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WO EN'S HEALTH

A CORE CURRICULUM

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Contents

Foreword v 4 Lower abdominal pain 49


Preface xi Edited by Vivienne O'Connor
A note to the student xii
Pelvic pain Ian Jones 50
Contributors xiii Endometriosis Vivienne O'Connor 51
Pelvic inflammatory disease
Abbreviations xvii
Vivienne O'Connor 52
Photographs and illustration credits xix

5 Contraception 55
Introduction Beverley Vollenhoven and Gareth Weston
Anne Ellison and Robert Burrows Edited by Beverley Vollenhoven

Reversible contraceptive methods 56


The menstrual cycle and
Emergency contraception 60
vaginal bleeding 5 Irreversible contraception 60
Edited by Beverley Vollenhoven
6 Health education before and
Premenstrual syndrome during pregnancy 63
Cindy Farquhar and Neil Johnson 7
Lucy Bowyer and Ratnasari Padang
Dysmenorrhoea
Edited by Lucy Bowyer
Cindy Farquhar and Neil Johnson 8
Abnormal bleeding
Counselling before pregnancy 64
Cindy Farquhar and Neil Johnson 12
Women with genetic concerns 67
Delayed puberty
Fall Langdana and Rosemary Reid 18 7 Antenatal care 73
Polycystic ovary syndrome Wayne Gillett 23
Hyperandrogenism Wayne Gillett 25 Edited by Sandra Carr
Premature ovarian failure
Michel Sangalli and Lynda Croft 28 Lifestyle issues in pregnancy Penelope Black
and William AW Walters 74
2 Vaginal discharge 33 Antenatal care - first trimester
Stephen O'Callaghan 77
Leo R Leader
Ectopic pregnancy Ujliana Milkovic-Pefkovic
Edited by Lucy Bowyer
and Thomas Taif 79
Miscarriage Lijliana Milkovlc-Petkovic and
3 Sexually transmitted infections 39
Thomas Tait 82
Edited by Vivienne O'Connor Antenatal care - second trimester
Warwick Giles 84
Genital herpes Mark Erian 40 Antenatal care - third trimester
Female genital warts (condylomata Andrew Bisits 86
acuminata) Mark Erian 41
Syphilis Ian Jones 42 8 The fetus 93
Gonorrhoea Ian Jones 44
Martha Finn
Chlamydia Vivienne O'Connor 44
HIV / AIDS Vivienne O'Connor 45
Fetal growth 94
Sexually transmitted Infections and
Assessment of fetal wellbeing 99
pregnancy Vivienne O'Connor 46

vii
Women 's health : A core curriculum
Co nte nts

9 Medical disorders in pregnancy 105 14 Specific obstetric emergencies 163 22 The menopause and beyond 235
Edited by Martha Rnn Nadia Badawl, Michele Batey, Jonathon Morris, Edited by Martha Rnn
Michael Nicholl
Hyperemesis g ravidarum Regina Wulf 107 Edited by Lucy Bowyer The menopause Alas/air MacLennan 236
Anaemia Petra Porter 109 Management at the menopause
Isoimmunisation Louise Komman and Antepartum haemorrhage 164 Alastair MacLennan 237
Helen Savala 111 Primary postpartum haem orrhage 167 Postmenopausal bleeding Paul Duggan 243
Abnorm al g lucose tolera nce Helen Lomml 113 Umbilical cord p ro la pse 169
Hypertension Mark Brown 116 Ma lpresentatlons 170 23 Principles of operative
Th romboembolic disease Petra Porter 119 Shoulder dystOCia 172 gynaecology 249
10 Infections in pregnancy 125 15 The newborn 177 Phil Wolters and Clement Chan
Edited by Lucy Bowyer
Michael Humphrey and Ajay Rane Paul Croven and Nadia Badewi
Edited by Vivienne O'Connor Edited by Lucy Bowyer 24 Principles of oncology 253
Rubella 126 16 Routine management of the Edited by Martha Finn
Hepatitis B 126 puerperium 187 Screening for cancer of the cervix
Urinary tract inlection 127
Edited by Sondra CalT Jennifer Cook
Varicella zoster virus 128 254
Parvovirus B19 129 Cervical carcinoma Jennifer Cook 259
Normal puerperium Sandra Corr 188 Screening tor b reast cancer Phillip Corson
Cytomegalovirus 129 261
Care after caesarean delivery Endom etrial cancer Bruce Ward
Toxoplasmosis 130 264
Michoel Humphrey 192 Gestaftonal trophoblastic disease
Group B Streptococcus 130
Puerperal sepsis Sandra Carr 193
Cho rloam nionitis 130 Marc JNC Kelrse 267
Secondary postpartu m haemorrha ge Cancer 01 the ovary Marc JNC Kelrse 270
Jon Dickinson 195
11 Preterm birth 133 Gen ital tract trauma ChrlS/ine White 197 25 Women and society 277
Edited by Lucy Bowyer
Edited b y Martha Finn 17 The psychological experience
Regina Wulf of pregnancy 203 Teenage pregnancy Karen Harris 278
Pre term labour 134 Jonathan Rampono Violence a gainst women and girls Dawn Miller.
136 Edited by Sandra Corr Angela Taft a nd Kelsey Hegarty 280
Preterm prelabou r rupture 01 m embranes
Loss and grlet In women's lives
12 Maternal, perinata l m ortality 139 The Psychological experience 204 Cella Devenish and Jeremy Tuohy 282
Psychologic al and psychiatric disorders 206
Gerord Garllan and Clement Chan
Postnatal mental health 207
Edited by Lucy Bowyer Index 287
18 Infertility 211
Maternal mortality 140
142 Michael G Chapman and Una Conway
Perinatal mortality
Edited by Lucy Bowyer
13 Labour and delivery 145
19 Unplanned pregnancy and
Edited by Beverley Vollenhoven ond Mortha Rnn
termination 217
Normal labour Andrea Barkehall-Thomas Paul Duggan and JeHrey Robinson
(Edited by Beverley Vollenhoven) 146 Edited by Martha Rnn
Prolonged and dystuncftonal labour
Andrea Barkeha ll-Thomas 20 Genital prolapse 223
(Edited by Beverley Vollenhoven) 15 1 Paul Duggen
Active managem ent of labour Roslyn MecKenzie Edited by Mertha Finn
(Edited by Martha Finn) 152
OperaMve vaginal delivery 21 Incontinence 229
Andrea Barkehall-Thamas Paul Duggan
(Ediled by Beverley Vollenhoven) 154 Edited by Martha Finna
Prolonged pregnancy Nader Gad
(Edited by Marthe Finn) 156

Mf:
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Women's health : A core curriculum

Beverley Vollenhoven MBBS (Hons), PhD,


FRANZCOG, CREI
Abbreviations
Senior Lecrurer and Clinical Supervisor,
Department of Obstetrics and Gynaecology,
Monash Universiry, Melbourne, Vic.
William AW Walters MBBS, PhD, FRCOG,
FRACOG, FACSHJ; FRSM
Emeritus Professor, Acting Head, Discipline of 17-0HP 17-hydroxyprogesterone E oestrogen
Reproductive Medicine, John Hunter Hospital, ACE angiotensin-converting enzyme ECF extracellular fluid
Newcastle, NSW ACIS adenocarcinoma-in-siru ECG elecrrocardiograph
ACR albumin creatine ratio ECV external cephalic version
Bruce Ward MBBS, PhD, FRCOG, FRANZCOG, EDD estimated date of delivery
ACTH adrenocorticotropic hormone
CGO EE ethinyl oestradiol
Gynaecological Oncologist, Mater Medical AFI amniotic fluid index
AFP alpha-fetoprotein ELA endometrial laser ablation
Centre, Brisbane, Qld. ELISA enzyme-linked immunosorbent assay
AIDS acquired immune deficiency syndrome
Phi! Watters MBBS, MRCOG, FRACOG, FRCOG, ALT alanin e transaminase
FRANZCOG AMC Australian Medical Council FBC full blood count
Honorary Senior Lecrurer, School of Medicine, FBE full blood examination
AP antero-posterior
Universiry of Tasmania, Hobart, Tas. FDIU fetal death in utero
APH anteparrum haemorrhage
FMH feromaternal haemorrhage
Gareth Weston MBBS, MPH, PhD APTT activated partial thromboplastin time
FNAB fine-needle aspiration biopsy
Department of Obstetrics and Gynaecology, AST aspartate transaminase
FSH follicle-stimulating hormoneF
Monash Universiry, Melbourne, Vic.
BMD bone mineral densiry GBS group B Streptococcus
Christine White RN, RM, BHlthSc (Nurs), Jl.fN BPS biophysical profile score
Clinical Midwife Consultant, King Edward GDM gestational diabetes melli rus
BV bacterial vaginosis GFR glomerular filtration rate
M emorial Hospital for Women, Perth, Wi\.
GHb glycosylated haemoglobin
Regina Wulf Medical State Examination (Germany), CF cystic fibrosis GnRH gonadotrophin-releasing hormone
Registrar in Obstetrics and Gynaecology, Royal CIN cervical intraepithelial neoplasia
Darwin Hospital, Darwin, NT. CMY cytomegalovirus . HAIRAN hyperandrogenism, insulin resistance,
COCP combined oral contraceptive piLI acanthosis nigricans
CRH corticotrophin-releasing hormone Hb haemoglobin
CRL crown rump length HbAlc haemoglobin Al c
CSF cerebrospinal fluid HBcoreAg hepatitis B core antigen
CTG cardiotocography HBeAg hepatitis B e antigen
CVS chorionic villus sampling HBIG hepatiris B immunoglobulin
HBsAg hepatitis B surface antigen
HBsAg+ve hepatitis B surface antigen positive
D&C dilatation and curettage
HCG human chorionic gonadotrophin
DCIS ductal carcinoma in-siru HDN haeqlOlytic disease of the newborn
D&E dilatation and evacuation HELLP haemolysis, elevated liver enzymes and
DHEA dehydroepiandrosterone low platelets
DHEAS dehydroepiandrosterone sulfate HG hyperemesis gravidarum
DIC disseminated intravascular HIV hwnan immunodeficiency virus
coagulopathy HMB heavy mensrrual bleeding
DMPA depot medroxyprogesterone acetate HNPCC hereditary nonpolyposis colon cancer
DNA deoxyribonucleic acid HPV human papillomavirus
DUB d:'sfunctional uterine bleeding HSIL high-grade squamous intraepithelial
DVf deep vein (venous) thrombosis lesion

MG'
*
Women's health: A core curriculum

HSV herpes simplex virus


hormone therapy
PCOS
PCR
polycystic ovary syndrome
polymerase chain reaction
Photograph and illustration credits
HT pulmonary embolism
PE
lAT immune antiglobulin test PG prostaglandin
intracytoplasmic sperm injection PGF 2 (l prostaglandin F2 (l
ICSI
immunoglobulin G PID pelvic inflammatory disease
IgG
immunoglobulin M PKU phenylketonuria
IgM
International Liaison Committee on PMS premenstrual syndrome
!LCOR
Resuscitation POD pouch of Douglas For all figures not listed below, see the source Peter Farkas/Clinical Photography Unit,
intermenstrual bleeding POEC progestOgen-only emergency
J..t'AB aclmowledged in the caption and detailed in Royal Darwin Hospital
intrauterine device contraception the reference list of each chapter. p 59, Fig 5.1; p 101, Fig 8.6; p 102, Fig
IUD
intrauterine insemination POP progestogen-only pill 8.7; p 226, Fig 20.4; P 257, Fig 24.5;
IUI
inttauterine growth restriction PPH postpartum haemorrhage Australian Institute of Health and Welfare
IUGR P 262, Fig 24.10; p. 263, Figs 24.11,
intrauterine pregnancy PPROM preterrn prelabour rupture of
IUP p 143, Fig 12.1; P 244, Fig 22.7 24.12; P 269, Fig 24.15; P 271, Fig 24.16
in vitro fertilisation membranes
IVF prelabour rupture of membranes Australian Prescriber Eric Hu/Royal Darwin Hospital
IVH intraventricular haemorrhage PROM
PSN presacral neureCtomy p 240, Fig 22.3
p 256, Figs 24.2, 24.3, 24.4; P 257, Figs
LAVH laparoscopic assisted vaginal PT prothrombin time Professor Suzanne Abraham 24.6,24.7; p 2S9, Fig 24.8; P 265, Fig
hystereCtomy PV per vaginam (for D Uewellyn-Jones) 24.13; P 267, Fig 24.14
LCR ligase chain reaction p 19, Figl.l0; p 21, Fig 1.12; P 94, Fig
lureinising hormone-releasing hormone RBC red blood cell Alastair MacLennan/Departrnent of Nuclear
LHRH 8.1; p 148, Fig 13.2; p 150, Fig 13.3; P
RCT randomised controlled trial Medicine and Bone Densitometry, Royal
LLETZ large loop excision of the 180, Fig 15.2; p 182, Fig 15 .3; P 260 Fig
transformation zone Rl"'lA ribonucleic acid Adelaide Hospital
24.9 '
last menstrual period RPR rapid plasma reagin p 238, Fig 22.1
LMP
LNG-IUS levonorgcstrel intrauterine system Paul Duggan
SFH symphysis-fundal height p 225, Fig 20.2; P 226, Fig 20.3
LS!L low-grade squamous intraepithelial sex-hermone-binding globulin
SHBG
lesion SIDS sudden infant death syndrome
LUNA laparoscopic uterine nerve ablation selective serotonin reuptake inhibitor
SSRl
STI sexually transmitted infection
M CH mean corpuscular haemoglobin
MCHC mean corpuscular haemoglobin TCRE transcervical resection of the
concentration endometrium
MCV mean corpuscular volume TENS transcutaneous electrical nerve
MEA microwave endometrial ablation stimulation
MIS minimally invasive surgery TIT thyroid function test
MR1 magnetic resonance imaging TL tubal ligation
MSAFP maternal serum alpha-fetoprotein TOP termination of pregnancy
TPHA T. pallidum haemagglutination assay
NSAID nonsteroidal anti-inflammatory drug
TSH thyroid-stimulating hormone
NTD neural tube defect
TVS transvaginal ultrasound scan
NTS nuchal translucency scan
TVT tension-free vaginal tape
OA occipito-anterior urinary tract infection
UTI
OCP oral contraceptive pill
OD optical density VBAC vaginal birth after caesarean section
OP occipito-posterior VDRL venereal disease reference laboratory
VZV varicella zoster virus
P progestogen
PAPP-A pregnancy associated plasma protein A WHO World Health Organization
PBAC piCtorial blood-loss assessment charr
postcoital bleeding ZIG zoster immune globulin
PCB

iif
*1
The menstrual cycle and
vaginal bleeding /
Edited by Beverley Vollenhoven V
Premenstrual syndrome, dysmenorrhoea, abnormal bleeding Cindy Farquhar and Neil Johnson
Delayed puberty Fall Langdana and Rosemary Reid
Polycystic ovary syndrome, hyperandrogenlsm Wayne Gillett
Premature ovarian failure Michel Sangeli and Lynda Croft

