometrial polyps. 

Table l Types of dysfunctional uterine 
bleeding 

Anovulatory 

■ Impaired positive f&etioack e.g adoiescems 

■ Inadequate Signal e.g. polycystic ovaries and 
prenienopau&e 

Ovulatory 

■ Inadequate lutealphase 

■ Id io path ic 

cervical carcinoma or stress. Postcoital 
bleeding may have similar causes. 

Dysfunctional uterine bleeding 

Dysfunctional uterine bleeding (DUB) 
is defined as heavy and often irregular 
bleeding, which occurs in the absence 
of any pelvic pathology, pregnancy or 
bleeding disorder. Both hypo- and 
hyperthyroidism can cause menstrual 
irregularity and should be excluded. 
Dysfunctional bleeding can be both 
anovulatory and ovulatory (Table 1). 

Anovulatory dysfunctional bleeding 

In the absence of ovulation, there is 
inadequate progestogenization of the 
endometrium, producing 
abnormalities in the production of 
prostanoids and steroid receptors. The 
unopposed oestrogen gives rise to 
persistent, proliferative or hyperplastic 
endometrium, resulting in irregular, 




Fig. 1 A typical example of a menstrual calendar. 



Fig. 4 The 'Swiss cheese' appearance of 
the endometrium in metropathia 
haemorrhagica. 



Disorders of menstruation I 



painless bleeding. An extreme form of 
this (metropathia haemorrhagica), 
results in excessive bleeding after long 
intervals. The endometrium has a 
classic cystic appearance, often termed 
a 'Swiss cheese' pattern (Fig. 4). 

Impaired positive feedback will 
cause anovulatory cycles by failing to 
produce the mid-cycle surge of 
luteinizing hormone that triggers 
ovulation. Failure of follicular 
development will occur in the 
perimenopausal age group, and in 
polycystic ovarian syndrome. If 
follicular development is insufficient 
there will be an inadequate oestrogen 
signal. Therefore a luteinizing 
hormone surge is not induced and 
ovulation does not occur. 

Ovulatory dysfunctional bleeding 

A shortened luteal phase arises from 
inadequate follicular development. 
Deficient luteal phase will cause 
irregular bleeding and may be 
associated with subfertility The 
idiopathic category of ovulatory 
dysfunctional bleeding is probably 
related to intrinsic prostaglandin 
imbalance. 

Dysmenorrhoea 

Dysmenorrhoea can be either primary, 
with the onset of menarche, or 
secondary, developing later (Table 2). 
There may be cramping lower 
abdominal pains, which often radiate 
to the back, or down the inner aspect 
of the thigh. These may be 
accompanied by faintness or 
gastrointestinal symptoms, including 
loose stools or nausea. 

Primary dysmenorrhoea 

Menstrual symptoms vary widely 
amongst individuals, but some suffer 
more severely than others. Primary 
dysmenorrhoea occurs almost 
exclusively in ovulatory cycles. 



Ta ble 2 Cau ses of d ys me n o rrh o ea 

Primary Secondary 

dysmenorrhoea dysmenorrhoea 

■ Prostaglandin production ■ Idiopathic 

■ Increased myometrial ■ Endometriosis 
contractility ■ Adenomyosis 

■ Decreased enrjomeirial ■ Pelvic inflammatory 

blood Row disease 

■ teukotnenes ■ PelvicvedOUS 

■ Vasopressin congestion 

■ Cervical stenosis 

■ Intrauterine device 

rjum 



Table 3 Treatment of primary 
dysmenorrhoea 

■ Analgesics 

- e.g. paracetamol 

■ Non-steroidal anli-inflammatory drugs [NSAIDs) 

- metenamic acid [Punstan] 

- ibuprofen 

- naproxen 
diclofenac 

(NSAIDs work by direct inhibition of the cyclo- 
oxygenase system reducing prostaglandin 
production] 
u Combined oral contraceptive pill (COG) 
[suppresses ovulation) 

■ Transdermal GIN 



Treatment of primary 
dysmenorrhoea 

Simple analgesia is often sufficient. 
Further treatment is based either on 
blocking prostaglandin formation with 
non-steroidal anti-inflammatory drugs 
(NSAIDs) or by suppressing ovulation 
(combined oral contraceptive pill) 
(Table 3). NSAIDs are best started just 
prior to the onset of menstruation, 
although timing this is only possible 
with regular predictable cycles. If 
symptoms remain debilitating, despite 
NSAIDs, the pill may be appropriate. 
This has the additional advantage of 
providing contraception. A 20 ug 
preparation mav suffice, and recent 
concerns about the increased risk of 
venous thromboembolism in third 
generation progestogen pills seem 
unfounded. Third generation 
progestogen pills reduce side effects 
such as acne and weight gain which 



make the pill unpopular amongst 
adolescents. 

Reassurance is essential and it may 
be appropriate to substitute a 
transabdominal ultrasound for a 
vaginal examination in a young girl 
who is a virgin. Symptoms not 
uncommonly settle with time, and 
there is no association with later 
problems, particularly infertility. 

Secondary dysmenorrhoea 

This develops after menarche and 
there may be identifiable underlying 
pathology (see Table 2). Treatment is 
dependent on the cause. Investigation 
may include thorough examination, 
ultrasound scan and laparoscope 
Although psychological factors are 
quoted as being involved in both 
primary and secondary 
dysmenorrhoea, the evidence for 
physical factors is strong. Recurring, 
debilitating pain may well cause 
depression and anxiety rather than 
depression initiating the pain. 

Toxic shock syndrome 

Toxic shock syndrome (TSS) is a rare 
condition occurring in women who 
forget to remove or regularly change 
tampons. It is caused by a 
Staphylococcus aureus exotoxin (toxic 
shock syndrome toxin-1). Influenza- 
like symptoms occur with high fever 
(39°C), diarrhoea, vomiting, rash, 
muscle aches and offensive vaginal 
discharge. Complications can be severe, 
including disseminated intravascular 
coagulation (DIC), renal, tubal or 
cortical necrosis, microthrombi, adult 
respiratory distress syndrome (ARDS) 
and tissue hypoxia. Mortality is in the 
order of 30 to 50%. Women should be 
advised to use the lowest absorbency 
tampon suitable for the flow, change 
4- to 8-hourly and to wash their hands 
before and after insertion. Toxic shock 
syndrome can also be associated with 
cases of septic abortion. 



Disorders of menstruation I 



Disorders of menstruation are common; at some stage over Z0% of women will complain of heavy periods, 
i Dysfunctional uterine bleeding is a diagnosis made by exclusion and can be either ovulatory or anovulatory, 
i Dysmenorrhoea may be primary or secondary - the latter requires full investigation, 
i Toxic shock syndrome (TSS) is caused by Staphylococcus aureus exotoxin - mortality is 30 to 50%. related to lost tampons and septic abortions. 



124 GYNAECOLOGY 



Disorders of menstruation II 



Management of dysfunctional 
uterine bleeding 

Management should include an 
assessment of the situation, the pattern 
of bleeding and the degree of loss. 
Menorrhagia with a regular cycle is 
probably ovulatory and does not require 
endocrine investigation. Endometrial 
biopsy is not considered necessary in 
women under the age of 40 years. 

Irregular periods warrant tests for 
follicle stimulating hormone, 
luteinizing hormone, prolactin, thyroid 
function and testosterone. A 
characteristic profile is found in cases 
of polycystic ovarian syndrome [see p. 
115). Anovulatory menorrhagia is 
common in the older perimenopausal 
woman. Endometrial carcinoma can 
present as irregular bleeding in the 
mid to late 40s - if there is any 
suspicion, endometrial assessment is 
warranted [see p. 138). 

Treatment for heavy bleeding 

Medical 

Treatment is initially by inhibition of 
prostaglandin synthesis (e.g. 
mefenamic acid) or an anti-fibrinolytic 
agent (e.g. tranexamic acid) (Table 1). 
The pill can also be used - it promotes 
anovulation by ovarian suppression, 
but provides short, regular controlled 
cycles. The levonorgestrel-impregnated 
intrauterine contraceptive device 
(Mirena) has changed the approach to 
the management of dysfunctional 
bleeding. It reduces blood loss in 70% 
of cases, and 20% of women will 



achieve amenorrhoea after 8 to 9 
months of use. Initially, there is a 30% 
chance of irregular bleeding. It is not 
only effective, but also provides 
contraception. Cyclical progestogens 
and danazol have also been used. 

Endoscopic 

Hysteroscopy 

This is the transvaginal approach to 
looking directly into the endocervical 
canal and the uterine cavity (Figs 1 and 
2), with an endoscope introduced into 
the endocervical canal and advanced 
under direct vision until the uterine 
cavity is reached. Fibre-optically 
transmitted light provides illumination. 
The endocervical canal and uterine 
cavity are slightly distended with an 
appropriate medium to obtain a 
panoramic view of the uterine cavity. 
Saline or Hyskon (32% dextran-70 in 
10% dextrose) are used as uterine 
distension media. Visualization can 
also be obtained with carbon dioxide, 
but vision is often obscured by gas 
bubbles. Complications related to 
dextran usage are very rare, but 
include anaphylaxis, pulmonary 
oedema, electrolyte imbalance (e.g. 
hyponatraemia and hypocalcaemia) 
and coagulation disorders. The 
incidence of complications is related to 
the volumes of Hyskon used, high 
distending pressures and long surgical 
procedures. Hysteroscopy itself has 
practically no complications. However, 
some blind manipulation may be 
required in sounding the uterine cavity 



Bladder 



Table 1 Treatment options for heavy bleeding 


Drag 


Regime 


Notes 


Combined 


As for contraception 


Useful if pain accompanies heavy, irregular bleeding and in 


contraceptive pill 




the younger age groups. Also if there is a contraceptive need 


NSAIDs 


Ibuprafen 400 nig His. orally 


Act by inhibiting prostaglandin synthetase. More effective for 




Naproxen 250 ing t.ds. orally 


pain control tnan blood loss, though will reduce this. Most 




Mefenamic acid 500 mg 


effective if commenced 1 2 days before onset of menses. 


Tratiexamic acid 


td.s. orally 


May cause side effects in patients with dyspepsia ard astnma 


1 g l.d.s. orally during menses 


An anti-fibrinolytic and inhibits plasminogen a clival ors 






Consistently effective m reducing flow, but will not regularize 






cycles. Can cause nausea, occasiunal vomiting and dianhpea 


Etamsylate 


500 mg q.d.s during menses 


Reduces capillary fragility Inhibits prostacyclin synthetase 
Can cause nausea, headaches and rashes. Cnniraindicated 
with porphyria 


Mirena HID 




Licensed now for 5 years in the UK. 20% of women become 
amenorrhoeic after 1 year 70% successful in reducbon of blood 
flow. 30% irregular bleedinu/sputtiny initially 


Progestogens 


Duphaston 10 20 nig days 5-25 


Still frequently prescribed. Poor bleeding control in clinical trials. 




or days 14-28 


Patients often sepott side effects of bloating, weight gain. 




Provera 10-20 mg as above 


premenstrual syndrome symptoms 




Noielinsterone 5 mg b.d. ort.d.s. 






as above 






Hysteroscope 
inserted along vagina 
Fig. 1 Hysteroscopy technique. 



Uterus 




Fig. 2 Performing hysteroscopy. 

or dilating the endocervical canal so 
that uterine perforation may occur, 
especially in the presence of severe 
cervical stenosis, acutely anteverted or 
retroverted uterus and the post- 
menopausal uterus. It is also 
associated with distortion of the 
uterine cavity secondary to myomas, 
occlusion secondary to adhesions and 
uterine anomalies or carcinomas. 

Diagnostic hysteroscopy is 
performed with a small-calibre 
endoscope of 3-5 mm diameter 
(Fig. 3). The smaller scopes can be 
used without cervical dilatation as 
outpatient procedures. 

Operative hysteroscopy requires a 
7-8-mm diameter endoscope and 
therefore cervical dilatation. The 
operating hysteroscope can be used 



Disorders of menstruation II 125 





Fig. 3 Hysteroscopic equipment. 

for division of uterine septa, severe 
intrauterine adhesions, tubal 
cannulation and some myomectomies 
for broad-based, sessile and large 
leiomyomas. Some authorities 
recommend simultaneous laparoscopy 
Endometrial resection can be 
performed with laser ablation, roller- 
ball electrocoagulation or the 
hysteroscopic resectoscope. When 
current is applied, the resectoscope 
will easily cut through a leiomyoma to 
produce a shaving of the tissue; the 
tumour is progressively shaved down 
to the level of the endometrium. The 
haemostasis of cut vessels is 
performed one by one with 
coagulating current The Nd-YAG 
lasers can also resect myomas. Carbon 
dioxide lasers have not proved 
effective. If perforation of the uterus 
occurs it is important to stop the 
procedure immediately and withdraw 
the instrument assessing where and 
how the perforation happened. 
Perforation with the larger operative 
instruments usually requires 
laparoscopy to assess the damage. 
Most perforations do not require active 
treatment unless bleeding persists. 

In women who receive endometrial 
ablation techniques, 15-30% report 
dysmenorrhoea and some proceed to 
hysterectomy because of pain, despite 
achieving bleeding control. Cellular 
regeneration can occur following 
resection with return of bleeding, and 
even the potential for carcinomatous 
change. 

Endometrial coagulation has been 
developed with an ultrasound-emitting 
probe or using heat. 



Fig. 4 Disposable laparoscopic tools. 



Minimal Access Surgery 

Laparoscopically assisted vaginal 
hysterectomy (LAVII) allows pedicles 
to be ligated and divided from above, 
whilst the uterus is removed, with 
morcelation if enlarged, from below. 

This advancement has depended on 
better equipment, e.g. grasping forceps 
and cutting scissors (Fig. 4), improved 
imaging (fibreoptic telescopes, cameras 
and TV monitors) and an enhanced 
level of training. 

Hysterectomy 

The indications for hysterectomy have 
reduced following the introduction of 
tranexamic acid and the Mirena I US as 
first-line treatment for dysfunctional 
bleeding, and minimal access and 
hysteroscopic techniques which allow 
resection of submucous fibroids. 
Hysterectomy, therefore, is reserved for 
either large fibroid masses that would 
be difficult to remove with the LAVH 
technique, which is time consuming, 
or for prolapse, when a vaginal 
hysterectomy would be preferred 
(Fig. 5). It is common practice to use 
GnRH analogues for 3 months prior to 
surgery in the case of very large 
fibroids to reduce the risk of 
interoperative bleeding (cf. 
myomectomies). It may also make the 
difference between entry via a 
paramedian incision or a Pfannenstiel 
incision. When counselling the patient 
preoperatively, a decision must be 
made whether to remove or conserve 
the ovaries which will depend on the 



Fig. 5 Vaginal hysterectomy. 



patient's age, whether she still has 
intrinsic ovarian function and, of 
course, her preference. A discussion 
should also take place as to whether 
the hysterectomy should be total or 
sub-total. Some authorities advocate 
conserving the cervix citing less risk to 
bladder and ureter, greater support to 
the vaginal vault with reduction in the 
risk of prolapse in later years and 
enhanced sexual function by 
preserving cervical orgasm. The 
counter-argument is the continuing 
need for cervical screening. 

The vaginal hysterectomy is possible 
if there is primary- and, certainly, 
second-degree cervical descent present. 
Most ladies who have had previous 
pregnancies will have sufficient 
ligamental laxity to allow a vaginal 
approach which is preferable for the 
obese patient who is therefore able to 
mobilise more promptly without an 
abdominal scar reducing the risk of 
postoperative thromboembolism and 
wound sepsis. 

All hysterectomy patients are 
advised that they will require 4-G 
weeks' convalescence. The vaginal 
hysterectomy patient should be 
specifically counselled regarding pelvic 
floor exercises and the avoidance of 
lifting weights and straining to 
defecate which will weaken the pelvic 
floor healing process. The risks of 
surgery are those common to all major 
procedures - haemorrhage, infection 
and thrombosis - and prophylaxis is 
recommended. 



Disorders of menstruation II 






■ Prostaglandin synthetase inhibitors decrease menstrual blood loss and myometrial contractility, 

■ Anti -fibrinolytics are useful as first-line management of dysfunctional bleeding. 

■ Ttie Mirena progestogen-secreting coil plays a useful role in dysfunctional uterine bleeding, also providing contraceptive cover, 

■ Endometrial ablation can be used in women where medical treatment fails. 



126 GYNAECOLOGY 

Acute and chronic pelvic pain 



The elicitation of the history is very 
important in cases of pelvic pain as the 
patient may find it hard to express how 
the pain affects her. There may also be a 
lot of visual clues so watching the 
patient as she describes her illness is 
more important than writing down 
what is said! The nature of the pain, its 
site, radiation, relieving and aggravating 
factors should all be elicited. 

Pain of visceral origin, conveyed 
along T10-L1 and associated with 
distension of organs or stretching of 
the overlying peritoneum, will be 
harder for the patient to pinpoint than 
pain of somatic origin (S2-4). Pelvic 
pain may be from the uterus, fallopian 
tube, ovary, bladder, ureter or bowel, 
so questions must cover all areas. 

Acute pain 

Pain may be due to ectopic pregnancy 
(see p. 98), miscarriage (see p. 92), 
ovarian cyst accident (see p. 140), pelvic 
infection (see p. 100), ureteric calculus, 
painful bladder conditions, 
appendicitis, diverticular disease or 
irritable bowel syndrome. 
Investigations of the cause of acute 
pelvic pain are listed in Table 1 and the 
management of acute pain is outlined 
in Figure 1. 

Chronic pain 

Chronic pelvic pain is a considerable 
problem in women of reproductive age 
and may account for as many as one- 
third of referrals in this group. Slightly 
more than half of diagnostic 
laparoscopics are carried out for 
investigation of chronic pelvic pain, 
often with a normal pelvis seen. An 
increased incidence of neurotic-type 
personality in these patients may be an 
effect of coping with pain long term 
rather than the cause of the problem. 

Diagnosis (Table 2) 
Assessment of pain may be facilitated 
by documentation (Fig. 2) which 
enables a clearer view of the timing of 
pain in relation to other events such as 
menstruation, bowel or bladder 
fullness and sexual intercourse. 

Pelvic pain syndrome (PPS) is a 
disorder of the premenopausal 
woman. In PPS there would be 
tenderness on palpation over the ovary. 
The pain responds to postural change, 
in that lying flat eases the pain 



Cable 1 Useful investigations in cases of acute pelvic pain 



Bimanual pelvic examination 


To check for cervical excitation sizs of uterus, state of as and presence of 




pelvac mass 


Urine Dipstix 


Protein may suggest infection 


1 mmi jnologi ca 1 p reg nancy test (1 PT] 


99.5% accuracy 


Pelvic ultrasound scan 


Gestational sac by 4.5 weeks, fetal pole by 5 weeks, fetal heart movement by 




6 weeks 


Quantitative beta hCG 


48-hour doubling time is normal - less may indicate an ectopic pregnancy 


Diagnostic laparoscope 


To investigate the acute abdomen 




Is there a period of 
amenorrheas? 



+ve IPT 



Pelvic ultrasound 





Pelvic mass on 
p.v. examination 
? ovarian accident 



Mid-cycle pain 
? Mittelschmerz 



Gestational sac 
in uterus 



Empty uterus 
or pseudosac 



Possible 

spontaneous 

abortion 



FH+ve 



Ongoing 

pregnancy 
Expectant 

management 



FH -ve 



Rescan if <7 weeks 
or manage early 
pregnancy loss 



Fig. 1 The management of acute pelvic pain. 

whereas standing, walking and 
bending all make the pain worse. The 
postcoital ache is characteristic in that, 
unlike that due to other pelvic 
pathologies, it continues after 
intercourse. 

Irritable bowel syndrome (IBS], 
found twice as often in women 
compared to men, is commonly found 



Cannot exclude Any predisposing 

ectopic pregnancy factors for PID or 
Measure phCG levels non- gynaecological 

pain? 



Possible ectopic 

pregnancy 

—*■ A laparoscopy 



in those presenting with pelvic pain. 
Pain may be localized to the left iliac 
fossa, there is an increase in flatus, 
increased rectal mucus and feelings of 
incomplete rectal emptying. From the 
long list of symptoms, three of the 
above noted will enable a diagnosis of 
IBS to be made. 



Table 2 Diagnosis of the causes of acute pelvic pain 



Possible diagnosis 

Chronic pelvic inflammatory disease [PID1 

Endometriosis 

Pelvic pa?n syndrome (PPS) 



Associated symptoms 

Vaginal discharge, pain worse during manses, saxuaily active 
Dysmenorrhea, deep dyspareuma. pelvic ache 
Pain worse when standing o r ambulant, deep dyspaieunia and 
postcoital ache 



Irritable bowel syndrome [IBS) 


Alternating :oosc bowels and constipation, abdominal bloating, 
pain often in left iliac fossa 


Nerve entrapment 
Residual ovary syndrome 


Previous pelvic surgery, pain easy to pinpoint 
Previous hysterectomy, deep dyspareuma 


U urogenital prolapse 


Dragging sensation, dull pelvic ache, vaginal bulge 


Urethral syndrome 


Urinary frequency and urgency, voiding difficulty 


1 ntcrstit' a i cystitis 


Urinary frequency and urgency, pain relist with voiding, haeoiaturis 


Idiopathic 


Many other symptoms but other ciag noses excluded 



Acute and chronic pelvic pain 127 



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1 1 Bk piir ii- liMJflAy oe. 



pjc'rir: seeing fnrrdti. £'■-'• ' 



NDrOitl 
l> lto» vniUpiiKU^oK JWc-wnt CTij-^TLrtH *f l«fif T 



i ■! ,t.!i ■■ ci I- ■ - .it ■'.■: 

* Docb the -iiir, mtrjf-nt *ilb y wB deep'. 1 



Fig. 2 Pain assessment chart for chronic pelvic pain. 



Management 

The approach to this problem must be systematic to ensure 
early diagnosis of treatable pain and to allow a sympathetic 
approach to pain which may be persistent despite a 
diagnosis having been reached. Pain management may 
include suitable analgesia, nerve root injections, antibiotic 
therapy for pelvic infection (see p. 100), progestogens or 
gonadotrophs releasing hormone (GnRH) analogues for 
endometriosis (see p. 128), surgery for residual ovary 
syndrome or prolapse and a variety of therapies for bladder 
problems. 

The pelvic pain syndrome has been characterized by the 
finding of dilated pelvic veins (Fig. 3) in these patients when 
examined with pelvic venography (Fig. 4). It is proposed that 
this is a response in some people to high oestrogen content 
in the blood and can be shown in the vessels draining the 
ovary with the developing follicle which thus have a higher 
oestrogen content. Treatment is directed to reducing the 
ovarian production of oestrogen - medroxyprogesterone 
acetate daily has been shown to be effective. 




Fig. 3 Laparoscopic view showing dilated 
pelvic veins. 




Fig. 4 Venogram showing pelvic venous congestion. 



Ovarian suppression can be used as a diagnostic tool 
before proceeding with the more definitive management of 
removal of the pelvic organs. Total abdominal hysterectomy 
and bilateral salpingo-oophorectomy may give dramatic relief 
of pain but in premenopausal women loss of ovarian 
function may have long-term implications (osteoporosis, 
cardiovascular disease). Thus using ovarian suppression 
before surgery would allow a trial of whether ovarian 
removal would be likely to be associated with pain relief. 

Psychotherapy will have an invaluable role in management 
of chronic pain and is probably the most reasonable 
approach in those with idiopathic pain. Helping the patient 
to understand the role that stress hormones play in 
exacerbating pain will encourage involvement in relaxation 
therapy. Better outcomes in pain management are achieved 
when incorporating this approach. 



■ Pelvic ultrasound may allow a diagnosis to be reached but also allows exclusion of some acute conditions. 
1 Pelvic pain syndrome is difficult to manage but may respond to progestogens, though best results are found in conjunction with counselling. 



Acute and chronic pelvic pain 

1 Pelvic pain may be a sign of acute disease or of a more long-term nature. 
1 A good history may guide you to the source of Ihe pain. 



128 GYNAECOLOGY 

Endometriosis 



Endometriosis is a common benign 
condition estimated to affect between 10 
and 25% of women. It is commonest 
among European and nulliparous 
women and has its peak incidence 
between 30 and 45 years of age. 

Pathology 

Endometriosis may be defined as the 
presence of tissue outside the uterus 
that is histologically similar to that of 
the endometrium. This can be found 
within the pelvis or at more distant 
sites. The site will in turn determine 
the presenting symptoms and signs as 
the ectopic endometrial tissue will 
continue to bleed (Table 1) on a 
cyclical basis under hormonal control. 

Endometriosis can be diagnosed 
accurately by visualization and 
inspection. Histological confirmation is 
not usually required. Endometriosis 
involving the ovaries may lead to 
endometriomas ['chocolate cysts'; 
Figs 1 and 2). 

Aetiology 

There is uncertainty surrounding the 
aetiology of this common condition 
(Table 1). An immunological 



Table 2 Possible aetiologies of 
endometriosis 

■ Retrograde menstruation arid implantation 

■ Lym phatic a n rl h aematog enous spread 

■ Transformation of eoelomic epithelium 

■ Genetic and familial aspects 

■ Implantation at operation 



mechanism may account for why 
certain susceptible individuals go on to 
develop the disease. Antigens, 
produced by degrading endometrial 
proteins, have been identified which 
stimulate an immune response 
characterized by peritoneal irritation 
and fibrosis. There appears to be 
evidence of decreased cellular 
immunity to endometrial tissue in 
sufferers. 

Another theory is that of 
transformation of eoelomic epithelium 
which proposes that adult cells 
undergo de-differentiation by 
metaplasia back to their primitive 
origin and then transform to 
endometrial cells, influenced by 
prolonged oestrogen stimulation. 

Vascular and lymphatic 
embolization to distant sites outside 
the peritoneum are probable and 



Table l 


Documented sites of endometriotic implants with associated symptoms 




Site 




Symptoms 


Intra pelvic 


Ova nan. uteres acra 


ligamenLs. pelvic 


Dysmenorrhoea. lower abdominal pam. pelvic pain 


[common 


peritoneal surfeces, 


eg. broad ligament 


dyspareuma. low Pack pam. ovarian accident - torsion 


E*tra pelvic 


tubes 




or f li ptu re of en d ometno m a. i nferti 1 ity 
Obstruction 


Small bowel 




[rare] 


Appendix 




Pscudoappendicitis 




Rectum 




Cyclicaf rectaJ bleed, tenesmus, cyclical pain with 
defecation /altered bowel habits 




Ureters 




Ureteric obstruction 




Bladder 




Cyclical hacmatuna/dysiJna 




Lungs 




Cyclical haemoptysis 




Surgical scars, e.g. caesarean or 


Cyclical pain and bleeding 




hysterectomy scar, vaginal vault 






Umbilicus 




Cyclical pam and bleeding 




Lim hs/j t>j nts/S ki n 




Cyclical pam and swelling 




bowel 



Fig. 1 Ovarian endometriosis. A pseudo ('chocolate'] cyst has been created (containing altered 
blood and breakdown products) surrounded by dense fibrosis. 



endometriotic tissue has been found 
within lymph channels, lymph nodes 
and pelvic veins. 