Learning objectives

Knowledge recall the physiological changes in the


endometrium during the menstrual
At the end of this chapter, the student cycle
will be able to:
• describe the Investigations for
menorrhagia In a teenager and a
Premenstrual syndrome
woman of perimenopausa l y ears
define premenstrual syndrome ond
Indicate Its prevalence outline the principles of management of
menorrhagia
list the common symptoms of
premenstrual syndrome Delayed puberty

outline a management plan for a describe the pubertal process and the
woman with premenstrual syndrome development of secondary sexual
characteristics
Dysmenorrhoea
• list the common causes of delayed
differentiate between primary and puberty
secondary dysmenorrhoea
outline an investigation and
list the causes of secondary management plan for delayed puberty
dysmenorrhoea
Polycystic ovary syndrome
d(scuss the social and economic effects
of dysmenorrhoea • define polycystic ovary syndrome
construct a plan for Investigation and describe the clinical manifestations of
management of dysmenorrhoea polycystic ovary syndrome
Abnormal vaginal bleeding summarise the long-term complications
of polycystic ovary syndrome
define the terms menorrhagia,
dysfunctional uterine bleeding , describe the prinCiples of management
intermenstrual bleeding and postcoital of a woman with polycystic ovary
bleeding syndrome
(Continued over)


1 The menstrual cycle and vagi nal bleeding
Women 's health: a core curriculum

(leaming objectives continued)


write a prescription for a nonsteroidal anti-
inflammatory drug or oral contraceptive
pill and explain to the patient how she
* Premenstrual syndrome Symptoms and signs
Women with PMS will often feel 'overwhelmed'
Hyperandrogenlsm should take the medication Common clinical presentation or 'out of control' and have one or more of a range
appreciate the wide variation in hair For one week out of every four, before her of psychological and physical symptoms. The
take a comprehensive history from a
distribution and density in different ethnic woman with menorrhagia menstrual period, a busy professional woman symptoms are not an exacerbation of another psy-
groupS with a young family feels 'out of control', snap- chiatric disorder. Thus PMS is, in part, a diagnosis
counsel a woman concerning treatment of exclusion.
describe the normal cycle of hair growth ping at her children, weeping and foiling to
options for menorrhagia
cope at work. She would like you to prescribe Typical psychological symptoms include:
• list the normal sites of androgen • elicit a relevant personal and family '0 pill to sort out my hormones'.
production history from a peripubertal girl • affective lability - tearfulness, irritability or
anger
discuss the causes of excess androgen take a comprehensive history from a girl
production and its effects presenting with primary amenorrhoea • anxiety or tension
Epidemiology • depression
discuss the social consequences af • assess the development of secondary • loss of interest, difficulty concentrating, lack of
hyperandrogenism sexual characteristics in a girl Premensnual syndrome (PMS) is defined as the energy, sleep disturbance, appetite disturbance.
counsel a woman on the benefits of weight cyclical occurrence JUSt before menses of a range
outline an Investigation plan that
distinguishes benign from malignant loss and the long-term consequences of ,. of symptoms that are severe enough to impact on Physical symptoms accompanying PMS may
causes of hyperandrogenism polycystic ovary syndrome lifestyle, relationships or work, and that resolve include:
with the onset of menses. A symptom-free week
• explain the cosmetic and drug treatment examine a woman for signs of • breast tenderness
hyperandrogenism and virilism after menses is an essential diagnostic feature.
options for hyperandrogenlsm While 95% of women of reproductive age experi- • fluid retention and weight gain
Premature ovarian failure counsel a woman with premature ovarian ence some physiological symptoms premensnu- • headaches
failure on the use of hormone therapy and • aching joints.
define premature ovarian failure ally, approximately 50/0 of women are severely
assisted reprod uction .
incapacitated by these symptoms. The typical age
list the causes of premature ovarian failure at presentation is 30-40 years. PMS presents in all Evidence
outline how to investigate and confirm the Attitu des ethnic groups, although the reported symptom A substantial placebo response in PMS should not
diagnosis of premature ovarian failure clusters may vary with ethnicity. discredit the psychosocial aspects of the
At the end of this chapter, the student doctor-patient encounter. Indeed, the response to
discuss the short- and long-term effects of
should reflect upon : Pathoph ysiology an interested, understanding, empathetic and edu-
premature ovarian failure
• the effects of premenstrual syndrome on
cational approach from the doctor is very impor-
discuss a management plan for a woman Both medical and social models of the pathophys- tant. However, because this placebo response is a
with premature ovarian failure. family and social dynamics iology and approach to the management of PMS possibility, studies of possible treatments must be
• the broader social and economic impacts have been proposed. The most plausible hormon- double-blind randomised controlled trials (RCTs)
of abnormal vaginal bleeding al explanation is high levels - or, probably more to assess treatment effects rigorously - lower lev-
Skills accurately, rapidly declining levels - of proges- els of evidence are notoriously unreliable.
• the implications of delayed puberty for
At the end of this chapter, the student interactions at school and In the family terone (or the progesterone/oestrogen ratio) in the Attention to lifestyle, relationships and work
should learn how to: luteal phase of the cycle. Other medical patho- interactions may shift the focus of what was
• obesity as a public health issue
physiological theories include contributing factors assumed to be PMS. Changes that allow women to
• counsel a woman on the evidence-based the social consequences of such as increased renin-angiotensin-aldosterone exert greater control over their lives are most
treatments and other strategies for hyperandrogenism and obesity activity, changing prostaglandin levels, vitamin
management of premenstrual syndrome
likely to produce a lasting benefit. Relaxation
psychosocial and health implications of deficiency, excess prolactin secretion and endoge-
premature 'ageing' for a woman and her techniques are often helpful. Exercise may allevi-
exp lain the nature of primary nous endorphin depletion.
family.
ate symptoms for some women. Homeopathy and
dysmenorrhoea The psychosocial models acknowledge that the
herbal remedies have been used, but robust evi-
symptoms may be exacerbated by:
dence of their efficacy is lacking.
• a negative anticipation of mensnuation There is evidence from RCTs to support
• pressures of caring for famil y and pursuing a the effectiveness of selective serotonin reuptake
career inhibitors (SSRls). The response to gonadotrophin-
• an underlying predisposing personality releasing hormone (GnRH) agonists - so-called
• stereotypic expectation among men and medical oophorectomy - usually gives a useful pre-
women of premensnual symptoms. diction of the response to surgical oophorectomy.


l). · ~\l\J, s""",~r1,:-
1c-1''''-(c.0\.Of'j V~ c..A·
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(fl.VN4 1 The menstrual cycle and vagin o l bleed ing
Women's health: a core curriculum
! rl

However this approach remains conrroversial,


being co~sidered by many to be excessively inva-
* Dysmenorrhoea " Se.vo~ 'I
,-------------------------------------------------~

Ureter ------li--t-l+l-=f---fl
sive when cure cannot be guaranteed. Refs have Common clinical presentation
Umbilicus ---......,~
failed to provide supporting evidence for the effec-
During a consultation with a 34-year-old
tiveness of evening primrose oil, which proVIdes woman who Is concerned that she has not Small bowel ---IIL...--h4----\-+
linoleic and gamolenic acids, precursors of been able to conceive 12 month. after stop-
prostaglandin E or progestogens. . ping the oral contraceptive pili, a coincidental Caecum
-\-l,<:~~_l..-..\\..-- Pelvic peritoneum
Other rrearrnents that are commonly used m finding Is that she has always hod debilitating
Appendlx----1\----\----/-.f.-,l>,) ~.>Y~~~-.w.....:>.--\--4I>__- Fallopian tube
practice, but for which there is either conflicting menstrual period pain. She has always been
evidence or an absence of eVIdence from Refs, told by her mother and the family GP that 'this laparotomy
~?-~~~~\!ti-SigmOld colon
include the combined oral contraceptive pill is the normal thing all women go through'. scar Ovary
::;:;; _ (COCP), continuous progestogens, pyridoxine Inguinal ring Surface of uterus
(vitamin B6), nonsteroidal antl-mflammatory Myometrium (adenomyosis)
drugs (NSAIDs), calcium or magnesium. . Round
Uterosacral ligament
When certain physical symptoms are a prOID!- Epidemiology ligament
Rectovaglnal septum
nent part of a woman's PMS, specific treatments Dysmenorrhoea is painful mensrrual cramps of Bladder
Cervix
may be indicated: uterine origin. It is very common, affectmg up to Uterovesical Vagina
spironolactone for fluid retention 50% of all women. It is termed secondary dys- told
___ ~\..-7~.z.:...--7'L..--perineum
bromocriptine or everung pruruose oil for menorrhoea when identifiable pathology such as Groin
breasr tenderness. endomerriosis, adenomyosis, pelvic congestion or
pelvic adhesions indicating pre~ious inflammanon Vulva and
Bartholin's
Natural history is present; miillerian abnormalities, cervical steno- gland
sis and gynaecologlc malignancy are all rare causes
Women usually find strategies to cope with PMS, of secondary dysmenorrhoea. In all women with
with assistance from an understanding doctor, As pain and vaginal bleeding, pregnancy should be FIGURE 1.1 The distribution of endometriosis ( Based on Smith 2002, p 105)
the pathophysiology relates to cyclical hormonal considered and excluded.
change, the condition resolves afrer menopause. Primary dysmenorrhoea refers to mensrrual
cramps in the absence of .organic pathology. women. Most of the PGF 1a is released during the condition affecting up to 1 in 6 of all women (most
Impact/outcomes Primary dysmenorrhoea typically begIns 6-12 first 48 hours of mensrruation, coinciding with the of whom have mild disease). It results from one or
PMS affects family and social dynamics. It has months afrer menarche (the onset of menses), once greatest severity of symptoms. more of four possible mechanisms:
been deemed., in eXtreme cases, to be responsible the cycles become ovulatory (anovulato.ry cycles The following conditions are the most com-
for criminal acts; indeed., PMS has been used as a tend to be associated with non-painful menses). mon causes of secondary dysmenorrhoea: • rerrograde menstruation
successful legal defence against murder charges. Secondary dysmenorrhoea usually commences • coelomic metaplasia
years afrer menarche, in women more advanced • endometriosis • inrraperitoneal immune system deficiencies
into their reproductive years. Pain from secondary • adenomyosis • embolic transport of endometrial cells via the
Health maintenance • pelvic congestion bloodsrream or lymphatics.
dysmenorrhoea also rypically occurs 24 hours .or
lifestye adaptations - including the more before menstruarion and lasts for Its enme • pelvic pain related to previous pelvic inflam-
adoption of a healthy diet, exercise matory disease and adhesions. Adenomyosis is the occurrence of ecropic
duration. endomerrial implants within the myomerrium.
and relaxation techniques - may
help to manage PMS. Endometriosi5 is the occurrence of ectopic Pelvic congestion is associated with chronic
Pathophysiology endomerrial tissue ourside the uterus. The mOSt dilatation of the pelvic veins, particularly in the
Prostaglandin F2a (PGFrol is the agent responsible common sites are the ovaries (where the tissue may luteal phase, primarily under the influence of
for primary dysmenorrhoea. It IS produced i l l the form 'chocolate cysts'), the pouch of Douglas, the oesrrogen. Such veins are prone to stasis of blood.,
secretory endomerrium and mduces contracnons uterosacral ligaments and the broad ligamenrs, leading to engorgement - or congestion - of the
of the myometrium. Progesterone IS reqU1[ed f~r although other sites may be affected (Fig 1.1). Deep pelvic organs.
the endometrial production of PGF 2a; this nodular lesions may affect the rectovaginal seprum. Chronic pelvic pain is a cornmon sequel of pre-
explains the absence of dysmenorrhoea in anOVU- In severe endomerriosis, adhesions and scarring vious acute pelvic inflammatory disease (PID). This
latory cycles. The amount of PGF 2a produced by mvolvmg all pelvic organs may result in a 'frozen has ofren been referred to as 'chronic PID', but
women with primary dysmenorrhoea IS far grea((;:r pelvis'. Rarely, endometriosis can occur at sites dis- should more appropriarely be called 'recurrent
than that produced by non-dysmenorrhoelc tant from the pelvis. ;:: ndometriosis is a cornmon pelvic pain following acute PID', since rrue chronic