There are racial differences and a 
higher incidence of endometriosis is 
encountered in the first-degree 
relatives of patients. 

Presentation 

The most common site for 
endometriosis is the ovary, followed by 
the pelvic peritoneal surface, the 
uterosacral ligaments and the posterior 
aspect of the uterus. 

The classic symptom of 
endometriosis is pain - deep 
dyspareunia, secondary 
dysmenorrhoea or pelvic pain. 
'Crescendo' dysmenorrhoea is typical, 
where the pain precedes the onset of 
menstruation by several days, reaches a 
climax, and is relieved when bleeding 
commences. There is a wide variation 
- some women are asymptomatic yet 
have a severe degree of endometriosis 
on laparoscopy, others have only one 
or two localized deposits and 
experience considerable pain. 

Endometriosis is associated with 
infertility. Luteal phase deflency and 
luteinized unruptured follicles (LUf) 
syndrome occur with increased 
frequency. Dyspareunia may reduce 
the frequency of intercourse and 
inhibit penetration. 

Diagnosis 

There may be cervical excitation on 
bimanual assessment. The uterosacral 
ligaments may feel scarred, nodular 
and irregular, and there may be 
exquisite tenderness in the pouch of 
Douglas. Adnexal endometriomas may 
be palpable. Chronic pelvic infection 
(see p. 100) should be excluded as this 
can also present with dysmenorrhoea, 
pelvic pain, deep dyspareunia and 
infertility. Corroboration is by 
diagnostic laparoscopy - the 
appearance of endometrial peritoneal 
deposits varies (Fig. 2). 

The typical lesion is the slate-grey 
powder burn. Other appearances 
include white opacification of the 
peritoneum, red flame-like lesions 
(Fig. 2a), glandular excrescences, 
subovarian adhesions in the fossa 
ovarica (Fig. 2d), yellow-brown 
peritoneal patches, and cafe-au-lait 
spots (Fig. 2c). Accumulation of scar 
tissue may deform the surrounding 



Endometriosis 129 




Fig. 2 Laparoscopic appearance of endometriosis, [a) Endometriotic deposits - red 'flares', (b) Intact endometrioma. (c) Uterovesical fold - cafe-au- 
lait spots, (d) Filmy adhesions over ovarian cyst. 



peritoneum resulting in the 
development of adhesions between 
adjacent pelvic structures leading to a 
'frozen pelvis'. 

Attempts to find a non-invasive test 
for endometriosis include serum 
markers, ultrasonography, 
computerized tomography, magnetic 
resonance imaging and immuno- 
scintigraphy. The latter is an attempt to 
combine tissue labelling and isotope- 
labelled marker with gamma camera 
imaging. Unfortunately the results still 
show great overlap with other 
conditions, particularly pelvic 
inflammatory disease. 

Many centres have introduced the 
American system of charting the 
degree of endometrial deposits to stage 
the severity of the disease. This is 
particularly useful if subsequent 
laparoscopy is performed to evaluate 
response to treatment. 

Treatment 

Endometriosis is a particularly difficult 
disease to treat Medical treatment 
relies on 'suppression therapy for G-9 
months, creating either a 
pseudopregnancy or a 
pseudomenopause [Table 3). The 
endometrial deposits regress, but 
eventually recur in up to GO°/o of cases. 
Counselling and self-help groups may 
be beneficial. 

Radical surgery should be reserved 
for patients with unsuccessful medical 
treatment who have severe intractable 
pain and who have completed their 
family or who have no desire to 
maintain their fertility but would 
rather improve their quality of life. In 
cases requiring total abdominal 
hysterectomy and bilateral salpingo- 
oophorectomy most clinicians would 
agree that progestogen should be 
prescribed with oestrogen replacement 
for 6 to 9 months following surgery to 
prevent reactivation. 

Endometriosis can be reactivated in 
postmenopausal women by hormone 
replacement therapy. 



Adenomyosis 

This is a term used to describe ectopic 
endometrium which penetrates deep 
within the myometrium and produces 
a bulky, tender, smooth, globular uterus 
(Fig. 3). It usually presents with 



dysmenorrhoea and menorrhagia and 
affects a different population to that 
affected by endometriosis, e.g. 
multiparous patients. It is only 
diagnosed after hysterectomy. 



Table 3 Treatment modalities for endometriosis 



Medical 

Pseuda pregnancy 

Combined oral contraceptive pill 

Didrogestercne (Duphaston) 

Medroxyprogesterone acetate [Piovera] 
Norethisterone [Primului) 

Danazol (Danol} 

Gesmnore 
Pseudo menopause 
GnRH analogues 



Use conn nually with no pill-tree intervals 

Use a monophasic pill with an androgenic progestogen 

10 mg b d Zeds, continuously. Side effects: weight gam. acne, ntastafgia, 

PMT symptoms, depression 

ID mg bd/lds continuously. Side effects: as above 

5 mg boYqds continuously. Sine effects: as above, probably more 

pronounced as more androgenic 

200 mg od/bd [rnax. dose qds] Side effects: weight gam. acne, nausea. 

dizziness, virilization, receding hairline, deepening voice in a few cases 

2.5 mg twice weekly far 6-9 months. Side effects: as above 

Implants: goserelin (Zoladex] 

Injections: leuproretn (Prostap). goserelin [Zoladex) 

Nasal spray: buseralm (Sop recur), nafarelin [Synareli) 

Side effects: climacteric symptoms, prolonged therapy will cause 

osteopenia therefore vvill need add back' ho-mane replacement therapy 



Surgical 

Conseivaiive 

Laparoscopic diathermy or laser ablation 

therapy 

Laparotomy, tubal reconstruction, 

adhesion lysis, enucleation ot endometrjomas 

with ovarian reconstruction 

Radical 

Total abdominal hysterectomy and bilateral 

salpingo -oophorectomy with excision ol all 

deposits 



Certain deposits near the ureters or rectum may not be amenable to 

treatment without risk of damage 

Surgery may oe difficult with variable lesults 



Difficult dissection, risk of bowel and bladder damage, less ol fertility 




Endometriosis 



Fig. 3 Adenomyosis. The cut surface of the 
uterus showing the typical interdigitating whirled 
appearance. 



■ This is a common condition affecting 
10-25% of women. 

■ Peak incidence is 30-45 years Qf age. 

■ The main symptom is pain: there is an 
association with infertility, 

■ Diagnosis is by laparoscopy. 

■ Medical treatment relies on suppression 
therapy. 

■ Surgical treatment can be radical or 
conservative, 

■ Treatment can be difficult, relapses can 

occur, support groups are helpful. 



130 GYNAECOLOGY 



Investigation of infertility 



Infertility exists when a couple trying 
for pregnancy have not achieved this 
after 12 months. Eight in 10 healthy 
couples will become pregnant in the 
first 12 months of trying, so it is 
reasonable to commence investigations 
if pregnancy has not been achieved in 
this time. 

Physiology 

The sperm meets the egg in the tubal 
ampulla and an understanding of the 
complexity of the process leading to 
that moment and the subsequent 
fertilization (Fig. 1) and implantation is 
important to the understanding of 
infertility. The human female starts life 
with many eggs and 'wastes' most: 



Fetus 


2 000 000 ova at about 




20 weeks 


Birth 


750 000 ova 


Puberty 


250 000 


Reproductive 


200-300 ovulations 


life 




Menopause 


a few residual ova but 



menstrual cycle results in 13 
ovulations per year. Couples should be 
encouraged to have regular intercourse 
throughout the menstrual cycle. 

The early conceptus produces 
human chorionic gonadotrophin 
(hCG) which is necessary for the 
continuation of the pregnancy and is 
the basis of urine and blood tests to 
confirm pregnancy. The production of 
progesterone by the corpus luteum is 
also essential for at least the first 
9 weeks of pregnancy, until placental 
production takes over this role. 

Infertility affects 1 in 10 couples 
with varying causes predominating in 
different countries. The common 
causes of infertility in the UK (usually 
a combination of causes) are: 



unresponsive to follicle 
stimulating hormone. 

Eggs are held in prophase of first 
meiosis. Meiotic division resumes as 
the follicle matures and is complete by 



unexplained 


28% 


sperm problem 


21% 


ovulatory failure 


18% 


tubal damage 


14% 


endometriosis 


6% 


coital problems 


5% 


cervical mucus hostility 


3% 


other male problems 


2% 



In the USA the male factors can 
account for 40% of cases of infertility. 
Female factors (e.g. tubal blockage 



secondary to pelvic inflammatory 
disease) are high in the Caribbean and 
West Indies. The tendency for women 
in 'advanced' countries to delay 
childbearing whilst establishing a 
career may result in more cases of 
infertility as fecundity decreases with 
increasing maternal age. There are 
increasing numbers of anovulatory 
cycles and the oocytes are ageing 
whilst there is a lower frequency of 
sexual activity with increasing age. 

Investigations 

Investigation of an infertile couple 
(Fig. 2) needs to rapidly assess 
ovulation, patency of tubes and 
presence of sperm. A diagnosis allows 
formulation of a management plan to 
help allay anxiety and ensure that 
older couples do not miss the chance 
of assisted conception (see p. 132). 

Check the rubella status and offer 
vaccination if negative - remember to 
advise avoiding pregnancy within 
1 month of vaccination. Advice to take 
folic acid whilst trying to conceive is 
appropriate, along with advice to stop 
smoking and reduce alcohol intake to a 
minimum. A body mass index (BMI) over 
30 necessitates a supervised weight loss 



ttip timp rtf rt\7iilafii 



A rptfiilar IR-Aav 



Muscular contractions 
of the tube are associated 
with a to-and-fro movement 
of the egg f 



-*■ Cilia beating moves 
egg towards uterus 
(not thought to be 
critical in human egg 
movement) 



Blastocyst entering 
the uterine cavity 




Day 1 
fertilised egg 




Sperm motility gets them 
into the cervical mucous. 
The ejaculate has 

2 million sperm - most 
lost by drainage out of 
the vagina 



Non-pregnant state 

Fig. 1 The physiology of fertilization. 



Pregnant state 



INFERTILITY 



TESTS FOR OVULATION SEMINAL ANALYSIS 



No ovulation 

Or infrequent 

I 

CLOMIPHENE 
CITRATE 



Ovulating Normal Abnormal 

w 

If tubes 
patent 



Swim up 
test 



Ovulation but 
no pregnancy 



GIFT 



GONADOTROPHINS Check TUBAL "- 
PATENCY 

(consider as part ot 

IVF programme) — •> IVF + ET 



Check chromosomes - 

FSH i ovarian biopsy 



Good Poor 



T 

lUI 



Fails 
\ 
Fails 



\l 



Investigation of infertility 131 






TESTS OF TUBAL PATENCY 
HSG Laparoscopy 



Possibly Assess 
as part tubes 



of GIFT 



Patent tubes Blocked 
t- ovulation tubes 
- good seminal 

analysis] 

Tubal 
surgery 

\ 
GIFT IVF + ET 



re surgery 



Consider adoption 



Premature 
menopause 



Presence of 
Y chromosome 



Needs HRT Needs gonadectomy 
10% malignancy risk 



Fig. 2 Investigation of the infertile couple. 



programme. The male partner should 
also be advised to stop smoking and limit 
alcohol to optimize his reproductive 
performance. Intercourse two to three 
times per week throughout the cycle 
should optimize the chance of conception. 

Semen analysis 

The World Health Organization normal 
values are: 



2-5 ml 

> 20 million sperm 
per ml 

> 50% progressive 
motility 

> 30% normal 

forms 

< 1 million/ml 

within 30 mins 



■ volume 

■ sperm count 

■ motility 

■ morphology 

■ white blood 
cells 

■ liquefaction 
time 

Counts below 20 million sperm per ml 
are associated with lower pregnancy 
rates. Over recent years decreased sperm 
counts have been noted - possibly due 
to environmental pollutants such as 
agricultural chemicals, stress, 
intercurrent illness and jet lag. With 
azoospermia, luteinizing hormone (LH) 
and follicle stimulating hormone (FSH] 
should be checked - high FSH suggests 
failure of sperm production and needs 
further investigation with chromosome 
study. Normal FSH may imply a 
blockage to the outflow of sperm. 

A sperm migration test will assess the 
number of viable sperm with good 
forward motility (normal value 
> 5 million/ml). Antibodies can be 
detected in semen (IgA and IgG) using 
immunofluorescent techniques. 



Antibodies may be found on the head 
(affecting ability to fertilize the egg] or 
tail (affecting sperm motility]. 

Tests of ovulation 

Measurement of serum progesterone in 
the mid-luteal phase confirms ovulation if 
> 30 nmol/1. Ultrasound 'tracking' of the 
ovaries can follow developing follicles 
during ovulation induction cycles (Fig. 3). 

Tubal function 

Hysterosalpingography (HSG] and 
diagnostic laparoscopy are 
complementary methods for assessment 
of tubal patency. Before instrumentation 
of the uterus, screen for Chlamydia 
trachomatis or give appropriate 
antibiotic prophylaxis. At HSG, radio- 
opaque dye is introduced through the 
cervix and outlines the uterine shape 
and fallopian tubes, determining their 
patency (Table 1). 

Laparoscopy allows assessment of the 
pelvis for endometriosis (see 
p. 128] and peritubal adhesions due to 
infection (see p. 100]. There may be an 
obvious corpus luteum (evidence of 
ovulation) and free fluid from the pouch 
of Douglas can be assessed 
bacteriologically to rule out pelvic 
infection. Dye injected through the 
cervix can be observed flowing from the 
fimbriae of the tubes in healthy cases. 



A sensible investigation plan allows 
speedy diagnosis of the problem and 
the most appropriate management. 




Fig. 3 Ultrasound scan showing a follicle 
being measured. 



[able 1 Assessing th 


3 results of 


hysterosalpingography 


Findings al HSG 


Presumptive diagnosis 


ULenne synechias 


Ash errnyn's Syndrome 


Irregular uterine cavity 


Uterine fibroids 


Septum in cavity 


Congenital abnormality 




ol uterus 


Comuai blockage 


Spasm of tubes 


Tubal distension 


Stocked tubes 


Peritonea" spread of dye 


Normal tubai patency 



Investigation of infertility 



Infertility investigations can commence after 1 2 months of intercourse not resulting In pregnancy. 
An investigaiion pian should enable couples to learn rapidly the cause of their infertility. 
Investigation should always be in parallel for male and female partners. 



132 GYNAECOLOGY 



Management of infertility 



Management of anovulation 

Clomifene citrate 

Clomifene citrate is used in cases of 
anovulation or infrequent ovulation 
found in the presence of normal 
seminal analysis before any further 
investigation is needed. The oestrogen 
like structure of clomifene confers 
anti-oestrogenic properties and induces 
a rise in follicle stimulating hormone 
(FSH) and luteinizing hormone (LH) 
output possibly by affecting 
gonadotrophin releasing hormone 
(GnRH) release. Treatment is given on 
days 2-6 of the menstrual cycle in the 
UK [to avoid the anti-oestrogenic effect 
on the cervical mucus], though in the 
USA, where treatment is given on days 
5-9, similar results are obtained. The 
starting dose is 50 mg daily with step- 
wise increase until ovulation is 
achieved - as evidenced by appropriate 
rise in the mid-luteal progesterone. 
Seventy five percent of pregnancies 
occur in the first three ovulatory 
treatment cycles. 

Conception rates, if no other causes 
of infertility are present approach 
normal [80-90%). There is a 
cumulative rise in pregnancy rate up to 
9 months of treatment so alternative 
therapies should be considered at this 
stage. If used in conjunction with 
intrauterine insemination (see below) 
timing of ovulation is important. Once 
ultrasound shows a follicular diameter 
of 18-20 mm or appropriate serum 
estradiol levels, a human chorionic 
gonadotrophin (hCG) injection can be 
given - usually around day 11. 
Ovulation occurs 3G-40 hours later and 
sperm can be introduced at this stage. 

Side effects of clomifene include a 
15°/o incidence of poor cervical mucus, 
which may hamper sperm transport. A 
multiple pregnancy rate of 5% is 
reported. There may be a slight 
increase in risk of ovarian carcinoma 
with clomifene, but not if used for 
fewer than 12 cycles. Ovarian 
hyperstimulation (see below) is rare 
but can occur particularly in 
association with polycystic ovarian 
syndrome (PCOS). Headaches, 
dizziness and abdominal discomfort 
are also reported. 

Gonadotrophins 

The gonadotrophins are controlled by 
gonadotrophin releasing hormone 



(GnRH) from the hypothalamus and 
manipulation of their levels is used to 
affect egg production. FSH is used to 
achieve ovulation in women with 
clomifene-resistant PCOS. GnRH 
analogues can be used to suppress 
endogenous activity in the 
pituitary-ovarian axis but there is no 
increase in pregnancy rate in women 
with clomifene-resistant PCOS and 
there may be an increased risk of 
ovarian hyperstimulation (see below). 

Down-regulation with a GnRH 
analogue allows exact timing of 
ovulation so that it coincides with 
theatre time if a gamete intrafallopian 
transfer (GIFT - see below) cycle is in 
progress or the presence of an 
embryologist if an in vitro fertilization 
(IVF) cycle is planned. The analogue is 
commenced during the middle of the 
cycle prior to the procedure (long cycle) 
or on day 1 of the treatment cycle 
(short cycle). Once low FSH, LH and 
estradiol are achieved, FSH is 
commenced at 150 IU per day until 
three or four 18-22 mm follicles are 
produced (follicle maturation) as 
followed by ultrasound tracking. 

During IVF and GIFT procedures 
the gonadotrophins are used to 
produce more than one egg per cycle 
(superovulation). Purified FSH is given 
starting with a low dose and 
monitoring the response with serum 
estradiol and ultrasound scanning of 
the ovaries. When three or four 
follicles 18-22 mm diameter are noted, 
hCG is given to mature the eggs prior 
to harvesting. Spare eggs may be 
frozen for use in subsequent cycles. 

Egg collection 

The technique is by transvaginal scan 
using a needle guide to ensure correct 
placement of the needle (Fig. 1) and 



harvesting the eggs using suction. This 
allows the eggs to be fertilized in vitro 
and replacement of up to three 
embryos per cycle into the uterine 
cavity. The legal limit of three embryos 
per cycle (UK) maximizes the chance 
of a successful pregnancy whilst 
minimizing the risk of a high-order 
multiple pregnancy, though many 
units replace two routinely. 

Gamete intrafallopian transfer 
[GIFT) 

This procedure was introduced for the 
management of unexplained infertility 
and is now used also with mild 
oligospermia or mild endometriosis. As 
ovulation timing is difficult to predict in 
a natural cycle, and usually produces 
only one or two eggs, gonadotrophins 
are used (see above). Egg collection is 
carried out at laparoscopy, allowing 
replacement of eggs and 'washed' sperm 
into the fallopian tube at the same time. 
Two or three oocytes per tube are 
placed just proximal to the tubal 
ampulla. There has been an increased 
incidence of corpus luteal dysfunction in 
these cycles so progesterone 400 mg is 
given twice daily for 2 weeks after the 
GIFT procedure. 

In vitro fertilization and embryo 
transfer (IVF and ET) 

The classic indication for this is in the 
patient with tubal disease which is not 
appropriate for surgery. The tube is by- 
passed, and multiple oocytes are 
collected and made available - allowing 
in vitro fertilization with sperm (Figs 2, 
3, 4). If more than three embryos 
develop, the extra ones can be 
cryopreserved, allowing two or three IVF 
cycles to be achieved from one ovulation 
induction cycle. There is at least a 25% 
loss of embryos at defrosting. The 




Fig. 1 Ultrasound scan of egg collection. 



Fig. 2 The zona pellucida is chemically 
eroded to assist access to the eggs. 



Management of infertility 1 33 




Fig. 3 Ultrasonically guided egg retrieval 
via posterior fornix. 



Fig. 4 Incubation process for egg 
fertilization. 



Fig. 6 Laparoscopic view showing 
damaged tubes. 



pregnancy rate is often higher in the 
cycle where no ovulation induction is 
needed, but remains only - 20-25%. 

Intracytoplasmic sperm injection 
(ICSI) and embryo transfer 

This overcomes any problem with the 
sperm penetrating the zona pellucida. 
It also ensures that only one sperm 
fertilizes the egg (Fig. 5). It is indicated 
when IVF has failed to generate 
embryos, where sperm have been 
recovered from the epididymis or testis 
by aspiration, or when seminal 
analysis shows sperm with very poor 
motility. The technique enables men to 
father children themselves rather than 
resorting to AID (artificial 
insemination with donor sperm - see 
below). 

Intrauterine insemination (IUI) 

This technique is used in cases of 
unexplained infertility, male antisperm 
antibodies, post-vasectomy antibodies, 
if white blood cells are found in 
semen, or possibly if borderline 
oligospermia is detected. Coital 
difficulty may also be managed this 
way. The semen sample is washed, 
centrifuged and the sperm pellet 
suspended in medium. The healthy 
sperm swim into the medium and 
0.1-0.2 ml is injected directly into the 
uterine cavity. This avoids the cervical 
mucus barrier and the washing 
removes the prostaglandin content of 
the seminal fluid which can cause 
intense uterine contractions. Artificial 
insemination with donor sperm may 
be indicated in cases of azoospermia or 
severe oligospermia. 

Tubal surgery 

The role of surgery on damaged tubes 
(Fig. G) has advocates who usually feel 
it is essential that the surgeon is 
specifically trained and uses 
microscopic techniques but many feel 
that it wastes resources. If the fallopian 




NEW SOCIETY 



Fig. 5 Intracytoplasmic sperm injection. 

The egg is held by a suction pipette (left] and the 
sperm injected into the cytoplasm. 



tube is obviously enlarged and has 
been damaged for a number of years, 
the chance of restoring function is very 
small, so IVF may be more cost- and 
time-effective. However, if there is 
minimal fimbrial clubbing 
laparoscopic laser surgery may be able 
to achieve a good result. In patients 
wishing reversal of their sterilization, 
high success rates can be achieved 
using a microsurgical technique. 

Unexplained infertility 

After appropriate investigation there 
will be a group of patients whose tests 
are normal and who have unexplained 
infertility. The decision on when to 
treat will depend on the duration of 
infertility, the woman's age and the 
previous pregnancy history. It is 
reasonable to wait for up to 3 years 
with no treatment in younger women. 



Life in their hands — should 
science tinker with creation^ 




Fig. 7 An area of controversy. 



IUI with ovarian stimulation, GIFT or 
IVF are all effective treatments in this 
group (Fig. 7). 

Ovarian hyperstimulation 

Ovarian hyperstimulation syndrome 
(OHSS) is a potentially serious side 
effect of ovulation induction and is 
associated with large ovarian cysts. 
There is increased vascular 
permeability leading to ascites, pleural 
effusions and intravascular 
hypovolaemia. Thrombosis may ensue. 
OHSS is found particularly in patients 
with polycystic ovarian syndrome and 
older women. The mild form, found in 
approximately 30% of patients, 
responds to conservative management 
and no further ovarian stimulation. 
The severe form (found in < 2%) 
requires fluid replacement, 
antithrombotic measures and bed rest. 



Management of infertility 



i Clomiphene citrate in women with PCOS may enable them to achieve near normal conception 
rates. 

i Multiple pregnancy is increased with any ovulation induction and patients should be counselled 
accordingly; the possibility of fetal reduction may be discussed. 

i Tubal surgery should only be performed by those with specific training using microsurgical 
techniques. 

i Advances in freezing/defrosting techniques have improved the outlookfor infertile couples, 
making the cost of each cycle of treatment more attainable. 



134 



GYNAECOLOGY 

Cervical intraepithelial neoplasia (CIN) 



Definition 

Cervical intraepithelial neoplasia (CIN) 
is a premalignant condition of the cervix. 
It is usually asymptomatic and is 
detected by routine cytological 
screening. The degree of severity is 
graded CIN 1 to CIN 3. 

Aetiology 

The causes of CIN are the same as 
those of cervical carcinoma, since one is 
a precursor of the other (Table 1). 

At puberty, the squamo-columnar 
junction corresponds to the anatomical 
external os. Hormonal changes cause 
cervical oedema with exposure of the 
columnar epithelium - an ectropion; 
common misnomer, an erosion'. The 
exposure of the fragile columnar cells to 
vaginal acidity stimulates squamous 
metaplasia. Tongues of squamous cells 
grow inwards to cover the exposed 
columnar epithelium. It takes 
approximately 3 months for this 
metaplasia to mature into stable 
squamous epithelium. Early sexual 
intercourse will expose immature stable 
metaplasia to several potentially 
oncogenic agents. The area of previously 
exposed columnar epithelium that 
undergoes squamous metaplasia is 
known as the transformation zone (TZ) 
(Fig. 1). 

Screening 

Screening for CIN is based on a cervical 
smear - sampling surface cells from the 
cervix with a spatula. The success of any 
screening programme depends on the 
age screening commences and finishes, 
how frequently it is performed (1- to 
3-yearly) and the reliability of the 
cytology laboratory (the number of false 
positive and false negative results). 




Columnar epithelium 
(deep pink) lining 
endocervix 



Squamo-columnar 

junction 



o 



Squamous epithelium 
(pale pink} on cervix 




Squamous metaplasia 
growing inwards 




High oestrogen levels 
make ectropions common 
when pregnant, or when 
taking the combined 
contraceptive pill 



Process completed - 
transformation zone 



new 



Fig. 1 Ectropion and transformation of the transformation zone. 



Diagnosis 

To obtain a complete diagnosis the triage 
of cytology, colposcopy and histological 
biopsy are needed, as smears are often 
under reported (Fig. 2). 

Cytology 

Dyskaryosis is a cytological term. It 
describes features of individual cells 
such as size and staining of nuclei and 

Diagnostic triage 
Cytology Histology 



/ 



Colposcopy 



Fig. 2 Diagnosis of CIN. 



Table 1 The risk factors for CIN and cervical carcinoma 


Youny age at first intercourse 


Exposure to tumour promoters has a yrcaiei influence on immature cells 


Number of sexual partners 


Smoking 


Increases the risk of cervica! cancer four-fold, the risk remains elevated m 




ex-smokers 


Poor uptake ol screening programme 




Long-term use of the contraceptive pill 


Pill takers do not necessarily use barrier methods - increasing exposure to 




seminal Fluids 


Male rely tort nsklactors 


The number of the partner's previous sexual fetation ships is relevant 




Cervical cancer risk increased if partner has penile cancer 




Cervical cancer risk increased if partner's previous sexual con'act had cervical 




cancer 


Immunosuppression 


Risk increased with immunosuppressed renal jransplantpalients. and 




10 HIV-positive women 


HPV infection 


Mainly subtype 16 



the amount of cytoplasm [Fig. 3). 

Indirectly, it is commenting on the 
degree of cellular maturation, since 
parabasal cells should not be present at 
the surface of the epidermis and 
accessible to cellular sampling. Cytology 
reports always highlight the most 
immature cells present. 

Histology 

Dysplasia is a histological term. It 
requires a full-thickness biopsy for 
diagnosis [Fig. 4]. Carcinoma-in-situ and 
CIN 3 are more or less synonymous. 
The basement membrane remains 
intact. Precancerous lesions have also 
been identified for adenocarcinoma, 
termed mild or severe glandular atypia. 

Colposcopy 

The colposcope is a low-power 
binocular microscope which allows the 
cervix to be viewed stereoscopically [Fig. 
5), at magnifications of xG to x40. In 
dysplastic tissue the normal pattern of 
blood vessels becomes distorted and 
punctation (Fig. 6) and mosaicism (Fig. 
7) are seen. Abnormal tissue stains 
white with acetic acid but will not take 
up the brown iodine stain. Studying the 
vessel patterns and staining reactions, a 
colposcopist gauges the degree of CIN 
present. Colposcopically directed 
biopsies are taken from suspicious areas 
to exclude the presence of invasive 
disease. The extent of the lesion must 



Cervical intraepithelial neoplasia (CIN) 135 



Mild dyskaryosis 

• Superficial cell 

• Normal-Sized nucleus 

• Mild nuclear abnormalities 

• Abundant cytoplasm 

• Angular cell borders 



Moderate dyskaryosis 

• Intermediate cell 

• Nucleus larger than normal, 
but < 50% of cell 



Severe dyskaryosis 

• Parabasal cell 

• Nucleus > 50% of cell 

• Cell border rounded 

• Nucleus darker 
(byperpicnotic) 

• Nucleus irregular 



W&:*<% 



fc-.-v* 



Fig 3 Cytology of CIN. 



CIN 1 

• Upper 2 3 of epithelium exhibits 
reasonable differentiation 

• Mild nuclear abnormalities, 
most marked in basal layer 

• Few mitotic figures, confined to 
basal '£ 

CIN 2 

• Upper ''s ot epithelium well 
differentiated 

• Moderate nuclear eel I 
abnormalities 

• Mitotic figures (some abnormal) 
present in basal 2 a 

CIN 3 

• Maturation confined to 

superficial ''a (or absent) 

• Nuclear abnormalities marked 
and throughout full thickness 

• Mitotic figures numerous, 
bizarre and at all levels 

Fig. 4 Histology of CIN. 











Fig. 5 Colposcope. 



Fig. 7 Mosaicism. 




Fig. 6 Punctation seen with carcinoma-in- 
situ and microinvasion. 

also be defined. If the lesion enters the 
endocervical canal the colposcopist must 
be sure that the upper limit is clearly 
visualized. This will determine whether 
the lesion is suitable for local destructive 
techniques or if a cone biopsy is 
required. Destruction is carried out by 
an expert. There must be adequate 
cytology and colposcopy follow-up. 

Local treatment 

There are several different treatment 
modalities including cryocautery, cold 
coagulation, electrodiathermy, carbon 
dioxide laser, loop diathermy. Small 
localized lesions of CIN 1 and possibly 
of CIN 2 may be treated by cryocautery. 
Lesions entering the canal and those 
that look more severe require either 



Fig. 8 Loop diathermy apparatus. 



laser ablation or loop wedge excision. 
Laser treatment destroys the tissue by 
evaporation and coagulation. It has been 
superseded by loop diathermy which 
involves running an electric current 
through a thin loop of varying size and 
shape (Fig. 8). The tissue is excised rather 



than ablated and, therefore, pathology 
can be reviewed if questions arise later. 
It is an easier technique to learn. 

Cone biopsy 

Cone biopsy is reserved for when the 
upper limit of the lesion cannot be seen, 
when there is a suspicion of invasive 
disease and if cytology is persistently 
positive with negative colposcopy. Most 
cone biopsies are now performed by 
loop diathermy. Some situations require 
knife cones. Complications include 
haemorrhage (10%), cervical stenosis or 
incomplete excision. Stenosis is related 
to the depth of the cone excised. 
Hysterectomy should be considered for 
a patient with recurrent abnormal 
smears suffering from menorrhagia and, 
in the case of an incomplete cone 
biopsy, when the family is complete. In 
a woman with a uterine prolapse, a 
vaginal hysterectomy would be ideal. 

If a hysterectomy is performed 
because of abnormal smears, annual 
vault smears should be performed. 

There is growing evidence to suggest 
a psychosexual morbidity following 
investigation. Patients need to be 
approached with confidence and 
sensitivity. 



Cervical intraepithelial neoplasia 



■ CIN is a premalignant condition of the cervix characterized by specific cytology (dyskaryosis) 
and histological (dysplasia) features. 

■ Aeliological factors are similar to those of cervical carcinoma. 

■ It is usually asymptomatic: diagnosis requires cytology, colposcopy and histology 

■ Cone biopsies are taken if the upper lima of the lesion is not clearly visualized. 

■ Loop excision is currently the most common treatment modality: laser is useful if dysplastic areas 
extend into the vaginal fomices 



136 GYNAECOLOGY 

Cervical carcinoma 



Epidemiology 

Worldwide, cancer of the cervix is the 
second most common malignancy in 
women after breast cancer - 77°/o of 
cases occur in developing countries. 
Finland, which has an advanced 
population-based screening programme, 
has one of the lowest rates in the world. 
Israel has a low incidence as a result of 
conservative sexual practice. 

Approximately 2000 deaths occur 
annually in the UK. A bimodal 
distribution with an initial peak of 
incidence for women in their 30s, and 
a larger peak for women in their 50s 
has emerged. The incidence of cervical 
cancer is higher in lower socio- 
economic groups. 

Risk factors 

The main aetiological agent is infection 
with certain subtypes of human 



papilloma virus (HPV). Several risk 
factors have also been identified 
(see p. 134). 

HPV infection is far more common 
than the development of cancerous 
change, so other factors must influence 
the malignant potential between one 
individual and another (Fig. 1). 

HPV subtype 1G appears to be the 
main oncological agent. It is present in: 

■ only 5% of cytologically normal 
women 

■ up to 50% of smears containing 
CIN1 

■ over 90% of invasive cervical cancer. 

HPV subtypes 18, 31 and 33 may also 
be implicated. 

Pathology 

Malignant tumours of the cervix may 
be squamous (85-90%) or glandular 



HPV 16 



Colonizes cells acted on 
by tumour promoters 



SMOKING 



CERVICAL CELLS 



MALE FACTORS? 



Reduces eel I- mediated 
immunity (reduction in 
Langerhans cells) 



Exposure via seminal 
fluid (which contains potent 
immunosuppressive agents) 



HPV 16 gene E6 action 



INHIBITION OF Cx cell p53 
TUMOUR SUPPRESSOR 
GENE 



Protection against tumour 
development LIFTED 



Fig . 1 Possible aetiological pathway for CI N and carcinoma. 



Table 1 Symptoms and signs of cervical carcinoma 


Symptoms 


Signs 


Confined [o cervix 


At routine examination 


■ Postcoital bleeding 


■ Cervix looks suspicious at time of smear 


■ Postmenopausal bleeding 


■ Abnormal cells, indicative of invasive carcinoma on 


m Intermenstrual bleeding 


cytology 


■ Offensive, blood -stained vaginal discharge 


Ai colposcopy 


Spread to adjacent structures 


■ Heavy, contact bleeding 


■ Fistulas ■ passage of urine, faeces or flatus vaginally 


■ Irregular stir face contour 


(if bowels bladder involved) 


■ Atypical vessels - capillaries ol irregular calibre and 


■ Renal failure - bilateral ureteric obstruction 


branching pattern 


■ Deep visceral cr nerve root pain [if sacral nerve root 




involved] 




1 ■ Lower limb oedema - extensive oelvic side wall 




infiltration 






Fig. 2 Cervical carcinoma. Exophytic lesion. 

(10%) in type. Microinvasion (stage la) 
is defined as invasion that is less than 
5 mm from the basement membrane. 

Most squamous cell carcinomas 
involve the external os and are visible 
on speculum examination. The lesion 
may be either exophytic, growing 
outwards in a papillary or polypoidal 
excrescence, (Fig. 2), or endophytic, 
infiltrating the surrounding structures. 
Ulceration and excavation frequently 
occur. Invasive squamous cell 
carcinomas vary in their degree of 
cellular differentiation, but often 
attempt to form a keratin pearl. 

Assessment 

Presentation 

Many women are asymptomatic. More 
advanced disease will present with 
symptoms (Table 1). Screening for 
cervical cancer has resulted in an 
increase in the number of women found 
to have asymptomatic disease (Table 1). 

Staging 

Accurate staging of the disease 
determines the treatment and 
prognosis (Table 2). Early detection is 
associated with significantly better 
survival rates. Clinical staging is based 
on an examination under anaesthesia 
(EUA). This should include: 

■ cervical biopsy 

■ cystoscopy 

■ a rectal examination including 
sigmoidoscopy 

■ dilatation and curettage. 

The patient should undergo an 
intravenous pyelogram (IVP) and a 
chest X-ray. Magnetic resonance 
imaging (MRI) is useful in assessing 



Cervical carcinoma 



Table 2 Staging and survival rates of cervical carcinoma 





5 -year survival rate 


Stage i Tumour conlmecito the cervix 




a Microinvasive carcinoma 




ai Stromal invasion £ 3 mm depth and < 7 mm. horizontal spread 


95 1% 


a2 Lesions with a depth > 3 mm. but S 5 mm. and a honzonlal spread S 7 mm 


94.9% 


b Clinical lesions confined to the cervix 




b t Turn cur d la ni eter < i cm 


60.1% 


b2 Tumour diameter £ 4 cm 




Stage ? Spread beyond the cravis. but not to the pelvic side wall, with involvement ol 


upper 


two-thirds of the vagina 




a Vaginal spread, but nn obvious parametria! spread 


66.3*3 


b ftn rametrial spread, b ut not as far as peKic side wall 


63.5* 


Stages Sptead in the petos 




a Invc Ivement of lower one-tn.rd of the vagina 


33 3* 


b Eiiensiontothe pelvic s<Se vva li oi hydronephrosis 


38 r< 


Stage* Distant spread 




a Spread to involve adjacent organs [bladder, rectum} 


T7. TT* 


fi Distant spread 


9.4* 



FIGO classification, Montreal 1994. FIGO Data for survival 1 990-1 992 (n= 1 1 945). 



early-stage disease and tumour 
extension into the bladder, rectum, 
vagina and pelvic floor. Computed 
tomography CCT) scanning or MRI 
can be used in later-stage disease. CT 
scanning is now routinely used for 
radiotherapy treatment planning. MRI 
is the imaging modality of choice 
when salvage surgery is indicated for 
an isolated central pelvic recurrence. 

Treatment options 

Microinvasive disease 

In the woman who has not yet 
completed her family, it is possible to 
adopt a conservative approach. A knife 
cone biopsy will provide both 
diagnosis and treatment and preserve 
the uterus. Ablative techniques are 
inappropriate. 

Stage la superficial invasion only 
occurs with squamous cancers of the 
cervix because the lesion spreads 
contiguously. Adenocarcinomas are 
known to have skip lesions in separate 
crypts and cannot be treated in a 
similar conservative fashion. 

Follow-up is indicated with cytology 
and colposcopy. Once the family is 
complete a hysterectomy may be 
appropriate. The vaginal approach is 
preferred as it is easy to remove a 
small cuff of vagina with the specimen. 

Invasive disease 

Radical treatment is indicated for 
stages lb, 2a and some cases of 2b. 
Either surgery or radiotherapy can be 
first-line treatment. Both modalities 
produce equivalent cure rates for 
patients with stage lb cervical cancer. 
Surgery offers several advantages: 

■ it allows preservation of the ovaries 
(radiotherapy will destroy them) 



■ there is better chance of preserving 
sexual function (vaginal stenosis 
occurs in up to 85% of irradiated 
patients, although use of topical 
oestrogens vaginally has reduced this) 

« a more accurate prognosis can be 
obtained as surgery allows nodal 
sampling. (Total staging is not 
possible from an EUA.) 

The classical surgical procedure is the 
Wertheim's radical hysterectomy 
including pelvic lymphadenectomy and 
3 cm vaginal cuff The original operation 
conserved the ovaries, since squamous 
carcinoma does not spread directly to 
these tissues. Oophorectomy should be 
performed in cases of adenocarcinoma 
of the cervix as there is a 5-10% 
incidence of ovarian metastases. Some 
surgeons remove the ovaries if the 
lesion is large (stage lb2) or if there is a 
poorly differentiated tumour on biopsy. 

Postoperative radiotherapy is given 
in all cases where there is proven 
lymph node involvement. 

Radiotherapy is recommended as 
first-line treatment in the following 
circumstances: 

■ when surgical expertise is not 
available 

■ in women with a tumour greater 
than 4 cm in diameter 



■ in women who are not medically fit 
for surgery. 

Obesity makes surgery more difficult, 
but may also compromise the delivery 
of radiotherapy. 

Some centres now perform 
laparoscopic lymphadenectomy, in 
conjunction with the radical vaginal 
hysterectomy - this may represent less 
morbidity than a radical abdominal 
operation. These new combinations 
await full evaluation. 

Advanced disease (stage 4) 

Combinations of chemo- and 
radiotherapy are used but the overall 
survival rate is very poor. 

Follow-up 

Follow-up is for 5 years with more 
frequent clinic visits initially as 90% of 
relapses present within the first 
3 years. Recurrent disease may present 
with weight loss, leg oedema, pelvic, leg 
or back pain, supraclavicular 
lymphadenopathy, vaginal discharge, 
renal failure, bone pain or haemoptysis. 
The most frequent sites of recurrence 
are in the pelvis, lung, para-aortic nodes, 
liver, bone, vulva, inguinal nodes and 
supraclavicular nodes. There are four 
possible therapeutic options for 
recurrent disease: 

■ radiotherapy 

■ chemotherapy, e.g. platinum, 
bleomycin or ifosfamide 

■ surgery, generally exenterative 

■ palliation. 

The role of surgery for recurrent 
disease is confined to specific 
subgroups of patients, where there is 
evidence of central pelvic recurrence 
without metastatic disease and where 
the patient accepts such radical 
intervention. As 40% of patients with 
cervical carcinoma will eventually die, 
palliative care for the terminally ill is 
very important. The objective is to 
relieve or control any symptoms 
affecting the patients' quality of life 
whilst maintaining dignity. 



J 



Cervical carcinoma 



■ Cancer of the cervix is still quite common - reduction in incidence depends on the quality of the 
screening programme. 

• The aetiology appears to be multifactorial; the prime oncogenic agent is probably HPV-16. 

a Microinvasive squamous tumours carry a good prognosis, allowing conservative treatment 

initially if required. 

■ Earty invasive squamous disease, stages 1 b. 2a (and some cases of 2b) may be treated by either 
a Wertheim's hysterectomy or radiotherapy as first-line treatment. 

■ Glandular tumours (adenocarcinomas) are not detectable by screening, are associated with skip 
lesions and require radical surgery. 



138 GYNAECOLOGY 

Carcinoma of the uterus 



Carcinoma of the endometrium forms 
the most common type of uterine 
cancer. These are mainly 
adenocarcinomas derived from 
endometrial glandular cells. There are 
some rare variations, e.g. 
adenoacanthoma. Sarcomas which are 
derived from stromal cells may be 
endometrial or myometrial in origin. 
Prognosis and treatment are different 
for these two categories of uterine 
cancer. 

Endometrial carcinoma 

This is a disease which predominantly 
presents in the postmenopausal years 
Cover 75% of cases). Around 3-5% of 
cases will present under the age of 
40 years. Over one-third of the 
premenopausal patients present with 
heavy, but regular periods. The 
incidence of endometrial cancer is 
highest in white North Americans, 
who have a rate approximately seven 
times higher than the Chinese. 

Risk factors for endometrial 
carcinoma 

Most of the known risk factors for 
carcinoma of the corpus uteri share a 
common basis - that of excessive, 
unopposed oestrogen stimulation of 
the endometrium (Table 1). A 
doubling in body weight results in a 
doubling of peripheral conversion of 
androgens to oestrone in the fat cells. 
In polycystic ovarian syndrome there is 
an increase in the free, unbound 
oestrogen fraction available to 
stimulate the endometrium Csee 
p. 114). 

There appears to be an association 
between endometrial cancer and non- 
insulin-dependent diabetes mellitus 
(NIDDM). Although rare, the 
granulosa-theca cell ovarian tumours 
secrete excess oestrogen - 10% of cases 
are associated with endometrial cancer 
and 50% are associated with 
endometrial hyperplasia. Mucinous 



Table 1 Risk factors for carcinoma of the 
uterus 

■ Obesity 

■ Impaired glucose tolerance 

■ Nulliparity 

■ Late menopause 

■ Unopposed ocstrog en 1 herapy 

■ Functioning ovarian tumours (granulosa-theca cell 
tumour] 

■ Family history of r^rcmoma of breast, ovary or colon 



Table 3 1 n vesti gati o n of postme nopa usal bl eed i ng 


History 


Look lor relevant risk feelers 


Examination 


To exclude pelvic masses, assess uterine size and mobility 


Ultrasound 


Transabdominallyor transvaginal ly (TVS] ic assess endometrial thickness and 




presence o( iniracaviiy fluid 


Endometrial biopsy 


Pipelle. 'Z' sampler. Vabra aspirator 


Hystcfoscopy 


Under general anaesthetic or as outpatient procedure 


Dilatation and curettage 


Endometrial sampling under general anaesthesia 


Sonohysterorjraphy 


The instillation of fluid into ihe uterine cavity during scanning 


U D scanning (still in 


Facilitates accurate volume measurements 


semi experimental stage) 




Doppler and colour flow 


Usetl to detect changes in uterine and eodometnai blood flow with malignancy 


imaging (still in 




semi-eipenniental stage) 





carcinomas, endometrioid carcinomas 
and Krukenberg tumours (squamous 
ovarian tumours) have also been 
associated with an increase in 
oestrogen secretion. 

Care must be taken when prescribing 
hormone replacement therapy (see p. 
150). The administration of unopposed 
oestrogens leads to a risk of developing 
endometrial carcinoma 7-10 times 
higher than that of the general 
population. Tamoxifen used in the 
treatment of breast cancer has also been 
associated with endometrial hyperplasia 
and cancer as it has both oestrogenic 
and anti-oestrogenic properties. 
Smoking appears to be protective. 

Presentation and investigation 

The commonest presentation of 
endometrial carcinoma is 
postmenopausal bleeding. Pain may 
indicate metastatic disease. Discharge 
is often associated with the presence of 
a pyometra. Although postmenopausal 
bleeding is the commonest 
presentation for endometrial cancer, 
and occurs in 80% of cases, 
endometrial cancer is not the 
commonest cause of postmenopausal 
bleeding (Table 2). 

All cases of abnormal bleeding must 
be thoroughly investigated including 
irregular and/or heavy regular bleeding 
in the premenopausal group. 



Tabie 2 Causes of 
bleeding 


postmenopausal 


Benign causes - 
88% of cases 


Malignant causes - 

12°* of cases 


Atrophic vaginitis 
Endometrial polyps 
Endometrial hyperplasia 


t nrJrjmetrial cafcinoniy (S%) 
Cervical carcinoma 
Ovaiiar 1 . tu incurs 
Rare uterine tumours 
Extragenital tumours, bladder, 
colonic and rectal cancers 



Ultrasonography provides a useful 
screening tool. Atrophic endometrium 
has a thickness of 3 mm or less - 
thickened endometrium in a 
postmenopausal woman is therefore 
suspicious. Some centres use 5 mm as 
a cut-off point but G°/o of cancers will 
be missed. With a cut-off point of 
4 mm most cancers are detected. 
Demonstration of fluid in the 
endometrial cavity is associated with 
uterine and extrauterine malignancy in 
25% of cases and warrants a careful 
inspection of the adnexa. 

Outpatient endometrial sampling 
techniques have been introduced 
together with visualization of 
endometrial tissue via the 3 -mm 
hysterosope (Table 3 and p. 124). 
There is always a small risk of uterine 
perforation in the presence of friable 
cancerous tissue. 

Introduction of the 
sonohysterogram (SHG), seems to 
improve the detection of endometrial 
polyps, submucous fibroids and focal 
thickening of the endometrium. 
Further techniques under evaluation 
include 3-D scanning and colour 
Doppler blood-flow imaging. 

Pathology 

Endometrial carcinoma appears as a 
raised, rough or even papillary area 
and often arises in the fundus. The 
internal os is rarely involved early in 
the disease (Fig. 1]. Endometrial 
carcinoma has several distinct sub- 
types; the commonest is the 
endometrioid adenocarcinoma, when 
the glandular pattern generally 
resembles a normal proliferative phase 
endometrium (Fig. 1). 

Prognosis 

A number of prognostic factors have 
been identified. Clearly, the stage and 



Carcinoma of the uterus 1 39 




As per FIGO classification, 1988. FIGO Data for Survival 1990-1992. 



Fig. 1 Endometrial carcinoma, (a) View of cut surface of the uterus. Cb) High-power view of 
Grade 1 cancer. 



grade of the disease are of paramount 
importance. Lymph node involvement 
and evidence of vascular spread reduce 
the survival rate [Tables 4 and 5). 

Patients with tumours involving the 
cervix have a higher risk of metastases 
to other pelvic organs and lymph 
nodes. The survival rate is 
approximately 20°/o less than those 
with tumour confined to the corpus. 
Cancer of the corpus uteri is staged 
surgically (Table 5). 

Treatment 

Treatment will depend on both the 
stage of the disease and the fitness of 
the patient The patient must be 
accurately assessed preoperatively to 
exclude suspicious lymphadenopathy, 
ascites or organomegaly. Renal and 
hepatic function tests, tumour 
markers, chest X-ray and possibly an 
intravenous urogram will need to be 
undertaken. The CA125 level increases 
with increasing spread of the disease. 

The operation of choice is a total 
abdominal hysterectomy and bilateral 
salpingo-oophorectomy. Removal of a 
vaginal cuff does not reduce the 
recurrence rate or improve survival. The 
pelvic and the para-aortic nodes should 
be removed if the cervix or adnexa are 
involved, or if the myometrium is 
obviously deeply infiltrated. 

Radiotherapy is indicated if the 
histology shows a poorly differentiated 
or high-grade tumour, if the nodes are 
involved, or if staging at the time of 
surgery scores more than a lb. 

The stage 3 patient should have 
further imaging to determine whether 
the disease is confined to the pelvis. If 
possible, radical surgery with 
radiotherapy should be offered. Stage 4 
disease most commonly spreads to the 
lungs followed by peripheral lymph 
nodes and the bladder. 

Approximately 70% of recurrences 
following primary treatment occur 
within the first 2-3 years. Early 
recurrences carry a grave prognosis as 



Table 4 Prognostic 


factors 


Age 


Older women have a 




worse prognosis 


Body shape 


Obese, diabetic. 




hypercholesterolaemic 




(betlet differentiated 




tumours/better 




prognosis) 


Stage of the disease 


Myornetrial invasion 




Peritoneal cytology 




Lymph node involvement 


Histological subtype 




Degree of differentiation 




Steroid receptor status 




Lymphatic/vascular involvement 



Tables Grading and staging 


of carcinoma of the uterus 




Grading 


Staging 


5-year survival 


G* Grade cannot, be assessed 


Stage 





Atypical hypetplasia/carcirioma -in -situ 




Gi Well differentiated 










G2 Moderately differentiated 


Stage 


la 


Tumour limned to endometrium 


90.9% 


G3 Poorly or undifferentiated 




lb 


Invasion < 50% myometrium 


88.2* 




Stage 


to 


Invasion > 50% myometrium 


81.0% 


Differentiation refers to the degree to 


2a 


Endocervical glandular involvement only 


76.9* 


wtricfi the tumour resembles 




2b 


Cervical stromal invasion 


67.1% 


adenocarcinoma. The more squamous 


Stage 


3a 


Tumour invades the serosa of the corpus 


60.3% 


or solid growth, the less differentiated 






and/or adnexa, ± positive cytology 








3b 


Vaginal metastases 


ill 2% 






3c 


Metastasis to pelvic or para-aortic nodes 


31 .7% 




Siage 


'a 


Invasion of bladder and/or bowel mucosa 


20 1% 






4b 


Spread outside pelvis, including intra-abdomma 
spread/distant organs and/or inguinal nodes 


5.3% 



they indicate an aggresive tumour. 
Radiotherapy is of great value for 
palliation. Medroxyprogesterone acetate 
has been widely used for distant 
recurrence - the response rate is 15-20%. 

Tamoxifen and aminoglutethimide 
(an aromatase inhibitor] have also 
been assessed for stage 4 disease, i.e. to 
shrink distant spread. 

Uterine sarcoma 

Endometrial stromal sarcomas and 
mixed Miillerian tumours rarely occur. 

Myometrial tumours 

Leiomyosarcoma 

This is the malignant counterpart of 
the benign leiomyoma (fibroids) and is 



the most common pure sarcoma of 
the uterus. The gross appearance is 
similar to that of a leiomyoma, 
although the cut surface may be paler 
and more yellow, with areas of 
haemorrhage and necrosis. 

The majority present with irregular 
or postmenopausal bleeding, vaginal 
discharge, pelvic pain or pressure 
symptoms. In some situations the 
sarcoma is detected when fibroids 
enlarge rapidly. Only 5-10% of 
leiomyosarcomata arise from pre- 
existing fibroids and these have a 
better prognosis. Surgery is the 
treatment of choice. 



noma of the uterus 



i Endometrial carcinoma commonly presents with postmenopausal bleeding, bul endometrial 
carcinoma is nor the commonest cause of postmenopausal bleeding. 

i Most of the known risk factors for endometrial cancer involve excessive unopposed oestrogen 
stimulation of the endometrium. 

i The differentiation [grading) and staging of the disease are the most important factors 
influencing survival. 

i Total abdominal hysterectomy and bilateral salpingo-oophorectomy is the treatment of choice 
[for stage l disease). 

i Sarcomas carry a much worse prognosis than endometnal cancer, but are a much rarer tumour. 



140 GYNAECOLOGY 




Benign ovarian conditions 



Figure 1 shows the stages of ovarian 
development from the primordial ridge. 
Cells in the ovary may develop from all 
three types, hence the diversity of 
problems that may be found within the 
ovary. The mesodermal ridge is covered 
in epithelium for development of 
gonads and invagination of the 
coelomic epithelium forms the 
Mullerian duct Primordial germ cells 
migrate from the yolk sac 

Physiological cysts 

The physiological cysts are a persistence 
of structures found during normal 
ovarian function. They are largely 
asymptomatic and frequently undergo 
spontaneous resolution. They may 
present with pain and need 
investigation. Rupture or torsion may 
both present with an acute abdomen 
needing surgical intervention (see 
below). Haemorrhage into the cyst, 
although painful, may be managed 
conservatively and laparoscopy is only 
performed if the symptoms fail to settle. 