1 The m enstrua l cycle an d vag inal bl eeding
Women 's health : a core c ur riculum

simple opiates and can be used in combination


PID (chronic pelvic inflammation where causative Investigations with non-NSAID analgesics
microbiological organisms may be continually iso- Transvaginal pelvic ultrasound examination may • the COCP - useful for primary dysmenor-
lated from the genital tract) is rare. This rype of diagnose or exclude ovarian cystS (including rhoea in up to 900/0 of all cases, since anovula-
pelvic pain often has the hallmark of pelvic adhe- endometriomas), or suggest a tubo-ovarian mass. tory cycles tend not to be associated with
sions ' other common causes of the latter are Pelvic magnetic resonance imaging (MRl) may give painful menses; helpful in some cases of sec- ~~""1
endo:netriosis and previous pelvic surgery. additional information; for example, it may help ondary dysmenorrhoea. /o.vJ.I/O~'"
with the diagnosis of adenomyosis. Laparoscopy RCT evidence supports the effectiveness of S'lf
Symptoms and signs under general anaesthesia is the gold-standard progestogens, COCp, gestrinone, danaz61 and .!Z)
The crampy central lower abdominal pain of pri- diagnostic test for causes of dysmenorrhoea or GnRH agonists for pelvic pain related to ~c ~ I
mary dysmenorrhoea, which can radiate to the pelvic pain (Fig 1.2). endometriosis, although in direct comparisons none v.. r1!A~1
lower back and upper thighs, may precede the Although parterns of pain and associated of these medical treatments is clearly superior to the ~~
onset of menses by several hours, tends to be most symptoms may scrongly suggest either primary or others. Usually these would be malled, ill this order, ...,,::. \ CJ..
severe in the first 24 hours and only occasionally secondary dysmenorrhoea, the most reliable diag- for a therapeutic response on cost and acceptability (i r'f \Jw '-I.I
lasts for longer than 48 hours. There may be asso- nosis is made by laparoscopy. Laparoscopic inspec- grounds, although danazol is now rarely used ~'i-
ciated symptoms, including vomiting, diarrhoea, tion of the pelvis enables endometriosis and pelvic owmg to androgenising side effects. c,.-
headache, fatigue and, rarely, syncope. congestion to be diagnosed and excludes patholo-
Secondary dysmenorrhoea rypically has its onset gy in· women with primary dysmenorrhoea. ~)
Laparoscopy does not need to be performed for all
Surgical treatment Sllw t(,Y
more than 24 hours prior to the onset of menses,
lasts for the entire duration of menstruation and young '.'.'omen with dysmenorrhoea, but the RCT evidence supports the effectiveness of laparo- l ~ SIf;
may be felt more on the left or right side. Associated option of its use in diagnosis should be discussed. FIG URE 1 .3 The laparosc oplc Image seen on scopic surgery for endometriosis in relieving pain. e-f~ifJV
symptoms may suggest a diagnosis of endometriosis Laparoscopy has the further advantage that the TV mon itor (Based on McKay Hart & Laparoscopic excision of deep and nodular ~r{
_ deep dyspareunia (pain with sex-ual mtercourse), surgical treatment for endometriosis or pelvic Norman 2000, p 84) endometriotic lesions is rational, although most 0---.J-)
non-menstrUal pain, dyschezia (defaecatory pain) or adhesions may be carried out simultaneously Wlth procedures include a combination of excision of
other bowel symptoms (constipation or diarrhoea, the diagnostic procedure, provided the woman has the deeper lesions and either ele=osurgical or
• high-frequency transcutaneous electrical nerve
often accompanied by menstrual exacerbations). A had appropriate prior explanation and given con- laser ablation of superficial endometriosis.
stimulation (TEN S)
history of infertility would also increase the index sent to such surgery, if required. In recent years, it RCT evidence does not support the use of:
• a multidisciplinary approach with a team of
of suspicion for endometriosis. has become standard practice to attach a camera to health professionals (including gynaecologists, • laparoscopic adhesiolysis (unless pelvic adhe-
Tenderness on pelvic examination, especially if the laparoscope eyepiece, allowing projection of pain specialistS, psychologists and counsellors), sions are severe)
associated with a fixed retroverted uterus or ten- the image to a television monitor (Fig 1.3). This which significantly improves many important • neuroablative surgical procedures, including
der nodules in the uterosacral ligaments or recto- facilitates precise laparoscopic surgery by provid- outcome measures for women with chronic laparoscopic uterine nerve ablation (LUNA)
vaginal seprum, suggests endometriosis. ing the surgeon and assistants with a magnified pelvic pain and presacral neurectomy (PSN) for women
view of the pelvic pathology. • counselling supported by an ultrasound scan to with either primary dysmenorrhoea or
Laparoscopy carries a low surgical risk in slim exclude pelvic cysts - effective in accelerating endometriosis, although some RCTs have sug-
women with no previous abdominal surgery, resolution of symptoms in acute exacerbations gested LUNA may be effective for women with
although the recognised major hazards are bowe~ of chronic pelvic pain. severe primary dysmenorrhoea.
bladder, ureteric or vascular injury. Such injuries
occur in fewer than 1 in 1000 low-risk women, but RCT evidence does not support the use of vita- Many women ultimately request a hysterecto-
this risk increases in the context of prior surgery, obe- min E, acupuncture, low-frequency TENS or my for very severe dysmenorrhoea and pelvic pain
spmal manipulation. ill general, whether or not they have endometrio-
sity or if complex endometriosis surgety is required.
sis. Hysterectomy is the only effective treatment
Conservative or alternative for some conditions, such as adenomyosis. While
Medical treatment a tOtal hysterectomy often improves symptOms of
treatment options pelvic pain (and cettainly prevents further men-
First-line treatment of primary or secondary dys-
There is RCT evidence to support the use of the menorrhoea includes: strUal periods!), pelvic pain relief cannot be guar-
following treatments, although many do not have anteed following hysterectomy, and some women
an established place in clinical practice: • analgesics, including paracetamol or opiate With chronic pelvic pain syndromes do not
analgesics improve following hysterectomy. The best ap-
• vitamin Bv vitamin B6, magnesium, fish oil
(omega-3 fatty acids) and a Japanese herbal • NSAIDs - owing to anti-prostaglandin mech- proach to hysterectomy is usually a laparoscopic
FI GURE 1.2 How ih e laparosco pe Is used (Based arusms, NSAID are usually more effective than aSSisted vagmal hysterectomy (LAVH), which
on McKay Hart & Norman 2000. P 84) combination

w,
Women's health : a core curriculum
1 The menstrual c y cl e and vag inal bleeding

combines the speedier recovery from vaginal sur- Ovulation


gery with the abiliry to remove all pelvic
endometriosis and adhesions. Whether to remove 50 0 - __ oProgesterone 40 1400
the ovaries at such an operation is an issue that
must be carefully discussed with women in A 50-year-old woman consulls you otter experi- o--a Oestradiol
advance. Nowadays, healthy ovaries are usually encing several years at symptoms that she hod 40 • ___ . FSH
conserved in women of reproductive age to retain attributed to menopause. These began with
Irregular periods and Intermenstrual bleeding. _lH
the benefits of ovarian steroid hormone produc- E ""i5 1000
tion, although this might increase the likelihood of
recurrent pelvic pain and the need for future sur-
but now she has postCOital bleeding. which Is
affecHng her sex IIIe.
::l

--
J:
'"
30
......... .....-...
_
E
,s

e'"
gical oophorectomy.
u.. ,,-~ ~ 20 c
A 28-year-old woman InSists you reter her lor a 'C
c 20
hysterectomy. as she is led up with very heavy a
• '~"
Natural history regular menstrual bleeding. :s CJl 500
e
0.
For some women, dysmenorrhoea improves after 10
childbirth. Pelvic pain from all causes tends ro
regress after menopause. Epidemiology
b
o
Menorrhagia is defined as abnormally heavy men- Menstrual
Impact/outcomes Proliferative
strual bleeding (HMB). The traditional definition is
Dysmenorrhoea affects not only personal health, a blood loss greater than 80 mL per period. The val- ~1 +'-----------I-~---------------4
but has a big economic impact through lost work- idated method for measuring menstrual loss, the Receptive 10
ing hours, Clear explanation of the cause and alkaline haematin technique, is available only as a implantalion
benign narure of primary dysmenorrhoea, and research too!' Other validated techniques, such as
reassurance that it docs not affect fertility, are the pictorial blood-loss assessment chart (pBAC),
important. Conversely, the infertiliry somerimes have been used to obtain an objective measurement
associated with endometriosis can make a painful of menstrual loss. Individual perceptions and cul-
condition more difficult to endure. Some women rural perceptions may playa role in what is accept-
with dysmenorrhoea may develop a chronic pain ed as 'normal'. Thus, in practical terms, a woman's
syndrome that is notoriously difficult to treat. own definition of her HMB is what is normally
used in clinical practice. As it is women who expe-
rience the impact upon qualiry of life and who
undergo investigation and treatment, sensible clini-
cians will encourage women to have a role in decid- a
Health maintenance ing on the management plan, after a full discussion Day at cycle
It Is important tor a woman to of available options. The prevalence of HMB
understand the physiological nature increases with advancing age in the reproductive
at primary dysmenorrhoea , years. It accounts for 2-4% of all GP consultations, FIGURE 1.4 The me nstrual cycle showln (0) h
but over 15% of GP referrals to specialists. HMB is (Based on Rymer et 01 199 7, P 2:'. Fig 36? ormona l chonges ond (b) endometrial changes
the commonest cause of iron-deficiency anaemia in
developed countries. Management of HMB has a
substantial cost implication for any health service. periods. If it occurs while the "oman is takin
Dysfunctional uterine bleeding (DUB) encom- the COC~ it is call~d breakthrough bleeding. g in the endometrium are largely determined by the
va PO~rCOltaI bleedmg (PCB) is bleeding or bloody flucruatIng concentrations of ovarian hormones.
passes both ovulatory DUB presenting as regular
HMB (menorrhagia) and anovulatory DUB pre- gIn dIscharge after sexual intercourse. Up to ov ulanon, the endometrium increases in
senting as irregular vaginal bleeding. It implies that thickness and endometrial glands proliferate (pro-
anatomical causes have been excluded and that a Anatomy and pathophysiology liferatIve phase). After ovu lation, under the influ-
subtle benign hormonal dysfunction is the under- ence of progesterone from the corpus luteum
lying cause.
Thhe phrsiology of normal cyclical biological
~h:ges resultIng from the interaction of the hypo-
the endometrium undergoes secretory changes u:
Intermenstrual bleeding (I1vlB) is vaginal bleed- preparation for reception of the implant-
d lIUC-plruItary-ovanan hormonal axis is
ing that occurs between expected menstrual Ing embryo. If a pregnancy does not occur, the
emonstrated in Figure 1.4. Physiological events
decreaSIng levels of progesterone from the

ME
1 The menstrua l cycle a nd vaginal bleeding
Women 's health: a c o re cu rric ulum

as squamous metaplasia. An exaggerated appearance Ovulatory DUB may result from an excess of tain the typical bleeding pattern. Menstrual bleed-
degenerating corpus luteum becom~ insufficient plasminogen activator, resulting in the breakdown ing problems may interfere with a woman 's so-
to maintain the endometnal mtegnty, allowmg of columnar epithelium on ci;e ectoceIVlX ~ knowr;
as a cervical ectopy or ectropIon (the term erosIOn of fibrin plugs (fibrinolysis) at the open spiral cial life, sex life and relationship. Paradoxically,
spasm of the spiral arterioles in the basal layer of arterioles of the endometrium (these fibrin plugs women with 1MB or PCB sometimes delay con-
the endometrium, and synchrorused sheddmg of is no longer used for this normal appearance).
normally minimise the heaviness of menstrual sulting a doctor because of a fear of cancer. This is
the more superficial endometrial layer occurs at The following conditions may be the cause of
bleeding). It may also result from an imbalance of particularly unfortunate, since cancers presenting
menstruation. Typically, the menstrual period lasts menorrhagia: prostaglandin (PG) levels - PGFza brings about with abnormal bleeding (typically endometrial or
5 days and the length of the cycle is 28 days, • fibroids arteriolar vasoconstriction and PGE z vasodilata- cervical cancer) have a high chance of curative
although these times vary m different women and • endometrial or endocervical polyps tion in these vessels, and poor constrictive activ- treatment if recognised early. Menorrhagia can
from cycle to cycle in the same woman. . • endometrial hyperplasia ity may lead to heavier blood loss. Anovulatory lead to fatigue from anaemia and, if severe, short-
Wilen the cervix is exanuned usmg a vagmal DUB usually results in irregular bleeding, as the ness of breath.
• adenomyosis
speculum, the squamocolumnar junction can usually normal cyclical stimulation of the endometrium Important examination signs include pallor and
• hypothyroidism
be seen, where the pink squamous epIthelium on the by steroid hormones does not occur. Three com- a pelvi-abdominal mass that may be present with a
ectocervix adjoins the more red-coloured columnar • coagulopathy
• presence of an intrauterine contraceptive mon patterns are recognised: fib roid uterus. Vaginal speculum examination may
epithelium emerging from the endocemcal canal. reveal a vulval, vaginal or cervical lesion, including
This exposed area of columnar epithelium on the device (IUD) • in adolescents soon after menarche, owing to
• endometrial or endocervical carcinoma cervical ectopy, polyp or malignancy. Bimanual
ectocervix is known as the trarJ.sformatlon zone, low oestrogen concentrations
DUB, if pregnancy and the above causes have pelvic examination is the best way to clinically
since the columnar cells are replaced, over many • in women with polycystic ovary syndrome diagnose a fibroid uterus (irregularly enlarged) and
years, by squamous cells in a normal process known been excluded. (PCOS), owing to unopposed oestrogen stimu- this may be confirmed by a pelvic ultrasound scan.
lation
• in women in the few years before menopause, Investigati ons
owing to a sharp rise and then fall of oestrogen
concentrations. Pregnancy should always be excluded. Women
with irregular bleeding must be investigated to
An older term for anovulatory PCOS-type exclude genital tract pathology. This usually
DUB was metropathia haemorrhagica. Women involves a hystt:roscopy and endometrial biopsy.
with PCOS-type DUB will often have infrequent Women who present with menorrhagia should
periods, rhen long periods with heavy bleeding. be investigated as follows:
They often develop 'Swiss-cheese endometrium'
(cystic hyperplasia). • A full blood count is performed for all women.
Intermenstrual bleeding might be purely DUB • Coagulopathy and thyroid functi on tests are
(and this is the case for most younger women with performed only if other clinical features suggest
1MB), but it is a warning symptom for endome- these diagnoses. However, teenagers with pro-
trial pathology. Postcoital bleeding may have a found HMB should have a coagulopathy
benign aetiology from a cervical ectopy, but PCB is screen because of the higher incidence of von
a warning symptom for cervical carcinoma, and the Willebrand's disease and idiopathic thrombo-
cervix must be inspected carefully to exclude this. cytopenia. ""
'9j.,A transva~al pelvic ultrasound scarfShould be
Symptoms and signs pertorme or women who are at hIgher risk of
endometrial pathology (hyperplasia and carci-
A woman presents not necessarily with heavy peri- noma): women >45 years of age and those
ods, but often with a change to her 0"''Tl typical with weight > 90 kg, nulliparity, a history of
cycle. It is important to ascertain the age of men- irUertility, a family histoty of endometrial or
arche, the typical bleeding pattern in teenage colon cancer.
years, the typical bleeding pattern if COCP has • A transvaginal sonohysterogram (ultrasound
been used, the commencement of menstrual cycle with saline fluid infusion into the uterine cavi-
abnormalities, their progression and any relation- ty) may provide the contrast needed to distin-
ship to body weight. Women with heavy periods guish endometrial polyps from submucous
often describe clots or flooding (causing social fibroids.
FIGURE 1 5 Multiple fibromyomas. ranging In size from 2 mm to 9 cm In dlamet~r. s~en embarrassment) and the need to use towels in • CT and MRI scans are expensive and there is
during abdominal hysterectomy (Reproduced w ith perm ission from Ma ckay. Belsc er. addition to tampons. A menstrual calendar may be no evidence of superiority over transvaginal
Pepperell & Wood 1992. P 385. Fig 27.1) helpful, especially if bleeding is irregular, to ascer- ultrasound.