■t| 

!®S 

t 



Gerr 


n celts 


Mesonephric 
duct 

\\ J 


^ 


j ®© 

J9 ® ® ^, 


Of 


Genital ridge 


Mesonephric 
swelling 


Coelomic epithe 


ium 


Gut 




Gerr 


n cells 


Mesonephric 
tubules 




Coelomic epithelium 
(primitive germinal epithelium) 




Degenerating 
mesonephric 
tubules and 
duct 



Table 1 Pathological ovarian cysts 


Derivation 


Pathology 


Coelomic epithelium 


Serous cystadenoma 




Mucinous cystadenoma 




Brenner cell tumour 




Endometrioid cystadenoma 


Germ cells 


Cystic teratoma (dermoid cyst) 




Solid teratoma 


Sex cord cells 


Granulosa/theca cell tumours 




Fibroma 




Sertoli -Leydrg ceil 




(arrhenoblastoma) tumour . 



Follicular. These cysts are small (but 
may reach 10 cm diameter), unilocular, 
common, lined by oestrogen-producing 
granulosa cells and contain clear fluid 
rich in hormones. They are particularly 
likely in patients undergoing ovulation 
stimulation. 

Luteal. These may present with 
intraperitoneal haemorrhage. Luteal 
cysts are formed when the corpus 
luteum does not regress. 

Pathological cysts 

The pathological cysts and their 
derivation are shown in Table 1. 

Serous cystadenoma. The most 
common presenting cyst (Fig. 2) is 
unilocular with papuliferous growths on 
the inner surface (may also be on the 
outer surface making distinction from a 
malignant tumour very difficult). The 
fluid content is thin and serous, 
epithelial lining is cuboidal or columnar 



Primitive follicles Mesentery of ovary 
Fig. 1 Development of the ovary. 





Fig. 2 Serous cystadenoma. 



Fig. 3 Mucinous cystadenoma. 



epithelium and they occasionally 
contain calcified granules known as 
psammoma bodies. 

Mucinous cystadenoma. These are 
unilateral, multilocular, full of thick 
mucin, lined by columnar mucin- 
secreting epithelium and may reach 
great size (recorded up to 100 kg) 
(Fig. 3). Rarely they rupture, releasing 
mucin-producing cells which may 
implant and continue to secrete mucin 
which compromises bowel function and 
gives rise to significant mortality 
(pseudomyxoma peritonei). 

Brenner cell tumour. A rare presentation 
with islands of transitional epithelium in 
dense fibrotic stroma. They are usually 
small and may secrete oestrogen, so 
they can present with abnormal vaginal 
bleeding. 

Endometrioid cystadenoma. This is 
seldom distinguishable from a cystic 
patch of endometriosis. 

Dermoid cyst (cystic teratoma). This is 
the commonest cyst presenting in young 
women (Fig. 4). Their derivation from 
the pluripotential germ cells means that 
all tissue types may be found with hair, 
sebaceous cells, fat cells and teeth being 
most common. One cell-line may 
predominate (e.g. struma ovarii with 
hormonally-active thyroid tissue). They 
are mostly asymptomatic but may tort 
or rupture. 

Solid teratoma. Another rare 
presentation which will be benign if it 
contains mature tissues. Immature 
tissues are malignant 

Granulosa cell tumour. The commonest 
hormone-secreting tumour - 25% of 
which are malignant 



Benign ovarian conditions 




Fig. 4 Opened dermoid cyst. Showing hair, 
fat tissue and peripheral infarction due to ovarian 
torsion. 

Symptoms found with ovarian cysts 
include: 

■ pain - due to torsion or 
haemorrhage 

■ asymptomatic - especially 
physiological cysts 

■ abdominal swelling - large cyst or 
associated ascites (fibroma) 

■ pressure symptoms - affecting 
bladder and bowel function 

■ menstrual upset due to hormone 
secretion. 

Investigations 

Bimanual examination (Fig. 5). This may 
allow distinction between an enlarged 
fibroid uterus and an ovarian cyst but 
ultrasound may also be necessary. 

Ultrasound scan. The cyst fluid will 
show as dark on the picture (see 
follicular cyst) with a white-flecked 
appearance if blood is present Dermoid 
cysts appear more complex. It is 
important to look for features which 
may suggest malignancy (Fig. 6) 
(protrusions inside the cyst, 
multilocular, neovascularization, ascitic 
fluid in pouch of Douglas). 



(a) (b) 
Fig. 6 Ultrasound examination of ovarian cyst, (a) Smooth outline in ; 

(b] Projections into a malignant cyst. 



non-malignant cyst. 




Hormone assays. If the main symptoms 
suggest hormone-producing cysts (such 
as menstrual upset, hirsutism or 
virilization) check oestrogen and 
androgen levels. 

CA125. This tumour marker will be 
modestly raised in the face of 
endometriosis but a high value is 
suggestive of malignancy. Unfortunately 
a low value does not completely exclude 
malignancy. 

Diagnostic laparoscopy. This allows 
visualization of the cyst, peritoneal 
washings for cytology if concerned 
about possible malignancy and 
treatment by laparoscopic removal if 
appropriate (see below). 

Treatment 

Asymptomatic cysts less than 5 cm in 
diameter in a young woman require 
no action as these will usually undergo 
spontaneous resolution. 

Asymptomatic cysts greater than S cm 
in diameter in a young woman should 
be rescanned in 6 weeks. The cyst will 
be either smaller (or the same size) and 
need no action, or enlarged in size, 
possibly with blood in the fluid, and 
would be best removed to avoid the 
risk of torsion and loss of the ovary. 

A cyst that is symptomatic or rapidly 
enlarging requires removal. The 
traditional approach is by laparotomy. 
An ovarian cystectomy conserving all 
normal ovarian tissue and restoring 
the ovarian surface to normal with 



minimal chance for adhesion 
formation is the aim. This ensures that 
future fertility is not compromised. A 
fine, inert suture is used on the ovary 
to excite less tissue reaction and 
peritoneal lavage used to remove all 
blood, which would promote 
development of adhesions. The need to 
limit adhesion formation has 
encouraged the development of 
laparoscopic techniques to allow 
removal of the cyst with minimal 
tissue handling. The contents of a 
dermoid cyst, if spilled into the 
peritoneal cavity, may cause a chemical 
peritonitis so this may be best 
managed through a mini-laparotomy 
incision. 

Laparoscopic management of simple 
cysts can be performed by drainage of 
the cyst contents then peeling off the 
cyst capsule, which is sent for 
histological examination. In the case 
where the cyst may be malignant it is 
sometimes appropriate to offer 
laparoscopic oophorectomy. This will 
be considerably less invasive for the 
patient than the previous practice of 
total abdominal hysterectomy with 
bilateral salpingo-oophorectomy and 
omentectomy in any woman over 
45 years old found to have an ovarian 
cyst. The ovary is captured in a bag 
and removed intact from the abdomen 
so there is no risk of peritoneal 
seeding if any tumour exists. The 
patient may not require to proceed 
with more major surgery if histology 
confirms benign disease. 



Benign ovarian conditions 



Ovarian cyst 

Fig. 5 Bimanual examination for ovarian 
cyst. 



i Asymptomatic, simple cysts in young women may be managed conservatively. 

i Torsion of an ovarian cyst is an emergency - the ovarian blood supply must be restored to 
prevent necrosis. 

i Ultrasound examination allows distinction between ovarian cysts and fibroids. 

■ Laparoscopic management allows minimal tissue handling which should help to limit adhesion 

formation within the pelvis. 



142 GYNAECOLOGY 



Ovarian carcinoma 




The peak incidence is between 50 and 
70 years and carcinoma is more likely 
with nulliparity and in those with a 
positive family history. The use of the 
combined oral contraceptive protects, 
probably because it reduces the 
number of ovulations, which is 
thought to be an aetiological factor. 
Presentation is usually with abdominal 
pain and swelling, but may be with 
urinary frequency, weight loss, 
dyspeptic symptoms or abnormal 
menses. Three-quarters of cases have 
spread outside the pelvis at 
presentation (to the peritoneum, 
diaphragm, para-aortic lymph nodes, 
liver and lung); hence the overall 
5-year survival of only 29%. Epithelial 
tumours account for 80°/o of all ovarian 
neoplasms and 90% of all primary 
malignant ovarian tumours. 

Management 

Malignancy in an ovarian cyst is more 
likely in those > 45 years, or in whom 
cysts are bilateral, or where there is 
ascites, or solid areas within the cyst 
or an irregular growth on the capsule 
or where the cyst is fixed. 

Staging (see Table 1) 

Investigations and treatment 

Initial investigations should be with 
ultrasound scanning (USS) 
(± computed tomography (CT) or 
magnetic resonance imaging (MRFJ), 
measurement of urea and electrolytes 
(U <Sf Es), liver function tests (LFTs), a 
cancer antigen 125 test (CA125) and 
chest X-ray a-fetoprotein (AFP), human 
chorionic gonadotrophin (hCG) and 
estradiol should also be measured if a 
sex-cord/stromal or germ cell tumour 
is suspected). Peritoneal fluid cytology 



may demonstrate malignant cells. 
Pleural fluid, if present, may also 
demonstrate malignant cells and this 
should be aspirated prior to surgery. 
CA125 is not a specific marker and 
may be elevated with many intra- 
abdominal problems including pelvic 
inflammatory disease, endometriosis 
and after surgery itself Preoperative 
bowel preparation should be given if 
bowel surgery is anticipated. On 
opening the peritoneum, peritoneal 
fluid should be aspirated or washings 
taken with saline. Conservative surgery 
(with removal of one ovary) may be 
warranted if the patient is young, plans 
further family, has unilateral disease 
and has no ascites. A peroperative 
frozen section may be used, but is 
often difficult to interpret. Otherwise, 
total abdominal hysterectomy, bilateral 
salpingo-oophorectomy and infracolic 
omentectomy should be performed. 
Peroperative rupture of intact cysts 
probably has no adverse prognostic 
effect providing careful peritoneal 
toilet is performed. If there is extensive 
disease, cytoreductive surgery 
(debulking) is appropriate to improve 
quality of life, improve response to 
chemotherapy, prolong remission and 
increase median survival. Some 
surgeons would consider pelvic and 
para-aortic node sampling to ensure 
accurate staging in apparent la and lb 
cases. 

Postoperative chemotherapy is 
usually given for epithelial tumours if 
the staging is > la (or for la if poorly 
differentiated), ideally with a platinum- 
based agent in combination with Taxol. 
Germ cell tumours are very sensitive 
to chemotherapy, so fertility- 
conserving surgery in the young 
patient is appropriate and the majority 



Table i 


FIGO staging of ovarian cancer 




Stage 


Definition 


S-year survival 


la 


rib ovary 


60-70% but can be 95* for la 


tl> 


Both ovaries 




1C 


Va or 1ft with ruptured capsule, tumour on the surface of the capsule, positive 
peritoneal washings or malignant ascites 




23 


Emensron to uterus and tubes 


30* 


21) 


Extension to other pelvic tissue, e.g. pelvic nodes, pouch of Douglas 




2C 


2a or 2b Willi ruptured capsule, positive peritoneal washings or malignant 
ascites 




3a 


Pelvic tumour wiih microscopic pentoneal spread 


10% 


3b 


Pelvic tumour with peritonea! spread < 2 cm 




3c 


Abdominal implants > 2 cm ± positive retroperitoneal or inguinal 




4 


nodes ^Fig 1) 




Irver parenchymal disease. Distant metastases. If pleural effusion, most 


10% 




have malignant cells 






Fig. 1 Omental 'cake' in a stage 3c 
ovarian adenocarcinoma. 



of these are cured even if metastatic 
disease is present. Sex-cord/stromal 
tumours may occur at either end of 
the age spectrum. Most are stage 1 at 
presentation and can be effectively 
treated with conservative surgery if the 
patient is young. 

Recurrent disease 

Most women with advanced epithelial 
ovarian cancer relapse after primary 
management There is considerable 
potential for palliative therapy in such 
instances. New chemotherapaeutic 
agents have traditionally been first 
evaluated in such patients, but if a 
patient is offered palliative 
experimental chemotherapy in this 
way, it is vitally important to consider 
the side effects, as these can 
considerably impair a patient's quality 
of life. If relapse occurs more than a 
year after platinum-based 
chemotheraphy, the disease will often 
respond again and patiens may gain 
useful palliation in this way. 

Screening for ovarian cancer 

The poor survival rates associated with 
advanced ovarian cancer have 
contributed to the concern that 
effective screening tests be developed. 
Presently there is no evidence that 
screening the general population is 
useful or cost effective. Women with a 
family history who are deemed to be 
at high risk should be considered for 
the national familial ovarian cancer 
screening study run through clinical 
genetics centres. 

Familial ovarian cancer 

Although overall there is an increased 
risk of ovarian cancer in those with a 
family history (relative risk 1.1 for 
mother, 3.8 for sister and G.O for 



144 GYNAECOLOGY 

Benign vulval conditions 



Anatomy 

The vulva consists of the mons pubis, 
labia majora, labia minora, clitoris and 
the vestibule. It is covered with 
keratinizing squamous epithelium, 
unlike the vaginal mucosa which is 
covered with non-keratinizing 
squamous epithelium. The labia 
majora are hair-bearing and contain 
sweat and sebaceous glands: from an 
embryological viewpoint, they are 
analogous to the scrotum. Bartholin's 
glands are situated in the posterior 
part of the labia, one on each side of 
the vestibule. Its lymphatics drain to 
the inguinal nodes and then to the 
external iliac nodes, and the area is 
richly supplied with blood vessels. 

Bartholin's cyst 

The greater vestibular, or Bartholin's, 
glands lie in the subcutaneous tissue 
below the lower third of the labium 
majorum and open via ducts to the 
vestibule between the hymenal orifice 
and the labia minora. They secrete 
mucus, particularly at the time of 
intercourse. If the duct becomes 
blocked a tense retention cyst forms, 
and if there is superadded infection the 
patient develops a painful abscess 
(Fig. 1). The abscess can be incised and 




Bartholin's 
abscess 



Posterior fourchette 



■<^r 



\^ 



Ci reunite ren I ial 

incision 



Sutures joining 
the base o( the 
abscess to the 
vaginal 
epithelium 



Fig. 1 Bartholin's gland may develop a 
retention cyst. Infection leads to abscess 
formation. 



drained, usually under general 
anaesthesia. Antibiotics are usually 
only necessary if there is additional 
cellulitis. 

Pruritus vulvae 

This is commoner in the > 40 age 
group and has numerous aetiologies: 

■ infection (Candida, pediculosis, 
threadworms) 

■ eczema 

■ dermatitis 

■ irritation from a vaginal discharge 

■ lichen sclerosus 

■ lichen planus 

■ vulval intraepithelial neoplasia 
(VINO 

■ vulval carcinoma 

■ medical problems, e.g. diabetes 
mellitus, uraemia or liver failure. 

A biopsy may be necessary to establish 
the diagnosis. If no cause is found, 
irritants and bath water additives 
should be avoided, soap substitutes 
used, the area dried gently (e.g. with a 
hairdryer), loose cotton clothing worn 
and nylon tights avoided. A strong 
cream b.i.d. for 3 weeks followed by 
milder hydrocortisone cream 1% daily 
as maintenance is useful, as is the use 
of soap substitutes (e.g. Oilatum). 
Antihistamines may also be of help. 
Primary or secondary depression may 
also warrant treatment. 

Vulvodynia 

This is chronic vulvar discomfort, 
especially that characterized by the 
complaint of pruritus, burning, 
stinging, irritation or rawness. No one 
factor can be identified as the specific 
cause and indeed there appear to be 
no clinically definable differences 
between groups of patients. It may 
occasionally be associated with 
previous sexual abuse. Vulvar 
vestibulitis is a chronic clinical 
syndrome with erythema, severe pain 
on entry or to vestibular touch, and 
tenderness to pressure localized within 
the vestibule. If symptoms are of less 
than 3 months' duration, there is often 
response to topical corticosteroids. If 
they are chronic, treatment is empirical 
and symptomatic, with vestibular 
resection being considered only as a 
last resort. Essential vulvodynia refers 
to the description of constant, 
unremitting burning localized to the 
vulva which may respond to low-dose 



tricyclic antidepressants (e.g. 
amitriptyline). 

Urethral caruncle 

A urethral caruncle is a polypoidal 
outgrowth from the edge of the 
urethra which is most commonly seen 
after the menopause. The tissue is soft, 
red, smooth and appears as an 
eversion of the urethral mucosa. Most 
women are asymptomatic but others 
experience dysuria, frequency, urgency 
and focal tenderness. If there are any 
suspicious features, an excision and 
biopsy may be required to exclude the 
rare possibility of a urethral 
carcinoma. 

Ulcers 

Ulcers of the vulva may be: 

■ aphthous (yellow base) 

■ herpetic (exquisitely painful multiple 
ulceration, see p. 104) 

■ syphilitic (indurated and painless, 
see p. 104) 

■ associated with Crohn's disease ('like 
knife cuts in skin') 

■ a feature of Behcet's syndrome (a 
chronic painful condition with 
aphthous genital and ocular 
ulceration. Treatment is difficult; the 
combined oral contraceptive or 
topical steroids may be tried) 

■ malignant 

■ associated with lichen planus or 
Stevens-Johnson syndrome 

■ tropical (lymphogranuloma 
venereum, chancroid, granuloma 
inguinale). 

Simple atrophy 

Elderly women develop vaginal, vulval 
and clitoral atrophy as part of the 
normal ageing process of skin. In 
severe cases the thin vulval skin, 
terminal urethra and fourchette cause 
dysuria and superficial dyspareunia. 
The labia minora fuse and bury the 
clitoris. Introital stenoses can make 
coitus impossible. Treatment is with 
oestrogen replacement, and may need 
to be for a few months. There is a 
small amount of systemic absorption 
with topical therapy and, if this route 
is chosen, treatment should be for no 
more than 2 or 3 months without 
either a break or a short course of 
progesterone to prevent endometrial 
stimulation. If the oestrogen is given 
orally, progesterone should be added 
as for any HRT 



Benign vulval conditions 14 



Benign vulval diseases 

These are classified as: 

Lichen sclerosus. This can present at 
any age, but is more common in the 
older patient and usually presents with 
pruritus, and less commonly with 
dyspareunia or pain. The skin appears 
white, thin and crinkly but may be 
thickened and keratotic if there is 
coexistent squamous cell hyperplasia. 
There may also be clitoral or labial 
adhesions. Diagnosis is by biopsy and 
there is an association with 
autoimmune disorders in < 10% 
(pernicious anaemia, thyroid disease, 
diabetes mellitus, systemic lupus 
erythematosus, primary biliary 
cirrhosis or bullous pemphygoid). It is 
nonneoplastic but may coexist with 
VIN and there is an association with 
subsequent development of squamous 
cell carcinoma of the vulva [probably 
between 2-9%) (Fig. 2). Long-term 
follow-up is probably warranted. 
Treatment is required only if 
symptomatic, e.g. Dermovate twice 
daily initially, reducing gradually to 
hydrocortisone twice daily, once daily, 
or less as symptoms require. Eosin 
paint may also be of help. Vulvectomy 
has no role, the recurrence being = 50%. 

Squamous cell hyperplasia. This 
frequently presents in premenopausal 
women with severe pruritus. Diagnosis 
is again by biopsy and treatment is 
with hydrocortisone as for 'lichen 
sclerosus'. 

Other dermatoses. These include: 

■ Allergic/irritant dermatosis. This 
may be caused by detergents, 
perfume, condom lubricants, 
chlorine in swimming pools or 
podophyllin paint There may be 
secondary infection. Irritants should 
be removed and the area treated 
with emollients + topical 
corticosteroids. 




■ Psoriasis. The vulva is an unusual 
site for this, but if present, 
moderately potent steroids are better 
than coal tar. 

■ Intertrigo with Candida. This 
responds to antifungal preparations. 

■ Lichen planus. This appears as 
purple-white papules with a shiny 
surface and keratinized area and 
may respond to strong steroids ± 
azathioprine or PUVA. It is usually 
idiopathic, but can be drug related, 
and tends to resolve within 2 years. 
Surgery should be avoided. 

Varieties of intraepithelial 
neoplasia (i.e. the presence of 
neoplastic cells within the confines of 
the epithelium). 

Squamous VIN. This is classified as 1, 
2 or 3 depending on the severity 
('Bowen's disease' and 'Bowenoid 
papulosis' have been used to describe 
atypical squamous lesions, but are part 
of the same process of VIN). It is 
considered that human papilloma 
virus (HPV) may be important in 
aetiology. Many are asymptomatic 
although pruritus is present in 
between one-third and two-thirds, and 
pain is an occasional feature. Lesions 
may be papular and rough surfaced 
resembling warts, or macular with 
indistinct borders. White lesions 
represent hyperkeratosis, and 
pigmentation is common. The lesions 
tend to be multifocal in women under 
40 and unifocal in the postmenopausal 
age group. Diagnosis is by biopsy, 
which may be taken at vulvoscopy, 
using 5% acetic acid as at colposcopy, 
under either local or general 
anaesthesia. The opportunity should 
be taken to look at the cervix as well, 
as there is an association between 
cervical intraepithelial neoplasia (CIN) 
and VIN. As the natural history is so 
uncertain, treatment is controversial. 
Regression has been observed 
(particularly in low-grade VIN) but 
progression of high-grade VIN to 
invasion may occur in approximately 
6% of cases and up to 15% of those 
with VIN 3 may have superficial 



invading vulval cancer. Treatment of 
VIN may be indicated in those > 45, 
those who are immunosuppressed and 
those with multifocal lower genital 
tract neoplasia. The main treatment is 
wide local excision (the exception is 
VIN 3 on the clitoris in young women 
- use an Nd-YAG laser). A colposcope 
should be used to inspect the vulva 
(keratinization may make visualization 
of abnormal cells difficult) and then 
take a biopsy with a 4-mm trephine 
under local or general anaesthesia 
(Fig. 3). It is also necessary to check the 
perianal area as there may also be anal 
intraepithelial neoplasia. 

Melanoma in situ. This is uncommon. 

Non-sauamous VIN (Paget's disease). 
This is also uncommon. There is a 
poorly demarcated often multifocal 
eczematoid lesion associated in 25% 
with adenocarcinoma either in the 
pelvis or at a distant site. Treatment is 
by wide local excision. 




Fig. 3 Squamous VIN. (a) There is a 

superficial hyperkeratosis. Hyperchromatic nuclei 
are seen within all cells from the basement 
membrane to the epithelial surface. CM There is a 
raised wart-like area of leukoplakia on the medial 
aspect of the left labia majora. A biopsy is required 
to differentiate this from other conditions with a 
similar appearance. 



Fig. 2 Lichen sclerosus has a small 
association with carcinoma of the vulva. 



J Benign vulval conditions 

■ Pruritus vulvae has numerous aetiologies. 

■ Appearances are often not diagnostic and biopsies are often required. 

■ Lichen sclerosus is common, associated with autoimmune disorders, and only rarely with VIN are 
vulval carcinoma. 

■ The natural history and optimal treatment of VIN are uncertain. 

■ There is an association between VIN and CIN. 



148 GYNAECOLOGY 

Vulval carcinoma 



Vulval cancer is not a common disease 
- approximately 800 new cases are 
registered annually in the UK. It is an 
unpleasant but potentially curable 
disease - even in elderly, unfit ladies if 
they are diagnosed and referred early. 

Vulval cancer should be referred to 
specialist centres where adequate 
numbers are seen to maintain a level 
of expertise. 

Treatment requires a 
multidisciplinary approach with 
adequate supportive care and 
counselling facilities. The patients are 
usually elderly and often have 
coexisting disease. 

Aetiology 

The majority of vulval carcinomas are 
squamous in origin with a number of 
much rarer cancers contributing to the 
remaining 10%. Basal cell carcinoma 
and verrucous carcinoma represent 
uncommon squamous subtypes. 
Malignant melanomas and Bartholin 
gland tumours can occur. Several risk 
factors have been identified for vulval 
carcinoma: 

■ other genital cancers 

■ smoking 

■ prior history of genital warts 

■ vulval carcinomas in situ (VIN) 

■ chronic vulval inflammatory 
disorders. 

Several conditions are thought to have 
malignant potential (Table 1) although 
progression to carcinoma has not yet 
been proven. Vulval intraepithelial 
neoplasia is graded in order of severity 
in a similar fashion to cervical 
intraepithelial neoplasia (ON] [see 
p. 135]. Patients with precursor lesions 
should undergo continued 
surveillance. Early biopsy is 
recommended if there is any change in 





(a) (b) 

Fig. 1 Vulval carcinoma, (a} Polypoidal lesion, (b) Ulcer. 



symptoms or appearance of the lesion. 
Multifocal or multicentric disease can 
be very difficult to manage. 

Diagnosis 

Most patients with invasive disease 
complain of irritation or pruritus 
(71%) and 57% notice a vulval lesion, 
which may be a polypoidal mass or an 
ulcer (Fig. 1). The presentation of 
symptoms and the appearance of the 
epithelium may be quite varied. Vulval 
symptoms in a postmenopausal 
woman should be promptly examined 
and atypical areas biopsied. One of the 
most worrying features of this disease 
is the delay between the onset of the 
first symptoms and the diagnosis of 
the condition - delays of over 
12 months have been reported. 

Warts are not common in 
postmenopausal women and should 
be treated with suspicion. 

Lesions that fail to respond to simple 
first-line treatment in premenopausal 
women should be investigated. 

Assessment 

Diagnosis should be confirmed by 
appropriate biopsy so that definitive 
management can be planned. It may 
be appropriate to remove a large 
ulcerated or fungating mass 



Table I Precursor lesions 


Lesfon 


Lifetime risk of vulval carcinoma 


Vulval intraepithelial neoplasia [VIN] 




Histologically recogntfabie atypra present 




VIN 1 - mild 


1 


VIN 2 - moderate 


L 5-10%(fangequctedai2-B0il} 


VIN 3 - severe 


J 


(Full thickness abnormal itres, disordered maturation. 




excess mitotic figures) 




Pagei's disease 


Rare, In 20% o( cases, there is evidence of malignancy 


A disorder of skir adnexas structures [apocrine sweat 


elsewhere 


glands) 




Lichen sclerosus 


3-5% 


Cause unknown, associated with autoimmune disorders 





completely at the first sitting, so that 
excision both provides a biopsy 
specimen and achieves symptomatic 
relief in the very frail. Small lesions 
(less than 2 cm in diameter) may be 
removed by a wide local excision as 
both biopsy and curative procedure. 

Once a diagnosis has been 
confirmed the patient requires a full 
explanation of the situation. 
Preoperative assessment must be 
thorough as the majority of patients 
affected are elderly and may have 
other medical conditions. In a younger 
patient who remains sexually active 
there are both psychological and 
psychosexual connotations involved. 

Female lower genital tract cancer is 
often multicentric and the 
investigation of a patient with vulval 
cancer must include inspection of the 
cervix and up-to-date cervical cytology. 
Nodal involvement, if present, must be 
identified before surgery. Full blood 
count, biochemical profile and chest 
X-ray are necessary. An 
electrocardiogram (in the elderly 
patient), intravenous urogram or 
lymphangiogram may be required. A 
magnetic resonance imaging (MRI) 
scan may be helpful if there is nodal 
involvement in defining the extent of 
the spread. 

Management 

The management of vulval carcinoma 
depends entirely on the stage of the 
disease at presentation. Early invasion 
of the vulva is termed 'superficially 
invasive vulval cancer 1 and is analogous 
to stage la cervical cancer. This is rarely 
associated with lymph node metastasis. 
The risk of metastasis increases with 
the depth of invasion of the tumour - 
tumours showing less than 1 mm 
depth of invasion appear to have a 
negligible risk of lymph node spread 
(Table 2). 



Vulval carcinoma 



la 



lb 



Table 2 Staging of vulval carcinoma 

Stage 

Ca re moma -in ■ Sii u . intra epithelial 

neoplasia grade 3 

Lesion confined to the vulva diameier 

< 2 cm with < T mm invasion, 
superficially invasive vulval carcinoma 
Lesion confined to the vulva, diameter 

< 2 cm. depth > 1 mm no nodal 
metastasis 

Lesion confined: to the vulva, and/or 
perineum, diameter > 2 cm -no nodal 
metastasis 

Lesion of any sue extending beyond ine 
vulva with adjacent spread to lower 
urethra and/or vagina, or anus, without 
grossiy positive groin nodes 
Lesion of any s»/e confined to the vulva 
and having nodal metastasis (unilateral or 
regional} 

Tumour invades any of the lollowing- upper 
urethra. Bladder mucosa, rectal mucosa, 
pelvic bone and/or bilateral nodes 
Any distant metastasis, including pelvic 
lymph nodes 



M> 



As per FIGO classification, including 1994 modifications. 
•The depth of the invasion is defined as the measurement 
of the tumour from the epithelial stromal junction of the 
adjacent, most superficial dermal papilla, to the deepest 
point of invasion. 

Table 3 Com p licati ons of. radica I su rge ry 

Short-term 

■ Wo und i n fect'on and b rea kdown 

■ Deep vei n th rombosis, pu imonary embolism 

■ Pressure sores 
Long-term 

■ I ntrortal stenosis, dyspareu n ia 

' m Urinary and faecal incontinence 

■ Reclocele 

■ Lymphoedema/lymphocyst 
Hernias 

Psychological and psychosexual problems 
Recurrence 



Spread can either be direct [to 
adjacent organs), lymphatic, or, in very 
late cases, haematogenous. The femoral 
and inguinal nodes are the sites of 
regional spread. Involvement of pelvic 
lymph nodes, (external iliac, hypogastric, 
obturator and common iliac nodes) is 
considered distant spread. Lymphatic 
drainage from the vulva and perineum 
is complex. Tumours that are close to 
midline structures, e.g. the clitoris, can 
spread quickly bilaterally. 

Management of early stage 
disease 

The high morbidity associated with 
radical surgical treatment of vulval 
cancer has prompted the development 
of more conservative, but effective, 
alternatives. Early stage disease is best 
treated by wide radical local excision, 
which should remove all areas of 
atypical epithelium - although this 
may be difficult to achieve in 
multifocal disease. In these situations, 
multiple diagnostic biopsies must be 
considered as it is important to try to 
exclude areas of occult invasion. The 
decision to perform groin node 
dissection would depend on the depth 
of the lesion (if > 1 mm). 

The site of the lesion will determine 
whether unilateral or bilateral groin 
dissection is required. For stage lb and 
stage 2 tumours the triple incision 
technique is employed - excision of 
the vulval tumour and then excision of 
the groin nodes via separate incisions 
[Fig. 2). This avoids the prolonged 



healing associated with the classical 
butterfly incision of radical vulvectomy. 

Advanced vulval disease 

The management of stage 3 disease 
will require radical dissection. There 
are no data available to support the 
use of the triple incision technique for 
stage 3 tumours when the nodes are 
obviously involved. In these situations 
radical vulvectomy via the butterfly 
incision with complete node dissection 
en bloc is the standard technique. 
Healing is by granulation [Fig. 3), 
unless skin flaps or skin grafting is 
employed. Wound breakdown still 
affects 30 to 50% of cases (Table 3). 
Consider reconstructive surgery at the 
time of radical excision. 

Preoperative radiotherapy with or 
without concurrent chemotherapy can 
cause tumour shrinkage - this may 
allow for urinary and anal sphincter 
conservation. 

Postoperative radiotherapy is 
considered valuable if two or more 
nodes are found positive, and if the 
primary tumour has not been 
adequately excised. 

Recurrent disease 

Local recurrence is associated with 
inadequate excision margins and is 
more likely with verrucous and basal 
cell carcinomas. Radiation may be 
useful and further excision may be 
possible in previously irradiated cases. 
Erosion into the femoral artery is the 
usual long-term outcome. 



/ 



N ^/** 




(a) ibi (c) 

Fig. 2 Surgery for early stage vulval carcinoma, (a and b] Triple incision technique, (c) Butterfly incision. 




Vulval carcinoma 



Fig. 3 Healing by secondary intention 



Vulval carcinoma is an uncommon gynaecological cancer affecting mainly the elderfy age group. 

9CM> of vulval cell carcinomas are squamous. 

Lesions less than 1 mm in depth have a negligible risk of lymph node metastasis. 

Early stage disease can be treated with wide radical local excision. 

Advanced disease is still treated by radical vulvectomy with en bloc node dissection. 



148 GYNAECOLOGY 

Menopause: physiological changes 



Definitions 

The menopause is the final act of 
menstruation. The climacteric is the 
phase in the ageing process when a 
woman passes from the reproductive to 
the non-reproductive stage. Thus the 
menopause is a single event and the 
climacteric is a period of time during 
which a woman may experience a 
considerable number of symptoms and 
signs (Table 1). 

The menopause may be physiological 
or artificial, induced by radiation, 
surgery [e.g. oophorectomy), or 
hormonal therapy (e.g. gonadotrophin 
releasing hormone analogues). This 
chapter deals with the physiological 
menopause, although the changes are 
common to both. Spontaneous cessation 
of menses before the age of 40 years is 
termed premature ovarian failure. 

Pathogenesis 

There are 7 million oogonia in the fetal 
ovary at 20 weeks' gestation. After the 
seventh month of gestation no new 
oocytes are formed. At the time of birth, 
the number has already dropped to 2 
million and by puberty there are only 
30 000 oocytes. Continued reduction 
follows. These large numbers are lost 
mainly due to the process of atresia, 
although some are lost through 
ovulation. 

At the menopause the sensitivity of 
oocytes to respond to gonadotrophin 
stimulation disappears. Estradiol levels 
are therefore low, removing negative 
feedback to the hypothalamus and 



pituitary, leading to very high levels of 
gonadotrophins, luteinizing hormone 
(LH) and follicle stimulating hormone 
(FSH) [see p. 120). 

Hormonal changes 

Changes occur in four different 
hormonal groups after the menopause: 
androgens; oestrogens; progesterone; 
gonadotrophins. 

There is a 50% reduction in circulating 
androstenedione. Adrenal androgens fall 
by 60-80% with age. 

The fall in testosterone is minimal. 
There is 14% conversion from 
androstenedione, but the majority is 
produced by hilar and luteinized 
stromal cells within the ovary that do 
respond to the increased gonadotrophin 
outpouring. The relative increase in 
testosterone compared to the other 
androgens may be manifest in a receding 
hairline, hoarse voice and the facial hair 
sometimes seen in elderly ladies. 

Estrone is the oestrogen of the 
menopause, mainly produced by the 
adrenals - although peripheral 
conversion from androstenedione 
doubles. Some estrone and testosterone 
peripherally convert to estradiol, 
accounting for the small percentage of 
estradiol still available. Cessation of 
ovulation heralds a 70% reduction in 
progesterone as there is no further 
corpus luteal production. Adrenal 
production continues. Pituitary LH and 
FSH levels rise considerably as estradiol 
levels fall, but are still released in a 
pulsatile fashion. 



Table 1 Signs and symptoms of the menopause 


General problems 


Sexual problems 




Daytime sweats and flushes 


Vaginal dryness/soreness 




Night lime sweats and flushes 


Vaginal itching 




Poor sleep pattern 


Dys pareunia 




Tiredness 


Postcoital bleeding 




Loss of energy 


Loss of libido 




General aches anti pains 


Difficulty achieving orgasm 




Generalised pruntus 

Fomiita&on [sensation of something crawling over the 

skin] 


Urinary problems 
Frequency 

Urgency 




Emotional problems 


Urge incontinence 




Tearulness 


Stress incontinence 




Depression 


Nocturia 




Reelings ol unworihrness 


Enuresis 




irritability 

Anger 

Panic attacks 
Palpitations 


Period problems 




Erratic cydes 

Uglier menstrual loss/heavier toss 




Intermenstrual bleeding 
Postmenopausal bleeding [bleeding after 


1 year's 


Personality problems 


amenorrhoea) 




Loss of memory 






Loss of concentration 






Feelings of personality disintegration 







Signs and symptoms 

Reproductive tract 

Although abrupt cessation of menses 
can occur, it is more usual to have 
oligomenorrhoea with increasing cycle 
irregularity. Polymenorrhagia with 
heavier and more frequent menses is 
uncommon and warrants endometrial 
assessment (see p. 138). The vaginal and 
cervical skin become thinner, drier and 
more fragile. The vaginal cytology 
confirms surface cells that are less 
mature and less keratinized. This results 
in vaginal soreness and dryness with 
superficial dyspareunia, postcoital 
bleeding and intercurrent infections. 

The uterus also undergoes changes. 
The normal endometrium becomes thin 
and inactive (see p. 138). The 
myometrium shrinks. The ovaries also 
atrophy. Easily palpable ovaries are 
suspicious and warrant further 
investigation. Ligaments and connective 
tissue lose tone and elasticity which 
predisposes to uterovaginal prolapse. 

Urinary tract 

As the bladder and vagina both share 
the same embryological derivation from 
the urogenital sinus, the urethra and 
trigone are predisposed to similar 
atrophic changes. This can give rise to 
symptoms of frequency and urgency, 
often mistaken for cystitis. 

External changes 

Breast tissue regresses in size and tends 
to sag. There is generalized thinning and 
loss of elasticity in the skin leading to 
wrinkling. The hair changes in pattern 
with sparser axillary and pubic hair and 
increased, coarse terminal hair. 

Psychological and emotional 
changes 

Psychiatrists report a premenopausal peak 
incidence of affective disorders relating to 
negative feelings regarding the onset of 
ageing and loss of fertility, especially in 
western cultures. Gynaecologists ascribe 
the increased incidence of tearfulness and 
depression to falling levels of estradiol 
and progesterone. Oestrogen receptors 
have been identified in the limbic system 
of the brain. The situation is complex - 
life crises can occur in this age group and 
genuine endogenous depression may also 
be present 

Vasomotor symptoms 

Flushes normally start on the face and 
spread downwards across the neck and 
chest. They may last a few seconds or 



Menopause: physiological changes 149 



10 minutes and can occur from once to 20 times a day. Night 
sweats may lead to chronic sleep depletion. Seventy percent of 
women exhibit vasomotor symptoms for 1 year, 30% for 
5 years and 10% for 10 years. There appears to be a temporal 
relationship between flushes and pulsatile release of LH. 

Osteoporosis 

Osteoporosis represents reduction in bone mass and micro- 
architectural disruption leading to enhanced bone fragility and 
increased fracture risk. The World Health Organization 
(WHO) definitions are as follows: 

■ osteopenia [1-2.5 SDs below adult reference peak bone mass) 

■ osteoporosis f> 2.5 SDs below adult reference peak bone 
mass). 

The bone remodelling process involves four processes [Fig. 1). 
Formation takes longer than resorption - the two are linked, 
or coupled. At the menopause the remodelling cycle becomes 
unbalanced, or uncoupled. The osteoclasts produce larger 
cavities which the osteoblasts do not completely fill with 
osteoid, resulting in a net decrease of bone mass. Oestrogen 
has an anti-resorptive effect 

In women, peak bone mass is achieved in the early 30s. It is 
influenced by diet [including calcium intake), exercise, genetics 
and environment Subsequently bone mass is lost gradually 
until the menopause, when falling oestrogen levels accelerate 
the process. When bone density falls below a critical level [the 
fracture threshold) the risk of fracture is increased. There is a 
50% loss of trebecular bone and a 5% loss of cortical bone 
[Fig. 2). The commonest fracture sites are vertebral body, 
upper femur, distal forearm, humerus, ribs. The incidence of 
these fractures varies with age (Fig. 3). One in four women in 
the 60s suffer vertebral crush fractures, causing pain, 
shortened stature and spinal curvature - the classical 
'dowager's hump' (Fig. 4). 

Cardiovascular changes 

Ischaemic heart disease (IHD) represents the biggest cause of 
death in women. Men suffer from IHD more commonly than 



Resting and resorption 



Quiescence 




^ — Lining cell 

Bone 
Osteocyte 



Activation 



Resorption 







^ C£> 



<s> 




Osteoclast 

Howship's 



Formation and resting 



Formation 




lacuna 



Osteoblast 

Osteoid 
New bone 



Quiescence 



Fig. 1 The bone remodelling process. 



women until women reach the menopause - subsequently 
catching up rapidly. Comparing age-matched groups of 
premenopausal and postmenopausal women, the incidence of 
IHD is found to rise with increasing age, but is consistently 
less in the premenopausal groups at all ages. This would 
suggest that oestrogen has a protective effect 

Total cholesterol is made up of low density lipoprotein (LDL) 
and high density lipoprotein (HDL) fractions. The former is 
easily deposited on damaged endothelium and predisposes to 
atherogenic change. At the menopause, total cholesterol, LDL- 
cholesterol and triglyceride levels rise. HDL-cholesteroI and in 
particular the HDL 2 subfraction falls. Oestrogen reverses these 
trends and appears also to act at the cellular level 




Fig. 2 (a) Normal and (b) osteoporotic bone. 




40 50 60 70 80 90 

Age (years) 

Fig . 3 Incidence of different types of fractures with age. 




Fig. 4 X-ray showing wedge fracture of the spine. 



Menopause: physiological changes 






■ Loss of oestrogen production has a profound' effect on several 
systems. 

■ Periods usually become lighter and less frequent. 

■ Estrone replaces estradiol as the chief oestrogen produced. 

■ Testosterone is relatively the most important androgen. 

■ Symptoms may be severe and prolonged. 

■ Bone loss is accelerated at the menopause, predisposing to fractures. 

■ The lipid profile alters to become more atherogenic. 

■ Oestrogen possesses anti-resorptive properties in bone and reverses 
the trends in the HDLADL ratio. 



150 



GYNAECOLOGY 

Menopause: management 



Hormone replacement therapy (HRT) is widely accepted as a 
treatment for symptoms of the menopause and osteoporosis. 
Epidemiological data suggest a role against ischaemic heart 
disease (IHD) and, from more recent evidence, Alzheimer's 
disease. 

Hormone replacement therapy 

HRT combines natural oestrogen with progestogens, synthetic 
derivatives of progesterone (Table 1). 19-nortestosterone 
derivatives are androgenic and produce more side effects (e.g. 
bloating, mood swings and mastalgia). C21 -progesterone 
derivatives are more progesterone-receptor specific and produce 
fewer side effects. Micronized progesterone is available in 
Europe and America. There are several oestrogens available. 

Progestogen is administered either cyclically for 12 to 
14 days a month (a sequential combined therapy, SCT), or 
continuously [a continuous combined therapy, CCT) (Fig. 1). 
The former will promote a monthly withdrawal bleed. The 
continuous combined preparations are reserved for women 
who have been amenorrhoeic for 12 months and do not wish 
to bleed. One preparation offers the chance of 3-monthly 
withdrawal bleeds (seasonal bleeds). 

Unopposed oestrogen may only be prescribed to 
hysterectomized women, as oestrogen induces endometrial 
hyperplasia and long-term use may promote endometrial 
cancer. The incidence of cystic hyperplasia varies between 
7 and 20%. Even after cessation of unopposed oestrogens, the 
increased risk of endometrial cancer persists for up to 
14 years. The added progestogen effects protection by 
secretory transformation. 

Several routes of administration are available (Table 2). No 
one preparation is better than another, but there is a wide 
variation in patients' needs, requiring a flexible approach to 
treatment. Oral HRT enters the enterohepatic circulation, 
activating hepatic enzymes that accelerate metabolism. 
Systemic HRT achieves 'liver bypass' entering the circulation 
directly. Patches or gels may therefore be better for epileptics, 
tablets for those with hypercholesterolaemia or skin 
conditions. Estradiol implants are useful for long-term therapy 



Table I Components of hormone replacement therapy and 
related preparations 

Oestrogens 

■ Conjugated equine oestrogens [CEEs) 

■ 1 7 beta estra dio I (pla m ext racl oestrogens) 

■ Es tradio I va lora te [plant extract oestrogens) 

■ Estrone 
Progestogens 

■ Progestero ne [the nat oral hormone) 

■ Progesterone analogues. C21 derivatives 

- didrogesterone 

- medroxyprogesterone acetate 

■ 1 9 ■ r i o rtestoste ra ne derivatives 

norethisterone/norel histerone acetate 

- levonorgestrel 
Gonadomimetics 

■ Tibolone [containing oestiogenic. prcgeslogenic and androgenic components) 
Selective oestrogen receptor modulators 

CSERMs) 

■ Raloxifene [modeled oestrogen molecule stimulating bone receptors, but not 
endomeinal and Dreasl receptors: also reduces cholesterol levels) 

Phyto-oestrogens 

■ Natural dietary lihre ocstrccens. obtained from a health food shop 



L 



□ □□□□□ 
Sequential combined therapy (SCT) 
- monthly bleeds 



C 



Continuous combined therapy (CCT) 
- no bleeds 



| Oestrogen 
Progestogen 



Oestrogen 
I Progestogen 



Seasonal bleed therapy 

- every 3rd month 



D Oestrogen 
Progestogen 



Fig. 1 Sequential combined therapy, continuous combined 
therapy and seasonal bleeds. 

Table 2 Routes of administration of HRT available 

Oestrogen 

■ OlLil 

■ Transdermal, patches or get 

■ Nasal spray 

■ Implants 

■ Vag ma I preparal ions . cream, pessary an d ring 
Progesterone 

■ Oral 

■ Vaginal, gel or pessary 
Progestogens 

■ Progesterone analogues. C2 1 derivatives 

oral 

■ Testosterone analogues 19-nortestosterone denvanves 
-oral 

- transdermal [as sequential combined and 
continuous combined preparations] 
Gonadomimellcs 

■ Oral 
SERMs 

■ Oral 



and can be given in conjunction with testosterone. Careful 
monitoring of the serum estradiol level is required to prevent 
tachyphylaxis. The body adapts to supraphysiological levels of 
oestrogen resulting in severe symptoms, even though levels 
are well above the accepted therapeutic range. 

Tablets, gels and nasal spray are administered daily, patches 
either once or twice a week and implants G -monthly. Vaginal 
preparations may be useful for relief of vaginal dryness. 

Approach to treatment 

Many women show great interest in HRT, but some express 
reservations. Main concerns focus on side effects, weight gain, 
risk of cancer and withdrawal bleeds. A structured approach to 
treatment includes information, counselling and HRT. 

Every woman should be fully counselled as to the risks and 
benefits of treatment (Table 3) and should be included in the 
decision-making process. Information should include what 
routes of administration and types of HRT are available, how 
long therapy should continue (for adequate bone protection a 
minimum of 5 years' therapy is advised), and what side effects 
may be encountered. Bleeding usually lessens over four to six 
successive cycles to a light, regular 3- to 5-day loss. Minor 
transient side effects may occur and the patient should be 
encouraged to persevere. Changing brands every 1-2 months 
promotes problems. 



Menopause: management 151 



Table 3 Risks and benefits of HRT 
Bwwflu 


R 


Increased incidence of breast cancer - duration of 


■ Protection against osteoporosis and reduced 


■ 


fracture rales [may 'buy hack' some lost bone] 




use effect 


■ Reduction in incidence ol colonic cancel 




- background populatton risk increased by 2 pet 


■ Protection against IHD (controversial) 




1000 if used from 50-55 years 


- increases HDL'LDL ratio 




- Background population risk increased by 6 per 


- reduction m insulin resistance 




10DD il used from 50-60 years [fiul 5-year survival 


- reduction in android fat distribution 




rates are better in women developing breast cancer 


- enhanced coronary artery blood flow 




on HRT compared to non-users) 


- beneficial effects on renin -angiotensin system 


■ 


increased incidence of thromboembolism 


m Delay in o nset of Alznei m e<" s d isease 


■ 


Increased risk of endometrial cancer (very small if 


[controversial] [improvement in mild to 




progestogens are used correctly) 


moderate disease) 


■ 


Urogenital atrophy/vaginal soreness 



Assessment and screening 

Diagnosis is normally made on clinical 
grounds. A follicle stimulating hormone 
(FSH) level may be performed if there is 
doubt, e.g. severe premenstrual 
syndrome. Independent medical 
conditions may coexist; both 
hypothyroidism and endogenous 
depression can mimic climacteric 
symptoms. Thyroid function tests and a 
fasting lipid profile are useful baseline 
tests. Pre-existing diabetes and 
hypertension should be adequately 
controlled prior to commencing HRT, 
but are not contraindications to 
treatment (Table 4). A personal or 
family history of thrombosis should 
prompt a full thrombophilia screen 
including anti-thrombin III, protein C, 
protein S, activated protein C resistance 



HRT increases breast tissue density - 
which makes interpretation more difficult 
A decision to perform mammography 
more frequently may also be taken. 

Bone densitometry is expensive and 
not routinely available. It is performed 
in high-risk groups (Table 5). If 
symptoms are present that require 
treatment, HRT is prescribed in a bone- 
sparing dose. Bone density 
measurements, including single or dual 
X-ray absorptiometry, are made over the 
lower lumbar spine and left hip (Fig. 1). 
The results are plotted against accepted 
norms for the age and sex of the patient 
(Fig. 3). 

The follow-up appointment 

The follow-up visit is normally at 
4 months, then 6- to 12-monthly 



Table h Absolute contraindications to 
HRT 

■ Severe hepatic impa rment 

■ Recurrent idiopathic thrombosis 

■ History of recent breast cancer 

■ Irregular vaginal b'eeding of unknown origin 

■ Myocardial infarction and stroke 



Table 5 Factors that indicate risk of 
osteoporosis 

■ Famify history oiosteoporosis 

■ Historyofspomaneousfiaclures 

■ Premature marianfaikjre 

M Oophorectomy or ovarian ablation 

■ Long-term steroid therapy 

■ Oronic immobilization 

■ Hyperthyroidism 

Weaker and less accurate predictors: 

■ Thin individual with slight frame 

■ Caucasian or Asian 

■ Low calcium intake 

■ Caffeine or alcohol excess 

■ Smoking 



thereafter if the patient is stable. A 
review is made at each visit of symptom 
control, side effects and the bleeding 
pattern achieved if on a sequential 
combined therapy. Weight and blood 
pressure are checked at each visit If 
there is irregular bleeding, an initial 
response would be to adjust the HRT 
regimen. If this fails to achieve control, 
the bleeding should be investigated. 