ME
Women 's health: a core curricu lum
1 Th e m enstrual c y cl e an d vaginal blee ding

progestogens, such as me d roxypro gesterone .d I Irregular DUB


acetate or norethisterone, were the most WI ~y An OCP or cyclical oral progestogens are usually
prescribed medication for HMB well lIltO e effective.
1990s but when used only in the luteal phase they H a woman presents with continual intractable
are th~ least effective! Long-course oral progesto- heavy vaginal bleeding, which is believed to be DUB,
~~--"-"QQl~-- Subserous
gen treatment (used for 3 out of every. 4 weeks) this can usually be controlled by bed rest, oral
is effective, but long-term use is limited by a tranexamic acid and high-dose oral progestogen
high incidence of side effects, The. OCP reduces treatment (such as norethisterone 15 mg three times
Submucous
HMB even if fibroids are a conmbutlIlg cause. daily, reducing after 48 hours to 10 mg three times
FIGURE 1.6 The Pipelle endometrial sompling device Ethamsylate is ineffecnve and no longer used. The daily). In this event, it is wise to control the cycle by Intramural
(Based on McKay Hart & Norman 2000, p 112)
Side effects of rlanazol, gestrlnone and GnRH I giving long-course oral progestogen treatment
analogs prohibit thelf use for HMB. The levo- -1! ofI I. (3 weeks out of 4) for at least 3 months. Rarely,
norgeStrel mtrautenne system (LNG-IUlb~ tht ~~intravenous high-dose oeStrogen or traneXarrllC acid
• Endometrial biopsy is indicated if the endome-
If
trial thickness is 12 rrun or greater, or if ultra-
sound is not available in the above higher-nsk
most
re~easeseffecnve notlSurgIcal
progestogen hormoneopoon
to att for blrthet
loamyMB. ""I_VV'[~might be usefuL Emergency D&C is occasionally
u£fi .
scenarios, Pipelle sampling, which can be per- endometrium.
""'" Bleeding may be expecte d to be Iess - ·.a m".",,", if medical treatment proves ins oent.
formed in the clinic during a pelVIC examma- than half as heavy as It was before mseroon (Wlth
around 1 in 5 women becorrung amenorrhoeiC),. at Surgical FIG URE 1.9 The d istrib ution and types of
tion for most women, is a less lIlvaslve method flbrolds (Based on Wllcocks & Phillips 1997,
of endometrial biopsy (Fig 1.6), The Plpelle IS the cost of an irlSertion procedure (the deVICe
P 227, Fig 14,1)
needs to be replaced every 5 years) and Irregular Endometrial ablation techniques are designed to
inserted into the uterine caviry until resIStance
at the fundus is encountered; the plunger .IS bleeding for the fust 2-3 months after msernon, partially or full)' destroy the endometrium. Two
The choice of medical treatment IS often influ- generations of techniques are available. First- gical expertise, and evidence suggests that they
then withdrawn to produce a ~acuum and os- prodUCe results comparable to those of first-gener-
sue is sucked into the Pipelle as It IS rotated and enced by a woman's other requirements. A woman generation techniques are performed under
needing contraception would choose the OCP or hysteroscopic guidance and include transcervlcal ation techniques. They may often be performed
slowly withdrawn, It is less common for a with local anaesthetic or intravenous sedation in
dilatation and curetrage (D&C) to be necessary, LNG-IUS ' a woman wishing to conceive or to resection of the endometrium (TCRE) (Fig 1.8),
have no:Wormonal treatment would choose rollerball ablation and endometrial laser ablation an outpatient setting, and include thermal balloon
especially as there is no evidence of any thera- ablation and microwave endometrial ablation
tranexamic acid or an NSAlD; the LN G-IUS or an (ELA). Second-generation techniques have been
peutic advantage from a D&C. . . (MEA)_ Generally, ablation is successful for four
• Hysteroscopy, a fine telescopic exanunaoon of SAID would be most appropnate for a woman developed for selected cases that require less sur-
with dysmenorrhoea. Combinations of tranexarruc out of every five women with regular HJ\1B, one
the endometrium, is the gold-standard diagnos- of whom is likely to become amenorrhoeic; ooe in
acid and NSAIDs may be used if response to eIther
tic technique for endometrial pathology diagno- five ablations are not successful, while the tech-
one alone is insufficient.
. (F'Ig 1.7) . This can often be performed
SIS . ( ,on an nique is unsuitable for women with irregular DUB.
outpatient basis with local anaesthesia a para- Blodder Hysterectomy involves major surgery, although
cervical block') if a suffiCiently narrow- it should be possible to carry Out at least 70% of
calibre hysteroscope and minimal distensIOn hysterectomies by the vaginal route (rather than
medium (carbon dioxide or salme) are used. abdominal hysterectomy) for DUB.

Tre atm ent Fibro id s


For some women, explanation of the concept of The distribution of uterine fibroids and their
DUB ('no disease') as a cause for HMB IS suffiCient nomenclature is shown in Figure 1.9. Submucous
and no other treatment is reqUired. Anaerrua fibroids that distort the endometrium are rypically
should be treated by iron replacement. associated with Hj\lB. Heavy bleeding may also
occur where the uterus is substantially enlarged by
Medical intramural fibroids, which increase the surface
An antifibrinolytic agent, such as tranexamic acid area of the endometrium, Hysterectomy (via the
1 g tablets taken four times dally dunng menstru- abdominal route) has traditionally been the treat-
ation, is the most effective oral medical tr~atment Uterus
ment of choice for women with HMB related to
for HMB. NSAlDs, such as mefenamIC aCid fibroids. There is now increasing evidence con-
500 mg tablets taken three times daily durmg FIGUR E 1. 7 The hysteroscope (Based on FIGURE 1.8 How a TCRE Is performed (Based cerning other treatments.
;v1cKay Hort & ~lorman 2000, p 112) On ymon ds & Symonds 1998, p 232, Fig 22.9) There is insufficient evidence to support med-
menstruation, are also helpful. Cychcal oral
ical treatment options (other than OCP) . Evidence
Ht.{~ ~~fI.-'" L..,. ~V\N>.~
SwYtl -u:-t ME
- M.'I0vA~ ,Jc~
L 1<A~ loW v\(c,t...l
k~ho",)

- "'-'tS~", V'V'o7 ll'r


- ~I.cri~\r. [ "lj.4 c,-.. ,
1 The m enstrua l cycle and vag inal b lee ding
Women's health: a c or9 c urr iculum

does not support the surgical removal of fibroids Impact / outcomes


to treat infertility or to prevent a fibrOId from Menorrhagia may affect social activity, relation-
turning into a malignant leiomyosarcoma (very ships and employment. Inadequate treatment.of
rare, fewer than 1 in 1000 cases). Myomectomy menorrhagia may lead to chromc anaerma, ill- 5G)
(removal of fibroid) rather than. hysterectomy health and psychological upset. The cost of men- >-
should be considered for women Wlth HMB who strual hygiene productS may be qwte conSiderable E
.B Height
wish to retain fertility and for whom there are no for women with intractable HMB.

II
'"
C
other treatment options. Submucous fibroids Fertility issues may have an impact on the man- G)

impinging on the uterine cavity may be resected agement of anovulatory DUB .. Ovulanon mduc- E
~
with a transcervical myomectomy techmque SlIDI- tion treatments (such as clormphene citrate for 0
anovulatory PCOS) will often improve cycle con- .s
lar to TCRE. :E
In women who need to undergo hysterectomy trol as ovulation is established. C>
a;
for fibroids, preoperative medical treatment to Fear of a cancer diagnosis is prominent among :J:
shrink fibroids (for example with GnRH analogs) women with menstrual bleeding disorders. In
may allow a less invasive operation: for example, some cases this can delay presentation for medical
a vaginal rather than an abdominal hysterectomy: advice and compromise the prognosis. Abnormal 8 9 10 11 12 13 14 15 16 17 18
Fibroid embolisation (by an intervennonal radi- menstrual bleeding should be invesngated thor- ,- Age (years)
ologist) is a new technique that might avoid a hys- oughly, especially in women who. have u:regular
terectomy in some circumstances, although rare bleeding, 1MB, PCB or other risk factors for
hazards associated with embolisation (such as the endometrial cancer.
FIGURE 1. 10 The sequence of pubertal events (Based on Llewellyn -Jones 1999, p 9, Fig 2.1)
need for emergency hysterectomy soon after- Health maintenanc e
wards, premature ovarian. failur~ or severe li£e-
threatening sepsis) mean thiS reqUIres further eval- Early presentatio n with symptoms o f
uation before it can be widely recommended. abnormal menstrual bleeding allows physically, s~xually and psychologically. The onset development of the breast, known as thelarche, is
early detection of endometrial generally varies between 9 and 14 years. the first sign of oestrogenisation and usually occurs
cancer and a good prognosIs. The physical e"cnts of puberty tend to follow around 10-11 years of age (Fig 1.11). The growth
Natural history Cervical screening programs have
been shown to prevent deaths from an ordered sequence in time (Fig 1.10) . Although of sexual hair is controlled by adrenal androgens
Most cases of DUB run a benign course, although the most obvious changes are within the reproduc- and is termed adrenarche.
abnormal menstrual bleeding may herald malig- cervical cancer.
tive system, the first sign is generally a pubertal Depositio]] of subcutaneous fat occurs and gives
nancy and this should be excluded. The peak inci- growth spurt. Girls tend to go through puberty both the more rounded female contour and the
dence for endometrial carcinoma occurs at age 61
and only 25% of cases occur before menopause.
The majority of younger women who develop
endometrial cancer have experienced prolonged
* Dela yed puberty earlier than boys and are therefore often taller and
heavier than boys of the same age; at later stages,
females grow less than males because of earlier
epiphyseal closure. The growth spurt is followed
greater prominence of the labia majora and the
mons pubis. The infantile uterus enlarges and its
body increases in relative size compared to the
cervix. The uterine lining changes from cuboidal to
unopposed oestrogen stimulation of the endo- Common clinical presentations
by the early development of secondary sexual colW1U1ar and becomes secretory. The vagma length-
metrium, as can occur in anovulatory PCOS, A child is taken to see her GP because she has characteristics. Menarche, the first menstruation,
where the endometrium is not exposed to the pro- ens, thickens and begins to sectete mucus_ The pelvis
become self-conscious In the school changing occurs between 11 and 14 years. Finally, secondary
tective effectS of progesterone. The peak incidence acquires the female configuration. All these changes
rooms about the fact that she has not devel- sexual development is completed and is accompa-
for cervical carcinoma is currently under 50 years oped breasts or pubic hair like her classmates.
occur under the influence of oestrogen.
nied by a further growth spurt. Menstruation usually first occurs at around
and continues to fall. Those countries with well-
A mother takes her daughter to see the GP 13 years of age (11-14 years) arid this links to
organised cervical cytology screening programs Seconda ry sexual characteristics
because all her daughter'S peers seem to have approximately Tanner stage 4-5 of breast develop-
have reduced their incidence of cervical cancer, commenced their menses, but her daughte f
with appropriate use of colposcopy and conserva- Secondary se 'ual characteristics comprise five ment. In 95% of girls it has occurred by age 13.
has not. ch~ges: the development of breasts, pubic and Bleeding can be erratic and sometimes heavy
tive excisional surgery for cervical intraeplthelial
neoplasia (CIN), the premalignant condition . of axillary hair, the growth spurt and the onset of because many initial 'menstruations' represent the
the cervix. Very rarely, abnormal vagillal bleeding menstruation (menarche). shedding of the uterine cavity endometrium when
may be due to fallopian rube cancer or to a hor- Normal puberty The first physical sign of puberty is generally oestrogen-stimulated growth outgrows blood sup-
mone-producing cancer of the ovary (granulosa breast development, followed by growth of sexual ply, rather than the culmination of an ovulatory
Puberty is the time at v.'hich, under the influence hair in the pubic area and then the axillae. The hormonal cycle.
cell tumour), which influences endometrial
of sex hormones, a ch ild becomes an adult
growth and shedding.
Women's health: a co re c urric u lum

All the physical changes of pubeny occur as a


History and examination
(0 result of endocrine maturation. Stimulated by
C0 C0 luteinising hormone-releasing hormone (LHRH) Past general health, height and weight records are
from the hypothalamus, the pituitary gland important, along with relevant behaviour such as
Stage 1 extreme exercise or abnf)rmal eating habits.
secretes follide-stimulating hormone (FSH). This
release of FSH is pulsatile and begins initially at Physiologic delayed pubert;. tends to be familial
I night but, as the pulse frequency and amplitude and hence the height and pubertal milestones of
older siblings and parents are important.
increase, it is also secreted by day. In turn, the FSH
On physical examination, in addition to Tanner
l' stimulates the ovaries to increase the release of
17~ oestradiol, which stimulates breast growth.
The ovaries also secrete androgen, primarily dehy-
staging of any secondary sexual characteristics
present, a search for signs of hypothyroidism,
gonadal dysgenesis and chronic illness should be
Stoge 2 droepiandrosterone (DH£A), which instigates the made. The commonest form of gonadal dysgenesis
(0 development of sexual hair growth. The matura- is associated with Turner's syndrome (45XO) (Fig
tion of the hypothalamus is also associated with an 1.12). Other signs of this syndrome include short
increased secretion of growth hormone and hence stature, web neck, lymphoedema, coarctation of
the growth spun. aorta and scoliosis.
Neurological examination is important. Signs
Dela yed puberty of intracranial disease, restricted visual fields or
Since there is a wide variation in normal develop-
Stage 3
ment, it is difficult to define the patient with
abnormally delayed sexual maturation, Delayed
pubeny may be defined as the absence of second-
ary sexual characteristics by the age of 14 years.
Common causes of delayed p ubeny can be classi-
fied as foUows:

Hypergonadotrophic hy pogonadism
Stoge 4
Ovarian fail ure with abnormal or normal karyotype