1.0 


BMD (Troch) = 492 (30) 


1.6- 
1.4- 

f 2- 

1.0 : 
0.8- 

0.6- 
0.4- 

12- 

i.o- 

0.8- 
0.6 : 
0.4 
0-2 : 

0,0 : 


BMD (inter) = 0.791 (29) 


0.8- 


~~~~— - — _^__ 


0.6 


~~~~-~~—S^^' 


~~~~~~-~^^ 


0.4- 

0.2- 
Q 


^^ 


""- 4 \ 


1 






00. 

1.4- 


BMD (Total) - 0.646 (28) 


BMD (Ward's) = 0.333 (20) 


1.0- 


~~~~— --^^ 


0.8- 


~~~~— — ^^~~^ 


0.6 
0.4" 
0.2- 


~~^- 



20 30 40 50 60 70 80 



20 30 40 50 60 70 80 



Fig. 2 Bone densitometry equipment. 



Age 
Fig. 3 Bone densitometry plot for hip. 



(APCR), anti-nuclear factor, lupus 
anticoagulant and anti-cardiolipin 
antibodies. A cervical smear need only 
be performed at the initial assessment if 
it is overdue. 

Mammography is routinely offered in 
many countries. In the UK screening is 3- 
yearly between the ages of 50 and G5 
years. If HRT is commenced before the 
age of 50 years, mammography is not 
routinely performed. If there is a family 
history of breast cancer, or a past medical 
history of benign breast disease, baseline 
imaging prior to treatment is useful, as 



Menopause: management 

■ There is a wide varety ot HRT regimens available and treatment should be tailored to the 

individual's needs. 

■ Clear explanations and adequate counselling improve compliance. 

■ Medical conditions mimicking climacteric symptoms should be excluded. 

■ Unopposed oestrogen increases the risk of uteri he cancer and must be given in conjunction 
with progestogens, either cyclically or continuously. 

■ The risk of breast cancer with HRT is duration-dependent, but remains small for 5 years Of use 
after the age of 50. 

■ Regular follow- up should assess symptom control, side effects and bleeding pattern. 

■ Abnormal bleeding should be investigated. 

■ HRT should not be prescribed in the presence of undiagnosed abnormal bleeding. 



152 GYNAECOLOGY 



Uterovaginal prolapse 



Uterovaginal prolapse is rare in 
quadripeds, but evolution to an 
upright posture has added additional 
strain to the biped pelvic floor. 

Aetiology 

The pathogenesis of prolapse is thought 
to be multifactorial, with congenital 
weakness of supporting structures, 
damage to pelvic floor musculature 
during childbirth, menopausal atrophy 
of the tissues and raised intra-abdominal 
pressure. Potential aetiological factors 
include the following. 

Congenital weakness 

A deficiency of the supporting tissues 
may be important There are families 
where prolapse is noted through the 
generations. Nulliparae may also 
develop prolapse. This may be a less 
extreme form of cases where herniae 
formation are well recognized. 

Childbirth 

It is well recognized that childbirth 
damages the pelvic floor innervation and 
the secondary muscle atrophy 
predisposes to uterovaginal prolapse. 
Caesarean section appears to afford some 
degree of protection over vaginal delivery. 
It has been assumed that the length of 
the second stage of labour and heavy 
birth weight would be factors associated 
with prolapse, but surprisingly studies 
have not confirmed this. Tearing of tissue, 
as might occur with a precipitous labour, 
may be a factor. 

Menopause 

After the menopause there is marked 
atrophy of the vaginal tissues. While 
this may be associated with stenosis of 
the vagina, it is more common to find 
some form of prolapse. 

Raised intra-abdominal pressure 

Chronic cough or the presence of an 
intra-abdominal mass is associated 
with raised intra-abdominal pressure 
and may be a factor in the 
development of prolapse. Work has 
shown that obesity is not a factor in 
transmission of raised pressures to the 
urinary tract, thus it is of questionable 
importance in the genesis of prolapse. 

Other factors 

Chronic straining at stool with 
perineal descent may damage pelvic 
floor innervation, thus putting the 



connective tissue supporting structures 
under additional strain. The type of 
connective tissue found in those with 
prolapse may predispose them to 
tissue failure contributing to the 
genesis of prolapse. 

Presentation (Table l, Fig. l) 

History 

Commonly the patient complains of a 
lump or fullness within the vagina 
which may have been first noticed 
during a lifting episode or be of 
gradual occurrence. It is commonly 
worse in the evening, after standing. 
There is often associated back pain 
(possibly due to tension on the utero- 
sacral ligaments), and bleeding and 
discharge may be present if the prolapse 
has ulcerated. Care should be taken not 
to miss a coincidental endometrial 
carcinoma. Associated symptoms may 
be urinary incontinence and frequency 
(see p. 154) or problems with 
defecation - or, less commonly, faecal 
incontinence. Patients may mention the 
need to reduce a posterior prolapse in 
order to complete defecation or a 
cystocele to aid voiding. 

Examination 

On examination there may be signs of 
vaginal wall laxity at rest - asking the 
patient to bear down or cough should 
demonstrate the problem. Urinary 
incontinence may also be 
demonstrable. The patient is then 
placed in the Sims' position and 
examined using the Sims' speculum 



TabJe 1 Types of prolapse 


Name 


Condition 


Cystocele 


Prolapse of the anterior vaginal 




wall and bladder 


Urethrocele 


Prolapse of the anterior vaginal 




wall and urethra - often found with 




cystoceJe 


Recta eel e 


Prolapse of Ihe posterior vaginal 




wall and rectum 


Enterocele 


Prolapse ol the upper posterior 




uaginai wall (posterior fornix) and 




pouch of Douglas 


Uterine prolapse 


The cervix uten descends within 


1 st degree 


the vagina but does not pass 




outside the introftUS during 




straining 


Ulerine prolapse 


The cervix uteri protrudes beyomd 


2nd degree 


(he introitus during straining 


Uterine prolapse 


Total prolapse of the uterus and 


3rd degree 


cervix outside the vaginal introicua, 


[procidentia) 


dragging the vaginal walls and 




associated structures with u 




Enterocele Rectocele 

Fig. 1 Types of uterovaginal prolapse. 

(see p. 86), examining first the anterior 
vaginal wall with cough to 
demonstrate urinary incontinence and 
then the posterior vaginal wall by 
reversing the speculum. The patient is 
then returned to the dorsal position 
and a bimanual examination 
performed to assess the size of the 
pelvic organs. Neurological 
examination as in cases of urinary 
incontinence (see p. 154) may be 
appropriate. Urinary symptomatology 
may necessitate urodynamic 
investigation (see p. 154). 

Management 

The management may be conservative 
or surgical, the conservative approach 
being appropriate in patients who 
prefer this, who wish to avoid surgery 
or who may be unfit for surgery. 
Surgical treatment includes anterior 
colporrhaphy, Manchester repair 
(anterior repair and cervical 
amputation - rarely performed), 
vaginal hysterectomy, posterior repair, 
repair of enterocele and vault fixation. 



Uterovaginal prolapse 153 




Fig. 2 The shelf pessary (black) may be 
needed if the perineum is deficient or the 
prolapse pushes out the ring pessary 
(white). 

Conservative (Fig. 2) 
A ring pessary made of a circle of 
pliable plastic is inserted by 
compressing it into an oval shape. 
When it regains its circular shape in 
the vaginal fornices it is then larger 
than the vaginal outlet and keeps the 
vaginal walls elevated. Patients should 
be unaware of it once it is correctly 
positioned and should be able to lead 
a normal life including sexual 
intercourse. It is changed every 
G-12 months and oestrogen cream 
may improve tissue quality, preventing 
ulceration of the ring site. A shelf 
pessary may be used in very unfit 
patients not suitable for surgical 
correction where the ring pessary will 
not stay in place. Vaginal cones may be 
used to strengthen the pelvic floor in 
more mild degrees of uterovaginal 
prolapse (see p. 1553. 

Surgical 

Numerous operations exist for 
correction of prolapse. The principle 
behind them all remains the same - 
that of correction of the protrusion 
with placement of supporting sutures 
and tissues to prevent recurrence. The 
problem with this approach is that the 
tissues have failed in their supporting 
role already and thus may fail again, so 
the patient should be warned of this 
before surgery is undertaken. 

Anterior colporrhaphy (or anterior 
repair). The anterior vaginal wall is 
opened, the bladder and urethra 
dissected free, and sutures placed from 
the pubocervical fascia under the 
bladder neck to the pubocervical fascia 
on the other side, giving support and 
continent function. The operation is 
completed with supporting sutures to 
the bladder base, if possible, repairing 
the fascia under the bladder (Fig. 3). 




Urethra 



Fig. 3 Anterior repair. 



Posterior colporrhaphy or 
colpoperineorrhaphy (or posterior 
repair). The posterior vaginal wall is 
opened in the midline and tissues 
dissected free from the vagina until the 
fascial plane is clear. An overlapping 
fascial repair is performed above the 
rectum. The tissue has already failed, 
so its strength is questionable. If there 
is also an enterocele, the hernial sac 
should be located, a purse-string 
suture applied round this and the 
uterosacral ligaments brought together 
in the midline to supply support 
underneath this. There is usually an 
associated deficiency of the perineum, 
corrected by sutures to the superficial 
perineal muscles. 

Vaginal hysterectomy. This procedure 
is seldom carried out alone for 
prolapse but often in combination 
with anterior and/or posterior repair as 
the descent of the uterus usually drags 
other structures with it (Fig. 4). 
Operating from the vagina, the uterus 
is removed and the uterosacral 
ligaments used to provide support to 
the vaginal vault 



Uterovaginal prolapse 



Midline anterior 
repair 

Opened 
anterior vaginal 
wall 



Cervix 




Fig. 4 A procidentia (whole uterus outside 
the body) may be best treated with a 
vaginal hysterectomy. 

Clinical note 

Bleeding from an ulcerated prolapse 
may mask endometrial carcinoma - 
assessment with ultrasound and 
endometrial sampling is important to 
exclude this. 



■ Prolapse is caused by childbirth, menopause and/or congenital weakness. 

■ It is important to establish any history of associated unnary and bowel problems 

■ Examination should include use of Sims' speculum and neurological examination. 

■ Conservative management with pelvic floor exercises may supplement surgery to correct the 
prolapse. 



154 



GYNAECOLOGY 

Urinary incontinence 



The main conditions affecting women 
are urodynamic stress incontinence 
(US I) and detrusor overactivity (DO). 
Between them these comprise over 
90% of female incontinence with 
45-50% being USI. The remaining 
5-10% are a mixture of congenital 
abnormality, neurological problems 
resulting in overflow incontinence, and 
postsurgical or postdelivery problems. 
Urinary symptomatology may trouble 
a woman at any stage in her life but 
onset is particularly prevalent any time 
after childbirth and through into the 
postmenopausal phase. 

Genitourinary fistulae have an 
unknown incidence as many affected 
women throughout the world do not 
seek medical help. In developing 
countries, fistulae are mainly of 
obstetric origin due to obstructed 
labour leading to pressure necrosis or 
due to a traumatic delivery with injury 
to the urinary tract In developed 
countries, most genitourinary fistulae 
are due to pelvic surgery, malignancy 
or radiation therapy and if of obstetric 
origin are likely to be the result of 
forceps delivery, caesarean section or 
peripartum hysterectomy. 

Symptoms 

The symptoms show wide variation 
and include stress incontinence, 
urgency, urge incontinence, frequency 
and nocturia (Table 1). Enquiry for 
voiding disorder includes completeness 
of bladder emptying, straining to 
initiate micturition, and whether the 
urinary stream has a good volume and 
is constant. However, the history is a 
surprisingly poor discriminator of the 
different diagnostic groups. This 
makes investigation important 

Examination 

Examination of the patient should 
include general examination, including 
the chest for signs of chronic 
obstructive airways disease resulting in 
chronically raised intra-abdominal 



pressure, and general neurological 
examination - especially testing S2,3,4 
perianal sensation, informing on the 
innervation of the bladder. Abdominal 
palpation should rule out the presence 
of a full bladder or pelvic mass (see 
p. 8G). 

Pelvic examination is performed first 
in the dorsal position. The health of 
the vaginal tissues is determined and 
whether there is any redness due to 
incontinence. Parting the labia to reveal 
the external urethral meatus allows 
demonstration of stress incontinence 
with coughing. If the jet of urine is not 
simultaneous with the cough it may 
point to cough-induced detrusor 
overactivity. 

An assessment of the degree of 
prolapse is performed in Sims' 
position. Examination is completed by 
a bimanual examination, during which 
assessment is made of the strength of 
pelvic floor muscle contraction. 

Investigations 

Mid-stream urine examination for 
infection is always the first 
investigation as many of the patient's 
symptoms may be caused by urinary 
tract infection. Uroflowmetry will 
allow assessment of the voiding time 
and also the peak flow rate achieved. 
In females this is commonly 50 ml/sec 
as the short, wide urethra allows rapid 
voiding (Fig. 1). The lower normal 
limit is 15 ml/sec, although voiding 
disorder is quite uncommon in the 
female patient 

Subtracted cystometry is performed 
to assess the detrusor pressure during 
filling of the bladder and voiding. 
Intravesical pressure is a mix of 
intra-abdominal pressure and 
intravesical pressure. By measuring 
intrarectal pressure and subtracting 
this from intravesical pressure, 
detrusor pressure or pure bladder 
pressure is measured (Fig. 2a). 

The standard approach is to use fast- 
fill cystometry (50-100 ml per minute), 



58 
40' 
30 
20- 
10 





C 



1000 
800 
600 1 

g 

400 \ 

200 





Table 1 Symptoms 


of urinary incontinence 


Symptom 


Meaning 


Stress n continence 


Leakage of urine during raised intra-abdominal pressure, e.g. coughing, laughing 


Urgency 


Uncontrollable desire to micturate, necessitating rushing lo toilet 


Urge incontinence 


Urinary leakage associated with uncontrollable need tn micturate 


Frequency 


Voiding more than seven times during day 


Nocturia 


Woken to vord Iwice or more at night 


Continuous leakage 


Possible genitourinary fistula 


Enuresis - child hood oi 


Bed -wetting - noi woken with the desire to void 


adult onset 





Fig. 1 Uroflowmetry. A normal female flow. 

which is a provocative manoeuvre for 
detrusor contraction whilst the patient 
attempts to inhibit this. The usual 
bladder capacity is - 500 ml and during 
filling there should be no appreciable 
rise in detrusor pressure. Other 
provocations used during filling include 
coughing, listening to the sound of 
running water, and change of position. 
The patient coughs when standing. 
Should coughing produce incontinence 
with a flat detrusor pressure the 
diagnosis is USI. Various patterns of 
raised detrusor pressure are noted 
which make the diagnosis of DO (Fig. 2b). 

The patient then voids on a 
commode while the pressures are still 
being measured, allowing an 
assessment of whether voiding is by 
abdominal straining, detrusor 
contraction, or purely by pelvic floor 
relaxation. These basic investigations 
may not result in a diagnosis in all 
patients and improved sensitivity may 
be obtained by using ambulatory 
cystometry or filling using contrast 
medium to allow visualization of the 
urinary tract (videocystometry). Pelvic 
ultrasound can assess whether the 
patient voids to completion and 
investigation of the kidneys with 
intravenous urography may be 
appropriate if haematuria is noted. 
Cystoscopy may also be indicated. 

Management 

Once the diagnosis is made a decision 
about the type of management is 
necessary. For both USI and DO there 
are conservative and surgical options. 

Conservative management of USI 

Conservative management of USI 
centres around controlling and 
improving pelvic floor function. There 
are many ways to do this. The 
physiotherapist teaches pelvic floor 
exercises, either using digital 
examination and teaching the patient 
to do this herself whilst contracting the 
pelvic floor, or aided by the use of a 
perineometer which grades the 
strength of contraction achieved. 



Urinary incontinence 




(a) (b) 

Fig. 2 [a] Normal subtracted cystometry. Good subtraction and a clear detrusor line. 

(10 Systolic detrusor overactivity with detrusor contractions provoked by bladder filling. 



Vaginal cones are a set of graduated 
weights [Fig. 4) used to improve the 
pelvic floor muscle strength and can 
demonstrate the improvement the 
patient is making, thereby aiding 
compliance. 

Interferential therapy stimulates 
pelvic floor muscles and improves 
their strength by application of two 
currents set to form an interference 
pattern at the level of the pelvic floor. 
This allows greater stimulation of the 
muscle than a direct application of 
current which has to overcome skin 
resistance. 

Having been objectively assessed all 
these methods are now in more 
common use than in the 1970s when 
surgery was the first-line treatment for 
many women. 




Conservative management of DO 

Bladder drill is the main conservative 
method of managing DO. This 
involves teaching the patient to retrain 
her bladder by regular, timed voiding 
and step-wise increasing of the time 
between voids. This may be useful in 
80% of patients, is non-invasive, and if 
a relapse occurs they may try the same 
treatment again. Combining this with 
drug therapy may improve results 
though admission of patients for 
inpatient retraining has not been 
shown to be superior. 

As the cause for detrusor 
overactivity is unknown, treatment has 
to be symptomatic. Anticholinergic 
medication will damp down smooth 
muscle contractions but side effects 
include dry mouth, constipation, and 
trouble with visual acuity. A commonly 
used drug is oxybutinin hydrochloride 
with the dose titrated against the 
patient's symptoms and side effects. 



The long-acting formulation is 
associated with fewer side effects and 
tolterodine also has a better side effect 
profile. Imipramine or antidiuretic 
hormone may be helpful with adult 



Surgical management of USI 

Various surgical procedures may be 
appropriate with the colposuspension 
often being first-line in a case where 
there is adequate vaginal mobility to 
allow the elevation of the vaginal 
mucosa towards the ileopectineal 
ligaments. This raises the level of the 
bladder outlet and as a first time 
procedure would result in ~ 90% of 
patients being dry. 

The TVT (tension-free vaginal tape] 
procedure, which aims to reproduce 
the action of the pubourethral 
ligaments, has similar results to the 
colposuspension but is performed 
under local or regional anaesthesia. 
Long-term follow-up for TVT is 
awaited. 

Surgical management of DO 

Surgical management of DO is used 
only if bladder drill and medical 
treatment have failed to control the 
symptoms. The surgical approach 
attempts to denervate the bladder, with 
varying success. The 'Clam' 
ileocystoplasty inserts an ileal patch 
and allows the raised pressure during 
a contraction to be dissipated. 

Surgical management of fistula 

Unless the fistula is detected within a 
few days of its formation, conservative 
management with continuous catheter 
drainage in the hope of spontaneous 
closure has little to offer. The 
principles of surgical management 
include antibiotics to ensure no 
infection in the field, wide mobilization 
of the tissues around the fistula, a 
layered tension-free closure, 
augmentation of the repair by use of 
surrounding healthy tissue or omental 
graft, and adequate urine drainage 
postoperatively. 



Urinary incontinence 



Fig. 4 Vaginal cone. Tampon pictured for size 
comparison. 



i Urodynamic stress incontinence (USI) and detrusor overactivity [DO] are the two main causes of 
female incontinence 

i The incidence of genitourinary fistulae is unclear due to the large numbers of women who do not 
seek medical help. 

i Investigation of urinary symptoms is needed as there is large overlap in symptoms between DO 

and USI. 

i Su rgery or co nse rvative the ra pies are app ropriate for US I a n d D but the bsla nee favo u rs 
surgery for USI and conservative treatment for DO 



156 GYNAECOLOGY 

Emotional disturbances in gynaecology 



It is important to think holistically 
when assessing a woman presenting 
with emotional lability. A number of 
different possibilities must be 
considered: 

■ endogenous depression 

■ reactive depression 

■ thyroid imbalance 

■ severe premenstrual tension 

■ pregnancy 

■ perimenopausal or menopausal status. 

It is easy to distinguish between some 
of these possibilities, but in other cases 
diagnosis is more difficult. Women in 
their late 40s often have increasingly 
severe premenstrual tension. It is quite 
easy to confuse severe premenstrual 
with perimenopausal women who 
have mood swings, but the latter may 
have an elevated basal follicle 
stimulating hormone (FSH). 

Women entering the menopause are 
not immune from other problems. 
There is often a change in the 
psychodynamics of the family unit at 
this time. Children grow up and leave 
home; the woman who until now has 
worked part-time to be available for 
the family may feel isolated and under- 
valued. The desire to go back to work 
full-time may be hindered by loss of 
self-esteem and self-confidence. Marital 
relationships may deteriorate and a 
long-standing partner leaving for a 
younger woman further reinforces 
feelings of low self-esteem and 
unworthiness. 

Financial considerations represent 
an added burden. Redundancy, early 
retirement due to ill health, or sudden 
bereavement may leave the woman in 
financial difficulties. These women 
often present as withdrawn and tearful 
and need careful assessment to 
establish what proportion of their 
symptoms are hormonally-related and 
what are due to reactive depression. 

Endogenous depression may arise 
without any precipitating extrinsic 
factors. A family history of depression, 
a previous history of postnatal 
depression, or severe premenstrual 
tension may act as warning signs. The 
patient usually presents with classic 
symptoms of early morning waking, 
inability to cope and a withdrawn and 
blunt affect. She may need assessment 
by a psychiatrist, or counselling and 
therapy from a clinical psychologist. If 
the general practitioner has known the 
patient for a long time and has a good 



rapport, he/she is in an excellent 
position to supervise and maintain 
treatment 

Premenstrual syndrome 

Premenstrual syndrome (PMS) is a 
disorder of unknown aetiology. It may 
represent an exaggerated response to 
the physiological levels of ovarian 
hormones through the cycle. There is a 
wide range of proposed theories. 

Symptoms 

Classically, the symptoms occur in the 
luteal phase. In primary PMS, the 
symptoms resolve completely by the 
end of menstruation, whereas in 
secondary PMS the symptoms 
improve by the end of menstruation 
but do not disappear. The 
improvement should be sustained for 
at least 1 week. The range of 
symptoms reported are numerous but 
fall mainly into four categories: 

■ mood, including irritability, 
tearfulness, depression and hostility 

■ cognitive function, including poor 
concentration, forgetfulness and 
confusion 

■ somatic manifestations, including 
bloating, mastalgia, headaches, 



Please mark ALL sympiams with a tick v. Score if 
you have never experienced that symptom, t if mild. 
2 if moderate and 3 if severe 







1 


2 


3 


Muscle stiffness 










Headache 










Cramps 










Backache 










r,-j!:rji;e 










General aches and pains 




















Lowered work performance 










Stay at home 










Avoid social activities 










Decreased efficiency 




















Dizziness. 










Cold sweats 










Nausea, vomiting 










Hoi Hushes 




















Affectionate 










Orderliness 










Excilemen) 










Feelings of well being 










Bursts of energy 




















Insomnia 










ForgetfuJness 










Contusion 






Lowered jud^ 
nrffleui*' 





Fig. 1 Premenstrual symptom 
questionnaire. 

tiredness and both appetite and sleep 
disturbance 
■ behavioural change, including social 
withdrawal and inability to cope. 

It is often helpful to have the patient 
score the severity of her symptoms 
(Fig. 1). It is also important to assess the 



Emotional levels 
— . always high 



Non-menstrually 
related disorders 



Asymptomatic 




Emotional levels 
always low 



Emotional levels 
vary cyclically 



Menses 



Ovulation 



Menses 



Fig. 2 Menstrual diary evaluation of PMS. 



Emotional disturbances in gynaecology 157 



degree of underlying psychological 
dysfunction using established 
psychiatric questionnaires. Quality-of- 
life questionnaires will assess the degree 
to which the woman's life is disrupted. 

Diagnosis 

This is based on the history and 
supported by cycle charting (Pig. 2). 
Symptom charting is required to obtain 
a sound diagnosis and to monitor 
therapeutic interventions. Cycle charting 
increases patient insight into the 
condition and empowers her to take 
control of her own experiences. Charting 
will clearly differentiate cyclical symptoms 
with a symptom-free week from those 
where the symptoms are continuous, e.g. 
endogenous depression, hypothyroidism, 
lethargy due to anaemia. 

It is important to differentiate 
cyclical from non-cyclical breast pain 
which may require mammography or 
ultrasonography. Breast cancer must 
be excluded. 

Few women exhibit significant fluid 
retention with PMS - daily weighing 
may differentiate. 

In ambiguous cases a therapeutic 
3-month trial of a gonadotrophin 
releasing hormone (GnRH) analogue to 
suppress ovarian function is very 
helpful. If symptoms persist, despite 
amenorrhoea, the diagnosis cannot be 
PMS. 

Management 

The list of therapies employed in PMS 
is extensive, partly because the theories 
of aetiology are numerous. It is 
reasonable to start with simple, non- 
hormonal approaches (Fig. 3) and ask 
the woman to complete a stress 
management diary. There may be 
certain situations which trigger stress 
or inability to cope. These are best 
avoided in the premenstrual phase. 
Exercise may reduce stress by 
enhancing endorphin metabolism in 
the luteal phase. 

Some women report benefit from 
caffeine withdrawal. An evening meal 
which is carbohydrate-rich and 
protein-poor has been recommended - 
this could have an effect via serotonin 
metabolism. 

Orcadian modification has been 
shown to reduce the severity of PMS 
symptoms. The manoeuvre involves 
sleep deprivation for 1 night early in 
the luteal phase. Postulated 
mechanisms involve melatonin 
secretion. PMS appears to be a 
seasonal variation disorder, as it is less 
troublesome in the summer. 



Counselling 

Education 

Reassurance 



Stress management 
strategies 



Exercis 



Dietary 
modifications 



X 



Orcadian 
modification 







Fig. 3 Management of PMS. 

If non-medical treatments are 
unsuccessful a combination of oil of 
evening primrose, vitamin B6 or 
calcium and magnesium supplements 
may be considered. Some also make 
claims for zinc and copper 
supplements. Oil of primrose contains 
the polyunsaturated essential fatty 
acids linoleic and gamma linolenic 
acids, which are the dietary precursors 
of several prostaglandins, mainly El 
and E2. Efficacy and treatment has 
probably been over stated, but some 
studies do demonstrate benefits over 
placebo. Many patients will have self- 
prescribed before seeking medical 
treatment; one problem with this 
approach is cost. 

Ovulation suppression with the pill 
or depot progestogens is successful. 
Danazol is helpful, but because of its 
side-effect potential is not first-line 
therapy. Natural progesterone 



suppositories have been used 
extensively, but no study has 
demonstrated a benefit superior to that 
of placebo. 

Diuretics, e.g. aldosterone 
antagonists, should be reserved for 
those who demonstrate true fluid 
retention. 

Antidepressants have been used 
with some benefit. The selective 
serotonin re-uptake inhibitors appear 
to be especially beneficial, e.g. 
fluoxetine (Prozac). Oestrogens in the 
form of implants or transdermally as 
patches have produced measurable 
benefits. For the intractable, severe 
cases of PMS it may be necessary to 
refer to a clinical psychologist to offer 
group and individual therapy. No 
woman should be subjected to 
bilateral oophorectomy as a treatment 
until a proven benefit from ovarian 
suppression has been confirmed. 



Emotional disturbances 



■ In the pen menopausal age group, severe premenstrual tension, endogenous or reactive 

depression may present with emotional lability. 

■ The patient must be treated with care and sensitivity, or background social and emotional 

problems may be missed. 

■ The diagnosis of PMS depends on proven, cyclical variation with 1 week clear of symptoms, or at 

least a reduction in seventy of symptoms. 

■ Ovulation suppression will eradicate symptoms: failure to do so puts the diagnosis in question. 

■ Treatment options are varied, but should involve the woman and ideally start with non-hormonal 

therapies. 



158 GYNAECOLOGY 






Psychosexual disorders 



Psychosexual disorders are very 
prevalent They may be secondary to a 
physical problem or the primary 
aetiology may be psychogenic or 
psychosocial. Often women are 
reluctant to admit to problems and 
find it easier to consult their doctor 
about 'discharge' or 'general malaise', 
hoping their real concern will 
eventually be addressed. Sometimes 
the problem is more obvious, e.g. non- 
consummation, and the partner or the 
family, concerned about lack of 
offspring, may demand referral. 

Physiology of sexual arousal 

Human sexual response is a 
specialized autonomic reflex, which is 
extensively modulated by the higher 
centres of the central nervous system. 
There are several discrete, yet inter- 
related physiological and 
psychosensorial components (Fig. 1). 
Sexual response can be triggered and 
developed psychogenically by stimuli 
arising within the central nervous 
system, or reflexogenically in response 
to tactile stimulation of the genitalia or 
other erogenous zones. When arousal 
reaches a threshold level, orgasm is 
triggered (Fig. 2). Following orgasm, 
loss of arousal to prestimulation levels 
occurs, so-called resolution, if the 
stimulus is withdrawn. In women, 
continued stimulation may result in a 
series of orgasms known as a multi- 
orgasmic response. Three factors are 
involved in this model of arousal: 

■ effective stimulation 

■ sexual drive and sexual desire 

■ sexual arousal and sexual 
excitement 

Many women increase psychogenic 
stimulation during sexual activity by 
sexual fantasies to enhance their arousal. 
Reflexogenic sexual stimulation is a 



Sexual drive 



Sexual desire 

\ 



i 




Orgasm 






Threshold fevet 












ffl 








■Ji 






O 










o 








< 






\ tt 



Physiological arousal 
(genital vasocongestion 
and lubrication) 




Cognitive awareness 

J 
Sexual excitement 



Sexual partner 

(if applicable) 



Sexual behaviour 

4 



Orgasm - 

I 

Resolution 



Sexual satisfaction 



From 

Riley A.J. and Athanasiadis L. (1997) 
Impotence and lis non-surgical management 
Br.J.CIm Practice 51 99-105 



Fig. 1 Physiological model of female sexual function. 



partly learned phenomenon. Negative 
stimuli include anxiety, guilt feelings of 
inadequacy, low self-esteem and pre- 
occupation with other issues. 

Sexual arousal in women induces 
local vasocongestion, which makes the 
organs turgid and spongy, providing a 
cushioning effect against possible 
trauma caused by penile penetration. 
Simultaneously, vaginal transudation 
provides increased lubrication. The 
upper two-thirds of the vagina balloon 
and the uterus and cervix move away 
from the penetrating object. Some 
women have an inability to associate 
these physiological changes with erotic 
feelings. 

Taking a sexual history 

There is a wide range of sexual 
problems. Sexual dysfunctions, e.g. lack 
of libido, aversion to penetration, 
difficulty in obtaining orgasm or 



superficial and deep dyspareunia, are 
the most common problems seen in 
gynaecology. A full history should be 
taken (Table 1). A sex therapist or 
psychosexual counsellor will interview 
both partners and may spend 3 or 4 
hours with the couple. A gynaecologist 
or general practitioner is less able to 
afford this time, but often each 
appointment will last 1 hour. It is 
important to modify the history to 
assess the main points, e.g. was sexual 
function always difficult or has there 
been a recent deterioration? Can 
triggering factors be identified? Is there 
interest in or desire for sexual activity, 
or does the act cause revulsion? 
During sexual activity does adequate 
excitement and lubrication occur? If 
there is adequate stimulation is 
orgasm unreasonably delayed? 

Care must be taken in eliciting 
whether there is genuine loss of libido 



Fable ' Areas to cover in a sexual history 


Details of the problem 


Nature, duration and development 


Rclat onship history 


With current and previous panne's quality of general relationship, scpa r ation. 




in fidelities, areas of conflict hopes 


Sexual development 


Puberty, menarche. menopause [and attitude to these Changes}, sexual 




experiences [tooth positive and negative), masturbation 


Past medial and surgical history 


Including past and current medication and contraceptive history 


Past psychiatrc history 


Any current psychiatric illnesses, any previous sexual/relationship difficulties 


Family history 


PjTemai relationships, family and teligrous influences, relationship with in -laws 




and children 


Social history 


Education, leisure activities, work history, occupational factors - e.g shift work. 




time away from home, periods of unemployment 


Alcohol intake/drug usage 


Sex education 


Level of sexual knowledge, patient's beliefs and expectations of sexual fund. en. 




aims and goals ol seeking therapy 



Time 
Fig. 2 Human sexual response. 



Courtesy of Dr Lynne Webster, Consultant Psychiatrist with a special interest in Psychosexual Medicine, Manchester Royal 
Infirmary. 



Psychosexual disorders 159 



or sexual drive. A woman who 
presents with loss of urge to have sex 
with her partner, but who masturbates 
regularly and who can generate sexual 
fantasies, has an intact sexual drive but 
an absent sexual desire directed to her 
partner. A women who experiences no 
desire to masturbate and is unable to 
generate any sexual fantasies appears 
to have a sexual drive disorder which 
may be organic in origin. 

It is important to exclude organic or 
psychiatric conditions. Hyper- 
thyroidism reduces sexual drive; 
testosterone deficiency, 
hyperprolactinaemia and 
hypothyroidism affect arousal. Brain 
trauma (e.g. head injury, tumour or 
stroke) may impact on sexual drive 
and arousal. Conditions affecting the 
spinal cord [e.g. multiple sclerosis, 
syringomyelia and tabes) and those 
affecting peripheral nerves (e.g. 
diabetes, alcohol abuse, vitamin 
deficiency, prolapsed intervertebral 
disc, lumbar canal stenosis and 
multiple sclerosis) also have an effect 
Epilepsy can be implicated. 

Dopamine agonists (e.g. neuroleptics 
and metoclopramide) and depressants 
(e.g. sedatives, hypnotics and alcohol) 
will reduce both sexual drive and 
arousal. Alpha adrenoserotonin 
antagonists, antidepressants, pelvic 
inflammatory disease [by causing 
pain), sympathectomy and pelvic 
surgery may affect the ability to 
achieve orgasm. 

Counselling skills 

The physician must build a rapport 
with the patient, as intimate and 
sensitive areas are being discussed. 
Some factors will prevent this 
happening: 

■ embarrassment 

■ powerlessness 

■ poor communication skills. 

If either the patient or the doctor is 
embarrassed, this can effectively put an 
end to any further useful 
communication. The doctor may feel 
out of his/her depth, that a 
consultation will get out of control, 
that issues will be raised that the 
doctor is unable to answer. If revulsion 
is shown at any stage this reinforces 
the patient's feeling of guilt and 
inadequacy. Taking a useful sexual 
history requires a great degree of trust 
and openness in the consultation - 
particularly if both partners are 
present. Any doctor should be able to 
at least identify that there is a problem 



and to offer the patient hope that 
therapy or treatment is possible, 
referring her to someone who can 
provide it. 

Painful penetration 

The causes of painful penetration are 
numerous (Table 2). It is important to 
exclude anatomical or pathological 
causes by examination. Vaginismus 
and painful penetration are closely 
linked. Vaginismus or involuntary 
tightening of the vaginal musculature 
can be a cause of superficial pain, but 
may have originally occurred 
secondary to infection and become a 
conditioned reflex as the woman 
continues to anticipate pain. 

Vaginismus may be secondary to a 
psychogenic cause, e.g in situations of 
non-consummation where the woman, 
for whatever reason, is scared of 
penetrative intercourse. Due to her fear 
there is inadequate arousal leading to 
poor lubrication, pain and resulting 
vaginismus. Ultimately the vaginismus 
becomes a primary event, further 
enhancing the negative feedback. Pain 
on palpating the pelvic floor muscles 
indicates vaginismus. 

The treatment of painful penetration 
will depend on the cause. Management 
may involve advice on how to cope 
with the pain. Practical measures 
include artificial lubricants, relaxation 
techniques, pelvic floor exercises and 
experimenting with different coital 
positions. Often an explanation of the 
physiology of arousal and the effects of 
stress and fear on the arousal 
mechanism is all that is required. If 
there is no organic cause for the 
problem, then exploration of possible 
psychogenic causes will be necessary. 

Pelvic floor exercises help with 
involuntary spasm of the vaginal 
muscles. Graded tasks might start with 
the woman self-exploring initially with 
one digit, then two, or possibly with 
graded dilators, leading eventually to 
penetration. The sensate focus 
technique requires the couple 



j Table 2 Causes of painful penetration 



Anatomical 


Intact fiymen/hymena! 




icmnants 




Vaginal stenosis 




Ridged" symphysis 


Pathological 




Superficial 


Vulval and vaginal 




allergies 




atrophic changes 




bartholinitis 




Camt'&a 




eczema 




herpes 




psoriasis 




vestibulitis 




genital warts 




Tuchomonas 




bacterial vaginosis 




Urethral 




cystocele 




urethral caruncle 


Deep 


Uterus 




endometritis/myometritis 




fibroids 




Adnexa 




endometriosis 




pelvic inflammatory disease 




ovarian cysts 




Bladder 




'■.?r..v 




Bowel 




constipation 




rrntable bowel syndrome 




[and inflammatory bowel] 


Iatrogenic 




Medical 


Beta- blockers 




High-dose anxiolytics 


Surgical 


Episiotorny 




Anterior and posterior vaginal 




repair, vaginal hysterectomy 



to learn to explore each other 
physically without penetration, 
focusing on personal experience rather 
than pleasing the partner. Contact is 
then gradually increased. 

Specific situations 

Loss of interest in sex may persist after 
delivery; fatigue, especially in breast- 
feeding women, and physical 
discomfort are common reasons given. 
Poor libido at the menopause may be 
due to poor sleep, sweats and vaginal 
dryness, responding to oestrogen, or 
lack of testosterone, especially after a 
surgical menopause. 



Psychosexual disorders 



i Women are reluctant to admit to sexual difficulties and often repeatedly present with trivial 
problems 

i Tact and diplomacy are needed in taking an accurate and full psychosexual history. 

i Genuine loss of sexual desire must be distinguished from difficulties with the current relationship. 

i Vaginismus is a common cause of painful penetration. 

r Sexual difficulties following delivery are not uncommon. 

i Loss of libido at the time of the menopause may be primary, requiring testosterone, or secondary. 
responding to hormone replacement therapy. 



160 GYNAECOLOGY 



Postoperative care 



Postoperative gynaecological care has 
been radically changed, aiming to 
manage most patients as day cases 
(approximately 70%). Outpatient 
procedures frequently replace the need 
for admission (see p. 116). Surgical 
procedures that require hospital 
admission are discharged earlier. The 
aim is to increase patient throughput 
and reduce bed occupancy. An 
abdominal hysterectomy may stay for 
2-4 days (previously 7) and vaginal 
hysterectomies may be discharged 
within 1-3 days. Endometrial ablative 
techniques and laparoscopically- 
assisted vaginal hysterectomy (LAVH) 
are being performed in some centres - 
the former as day cases, the latter with 
overnight stay. 

Work has been done with 
community teams of multi-skilled nurse 
practitioners who will visit the patients 
at home once they have fulfilled 
guideline criteria to be discharged from 
hospital. Others have looked at the 
American model of discharging the 
low-risk patient from the hospital ward 
to a hotel-style setting where the 
patients are more ambulant and 
nursing care is less labour intensive. 

The postoperative patient is entitled 
to high-quality care and the traditional 
approach to postoperative management 
continues - common to all surgical 
specialties. The management of fluid 
balance, drains and catheters, and the 
ability to detect the signs of 
postoperative complications and act 
upon them remain essential. Within 
each specialty however, particular skills 
and specialized requirements may be 
necessary. 



Fluid balance 

A patient's fluid requirement will vary 
depending on: 

■ the body mass index of the 
individual 

■ the ambient temperature which 
affects insensible loss 

■ the potential for fluid loss from 
various sites. 

The input/output chart allows ongoing 
monitoring of the fluid received and 
lost by the patient avoiding negative 
balance. This chart should be assessed 
daily and the infusion regimen 
adjusted accordingly, allowing for 
potential loss of electrolytes. When 



electrolyte derangement is likely, 
serum urea and electrolyte estimation 
should be performed daily until the 
patient is stable as the clinical 
consequences can be profound. 

The use of catheters and drains 

Prophylactic catheterization of patients 
aseptically in theatre for the first 24 or 
48 hours reduces the incidence of 
postoperative urinary tract infection. 
Uncatheterized patients who do not 
void spontaneously require 
catheterization on the ward where the 
environment is less aseptic. 

Spontaneous retention is more 
likely after large pelvic masses and 
posterior vaginal repairs where 
neurogenic retention can occur. For 
routine vaginal and abdominal surgery 
a urethral catheter is adequate. For 
surgery on the bladder neck a 
suprapubic catheter is usually inserted 
(see p. 155) and, after allowing 
periurethral oedema to settle, is 
clamped (Fig. 1). If the patient is 
unable to void, the clamp is released 
and the catheter left on free drainage 
for a longer period. Further 
instrumentation of the patient is thus 
avoided. 



It is usual to leave a drain for 
difficult surgery, e.g. major oncological 
procedures, and where oozing is likely 
to occur, e.g. myomectomy or 
colposuspension. A closed-system 
drain allows blood loss to be assessed 
accurately and is left until the loss is 
less than 30-40 ml in a 24-hour period 
(Fig. 2). Surgery on a patient with 
established disseminated intravascular 
coagulation (DIC) will require a wide- 
bore rather than suction drainage, and 
clotting factors must be corrected. 

Perioperative prophylactic 
management 

Prophylactic antibiotic cover is 
widespread for vaginal surgery where 
vaginal flora may precipitate 
opportunistic infection if the patient's 
resistance is reduced. The antibiotic 
should be effective against anaerobes. 
The final decision as to which broad- 
spectrum antibiotics are used will 
depend on local bacterial factors and 
the patient's history of drug sensitivity. 

The prophylactic use of anti- 
thrombogenic agents is now well 
recognized. Many will use them 
routinely for all gynaecological 
procedures, but specifically targeted 




Pig. 2 Closed-system drainage unit. 



Fig. 3 Postoperative measures to avoid 

thrombosis. Patient wearing TE D elastic 
stockings 



Postoperative care 161 



patients include the overweight, those 
with a previous history of 
thromboembolism, and surgery for 
pelvic carcinoma involving node 
dissection or a pelvic mass. Elastic 
stockings (Fig. 3] are routinely applied 
to reduce the risk of deep vein 
thrombosis, but extensive pelvic 
surgery carries the risk of pelvic 
venous thrombosis. 

The new low molecular weight 
heparins appear to be safe and 
effective. These are administered 
subcutaneously until the patient is 
fully mobile. The dose prescribed will 
depend on the body mass index of the 
patient. Frail old ladies will require a 
lower dose than an obese patient Full 
heparinization would only be indicated 
if deep vein thrombosis or pulmonary 
embolism developed. 

Postoperative complicatons 

Postoperative complications can be 
divided into immediate, intermediate 
and late. Some are common to all 
surgical procedures, e.g. wound 
infection or thromboembolism, some 
are confined to specific operations. The 
latter are dealt with in the relavant 
chapters. Prophylaxis has greatly 
reduced the incidence of 
complications, but an understanding of 
when they are likely to occur and the 
presenting symptoms is essential 
(Table 1). The early detection of 
complications is the main reason for 
daily postoperative ward rounds. It is 
also important that the patient feels 
that she has regular access to the 
medical team conducting her care, 
who should work in conjunction with 
the nurse practitioners. 

Medicolegal aspects of care 

The concept of risk management is 
now widespread and is based on the 
theory that if problems arise they 
should be recognized promptly, dealt 
with efficiently, and the patient kept 
fully informed at all times. Notes 
should contain a full and 
comprehensive account of all 
investigations, actions and discussions 
with the patient - particularly if the 
latter have been contentious. It is often 
advisable to conduct discussions with a 
third party present It is always 
important to obtain senior help early if 
complications arise. Problems should 
be relayed to the consultant in charge 
of the case. Some hospitals have a 
specific risk management officer who 
acts as the liaison between clinical staff 
and the hospital's solicitors. 



Site Timescale Presentation 


Predisposing factor* 


Chest 








Atelectasis 


In first 24 hours 


Poor basal an entry. 


Poor lung expansion. 






spike of temperature 37.3 


poor drainage, lying Hat 
on back 


Pneumonia 


2 3 days 


Febrile, productive 


Smoker, infection secondary 






cough, inspiratory 


lo atelectasis 






wheeaes 




Urinary tract 








Cystitis 


2-1 days 


Moderate temperature 375 


Urogenital tract instruments ion. 






dysuria. frequency 


catnetenzation 
Poorly-treated UTl 


Pyelonephritis 


4-7 days 


Rigors, nausea, vomiting. 






lower abdominal pains. 








loin pain 




Wound infection 


4-5 days 


Tense, tender erythematous 


Secondary to wound 






wound * fluctuation 


naematomas, poor aseptic 
technique 


Thromboembolism 


Day 4 onwards 


Swollen, tense, tender calf. 


Poor mobilization, inadequate 






cnesl pain, dyspnoea, 


prophylaxis, previous varicosities. 






haemoptosis. cyanosis 


pelvic mass at surgery, 






± collapse (if PE) 


oncology case 



The multidisciplinary approach 
to care 

The standard of care for patients is 
greatly enhanced if all health-care 
professionals can work together in a 
constructive and integrated fashion. 
The physiotherapist has an important 
role teaching pelvic floor exercises, 
particularly relevant to vaginal and 
bladder neck surgery - in addition to 
the routine chest expansion, breathing 
and calf exercises that should be 
taught to all postoperative patients. 
Nursing staff mobilize patients early 
postoperatively to limit the risk of 
thromboembolism. 

The nurse practitioner is emerging 
as a professional with added 
responsibilities and roles in the 
discharge process. Integrated care 
pathways (ICPs) set objectives and 
goals for routine postoperative 
management. It may be necessary to 
involve community nurses, carers or 
the local surgery practice nurse in 
postoperative management if the 
patient is unlikely to cope unaided and 
has little family support Advanced 
oncology patients will require the 
involvement of the Macmillan nurses; 
urogynaecological patients may need 



the continence advisors. Both these 
specialized nurse practitioners will 
assess the patient on the ward and 
liaise with the medical team. Extensive 
ovarian cancer debulking requiring 
covering colostomy may need the 
involvement of stoma care sisters. 

Throughout all of this it is 
important to remember the patient. 
Staff must be perceived to be friendly 
and approachable. Great emphasis 
must be placed on communication 
skills. Many units now run 
hysterectomy support groups allowing 
discussion of indications for surgery 
and giving the patient the chance to air 
her views and concerns. Leaflets are 
essential to reinforce any message. 
Research has shown that probably 
only 30% of verbally-given information 
is retained. 

Ongoing postoperative management 
will vary and include hormone 
replacement therapy following 
oophorectomy, ongoing contraceptive 
issues following miscarriage or ectopic 
pregnancy and possibly suppression 
therapy following surgery for 
endometriosis. All of this must be 
explained with care to enhance 
subsequent compliance. 



Postoperative care 



i Patients are now discharged much earlier following gynaecological major surgery. 

i Integrated care pathways establish goals and objectives for patient discharge. 

i The routine use of prophylactic antibiotics and antithrombogenic agents has reduced 
postoperative complications. 

t Routine catheterization for 24 to 48 hours reduces the risk of postoperative infection. 

i Detailed notes and adequate communication with the patient reduce litigation. 



162 



Index 



Abdominal palpation, 4, 5, 8G-7 
Abortion 

induced, 94-5 
counselling, 94 
ethics, 94 
HIV infection, 17 
medical termination, 95 
method, 94-5 

psychological problems after, 95 
risks of, 95 

surgical termination, 95 
septic, 93 

see also miscarriage 
Abruptio placentae, 36-7 
Actinomycosis, 102 
Acupressure, 70 
Acupuncture, 70 

Acute fatty liver of pregnancy, 25 
Adenomyosis, 129 
Adnexal mass, 9i 
Adolescent contraception, 107 
Alcohol abuse, 74 
Alpha thalassaemias, 35 
Ambiguous genitalia, 88 
Amenorrhoea, 112—13 
disorders leading to, 112 
investigation of, 112 
management, 112-13 
pathological, 112 
physiological, 112 
Amniocentesis, 9 
Amniotic fluid embolism, G2 
Amfetamines, 74 
Anaemia, 32-3 
antenatal screening, 32 
diagnosis, 32 
folate metabolism, 32—3 
iron metabolism, 32 
response to blood loss, 33 
treatment, 33 
Anal incontinence, 59 
Analgesia, 70-1 
non-pharmacological 
acupuncture and acupressure, 

70 
audioanalgesia, 70 
hydrotherapy, 70 
massage, 70 
mobilization, 70 
transcutaneous electrical nerve 
stimulation, 70 
pharmacological, 70—1 
epidural analgesia, 71 
inhalational analgesia, 70—1 
narcotic analgesia, 71 
pudendal nerve block, 71 
Analgesics, 74 

Androgens, and fetal virilization, 88 
Anencephaly, 11 
Aneuploidy, 10 
Anovulatory dysfunctional bleeding, 

122-3 
Antenatal care, 4-5 
aims of, 4 
anaemia, 32 
antenatal visit, 4—5 
blood tests, 5 
clinical examination, 4 



diabetes, 30 

palpation of abdomen, 4, 5 

pattern of, 4 

presentation of findings, 4 

psychosocial problems, 44—5 

urine tests, 5 

venous thromboembolic disease, 
42 

see also Pre-conceptual 
counselling 
Antepartum haemorrhage, 36—7 

abruptio placentae, 3G-7 

cervical carcinoma, 37 

cervical lesions, 37 

concealed, 37 

mixed, 37 

placenta praevia, 36 

revealed, 37 

ruptured uterine scar, 37 

vasa praevia, 37 
Antibiotics, 74 
Anticonvulsants, 74 

fetal anomalies, G, 25 
Antidepressants, 74 
Antihistamines, 74 
Antihypertensives, 74 
Antimalarials, 74 
Antiphospholipid syndrome, 93 
Antiprogesterones, induction of 

labour, 49 
Antipsychotic drugs, 74 
Apgar score, 80, 82 
Aromatherapy, 70 
Artificial rupture of membranes, 

48-9 
Asherman's syndrome, 112 
Audioanalgesia, 70 
Audit, 79 



Backache, 76, 77 

Bacterial vaginosis, 102 

Bacteroides spp., 102 

Bartholin's cyst, 144 

Benzodiazepines, 74 