Hypogonadotroph lc hypogonadism
Reversible: ~q ~ - We..
• Physiologic/constitutional delay
• Weight loss/anorexia
Stage 5
• Primary hypothyroidism
• Prolactinomas and other pituitary adenomas
• Congenital adrenal hyperplasia
Irreversible:
• GnRH deficiency
. St 2 breast b ud stage: e levation of breast and • Craniopharyngioma
Stage /, preadolescent: elevation of papilla °fn:~ e a~Z~la; region . Stage 3, further enlargement of
papilla os a small mound, with enlargement a r 'ectlon of areo la and papilla to
breast and areola without separation of their chonbtours 'tsstatggee4sP:~ture stage: projection at papilla Eugonadism
d ' ry mound above the level of t e reas. a ,
~o~~ ~e~~~i~~ f~om recession of the areola to the general contour of the breast.
• M ullerian agenesis
FIGURE 1,11 St ages of breast de velopment (Base d on Hac k e r & M oore 1998 , P 570, Fig 49.4 : • Androgen insensitiviry syndrome FIGURE 1.1 2 A p atient w i th Turner's syndrome
adapted (rom Marsha ll & Tanner 1969)
• Imperfo rate hymen (From Lle w e lly n-Jones 1999, p 316, Fig 42.2)

-OJ
Women's health : a core cu rrlcu ' c"n
1 The m e nst ru al c yc le ond vagina l b lee d ing

absent sense of smell are key findings. Anatomical


defects of the miillerian ducts must be sought,
especially when a disparity between normal puber-
Specific conditions associated
with eugonadism . * PolYcystic ovary
syndrome
the European definition of pcas, about 80% of
women with ultrasound evidence of polycystic
ty and absent menses is encountered. An imperforate hymen can lead to obstruction of ovaries have peas . The more stringent US cri-
the flow of me nstrual blood (cryptomenorrhoea), teria, which do not utilise ovarian morphology,
whereby girls with a functioning uterus present Common clinical presenlaflons
Investigations show a 4.5-11.2% prevalence of pcas. Women
with cyclical lower abdominal pain. In the A 35-year-old wom~n cannot predict when her with pcas have an increased incidence of diabetes
These include X-rays for bone age, brain imaging, advanced stages, a palpable abdominal swelling next period will be. Her cycles of 6- J 2 weeks mellitus, dyslipidaemia and possibly hypertension.
gonadotrophin and prolactin concentrations, will be present and separation of the labia will are aSSOCiated with increasingly heavy and All of these place the woman with pcas at a
adrenal and gonadal steroid measurements, and reveal the classic blue-coloured membrane. prolonged bleeding. higher risk of cardiovascular disease.
assessment of thyroid function. Patients with ele- Treatment is by incision and excision of the mem-
vated gonadotrophins require a karyotype, pelvic brane, leading to the release of large amounts of
A 36-year-old woman and her partner seek
help because of her inability to conceive. She
Pathogenesis - ~ .e..wl..:,~
ultrasound and, very occasionally, a diagnostic tarty chocolate-coloured fluid. c~ ~ -71' V\l~
has irregular cycles and can sometimes go The pathogenesis of polycystic ovaries and pcas
laparoscopy. Vaginal agenesis in the absence of a uterus can without a period for up to 3 months. On exami-
be managed by nonsurgical and surgical methods. is unknown. Insulin resistance is thought to be a
nation, she Is overweight with a 8MI of 38. She
The nonsurgical method involves reaching rhe gIrl key metabolic consequence of a complex genetic
Treatment of delayed puberty has mild faCial hirsutism and ocne.
to apply a vaginal dilator to the central dimple in trait disorder. The resulting hyperinsulinaemia
In physiologic delay, reassurance that the antici- the area of the introitus so that a functional vagina A 28-year-Old Woman with painful periods has causes an overproduction of ovarian androgens
pated development will occur is the only manage- a pelvic ultrasound showing large-volume and a decrease in serum sex-honnone-binding
can be produced. Surgical methods include creat-
ment needed. Removal or correction of the polycystic ovaries. globulin (SHBG), leading to elevated serum-free
ing a pouch or using a split skin graft to create a
primary aetiology when possible is imporrant, as neovagina. When the girl is sexually acnve, ha~mg testosterone. The high androgen concentrations
in the treatment of hypothyroidism. In hypo- intercourse will increase the length of the vagma. interfere with follicular growth and ovulation,
gonadism, hormone therapy will initiate and sus- Indeed, fonnation of a neovagina is only under- Definition and diagnosis thereby causing menstrual disturbances and infer-
tain maturation and function of secondary se,,:ual taken when the girl is approaching sexual activity. tility. Insulin may have direct hypothalamic effeCts,
characteristics and promote achievement of height Girls with comp lete androgen insensitiviry syn- The polycystic ovary syndrome (PCaS) is the such as stimulating appetite and gonadotrophin
potential. Long-term treatment is important to drome have a nortnal 46 XY karyotype but are commonest endocrine disturbance affecting secretion. Women with pca s are pron e to eating
prevent osteoporosis. phenotypically female. T he testes are normal and women. It may be characterised by the ultrasound disorders, perhaps because of a link with leptin,
Treatment can be initiated with very small may be found anywhere along the line of testicu- appearance of polycystic ovaries and the associa- which affects the hypothalamic pulsatility of
doses of ethinyl oestradiol 1 !-,g daily for approxi- lar 'descent from the abdomen to the labia. The tion of one or more of the follOwing clinical symp- gonadotrophin-releasing honnone, with impor-
mately 6 months, increasing to 2, 5, 10 and 20 fLg risk of malignancy in these gonads is around 5% toms or biochemical fe atures: oligomenorrhoea,
amenorrhoea, clinical or biochemical hyperandro-
cant effeCts on reproduction. -1- ~'L c.>Js, J-..t
at 6-monthly intervals. Low-dose ethinyl oestrad- and hence thev should be removed after the com-
iol is not widely available, and arrangements may pletion of pub·eny. This diagnosis can be devastat- genism, obesity, or elevated serum LH concentra-
tion. The accepted ultrasound criteria for defining
Clinical manife stations -- t ri.,>U \)t-\ .
need to be made with specialist uni ts. The low- ing, and extensive counselling of the mdivldual
polycystic ovaries are at least 10 follicles (usualJy The clinical signs and symptoms of pcas include
dose 171' oestradiol patch can be used as an alter- and family is often required.
8-10 mm in diameter) arranged peripherally menstrual cycle disturbances ranging from amenor-
native. around a dense core of ovarian stroma or scattered rhoea to irregular menstruation (typically those of
Traditionally, the cacp has been the drug of Health maintenance '
throughout an increased amount of stroma. In unopposed oestrogen effeCts), obesity, infertility and
choice for long-term treatment. With the advent of Reassurance Is the basis af manage- North America, the syndrome is described by the Signs of androgen excess (hirsutism, alopecia, acne).
a large variety of hortDone therapy (HT) prepara- ment at physialagically delayed Biochemical abnormalities include elevated serum
combination of hyperandrogenism and chronic
tions, a greater choice is available. puberty.
anovulation, where other secondary causes (e.g. concentrations of LH, testosterone, androstene-
Regimes with HT are superior because the type adult-onset congenital adrenal hyperplasia) have dione, dehydroepiandrosterone sulfate (DHEAS)
of oestrogen it contains and the dose are not asso- been excluded. In the N orth American context, and insulin. There is considerable heterogeneity of
ciated with an increased incidence of hypertension there IS no. need to identify the presence of poly- the symptoms and signs amongst women with
or unfavourable changes in lipid profiles. The cysnc OVarIes by ultrasonography. ather causes of pcas, and for an individual these may change over
overall oestrogen intake over a long period of time hyperandrogenaemia are discussed in the next sec- orne. Polycystic ovaries can exi>t without clinical
is also increased, as there is no hormone-free non of this chapter. signs of the syndrome, which may find expression
week, and this is beneficial in women with over time. Weight gain and loss are associated with
Turner's syndrome who have no endogenous Epidemiology increasing and decreasing symptoms respectively.
oestrogen production. Girls on long-term oestro-
Using the ultrasound criteria outlined above sev- PsychOSOCial stressors also affect how the individual
gen supplementation should have their bone min- eral studies have sh own that approxim'ately woman copes and manages her condition. The
eral density checked at regular intervals . hyperandrogenic effeCts of hirsutism and acne can
20-25% of women have polycystic ovaries. Using
be distressing, especially in the younger woman.

WI
t \ \A...t ~II\. ~ .s "'-.l.v....J.,oJ;.t Lt.u.c.c,- "'y~1( uV'CArc> ~ vIA .
Women's health: a c ore c urr icu lum
T L~ J 1 The menstru al cycle and va gi n a l b leeding

Symptom Frequency (range)


will induce endometrial atrophy and is effective
for long-term control of excessive and irregular
long-term consequences
The metabolic abnormalities that give rise to
* Hyperandrogenism
Ollgomenorrhoea 29-52% bleeding patterns. /" ........ ..\~ fli~ "",.,.Af'C".Le~h~l,.~ L - PC OS also put the .woman at risk of the longer- Common clinical presentallons
Spironolactone is an antiandrogen that acts by term ChrOillC condiuons of diabetes and cardiovas- During a routine consultation and examination
Amenorrhoea 19-51%
blocking androgen receptors. A 40-800/0 reduction cular disease. P~olonged anovulation, panicularly for contraception, the doctor notices that the
Hirsutism 64-69% III assoClatlon With obeSlty, appears to be a signifi-
in sexual hair can be achieved with spironolactone, woman has marked laclal and abdom inal hir-
35-41% but it may also take 6 months to take effect. Trus cant nsk factor for endometrial cancer in pre- sutism.
Obesity
menopausal women. Further studies are required
drug is best prescribed in low doses (25-50 mg
however, to determine the incidence of thes~
27-35% A 32-year-<lld woman has always been moder-
Acne
3-6% daily), increasing every 6 months if there is no ately overweight. She Is concerned about her
Alopecia condiuons, and clinical studies are required to
reduction of hirsutism, to a maximum of 200 mg evaluate the net benefit of the various screening weight gain In the last year and that she has
Acanthosis nig ricans <1-3%
daily. With the use of this drug, renal function tests been getting fewer periods.
20-74%
strategtes for each.
Infertility should be performed every 6 months to exclude The American college guidelines (Azziz 2003) A 25-year-<lld singer being treated with danazol
Elevated serum LH 40-51% electrolyte abnormalities. recommend that all women with PCOS be for endometriosis has noticed an Increase l.n
29-50% Clomiphene citrate is used to induce ovulation screened for both glucose intolerance and dyslipi- facial hair, and is concerned that she cannot
Elevated testosterone
in women with anovulatory cycles who suffer t-t,o ~ daenuas. In the absence of other clear clinical reach the high notes.
TABLE 1.1 Clinical sign s and symptoms, and from infenility. Clomiphene resistance is common, ~ gutdelines, the practising clinician ought to have a A 46-year-<lld nulliparous woman has noticed a
bio chemical changes associa te d with PCOS especially in the group who have elevated LH con- IA.e rugh degree of suspicion for long-term effects, and marked Increase In hair growth, acne, amenor-
centrations. Gonadotrophins, and then in vitro v-4... should promote good healthcare strategies of rhoea and a rapid weight gain.
Similarly, obesity is associated with low self-esteem fertilisation (NF) , are other options if clomiphene 2) ''1 weIght control, exerCise, stopping smoking and
and psychological difficulties. fails. vv-t... psychOSOCial stress relief.
Table 1.1 summarises the expected frequency Various pamal destructive operations of the
of the various clinical signs and symptoms and bio- ovary have been shown to temporarily improve Definition and causes
chemical parameters. ovulation and pregnancy rates. Laparoscopic ovar- Hyperandrogenism describes the clinical signs of
For the differential diagnosis of a woman pre- ian drilling, in which small burns are generated Women suffering from peas should be
androgen excess: rursutlsm, acne and alopecia.
~ given every encouragement and sup-
senting with hyperandrogenism or ovulatory dys- within the ovarian cortex, may be used to correct .I . l port to maintain a healthy lifestyle Table 1.2 descnbes the differential diagnosis and
function, see Hyperandrogenism. anovulation in about 50% of women. With this 'V v'\.~'( we lght loss programs, exercise, no typIcal features that will help rule them in. The
procedure ovulatory cycles will return, albeit 12.. I smoking) to avoid the long-term con- most co=on pathological cause of hyperandro-
Treat ment briefly, The validity of the drilling operation stems sequences of peas . gerusm IS peos, which affects 5-1 0% of women
m the reproductive age group (see discussion of
The management of PCOS is symp tom-oriented. from the older operation of wedge resection,
General measures include weight loss, wruch has which was shown to lead to a resumption of nor-
been shown to improve ovulation and the ability mal menses in some women. A reduction
to conceive. Both hirsutism and improvements in of intraovarian androgens occurs with destruc- Diagnosis Approx . frequency Clinical features Iypical of diagnosis
the menstrual cycle may occur with weight reduc- tion/excision of ovarian stroma and follicles. The Polycystic ovary syndrome 80-85% Ultrasound features of PCOS and exclusion of other
tion. Hirsutism may be managed by mechanical brief respite in intraovarian androgens leads to a causes
means, such as bleach.ing, plucking, waxing, shav- resumption of normal fo lliculogenesis. The surgi- HAIRAN 3-4% Severe Insulin resistance, acanthosis nigrlcans
ing, depilatory creams and electrolysis. cal option should be used with caution, however,
IdiopathiC hirsutism 5-10% Normal androgens , normal ovulation
Oral contraceptives will establish normal men- since adhesion formation is an adverse outcome.
srruation and often improve hirsutism and acne. There appears to be no advantage in using ovarian 21-OH-deficient nonclassic 1-2% An elevated 17a-hydroxyprogesterone, followed by
adrenal hyperplasia further Increase with ACTH stimulation test .
The antiandrogen cyproterone acetate -is available diathermy rather than gonadotroph.ins for ovula-
in some contraceptive brands and will funher help tion induction in women who do not respond to Ovarian/adrenal tumours Rare History Is key : sudden and severe signs, weight gain
the reduction of unwanted hair, but it may take as clomiphene. Other e.g. Cushing's: <5% History and examination are key to all of these also
long as 6 months to see an effect. There is increasing evidence that metformin acromegaly: hypothyroidism; abnormal thyroid function , elevated prolactin '
Other options for treatment of the disordered (an insulin-sensitising agent) will improve the reg- hyperprolactlnaemla: drug-
Induced, chronic skin
menstrual cycle include any therapy that regulates ulation of the menstrUal cycle and hence ovula- conditions
and/or reduces the impact of the anovulatory tion, and may increase the performance of other
cycle. Unopposed oestrogen effects will increase treatments such as NF. However, further srudies TABLE 1.2 Differential diagnosis of hirsutism
the risk of endometrial hyperplasia. The LNG-IUS are required to identify which patients will benefit
L..i) cR contains the progestogen levonorgestrel, wruch from this treatment .
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1 The m e nstrual cyc le and va g in a l b leed in g
women's health: a core curric ulum