Bereavement 84-5 
continued support, 85 
cremation and burial, 85 
intrauterine death and stillbirth, 

84-5 
miscarriage, 84 
neonatal death, 85 

Beta thalassaemias, 34 

Bimanual examination, 87 

Birthing chair, G8-9 

Birthing cushion, G8-9 

Birthing positions, G8 

Birthing stool, G8-9 

Bishop's score, 48 

Blood tests, 5 

Bottle feeding, 65 

Bowel problems, postnatal, 59, G7 

Breast development (thelarche), 90 

Breast disease, and oral 
contraceptives, 106 

Breast examination, &G 

Breast feeding, G4-5 
and oral contraceptives, 107 

Breech presentation, 40—1 



antenatal management 
Elkin's manoeuvre, 40 
external cephalic version, 40 

causes, 40 

complete breech, 40 

footling breech, 40 

frank breech, 40 

labour, 41 

persistent, 41—2 

preterm, 41 
Brenner cell tumour, 140 
Bronchodilators, 74 
Brow presentation, 53 



Caesarean section, 56-7 

elective, 59 
Candida albicans, 102-3 
Cannabis, 74 
Caput succedaneum, 83 
Cardiac disease in pregnancy, 24 
Cardiotocography, 50 
Cardiovascular system, 2 
Carpal tunnel syndrome, 77 
Caudal regression syndrome, 29 
Cephalohaematoma, 83 
Cephalopelvic disproportion, 52 
Cerebral damage in neonates, 82 
Cervical carcinoma, 136—7 

advanced disease, 137 

and antepartum haemorrhage, 37 

epidemiology, 136 

pathology, 136 

presentation, 136 

risk factors, 136 

staging, 136-7 

staging and survival rates, 137 

treatment 137 

see also Cervical intraepithelial 
neoplasia 
Cervical cerclage, 18—19 
Cervical incompetence, 93 
Cervical intraepithelial neoplasia 
(CIN), 134-5 

aetiology, 134 

colposcopy, 134-5 

cone biopsy, 135 

cytology, 134 

definition, 134 

diagnosis, 134 

histology, 134 

hysterectomy, 135 

risk factors, 134 

screening, 134 

treatment, 135 
Cervical smear test, 134 
Chickenpox, 15 

Chlamydia trachomatis, 100, 103 
Chorioamnionitis, 19 
Choriocarcinoma, 97 
Chorionic villus sampling, 8-9 
Chorionicity, 38 
Chromosome abnormalities, 8-9, 

93 
Chronic active hepatitis in 

pregnancy, 25-G 
Cirrhosis in pregnancy, 25 
Clomifene citrate, 132 
Coagulation changes in pregnancy, 3 



Cocaine, 74 
Coeliac disease, 77 
Colposcopy, 134-5 
Combined oral contraceptive pill, 
106-7 
adolescent contraception, 107 
breast disease, 106 
breast feeding, 107 
contraindications, 106 
drug interactions, 106-7 
emergency contraception, 107 
in endometriosis, 129 
practical prescribing, 106 
side effects, 10G 
and surgery, 107 
Condoms, 110 
Cone biopsy, 135 

Congenital adrenal hyperplasia, 88 
Congenital anomalies, 82—3 
Congenital heart disease, 10-11 
Connective tissue disease in 

pregnancy, 24 
Constipation, 76 
Contraception, 86, 110-11 
adolescents, 107 
barrier methods 
caps, 110 
diaphragm, 110 
female condom, 110 
male condom, 110 
chemical methods, 110-11 
contraceptive sponge, 110 
intrauterine contraceptives, 111 
spermicides, 110 
emergency, 107 
hormonal 
progestogen-dependent, 

108-9 
oestrogen-dependent, 106-7 
natural methods, 110 
and pelvic inflammatory disease, 

100-1 
postpartum, 65 
sterilization, 111 
Contraceptive caps, 110 
Contraceptive sponge, 110 
Cord prolapse, 62 
Cordocentesis, 9 
Counselling 
induced abortion, 94 
pre-conceptual, 6-7 
Couvelaire uterus, 37 
Cumberlege Report 72 
Cyproterone acetate, 115 
Cvstic fibrosis, 12 
Cystic hygroma, 12-13 
Cystometry, 155 
Cytomegalovirus, 14 



Danazol, 129 

Day care surgery, 116-17 
advantages of, 116 
changing surgical practice, 11G 
preoperative evaluation, 116-17 
role of nurse practitioner, 117 
setting, 11G 

Delayed puberty, 91 

Depression, 45 



Index 163 



Dermoid cyst, 140 

Developing countries, maternity 

care, 73 
Developmental gynaecology, 88-9 

abnormal genital tract 
development 
uterus, 89 
vagina, 88-9 

female pseudohermaphroditism, 88 

intersex disorders and ambiguous 
genitalia, 88 

male pseudohermaphroditism, 88 
Diabetes, 28-31 

alternative screening, 28 

antenatal care, 30 

definitions, 28 

delivery 
route of, 31 
timing, 31 

diabetic control, 29 

diagnosis and screening, 28 

gestational, 28 

intrapartum care, 31 

management, 30-1 

monitoring, 30 

neonate, 31 

physiology, 28 

postnatal care, 31 

potential, 28 

pre-conceptual counselling, 28-9 

pre-existing, 28 

premature labour, 31 

therapy, 30 
Diaphragm, 110 
Diaphragmatic hernia, 12 
Didrogesterone, 129 
DNA analysis, 9 
Domestic violence, 45 
Domino scheme, 73 
Down's syndrome, 7, 8 
Drug misuse, 74-5 

management, 74-5 

neonatal complications, 75 
Drug treatment in pregnancy, 7 
Dysfunctional uterine bleeding, 122 

aetiology, 122-3 

anovulatory, 122—3 

ovulatory, 123 

treatment of, 124 
Dysmenorrhoea, 121, 123 

primary, 123 

secondary, 124 

treatment, 124 
Dyspepsia, 76 
Dyspnoea, 3 



Eclampsia, 21 

Ecstasy, 74 

Ectopic pregnancy, 92-3, 98-9 

aetiology, 98 

management 99 

presentation, 98-9 

site ofi 98 
Elkin's manoeuvre, 40 
Embryo transfer, 132-3 
Emergencies, G2-3 

amniotic fluid embolism, 62 

cord prolapse, 62 

Mendelson's syndrome, 62 

shoulder dystocia, G2-3 

uterine inversion, 63 

uterine rupture, G3 



Emergency contraception, 107 
Emotional disturbances, 156-7 
Encephalocele, 11 
Endometrial carcinoma, 138-9 

aetiology, 138 

pathology, 138 

presentation and investigation, 
138 

prognosis, 138—9 

risk factors, 138 

treatment, 139 
Endometriosis, 12G, 128-9 

adenomyosis, 129 

aetiology, 128 

diagnosis, 128-9 

pathology, 128 

presentation, 128 

treatment, 129 
Energy balance in pregnancy, 3 
Epidural analgesia, 71 
Epilepsy in pregnancy, 25 
Episiotomy, 47, 58 

repair of, 58—9 
Essential hypertension, 20 
Europe, maternity care, 73 
Exomphalos, 11-12 
External cephalic version, 40 
Extra-amniotic saline, induction of 
labour, 49 



Face presentation, 53 
Fallopian tubes 
hysterosalpingography, 131 
pelvic inflammatory disease, 100 
surgery, 133 
Fallot's tetralogy, 11 
Familial ovarian carcinoma, 142—3 
Fem-ring, 108-9 
Female genital mutilation, 45 
Female pseudohermaphroditism, 88 
Female sterilization, 111 
Femidom, 110 
Fetal abnormality, 10-13 
abdominal wall defects 
exomphalos, 11-12 
gastroschisis, 11 
aneuploidy, 10 

congenital heart disease, 10-11 
cystic hygroma, 12—13 
fragile X syndrome, 8, 13 
genitourinary abnormalities 
polycystic kidney disease, 12 
posterior urethral valves, 12 
Potter's syndrome, 12 
pyelectasis, 12 
renal dysplasia, 12 
Huntington's chorea, 8, 13 
lung disorders 
cystic fibrosis, 13 
diaphragmatic hernia, 12 
pulmonary hypoplasia, 12 
multiple pregnancy, 38 
neural tube defects, 11 
polyhydramnios, 13 
risk of, 7 
screening for, 10 
Tay-Sachs disease, 8, 13 
see also Fetal chromosomal 
abnormality 
Fetal alcohol syndrome, 44 
Fetal chromosomal abnormality, 
8-9 



amniocentesis, 9 
chorionic villus sampling, 8-9 
cordocentesis, 9 
DNA analysis, 9 

fluorescent in situ hybridization, 9 
karyotyping, 9 
nuchal translucency, 8 
serum screening, 8 
see also individual conditions 
Fetal movement charts, 22 
Feto-fetal transfusion sequence, 39 
Fetus 
blood glucose levels, 29 
blood sampling, 51 
intrapartum monitoring, 50-1 
accelerations, 50 
active phase, 51 
baseline heart rate, 50 
baseline variability, 50 
cardiotocography, 50 
contractions, 51 
decelerations, 50 
descent of presenting part, 51 
latent phase, 51 
liquor amnii, 51 
partogram, 50-1 
intrauterine growth restriction, 

6,22 
small for dates, 22—3 
see also Fetal 
Fibroids, 118-19 
aetiology, 118 
investigations, 119 
management 119 
pathology, 118 
presentation 
menorrhagia, 118 
subfertility, 118-19 
types of, 118 
Fibrothecoma, 143 
Fitz-Hugh-Curtis syndrome, 103 
Fluorescent in situ hybridization, 9 
Folate metabolism, 32-3 
Foods 
iron in, 33 

potential infection risks, 14 
Footling breech, 40 
Forceps delivery, 54-6 

low/mid-cavity non-rotational 

forceps, 54, 55 
rotational forceps, 54, 55 
Fragile X syndrome, 8, 13 
Fruit infection risks, 15 



Gallstones in pregnancy, 25 
Gamete intrafallopian transfer 

(GIFT), 132 
Gardnerella vaginalis, 102 
Gastrointestinal tract, 2-3 
Gastroschisis, 11 
General anaesthetics, 74 
Genital infections, 102—5 

actinomycosis, 102 

bacterial vaginosis, 102 

Bacteroides spp., 102 

Candida, 102—3 

Chlamydia, 103 

genital warts, 103—4 

gonorrhoea, 103—4 

herpes, 104 

history, 102 

physical examination, 102 



syphilis, 104-5 

Trichomonas vaginalis, 104 
Genital warts, 103-4 
Gestational choriocarcinoma, 97 
Gestational diabetes, 28 

see also Diabetes 
Gestational hypertension, 20—1 
Gestational proteinuria, 20 
Gestrinore, 129 
Glucose 

fetal blood levels, 29 

handling in pregnancy, 3 
Glycosuria, 2 
Gonadal dysgenesis, 113 
Gonadotrophins, 132 
Gonococcal urethritis, 104 
Gonorrhoea, 103-4 
Granulosa cell tumour, 140 
Growth spurt, 90 
Gynaecological assessment, 86-7 

abdominal palpation, 86—7 

bimanual examination, 87 

breast examination, 86 

contraception, 86 

examination, 86 

menstrual history, 86 

pain, 86 

past obstetric history, 86 

pelvic examination, 87 

pelvic mass, 87 

sexual intercourse, 86 

speculum examination, 87 

urinary symptoms, 8G 

vaginal discharge, 86 



Haemoglobin, formation of, 34 
Haemoglobinopathies, 34-5 

formation of haemoglobin, 34 

sickle cell syndromes, 35 

thalassaemias, 34—5 
p-Haemolytic streptococci group B, 

15 
Haemorrhage 

antepartum, 36—7 

postpartum, 60—1, 66 
Haemorrhoids, 2, 67 
Hair growth, 90 
Heartburn, 2 
HELLP syndrome, 21 
Hepatitis, 15 
Hepatosplenomegaly, 14 
Herpes simplex, 15, 104 
Hirsutism, in polycystic ovarian 

syndrome, 114, 115 
HIV see Human immunodeficiency 

virus 
Hormone replacement therapy, 
150-1 

approach to treatment, 150—1 

assessment and screening, 151 

follow-up, 151 

risks and benefits, 150, 151 

types of regimens, 150 

see also Menopause 
Human immunodeficiency virus 
(HIV), 16-17 

clinical features, 16-17 

gynaecology, 17 

infection control, 17 

obstetrics, 17 

termination of pregnancy, 17 

vertical transmission, 17 



164 Index 



Huntington's chorea, 8, 13 
Hydatidiform mole, 9G-7 
Hydrosalpinx, 101 
Hydrotherapy, 70 
Hymen, 89 

Hyperemesis gravidarum, 25 
Hypertension, 20-1 

essential hypertension, 20 

gestational hypertension and pre- 
eclampsia, 20—1 

HELLP syndrome, 21 
Hyperthyroidism in pregnancy, 27 
Hypothalamic amenorrhoea, 113 
Hypothyroidism in pregnancy, 27 
Hysterectomy 

cervical intraepithelial neoplasia, 
135 

dysfunctional uterine bleeding, 
125 

management of fibroids, 119 
Hysterosalpingography, 131 
Hysteroscopy, 124-5 



Imperforate hymen, 113 
In vitro fertilization (IVF), 132-3 
Induction of labour, 48—9 
antiprogesterones, 49 
artificial rupture of membranes, 

48-9 
extra amniotic saline, 49 
failure of, 49 
fetal indications, 48 
maternal indications, 48 
prostaglandins, 48 
syntocinon, 49 
Infections in pregnancy, 14-15 
chickenpox, 15 
cytomegalovirus, 14 
|3-haemolytic streptococci group 

B, 15 
hepatitis, 15 

herpes simplex virus, 15 
Listeria monocytogenes, 15 
parvovirus, 14 
risks 
food, 14 
nurses, 14 
occupation, 14 
rubella, 14, 15 
toxoplasmosis, 14 
Infertility, 130-1 
investigations, 130-1 
management, 132-3 
clomifene citrate, 132 
egg collection, 132 
gamete intrafallopian transfer, 

132 
gonadotrophins, 132 
intracytoplasmic sperm 

injection, 133 
intrauterine insemination, 133 
ovarian hyperstimulation, 133 
tubal surgery, 133 
in vitro fertilization and embryo 
transfer, 132—3 
ovulation tests, 131 
physiology, 130 
semen analysis, 131 
tubal function, 131 
unexplained, 133 
Inflammatory bowel disease, 77 
Inhalational analgesia, 70-1 



Intermenstrual bleeding, 122 
Intersex disorders, 88 
Interstitial cystitis, 12G 
Intertrigo, 145 
Intracytoplasmic sperm injection 

(ICSI), 133 
Intrahepatic cholestasis of 

pregnancy, 25 
Intrapartum fetal monitoring, 50-1 

accelerations, 50 

active phase, 51 

baseline heart rate, 50 

baseline variability, 50 

cardiotocography, 50 

contractions, 51 

decelerations, 50-1 

descent of presenting part, 51 

latent phase, 51 

liquor amnii, 51 

partogram, 51 
Intrauterine contraceptive device, 

111 
Intrauterine death, 84-5 
Intrauterine growth restriction, 

6,22 
Intrauterine insemination, 133 
Iron 

in foods, 33 

metabolism, 32 

serum levels in pregnancy, 3 
Irritable bowel syndrome, 126 



Kallmann syndrome, 91 
Karyotyping, 9 



Labour and delivery, 46-7 
abnormal, 52—3 

abnormal labour, 52 

breech presentation, 40—1 

malpresentations and 
malpositions, 53 

precipitate labour, 52 

slow labour, 52 
alternative approaches, 68-9 

birthing cushion, chair and 
stool, 68-9 

maternal choice, 69 

water birth, 68 
analgesia, 70-1 

acupuncture and acupressure, 
70 

audionalgesia, 70 

epidural analgesia, 71 

hydrotherapy, 70 

inhalational analgesia, 70-1 

massage, 70 

mobilization, 70 

narcotic analgesia, 71 

pudendal block, 71 

transcutaneous electrical nerve 
stimulation, 70 
diabetic pregnancy, 30—1 
episiotomy, 47 
first stage, 46-7 

induction see Induction of labour 
initiation of labour, 46 
mechanism of labour, 46 
multiple pregnancy, 39 
preterm, 18-19 



second stage, 47 

third stage, 47 
problems of, 61 
Leiomyosarcoma, 139 
Leukotrienes, 121 
Lichen planus, 145 
Lichen sclerosus, 145 
Liquor amnii, 51 
Listeria monocytogenes, 15 
Liver disorders in pregnancy, 25—6 
Loss of libido, 123 
Low birth weight, 22 
LSD, 74 



Macrosomia, 29 

Malaria, 32 

Male pseudohermaphroditism, && 

Male sterilization, 111 

Malpresentation, 53 

breech see Breech presentation 

brow presentation, 53 

face presentation, 53 

occipitoposterior presentation, 53 

transverse/oblique lie, 53 
Massage, 70 
Maternal mortality, 78 
Maternity care, 72—3 

developing countries, 73 

Domino scheme, 73 

Europe and USA, 73 

midwifery-run delivery units, 73 

needs-based community service, 
73 

rural setting, 73 

United Kingdom, 72-3 
Meat, infection risks, 15 
Meconium aspiration syndrome, 83 
Medical disorders in pregnancy, 24- 
7 

acute fatty liver of pregnancy, 25 

cardiac disease, 24 

chronic active hepatitis, 25-6 

cirrhosis, 25 

connective tissue disease, 24 

epilepsy, 25 

gallstones, 25 

hepatic disorders, 25 

hyperemesis gravidarum, 25 

intrahepatic cholestasis of 
pregnancy, 25 

primary biliary cirrhosis, 26 

renal disorders, 26 

respiratory disorders, 26 

systemic lupus erythematosus, 
24-5 

thrombocytopenia 
fetal, 27 
maternal, 26—7 

thyroid disorders, 27 

urinary tract infection, 26 

viral hepatitis, 25 
Medroxyprogesterone acetate, 129 
Menarche, 90 

Mendelson's syndrome, 56, 62 
Menopause, 123, 148-9 

cardiovascular changes, 149 

definitions, 148 

hormonal changes, 148 

hormone replacement therapy, 
150-1 

osteoporosis, 149 

pathogenesis, 148 



signs and symptoms 
external changes, 148 
psychological and emotional 

changes, 148-9 
reproductive tract, 148 
urinary tract, 148 
vasomotor symptoms, 149 
uterovaginal prolapse, 152 
Menorrhagia, 118, 122 
Menstrual disorders, 122-5 
anovulatory dysfunctional 

bleeding, 122-3 
dysfunctional uterine bleeding, 
122 
treatment of 124 
dysmenorrhoea, 121, 123 
primary, 123 
secondary, 124 
treatment, 124 
intermenstrual bleeding, 122 
menopause, 123 
menorrhagia, 118, 122 
ovulatory dysfunctional bleeding, 

123 
toxic shock syndrome, 123 
treatment, 124-5 
hysterectomy, 125 
hysteroscopy, 124—5 
Menstrual history, 86 
Menstruation, 120-1 
control of menstrual blood flow, 

121 
mechanisms of blood loss, 120 
normal cycle, 120 
ovulation process, 120 
period pains (dysmenorrhoea), 
121 
Microcephaly, 15 
Midwifery-run delivery units, 73 
Mifepristone, 95 
Milk, 64 
Mirena coil, 109 
Miscarriage, 84, 92-3 
incomplete, 92 
inevitable, 92 
missed, 92 

recurrent spontaneous, 93 
septic abortion, 93 
spontaneous, 92-3 
threatened, 92 
see also abortion 
Mortality 
maternal, 78 
perinatal, 78-9 
Mucinous cystadenoma, 140 
Multiple pregnancy, 38—9 
chorionicity, 38 

chromosomal abnormalities, 39 
fetal abnormality, 38 
labour, 39 
management of, 39 
structural defects, 38—9 
triplets and higher multiples, 39 
twins see Twin pregnancy 
Mvometrial tumours, 139 



Naloxone, 81 
Narcotic analgesia, 71 
Natural family planning, 110 
Nausea and vomiting, 76 
Needs-based community services, 
73 



Index 165 



Neisseria gonorrhoeae, 100, 103-4 
Neonatal death, 85 
Neonate, 80-1 
diabetic pregnancy, 31 
examination, 81 
medication, 80-1 
naloxone administration, 81 
postpartum problems, 82-3 
cerebral damage, 82 
congenital anomalies, 82-3 
maternal drug abuse, 75 
meconium aspiration 

syndrome, 83 
prematurity-related, 82 
respiratory distress syndrome, 83 
seizures, &i 
trauma, 83 
resuscitation, 80 
surfactant, 81 
Neural tube defects, 11 
Nicotine, 74 
Norethisterone, 129 
Nuchal translucency, 8 
Nurse practitioners, 117 



Obesity, in polycystic ovarian 

syndrome, 115 
Oblique lie, 53 

Occipitoposterior presentation, 53 
Oedema, 3 
Oestrogen-dependent hormonal 

contraception see Combined 
oral contraceptive pill 
Oligohydramnios, 12 
Operative delivery, 54-7 

caesarean section, 5G— 7 

forceps delivery, 54-6 
low/mid-cavity non-rotational 

forceps, 54, 55 
rotational forceps, 54, 55 
ventouse, 56—7 
Opiates, 74 
Osteoporosis, 149 
Ovarian carcinoma, 142—3 

familial, 142-3 

investigations and treatment, 142 

management, 142 

pathology, 143 

recurrent, 142 

screening for, 142 

staging, 142 
Ovarian cysts, 140-1 

Brenner cell tumour, 140 

dermoid cyst 140 

endometrioid cystadenoma, 140 

granulosa cell tumour, 140—1 

investigations, 141 

mucinous cystadenoma, 140 

pathological, 140-1 

physiological, 140 

serous cystadenoma, 140 

solid teratoma, 140 

treatment, 141 
Ovarian hyperstimulation, 133 
Ovulation, 120 
Ovulation tests, 131 
Ovulatory dysfunctional bleeding, 123 



Painful penetration, 159 
Palpation, 4, 5, 8G-7 



Partogram, 50—1, 52 

Parvovirus, 14 

Pelvic arthropathy, G7, 77 

Pelvic examination, 87 

Pelvic inflammatory disease, 100-1 

acute, 100-1 

changes to fallopian tubes, 100 

chronic, 101 

diagnosis, 100 

incidence, 100 

treatment, 101 
Pelvic mass, 87 
Pelvic pain, 12G-7 

acute, 126 

chronic, 12G-7 
diagnosis, 12G 
management, 126-7 

see also Pelvic inflammatory 
disease 
Peptic ulcers, 77 
Perinatal mortality', 29, 78-9 
Perineal tears, 58 

repair of 58, 59 
Perineum, 58—9 

anal incontinence, 59 

bowel problems, 59 

elective caesarean section, 59 

episiotomy repair, 58 

perineal tears, 58 

postnatal urinary tract problems, 
58-9 

repair of tears, 58 
Period pains, 121 
Physical abuse, 75 
Pituitary adenoma, 113 
Placenta 

chorionicity, 38 

retention of, G0-1 

twin pregnancies, 38 
Placenta praevia, 36 
Placental separation, 47 
Placental site trophoblastic tumour, 

97 
Pneumocystis carinii, 16 
Polycystic kidney disease, 12 
Polycystic ovarian syndrome, 114—15 

amenorrhoea in, 113 

hirsutism in, 114 

investigations, 114-15 

symptoms, 114 

treatment, 115 
Polyhydramnios, 13 
Posterior urethral valves, 12 
Postnatal depression, 67 
Postnatal visit, G5 
Postoperative care, 160-1 

catheters and drains, 1G0 

complications, 161 

fluid balance, 160 

medicolegal aspects, 161 

multidisciplinary approach, 1G1 

perioperative prophylactic 
management, 1G0-1 
Postpartum haemorrhage, 60—1, 6G 

causes of, 60 

primary, 60-1 

secondary, 61 
Postpartum thyroiditis, 27 
Potter's syndrome, 7, 12 
Pre-conceptual counselling, 6—7 

diabetes, 28-9 

general, 6 

lifestyle education, 7 

medical, G 



obstetric, 6—7 

risk of fetal anomaly, 7 
Pre-eclampsia, 20—1 
Precipitate labour, 52 
Precocious puberty', 90-1 
Pregnancy, 2—3 

body water, 3 

cardiovascular changes, 2 

coagulation changes, 3 

drug treatment in, 7 

energy' balance, 3 

gastrointestinal tract, 2 

glucose, 3 

iron, 3 

medical disorders in, 24-7 

prolonged, 49 

respiratory system changes, 3 

thyroid, 3 

urinary tract, 2 
Pregnancy-related problems, 76—7 

backache, 77 

carpal tunnel syndrome, 77 

coeliac disease, 77 

constipation, 7G 

dyspepsia, 7G 

inflammatory bowel disease, 77 

nausea and vomiting, 7G 

peptic ulceration, 77 

pregnant pelvic arthropathy, 77 

urinary symptoms, 76 

vaginal discharge, 77 

varicosities, 76 
Premature infants 

breech presentation, 41 

labour and delivery, 18—19 

problems of 
central nervous system, 82 
gastrointestinal system, 82 
heat loss, 82 
respiratory support, 82 
retinopathy of prematurity, 82 
sepsis, 82 

see also Preterm labour 
Premenstrual syndrome, 156—7 

diagnosis, 15G-7 

management, 157 

symptoms, 15G 
Prenatal diagnosis, 8-9 
Preterm labour, 18-19 

benefits/risks of in utero 
existence, 19 

breech presentation, 41 

cenical cerclage, 18-19 

delivery, 19 

diabetic pregnancy, 31 

diagnosis, 18 

management, 18 

uterine suppression (tocolysis), 18 

see also Premature infants 
Preterm premature rupture of 
membranes, 19 

chorioamnionitis, 19 

see also Preterm labour 
Primary biliary cirrhosis in 

pregnancy, 2G 
Progestogen challenge test, 112 
Progestogen-dependent hormonal 
contraception, 108-9 

depot progestogen injections, 108 

Fem-ring, 108-9 

levonorgestrel intrauterine 
system, 109 

progestogen implants, 109 

progestogen-only pill, 108 



Prolonged pregnancy, 49 
Prostaglandins 
cervical ripening, 48 
induced abortion, 95 
Pruritus vulvae, 144 
Pseudomyxoma peritonei, 140 
Pseudosac, 92 
Psoriasis, 145 

Psychosexual disorders, 158-9 
counselling skills, 159 
painful penetration, 159 
physiology of sexual arousal, 158 
sexual history, 158-9 
specific situations, 159 
Psychosis, 45 

puerperal, 67 
Psychosocial problems, 44-5 
alcohol, 44-5 

depression and psychosis, 45 
domestic violence, 45 
female genital mutilation, 45 
racial aspects, 45 
smoking, 44 
teenage pregnancy, 44 
Puberty, 90-1 
abnormal 
delayed puberty, 91 
precocious puberty, 90-1 
normal 
breast development, 90 
growth spurt, 90 
hair growth, 90 
menarche, 90 
Pudendal nerve block, 71 
Puerperal cardiomyopathy, 24 
Puerperal psychosis, G7 
Puerperal pyrexia, 66 
Puerperium, 64—5 
abnormal, 66—7 
bladder and bowel problems, 67 
haemorrhage, 60—1, G6 
infection, 66 

musculoskeletal problems, 67 
puerperial affective disorders, 

67 
venous thromboembolism, 66-7 
bottle feeding, 65 
breast feeding, G4-5 
physiological changes, 64 
postnatal *dsit, G5 
postpartum contraception, 65 
routine care, G4 
Pulmonary hypoplasia, 12 
Pyelectasis, 12 
Pyosalpinx, 101 



Raw eggs, infection risks, 15 
5a-Reductase deficiency, 88 
Renal disorders in pregnancy, 26 
Renal dysplasia, 12 
Residual ovary syndrome, 126 
Respiratory distress syndrome, 83 
Respiratory tract, 3 

disorders in pregnancy, 2G 
Resuscitation, 80 
Retained placenta, 60-1 
Retained products of conception, 93 
Retinoids, 74 

Retinopathy of prematurity, 82 
Rhesus negative patients, 6 
Rokitansky syndrome, 89 
Rubella, 14, 15 






166 Index 



Ruptured uterine scar, 37 
Rural maternity care, 73 



Sacral agenesis, 29 

Seizures in neonates, Si 

Semen analysis, 130-1 

Septic abortion, 93 

Sexual abuse, S9 

Sexually transmitted disease see 

Genital infections 
Sheehan's syndrome, Gl, 113 
Shoulder dystocia, 62-3 
Sickle cell syndromes, 35 

management of sickle cell crises, 35 
Slow labour, 52 
Small for dates fetus, 22-3 

born too soon, 22 

fetal assessment 
biophysical profile, 23 
fetal movement charts, 22 
monitoring, 23 
symphysis-fundal height, 22 
ultrasound, 22-3 

intrauterine growth restriction, 
G, 22 

low birth weight, 22 

management, 23 
Smoking, 7 

Soft cheeses, infection risks, 15 
Speculum examination, 87 
Spermicides, 110 
Spina bifida, G, 11 
Sterilization, 111 
Steroids, 74 
Stillbirth, 84-5 

Sudden infant death syndrome, 75 
Surfactant, 81 

Sweeping the membranes, 49 
Symphysis-fundal height, 4, 22 
Syntocinon, induction of labour, 49 
Syphilis, 104-5 
Systemic lupus erythematosus, 24-5 



Tay-Sachs syndrome, 7, 8, 13 
Teenage pregnancy, psychosocial 
problems, 44 



Testicular feminization, 113 
Thalassaemias, 34-5 

alpha thalassaemias, 35 

antenatal diagnosis, 35 

beta thalassaemias, 34-5 
Thrombocytopenia 

fetal (alloimmune), 27 

maternal, 2G-7 
Thyroid, 3 

disorders in pregnancy, 27 
Tocolysis, 18 
Total body water, 3 
Toxic shock syndrome, 123 
Toxoplasmosis, 14, 15 
Transcutaneous electrical nerve 

stimulation (TENS), 70 
Transverse lie, 53 
Trauma in neonates, 83 
Treponema pallidum, 104, 105 
Trichomonas vaginalis, 104, 105 
Triplet pregnancy see Multiple 

pregnancy 
Trophoblastic disorders, 9G-7 

gestational choriocarcinoma, 97 

hydatidiform mole, 9G-7 

placental site trophoblastic 
tumour, 97 
Turner's syndrome, 113 

karyotyping, 9 
Twin pregnancy 

chorionicity, 38 

dichorionic, 38 

management of delivery, 39 

monochorionic, 38 

with one fetal death, 39 

placentation, 38 

see also Multiple pregnancy 
Twin reversed arterial perfusion 

sequence (acardia), 39 
Twin-twin transfusion syndrome, 39 



Ultrasound, fetal, 22-3 
Urethral caruncle, 144 
Urethral syndrome, 126 
Urethritis, gonococcal, 104 
Urinary incontinence, 154—5 

examination, 154 

investigations, 154 



management, 154-5 

symptoms, 154 
Urinary tract, 2 

history of problems, 8G 

infection in pregnancy, 26 

menopausal changes, 148 

postnatal problems, 58-9, 67 

symptoms in pregnancy, 7G 
Urine tests, 5 
Uroflowmetry, 154 
USA, maternity care, 73 
Uterine carcinoma, 138—9 

endometrial carcinoma, 138—9 

myometrial tumours, 139 

uterine sarcoma, 139 
Uterine fibroids see Fibroids 
Uterine sarcoma, 139 
Uterogenital prolapse, 12G 
Uterovaginal prolapse, 152-3 

aetiology 
childbirth, 152 
congenital weakness, 152 
menopause, 152 

examination, 152 

history, 152 

management 152-3 
conservative, 152—3 
surgical, 153 

presentation, 152 
Uterus 

abnormal development, 89 

anatomical abnormality, 93 

bicornuate, 89 

couvelaire, 37 

inadequate activity, 52 

inversion, 63 

rupture, 63 

septate, 89 

unicornuate, 89 



Vaccines, 74 

Vagina, abnormal development, i 

9 
Vaginal atresia, 89 
Vaginal cones, 155 
Vaginal discharge, 77, 8G, 104-5 

history, 104-5 

management, 105 



Vaginal septae, 88-9 
Varicose veins, 7G 
Vasa praevia, 37 
Vasectomy, 111 

Velamentous cord insertion, 37 
Venous thromboembolic disease, 
42-3 

antenatal care, 42 

gynaecology, 43 

postnatal risk assessment, 42-3 

postpartum, 66-7 
Ventouse, 56—7 

Viral hepatitis in pregnancy, 25 
Vulva, benign conditions, 144-5 

anatomy, 144 

Bartholin's cyst, 144 

herpetic ulceration, 104 

intraepithelial neoplasia, 145 

lichen sclerosus, 145 

pruritus vulvae, 144 

simple atrophy, 144 

squamous cell hyperplasia, 145 

ulcers, 144 

urethral caruncle, 144 

vulvodynia, 144 
Vulval carcinoma, 146—7 

aetiology, 146 

assessment, 146 

diagnosis, 146 

management, 146-7 
advanced disease, 147 
early stage disease, 147 

precursor lesions, 146 

recurrent, 147 
Vulval warts, 103 
Vulvodynia, 144 



Water birth, 68 



Zavanelli manoeuvre, G3