tually becomes a diffuse pattern of hair loss. PhYSical examination and acts by androgen receptor blockade. In severe
pcos, above). The diagnosis of PCOS, however,
However, alopecia may be due to other. causes Examination should include body mass index and
cases, cyproterone acetate may be prescribed in a
does not rule out other causes, since there may be larger dose (50-100 mg per day) and combined with
such as weight loss, thyroid dysfunCtIon or general signs of cardiovascular health. The degree
dual pathology. . oestrogen (30 mg ethinyl oestradiol) to control the
anaemia. Certain drugs, like danazol, may also of hirsutism is assessed by the well-known
The HAIRAN syndrome conSISts of hyperan- mensrrual cycle,
cause hair loss. Ferrirnan-Gallwey score (Ferriman & Gallwey
drogenism, insulin resistance, and acanthosIs 1961). Vtrilising fearures should be actively sought. Spironolactone also acts as an androgen recep-
nigricans. Acanthosis?igricans IS a velvety, tor blocker. It is an aldosterone antagonist, a mild
hyperpigmented change In the crease areasof the Virilisation diuretic and an antihypertensive agent (see PCOS).
Investigations
skin, It is a disorder charactensed byseveremsulm Virilisation is characterised by clitoromegaly, Side effects include dizziness, diuresis, nausea,
resistance and enlarged hyperthecotIc ovaries. deepening of the voice, androgenic muscle devel- Pelvic ultrasound to assess for PCOS is the most use- fatigue and headaches. Six months' treatment with
21_hydroxylase-deficient nonclasslc adrenal opment, breast atrophy, severe hirsutism and male ful investigation. Serum FSH, LH and prolactin will spironolactone is associated with significant subjec-
hyperplasia is a homozygous r~cesslve disorder pattern baldness, and is assOCIated. WIth severe aid the diagnosis of PCOS or the uncommon hyper- tive improvements in hirsutism, but its value for
that leads to excessive accumulano n of the precur- hyperandrogenism. Androgen-secrenng rumours prolactinaemia, which causes hyperandrogenism. arne in clinical practice is difficult to assess from
sor of the enzyme, namely 17u-hydroxyproges- Measurement of circulating androgen concentra- currently available research. It is best combined
should be suspected if androgeruc symptOms are
terone and an increase in adrenal androgen tions (e.g. tOtal testosterone) has limited diagnostic with the COCP.
sudden or severe. utility, except in the minimally hirsute or nonhirsute
producion. Excluding all other causes leads to the The effects of either cyproterone or spironolac-
diagnosis of idiopathic hirsunsm. woman ..,vith a mensrrual cycle disorder. Androgen tone may take 6 months to achieve. These drugs
Ovulatory dysfunction
levels do not necessarily reflect androgen produc- will not reverse the terrninalisation of veHus hairs
This is expressed as an abnormality of mensrrua- tion rate. Androgen-secreting rumours are suspected already transformed, but will stop new terminal
Signs and symptoms tion that varies between amenorrhoea and Irregu- by histoty and physical examination. An elevated hairs from growing. A:; patients age, they may
1ar bleeding. The high androgen concentrations 17a-hydroxyprogesterone (17u-OHP) suggests an experience a reduction in hair growth, associated
Hirsutism interfere with follicular bi ology. TyplCally, the adrenal cause (21-0H-deficiem nonclassic adrenal with a loss of hair follicles and a decrease in andro-
Hirsutism is an excessive hair growth in androgen- abnormal bleeding is associated with unopposed hyperplasia), The 17u-OHP should be an early- gens. Insulin-sensitising agents (e.g. metformin)
sensitive areas of the skin in women. It marufests oestrogen activity. morning specimen taken in the first 2 weeks of the will improve ovulatoty function, but their role in
as an excessive or inappropriate development and mensrrual cycle. If abnormal, stimulation with hirsutism is not clear.
growth of the pilosebaceous unit. A ,summary of Obesity adrenocorticotropic hormone (ACTH) is performed Glucocorticoids are commonly used for sup-
the anaroIDY and physiology of harr growth IS to investigate for nonclassic adult-onset congenital pressing adrenal androgen production in patients
Obesity also contributes to a worsening o.f the adrenal hyperplasia (CAH). Suppression tests (e.g.
found in Gray's textbook of anatomy (WIlliams with late-onset CAH.
effects of hyperandrogenism, espeaally those of dexamethasone) will help distinguish ovarian causes
et al 1995). Androgens cause transformation of
ovulatory and menStrUal dysfunctIOn. The meta- from adrenal abnormalities like Cushing's Long-term consequences
the vellus (fine and soft) hair inro termmal. haIr.
bolic risks including irnparred glucose tolerance, disease/syndrome or adrenal cancer. Cushing's and
The variability in sensitivity of the pilos.cba- The metabolic sequelae for hyperandrogenism result
ceo us unit affects the extent to w hich an mdivId- hypertenst'on and dyslipidaemias, are more com- acromegaly should be investigated if there is clinical from the associated hyperinsulinaemia and insulin
ual is affected by androgen excess. The hair cycle mon in the obese. suspicion. resistance, and the dyslipidaemias. These patients
varies in different parts of the body: It ranges from are potentially at long-term risk of diabetes and car-
3 ro 6 months on the face to 5 or more years on Psychological effects Treatme nt
diovascular disease but the precise extent and natu-
the scalp, Familial and ethnic differences will also The symptoms of hyperandrogenismcan be severe General measures are as described under pcas (see ral histoty of these risks are not known. In the
cause a wide variation. and distressing for women, espeCially younger above). These include measures to control associ- absence of other clear clinical guidelines, the practis-
Rapid development of hirsutism should alert women. Similarly, the association WIth obeSity will ated ovulatoty dysfunction, infertiliry and obesity. ing clinician ought to have a high degree of aware-
the clinician to the possibility of an adrenal or have further negative effects, with social reJecoon Psychological and social disability will require close ness of long-term effects, and should promote good
ovarian neoplasm. and isolation being common. emotional support, and counselling should always healthcare strategies of weight control, exercise,
be at the forefront of a management plan. The sur- stopping smoking and psychosocial stress relief.
Acne gical measures used for PCOS \\~U not help hir- . .Screening for diabetes mellitus, by a fasting blood '
Assessment and investigation sutism or acne. sugar test, should be an annual event.
Acne is commorrly present in female adolescents,
Specific phannacological m~a:;ures can be used
and persistence into the 20s is a feature of History to reduce the effects of excess androgen. The COCP Health maintenance
hyperandrogenism. A:; with hirsutism, there IS no
This should include information about the age of decreases ovarian androgen production but is not
correlation berween the degree of acne and fre e useful for women who already express fearures of
Women suffering from hyperandro-
testOsterone concentrations. onset and its relationship to thelarche and men- genism, whether problematic or not,
arche. The rates of development of all the fearures more than mild hyperandrogenism. Use of contra- should be advised on lifestyle
of androgen excess, mensrruaJ history, weIght ceptive brands containing the antiandrogen cypro- changes that may modify long-term
AndrogeniC alopecia terone acetate will be required to reduce unwanted
changes, family histoty, diet and lifesryle should all health consequences.
This may be the sole sign of hyperandrogenism. hair, Cyproterone acetate is a strong progestogen
Typically it occurs initially at the vertex but even- be sought.

Wi
1 The menstrual cycle an d vaginal bleeding
Women's health: a core curricu lum

* Premature ovarian
fa ilure
slight rise in pulse. Genital and urinary tract symp-
toms include a rise in vaginal pH, dryness and
increased risk of urinary infection. Psychological
function. It is thought that the ovary is damaged by
annbodies ill the same way that the thyroid gland is
damaged in autoimmune thyroid disease. Premature
ovarian failure is also associated with Addison's dis-
It is important to emphasise that premature
ovarian failure can be transient and that in most
cases one can never be certain that no follicles
remain in the ovary. The chance of a return to fer-
changes are also common, such as mood swings,
anxiety, insomnia, loss of libido and depresslOn. ease, type 1 diabetes, hypoparathyroidism and per- tility and subsequent natural pregnancy is around
Common clinical presentation nicious anaemia. 5-15% for women with a normal karyotype.
32-year-old nulliparous woman has Just There is some evidence that viral infections can There is no evidence that any treatment can
A Pathophysiology cause premature ovarian failure, the most common enhance this rate, and egg donation with IVF or
returned from overseas and has not had her
period for a year. She Is also having problems Premature ovarian failure is due to a reduction in being mumps. adoption remain options.
with intercourse and complains of vaginal dry- the number, or to the absence, of oocytes within
ness and lack of libido. the ovaries. Women with raised FSH, amenor- Iatrogenic causes Long-term consequences
rhoea and ovarian follicles in the ovaries have a
Iatrogenic causes include any pelvic surgery, par- Women with premarure ovarian failure experience
rare condition called resistant ovary syndrome,
ticularly ovarian cystectomy or hysterectomy symptoms of oestrogen deficiency, have an increased
which is believed to be due to either the absence of
where there may be damage to the ovary or the age-related mortality rate and are at increased risk of
Physiology gonadotrophin receptors on the follicles.or a
ovarian blood supply. Pelvic radiotherapy and sys- osteoporosis. Long-term hormone therapy that does
Menopause occurs with permanent cessation . of posrreceptor signalling defect. In the maJonty of not prevent conception is indicated until the age of
women, the cause of premarure ovarian failure is temic chemotherapy can also cause premarure
menstruation following the loss of ovanan acnvny. natural menopause is reached. Women should also
On average, menopause occurs at 50 years of age unknown. Identif}'ing a cause can help WIth the .~ ovarian failure. The effea depends on the dose
given and the age at the starr of therapy. Before be informed of the need for adequate calcium intake
(range 48-55 years). When it occurs before 40 years psychological trauma of an early menopause and and physical activiry. Long-term follow-up is neces-
of age (affecting 1% of women), it IS defined as pre- its consequences. commencing these therapies, the option of ovarian
cryopreservation can be offered in the hope that sary to check for the development of associated
mature ovarian failure. In 10-30% of such cases, It The causes largely fall into twO main groups: autoimmune endocrine disease.
genetic and autoimmune. techn ology to produce marure eggs from ovarian
occurs in the context of primary amenorrhoea.
In the embryo, germ cells develop from the tissue may be developed in the furure.
gonadal ridge and migrate to the primitive ovary. Genetic causes Health maintenance
They multiply to form approximately 7 million
Assessment and investigations Smoking Is assocJated with the onset
Two intact X chromosomes are needed for normal
oocytes. H owever, fewer than 500 eggs are re- ovarian function. The most common genetic cause A full history and examination are required as of menopause at on earller age .
quired duriog the reproducti e life span. Before of premarure ovarian failure is Turner'ssyndrome, other causes of secondary amenorrhoea need ro be Adequate physical activity and
birth, rwo-thirds of the eggs are destroyed, and considered, including PCOS, pregnancy, hyper- calcium intake min imise bone loss In
where there is one X chromosome rrussmg, 45 XO. women. Up-la-date Information about
berween birth arid 40 years of age they are gradu- Generally women with Turner's syndrome are of prolacnnaenua, stress, anxiery and weight disor- the risks and benefits of hormone
ally reduced from 1 million to 10,000 in each short stature and present with primary amenor- ders, cervical stenosis and Asherman syndrome. replacement Is Important.
ovary. Beyond 40 years of age, the destructive rhoea. The very early development of the ovary The diagnosis of premature ovarian failure is
process is accelerated. After menopause, there are appears to be normal but there is an accelerated confinned by measuring FSH and oestradiol con-
no remaining ovarian follicles. Currently, It. IS loss of germ cells prior to birth. Turner's syndrome centrations. The FSH concenrration needs ro
thought that acceleration of the oocytedesrruCtlon mosaics (45XJ46XX) or deletions in either arm of be measured on two separate occasions. Concen- References and further reading
process is the cause of premature ovarian failure. the X chromosome can also cause premature ovar- trations greater than 20 IUIL are rarely associated
During the normal menstrual cycle, FSH surnu- ian failure. There is evidence that a specific parr of with a successful pregnancy, and a level greater ACOG Practice Bulletin 2002 Clinical maoagement
lates the ovary to enable the follicle to marure. With the X chromosome is required for normal ovarian than 40 IUIL is diagnostic of ovarian failure. guidelines for obstetrician·gynecologists. Obstetrics and
advancing age, and particularly after the age of 40, Gynecology 100(6):1389-1402.
function. Oestrogen concentrations are low. Investigations
the number of primordial follicles, which secrete Premarure ovarian failure can occur where no should also include karyotyping, particularly with Adams J, Polson DW, Franks 5 1986 Prevalence of
inhibin decreases and more FSH is required to identifiable genetic defect can be found, and yet premarure ovarian failure and primary amenor- polycystic ovaries in women with anovulation and
marure'the follicle. As the FSH level requirements several members of the family are affected. It rhoea. Thyroid function tests and a general auro- idiopathic hirsutism. British M~dical Journal (Clinical
increase, anovulatory cycles become more frequent seems that familial premarure ovarian failure has anobody screen are performed, together with a R<search edo) 293:355-359.
and the menstrual cycle lengrh increases. This usu- several modes of inheritance. Other inherited dis- beta-human chorionic gonadotrophin (~-HCG) Azziz R 2003 The evaluation and management of hirsutism.
ally happens 2-8 years before menopause. orders associated with premarure ovarian failure level to exclude pregnancy. Ulrrasound is useful to Obstetrics and Gynecology 101:995-1007.
In the posrrnenopausal state, when no follicles include galactosaemia, fragile X syndrome and look at ovarian volume and evidence of remaining
remain in the ovary, oestradiol levels decrease and blepharophimosis. follicles. Balen A, Michelmore K 2002 What is polycystic ovary
FSH levels increase. With the decrease in oestrad- Once the diagnosis of premature ovarian fail- syndrome? H wn.m Reproduction 17(9):2219-2227.
iol, clinical features develop. Vasomotor symptoms Autoimmune causes ure 1S made, referral ro a specialist is indicated and Carpentet SEK, Rock JA 2000 Paediatric and adolescent
occur in up to 50-800/0 of ·: :omen. Hot flushes last the prognosis, implications for fertility, and long- gynecology, 2nd ecln. Lippincott Williams & WUkins
Premature ovarian failure due to an autoimmune
berween 1 and 4 minutes and are associated with a term oestrogen deficiency need to be discussed. Baltimore, pp 181-204. '
cause is usually associated with abnormal thyroid
rise in temperarure, peripheral vasodilatation and a

Wi
Women's health: a co re c urriculum 1 The m enstrual c ycle and vaginal bleeding

Clark M ..I, Thornley B, Tomlinson L et al 1998 Weight loss Marshall WA, Tanner jM 1969 Variations in pattern of
in obese infertile women results in improYC!rnem in pubertal changes in girls. Archives of Disease in
Questions 5. Which of the following scenarios would
reproductive outcome for all forms of fertility Childhood 44:291.
treatment. Human Reproduaion 13:1502-1505. be cause for concern in a 14-year-old
Mackay EV, Beischer NA, Pepperell Rj, Wood C 1993 1. Which is the most reliable method for girl?
Conway SG 2000 Premarure ovarian failure. British Illustrated textbook of gynaecology. WB Saunders! diagnosing endometriosis?
Medical Bulletin 56(3):643-649. BaiII~re Tindall, Sydney. a. Height of 150 cm
a. Pelvic MRI
Edmonds DK 1993 Primary amenorrhoea. Progress in McKay Hart D, Norman J 2000 Gynaecology ,Uusrrated, b. Hysteroscopy b. Breasts which are smaller than those
Obstetrics and Gynaecology 10:281-295 .

Farquhar C, Anoll B, Ekeroma A et al 2001


5th edn. Churchill Livingstone, Edinburgh.

Rymer ], Fish ANj, Chapman M 1997 Gynaecology, 2nd


c. Laparoscopy / of her peers
(3 Absence of any signs of pubertal
d. Transvaginal pelvic ultrasound development
An evidence-based guideline for the management of edo. Churchill livingstone, Edinburgh.
urerine fibroids. Australian and New Zealand Journal e. A thorough history of the nature of d . Widespread pubertal hair extending
of Obstetrics and Gynaecology 41 :125-140 . Smith RP 2002 Netter's obstetrics, gynaecology and pelvic pain symptoms onto the medial surface of the
women's bealth. Icon Learning Syscems, Teterboro. thighs and caUs in g embarrassment
Farquhar CM, Williamson K, Gudex G et al 2002 . 2. Which of the followin g is supported by
A randomized controlled trial of laparoscoplc ovanan when swimming
Speroff I., Glass RH, Kase NG 2001 Abnormal puberty and the strongest evidence of effectiveness
diathermy versus gonadotroph.in therapy for women growth problems. In: Speroff L, Glass RH, Kase NG for treatment of premenstrual e . Absence of menses, but with hair
with clomiphene-resistant polycystic ovary syndrome. syndrome?
(eds) Clinical gynecologic endocrinology and infertility, .0' and breast secondary sexual
Fertility and Sterility 78 :404-411.

Farquhar CM, Lee 0, Toomath R et al 2003 Spironolactone


versus placebo or in combination with steroids for
6th edn. Lippincott Williams & Wilkins, Baltimore,
pp 361-399 .

Speroff L, Glass RH, Kase NG, Seifer DB (eds) 2001


a. Selective serotonin reuptake
inhibitors
b . Evening primrose oil
I 6.
characteristics well developed

A 16-year-old girl comes to see you


hirsutism andlor acne. In: Cochrane Database of with her mother because she has not
Syste matic Reviews ([he Cochrane Library) . Online. Clinical gynecologic endocrinology and infertiliry, 6th c. Pyridoxine (vitamin 96 ) yet had a period. On examination, she
Available: hnp:!/www.update-software.com!cochrane. edo. Lippincott Williams & WLlkins, Baltimore,
d. Progestogens Is short in stature and there is no
pp 431-448.
~ condary sexual development.What
Fcrriman D, Gallwey JD 1961 Clinical assessment of body
Symonds ElVl, Symonds 1M 1998 Essential obstetrics and
e. Spironolactone Is the most likely diagnosis i
hair growth in women. Journal of Clinical
Endocrinology and Metabolism 21 :1440-1445. gynaecology, 3rd edo. Churchill L vingstone, a . Prolactlnama
Edinburgh.
3. Which of the following Is the most
Garden SA 1998 Problems with menstruation. In: Garden effecflve nonsurgical option for b . Congenital adrenal hyperplaSia
SA (ed) Paediatric and adolescent gynaecology. Arnold, Wilcocks j , Phillips K 1997 Obstetrics and gynaecology. ovulatory dysfunctional uterine
London, pp 127-154. bleed in g? c. Imperforate hymen
Churchill Livingstone, New York.
a. NSAIOs @ rurner 's syndrome ..,.
Hacker NF, Moore]G 1998 Essentials of obstetrics and Wtld RA 2002 Long-term health consequences of PCOS.
gynaecology, 3rd edn. Saunders, Philadelphia. Human Reproduaion Update 8:213-241. b. Tranexamic acid e . Mosaic 46XY I 45XO
Jacobs HS, Conway GS 1999 Le ptin, polycystic ovaries and c. Short-course pragestogens
WLlli.ms PI., Bannister LH, Berty MM er 01 (eds) 1995 7. A 30-year-old woman presents with a
polycystic ovary syndrome. Human Reptoducnon Gray's anatomy: the anatomical basis of medicine and ~ Levonorgestrel intrauterine system 6-month history of amenorrhoea and a
Update 5:166-171. surgery, 38th edo. Churchill Livingstone, London,
e. Transcervical resection of the vague history of hot flushes. Which of
Kalantaridou SN, Nelson LM 2000 Premarure ovarian pp 400-405 . endometrium the following statements is incorrect?
failure is not premature menopause. Annals of the New
Working Party for Guidelines for the Management of a . ~-HCG Is useful to exclude
York Academy of Sciences 900:393-402. 4. Which of the following is a
Heavy Menstrual Bleeding 1999 An evidence-based pregnancy
characteristic feature of Turner's
Llewellyn-Jones D 1999 Fundamentals of obstetrics and guideline for the management of heavy menstrual syndrome?
bleeding. New Zealand Medical ]oumal112:1 74-1 77. b . FSH is useful to diagnose ovarian
gynaecology, 7th edn. Mosby, London. failure
a . Karyotype of 46XX
b . Tall stature c. If the FSH Is >40 lUll, c lomiphene
can be given to induce OVUlation
c. Hyperprolactinaemia
d . If the FSH is >40 lUlL, a karyotype is
d . Web neck indicated
e. Ventricular septal defect
e. A family history Is relevant /"

w_
.. Women's health: a core curriculum

8. A 3D-year-old woman presents with a


6-month history of amenorrhoea and a
previous year. Her serum testosterone Is
elevated, as is a measurefl1ent of 17a-
Vaginal discharge
hydroxyprogesterone . What Is the usual
I. vague history of hot flushes. Which of
next management option? Leo R Leader
the following statements Is incorrect?
I a. Ovarian resistance syndrome is a
a. Prescribe a COCP containing
possible diagnosis.
cyproterone acetate. Edited by Lucy Bowyer
b . Perform an adrenal stimulation test.
b. A prolaclinoma should be excluded.
c. Reassure her that the diagnosis of
c. Thyroid disease should be excluded PCOS does not necessarily need
if ovarian failure is diagnosed.
treatment. /
d . Long-term oestrogen/progesterone d. Prescribe an aldosterone
substitution is contraindicated in anatagonist.
case of ovarian failure.
e. Use depilatory agents to control
e. Pregnancy is the most common hirsutism .
cause of amenorrhoea In this age
group. 11 . Which of the following is the single
. Learning objectives
most useful investigation in a woman
9. The ultrasound diagnosis of polycystic presenting with hirsutism and
ovaries is based upon which of the oligomenorrhoea?
following parameters? Knowledge Skills
a. Serum-free testosterone
a. An ovarian volume greater than At th e end of thi s chapter, the student At th e en d of this c hapte r, the studen t
12 cc b. Total testosterone wIll be able to : sh o uld learn how to:
b. Any ovarian abnormality that c. SHBG
contains more than one follicle discuss the role of oestrogen in the distinguish between a normal and a
d . Ovarian Ultrasound d evelopment and maintenance of pathological vaginal discharge
larger than 15 mm in diameter /'
e.DHEAS vaginal epithelium throughout a
c. Ten follicles (usually 8- 10 mm in woman's life develop a professional and articulate
diameter) arranged peripherally approach to an embarrassing problem.
12. Cyproterone acetate is effecli e in • list th e causes of vaginal discharge
around a dense core of ovarian reducing hirsutism because it Is which th roughout a w oman 's life
stroma of the following?
d. Multiple ovarian follicles in an Iden tify common infections of the lower
a. A strong progestogen and acts b y genital tract Attitu des
enlarged ovary androgen receptor blockude
construct an appropriate diagnostic At the e nd o f th is c ha p te r, the student
e. Follicles larger than 20 mm in b. An oestrogen and suppreises and management plan for each
diameter that persist longer than ovarian function sho ul d reflect upo n:
diagnosis considered
3 months
c. An Insulln-sensitising agent ..".-r • outline the management of recurrent the Importance of a woman 's
10. A 25-year-old woman menstruating d. An aldosterone anatagonist candidal infection. understanding of normal physiology.
every 3-4 months has noticed
increasing acne and hirsutism over the e. A depilatory agent

Wi
Women 's health: a c Ole urric ulum
2 Vaginal discharge

Common clinical presentations Management of leukorrhoea Candida' vaginitis (thrush) antibi otics, which destroy the normal vaginal
A 21-year-old woman taking the oral Take a history and make specific enquiries about: Candidal (or monilial) vaginitis is caused by flora.
contraceptive pili (OCP) presents with the timing of discharge - midcycle or premen- Candida albicans, a yeast-like fungus that appears First-line treatment is often topical: imidazole
excessive vaginal discharge. strual exacerbation; oral contraception - espe- [JUcroscoPlcalJy as long filaments (mycelia) or as drugs are very effective: for example, clotrima-
cially oestrogen concentration; use of douches, spores. zole. in cream or pessaries for 3 to 6 days. Vaginal
A 70-year-old woman consults for a vaginal
discharge and soreness.
additions to bath water or deodorising sprays; It can be found in the vaginas of 15-30% of applicaoons may be supplemented with local cream
recent medications - especially vaginal applica- asymptomatic women and is usually treated only for vulvitis. Many patients prefer to use oral treat-
tions, spermicides, antibiotics; and recent preg- when It IS symptomatic. Itching is the predominant ments, such as ketoconazole or fluoconazole, as such
nancy (Leader et al 1996). . symptom. The discharge is classically thick, white treatments are not messy like vaginal applications,
Normal vaginal discharge On examination, assess the amount of diS- and cheesy, and tends to stick to the walls of the but oral treatment should not be used during preg-
charge and check whether there is any redness of vagina, leaving a reddened area when removed. nancy.
In women of reproductive age the vagina is moist, the vulval, vaginal or perianal skin. Exclude pel vIC The vagina may be extremely sore, making exam- Recurrent infection occurs as local intravaginal
due to secretions from vaginal transudate and cer- or vaginal infection : if there is any doubt, take a ination painful. spores gernunate or WIth reinfection from a sexu-
vical mucus, and, to a lesser extent, to uterine, fal- high vaginal swab and an endocervical swab for The organism thrives in the presence of carbo- al parmer. Spores are not affected by either local
lopian tube and Bartholin's gland secretions. The culture and sensitivity. The diagnostic feature of hydrate, and is therefore more common during or oral treatment. Relapse is more likely to occur
volume of secretion that is accepted as normal by leukorrhoea is that there are no pus cells visible on pregnancy or the second half of the menstrual
individual women varies greatly, Excessive normal at the time of the menses, probably as a result of
microscopy in a wet saline preparation. cycle, in diabetes and following broad-spectrum changes in the pH in the vagina. Precipitating
secretion (leukorrhoea) usually produces staining Explain the physiology of the normal cycle.
of underclothes and vaginal odour due to the heat causes, such as antibiotic use, diabetes or even
Strong reassurance that the discharge is not due to Hrv, should be sought.
denaturation of the proteins in the secretions. an infection or any abnormality may be all that is
Secretions are clear to white and range in consis- Treatment of recurrent thrush is usually oral
required. Eliminate any aggravating cause such as therapy for 5 days, which can be repeated in sub-
tency from thick mucUS before menstrUation to a a high-dose oestrogenic pill, nylon underwear or
thin, watery, more profuse secrenon at ovulanon, sequent menstrual cycles. This pulse therapy will
inappropriate vaginal applications (Reed. & E~ler kill any spores thar start to germinate as conditions
Leukorrhoea is associated with: 1993). Give general advice regarding hYgIene, lim- become more favourable premenstrUally. The part-
• increased production of the ovarian steroids iting local heat to the genital area, avoiding ner should be treated either with local imidazole
(oestroge ns in particular), which occurs at the deodorising sprays, and wearing conan under- cream applied twice daily for 7-10 days or oral
time of ovulation; with the use of oestrogemc clothes that absorb some of the secretions. ketaconazole.
hormonal preparations (e.g. oral contraceptives Ablative therapy (cryocautery, diathermy, laser) to
or hormone therapy); in pregnancy the cervix is used in a minority of persisrent cases Gardnerella vag initis
• cervical ectropion (also incorrectly called a cer- to reduce the number of endocervical glands,
vical erosion), caused by hyperrrophy of the However, if the original precipitating factor is still This can be found in the vaginas of 10-30% of
endocervical columnar glands and their exten- present (e.g. oral contraception), relief will be asymptomatic women and is caused by a small,
sion from the cervical canal onto the ectocervix short-lived. non-monle, gram-variable coccobacillus (Gar-
dnerella vaginalis).
• increased vaginal transudate, which occurs with
sexual excitement and vaginal irritation (such as Pathological discharges The typical clinical presentation includes a vari-
chemical irritation from vaginal douches, per- able amount of thin discharge that has a fishy or
These usually present with other symptoms, such unpleasant odour, ofren more pronounced after
fumed producrs, vaginal applications or even use as vaginal/vulval pruritus, dyspareunia or pelvic intercourse and caustng local irritation but not
of spermicides) pain. J\ilany of the infective causes of vagInal
• increased uterine secretions: before menstrua- pruritus. Microscopic examination of a wet prepa-
discharge produce a classical vaginal reacoon; ranon mounted on a slide will show large numbers
tion, secretory changes in the endocervical and however, more frequently there is a nonspecific
endometrial glands may produce a premenstrual of coccobacilli fl oating between and attached to
discharge and a nonspecific vaginal reaction. vaginal epithelial cells in a stippled manner ('clu e
increase in vaginal discharge; following men- It is important to realise that organisms that cells').
struation, the last days of menstrual flow may be may cause a pathological discharge can be present
prolonged; irritation from an intrauterine con- Treatment is with tinidazole or metronidazole.
in the vaginas of many women, without producing
Alcohol sho uld be avoided, as these drugs are
traceptive device (IUD) any symptoms (Sobel 2000) . In studies of well FIGURE 2.1 Speculum examination of lateral metabolised in the liver and can cause nausea and
• granuloma (arising in the suture line at the vagi- women who have been attending family planning va Inal wall affected by candldol vaginitis vomiting.
nal vault following a hysterectomy), which can clinics, 15-30% of women have been found to shOWing w hite ' cottage cheese' -like
give rise to a profuse di charge that is besr treat- have Monilia or GardnereLla vaginalis, 10-15% app earance of adherent discharge (From Ten per cent of men will be asymptomatic
Trichomonas and 10-20% Chlamydia trachomatis. P kin et al 2003, p '03 , Fig 2) carriers of this bacterium and so should be treated
ed by cautery, either chemically or by diathenny. initially or if there is recurrence,

-E

7
Women's health: a core curriculum
2 Vagina l disc harge

Trichomonal vaginitis Childhood vaginitis


This is caused by a flagellate unicellular organism. This is uncommon and may be associated with a Questions
It is harboured, usually asymptomatically, in wide range of organisms, which are usually of low 2. Candida infection :
2-10% of males and can be transmitted sexually. It virulence. Select the correct answer to complete the a . is also known as Gardnerella
can also be found in the vaginas of 10--15% of Whenever a child presents with a vaginal dis- statement.
vaginitis
asymptomatic women. The discharge is classically charge, always suspect a foreign body. However,
1. White vaginal discharge :
frothy and yellow-green in colour, variable in Neisseria gonorrhoeae and Trichomonas vaginalis b. is also known as moniliasis /
amount and has a typical fishy odour. It is often do occur in children, and the possibility of abuse a . is called diarrhoea
c. is caused by a bacterium
associated with dysuria and prurirus. The vaginal should be considered. b. is always abnormal
walls and cervix may have an inflamed appear- d . is less common in women with
ance, with punctate 'strawberry' spots. The diag- c. is commonly caused by syphilis diabetes
Health maintenance
nosis can be made microscopically. Tinidazole or d . must always be examined with a
Most vaginal discharges are physio- va ginal swab for culture e. can be treated with antibiotics.
metronidazole are again used for eradication; the
logical. Wearing undergarments
male parmer should also be treated. made of natural fibres and avo iding e. may occur with Candida infection .
the use of perfumed products In the
Sexually transmitted infections
See Chapter 3 for chlamydia, gonorrhoea and
genital area will help to min im ise
vaginal Irritation and leukorrhoea. /
other sexually transmitted infections.

Atrophic vag initis References


Lack of oestrogen in posnnenopausal women Leader LR, Bennen M], Wong F 1996 Handbook of
results in a very thin vaginal epitheJium, which is obstetrics and gynaecology. Chapman Hall, London.
easily injured or infected. The responsible organ-
isms are usually nonspecific (producing a mixed Pitkin J, Beattie All, Magowan BA 2003 Obstetrics and
growth on culture) and of low virulence. gynaecology - an illustrated text. Chutchill
The discharge is thin, purulent and often Livingstone, Edinburgh.
blood-stained, and the vagina may appear red and Reed BD, Eyler A 1993 Vaginal infections: diagnosis and
ha':e many tiny bleeding points. Vaginal, vulval management. American Family Physician
and perineal soreness are frequently present and 47: 1805- 1818.
may make an adequate examination of the patient
Sobel JD 2000 Bacterial vagiuosis. Annual Review of
difficult.
Medicine 51:349-356.
Treatment of atrophic vaginitis consists of
oestrogen, locally in the vagina using either tablets
(oestradiol 25 f.45) or creams (oestriol). Oral
oestrogens can be used and, if the uterus is still in
situ, progestogen must be used to reduce the risk
of endometrial hyperplasia.

ME
*3
Sexually transmitted
I
infections
I
I Edited b y Vivienne O 'Connor

Genital herpes, female genital warts (condylomata acuminata) Mark Erion


Syphilis, gonorrhoea Ian Jones
Chlamydia, HIV I AIDS, sexually transmitted infections and pregnancy Vivienne O'Connor

Learning objectives

Knowledge • list the treatment options for removal of


genital warts
At the end of this chapter, the student Syphilis
wi ll be able to:
describe the symptoms, signs and time
Sexually transmitted Infectlans (ST/S) - frames of the primary, secondary and
general principles tertiary stages of syphilis

describe high-risk behaviour for the evaluate the diagnostic and screen
development of STis tests for syphilis

• discuss the educational initiatives to outline a management plan for the


Inform people about STis treatment of syphilis

summarise the public health impli - Gonorrhoea


cations of notifiable diseases and Indicate the prevalence of gonorrhoea
contact tracing Infection
Genital herpes • describe the symptoms of gonorrhoea
indicate the prevalence of genital infection
herpes list the long-term consequences of
describe the clinical findings and untreated gonorrhoea infection
laboratory diagnostic tests • outline a plan for the diagnosis and
management of gonorrhoea
• outline a management plan for primary
and recurrent infection Chlamydia
Genital warts describe the worldwide distribution of
ChlamydIa infection
indicate the prevalence of HPV Infection
and Its significance with respect to outline the short- and long-term
development of genital warts and consequences of pelvic infection with
genital neoplasia Chlamydia
• describe the clinical appearance and • describe the laboratory investigations In
distribution of genital warts the diagnosis of ChlamydIa infection
(Continued over)
3 Sexually Ironsmltted Infectio ns
Women's health: a c ore curriculum

• take a history and perform an acutely painful and precipitate dysuria and reten- valaciclovir 500 mg can be given 12-hourly for
(Learning objectives continued) examination for an STI with sensitivity tion of urine. Herpetic lesions can cause anorectal 5-10 days. Side effects of the above medica-
and respect in a non-judgmental spasm, discharge from the vagina and/or urethral tions include headache and nausea. Symp-
• design a plan for the diagnosis an.d manner discharge and local lymphadenopathy. Systemic tomatic management with analgesia and topical
management of Chlamydia Infection manifestations include fever, myalgia and, rarely, lignocaine 2% jelly is offered to those with
• explain the diagnosis t.o a woman with
HiV/AIOS a sexually transmitted Infection and autonomic neuropathy and even meningitis. pain. Treatment of secondary infections with
describe the epidemiology at HIV counsel her antibiotics and antifungals ma y be required. In
Infection explain to the patient the importance of Natural history severe cases, admission to hospital and the
adequate treatment for an infection insertion of an indwelling urinary catheter may
summarise the pathophysiology of HIV The primary episode may be atypical and asymp-
and follow-uP of contacts tomatic; occasionally, it is associated with very be required.
infection Recurrent herpes infections are managed with
provide pre-test counselling for a woman severe, painful manifestations that last for 4 weeks
list the Investigations performed to
about to undergo an HIV screen. suppressive regimens of acyclovir 200 mg 8-hourly
diagnose HIV infection and monitor host or more. Prolonged severe infection should raise
or 400 mg 12-hourly, valaciclovir 500 mg dally or
response the suspicion of immunosuppression, e.g. HIV
farnciclovir 250 mg bd for 3-4 months. This treat-
Attitudes infection.
• identify particular health issues of ment should then be discontinued intermittently
relevance to HIV-positive women
Recurrence may be precipitated by sexual con-
to assess the need for further courses. Episodic
At the end of this chapter. the studen t tact, fever, stress and general illness. The recurrent
therapy should be initiated by the patient at the
Srts and pregnancy should reflect upon: lesions may involve the genitals, anus and perianal
first sign of prodromal symptoms or very early
• describe the consequences of area, buttocks, legs and perineum. Neuralgic pain
• the need for community education on lesions .
antenatal infection with hepatitis B. .. in the lower back, perineum and inner or back of
Chlamydia. gonorrhoea. herpes. syphilis responsible sexual behaviour thighs represents nerve root irritation. Grouped
and HIV. • the requirement of informed consent for localised lesions along sacral dermatomes may
testing for STis. in particular HIV Health maintenance
occur unilaterally. Rarely, meningoencephalitis
Skills confidentiality may occur. There is an increased risk of HIV ttans- Community education about at-risk
mission and acquisition of opportunistic infections behaviour and STis Is Important and
At the end of this c hapte r. the student the effect of a diagnosis of pelvic in immunocompromised individuals. particularly relevant to individuals
infection upon personal relationships. under 25 years of age.
sh ould learn how to: body image and self-esteem.
Diagnosis
counsel regarding safe sexual
behaviour Laboratory diagnosis is essential to confirm the
infection and provide characterisation of the
strain. A polyme rase chain reaction (peR) test per-
formed from swabs or scraping of the lesion is
* Female genital warts
( CO ndylomata

* Genita l herpes
mild. However, they can pass on the infection to
sexual partners and newborns.
nearly 100% sensitive and can determine the virus
type. In some laboratories, culture of the virus may
be available. The lesion is swabbed and the swab is
kept in a viral transport medium, preferably cool,
acuminata)
Common clinical presentations
Common clinical presentations Pathophysiology during transportation to the laboratory. The virus A woman describes new lumps around her
A woman attends the emergency department Genital herpes is an infection with herpes simplex culture is more than 90% sensitive, with sensitivi- genitalia and anus.
because she has such severe genital pain that vims type 1 or type 2. About .10% of gemw ty decreasing if the swab was taken later than
she is unable to urinate. A woman has noticed that her partner has a
lesions are caused by HSV-2 acqUIred from symp- 36 hours afrer the active episode. However, this
penile wart. .
Having recently had casual sexual intercourse, tomatic or asymptomatic sexual partners, and method is expensive, labour-intensive and slow.
a 20.year-old woman no~ces some blistering from genital, oral and sexual contact- False-negative tests for HSV are not uncommon if
around her labia. taken more than 48 hours after the onset of an
Signs and symptoms attack or afrer medication has been applied. Epidemiology
Classically, there is blistering and ulceration of the Anogenital warts are caused by the human papil-
directly infected region(s), which i l l ,,":omen are
Management lomavims (HPV). Over 50% of sexually active
Epidemiology
usually on the labia majora, labia nunora and Drug treatment varies according to whether the adults have been infected with HPY, but most of
Seroprevalence studies show that 220/0 of adults around the clitoris and urethra. The leSIOns are infection is primary or recurrenL For a primary these in fection s are subclinical, benign and
have herpes simplex type 2 vlms (HSV-2). Most frequently multifocal, bilateral and at different infection, acyclovir 200 mg is given five times daily unrecognised. Clinical manifestation of H.PV in
women with HSV-2 infection are not aware that or 400 mg 8-hourly for 5-10 days. Alternatively, the form of genital warts is common.
stages of development and resolution. They can be
they have genital herpes, as their symptoms are

WI

'.
3 Sexuall y transmitted Intectlons
women's health: a c ore c urri c ul um

woman's and treating doctor's preferences, and of antibiotics. A resurgence occurred in the 1980s Early congenital syphilis
Pathophysiology the presence of concomitant pathology, e.g. cervi- and 19905, coinciding with the increased inci- Early lesions include rhinitis, rash, hepato-
More than 70 subtypes have been identified. cal intraepithelial neoplasia (CrN) or other STIs. dence of HIV infection. splenomegaly, meningitis, bone involvement and
Visible genital wartS are usually caused by HPV Treatment options for small areas include local anaemia, changes that are similar to those in sec-
types 6 or 11 and are usually benign. Types 16, 18, application of medications such as podophyllm, Pathophysiology ondary syphilis. This condition is infectious.
31, 33, 35 are mostly subclinical and can be seen podophyllotoxin, trichloroacetic acid, 5 -fluoro-
uracil, interferon and imiquimod, which have all Syphilis is caused by the spirochaete Treponerna
by colposcopy and not macroscopically. They are Late congenital syphilis
been tried with different degrees of success. pallidum, one of a group of related spirochaetes
associated with cervical dysplasia and with vulval,
penile and anal squamous intraepithelial neo- Cautery may be performed under local or gen- that includes T. pallidum subsp. pertenue (yaws) Similar to late acquired syphilis, this presents with
plasia. HPV is usually a sexually transnutted eral anaesthesia: local discomfort and scarring are and T. carateum (pinta). The infection may be teeth changes, deafness, gummas and neurosyphilis.
infection. Rarely, permatal infecDon can affect the recognised complications of this, and anal pain acquired or congenital.
and discomfort may be disabling. Laser treatmen t The usual mode of transmission is through sex- Diagnosis and management
newborn or infant.
is suitable fo r larger, multiple wartS, and treatment ual intercourse, but the infection can spread
around the urethral mearus and anus. Cryotherapy through blood contamination from using shared If primary syphilis is suspected, the chancre should
Natural history be sampled and the sample subjected to dark back-
causes cytolysis at the dermal-epidermal junction. needles, needles tick injuries or by direct contact
The incubation period is variable and may be pro- The freeze-thaw-freeze technique is employed with open lesions. It can also spread to the ferus ground examination, looking for the spirochaetes.
longed. Without treatment, the warts may stay the until a halo of a few millimetres appears around through transplacental transmission. Secondary syphilis is diagnosed serologically, but
same, enlarge or regress spontaneously, especially sprrochaetes may also be found in mucous mem-
each lesion. Necrosis and blistering are known
in young women. Immunosuppression and preg- branes. Tertiary syphilis should be investigated
complications. Excision under a local or general Signs and sym ptoms
nancy are often associated with persiStent, larger with serological testing and, where possible, CSF
anaesthetic is suitable for pedunculated and read-
and more numerous warts. Extragenital lesions examination if neurosyphilis is suspecred.
ily accessible warts. The recurrence rate varies Primary syphilis
may occur in the oronasal cavity and larynx. with the method and individual characteristics TeSts specific for syphilis - e.g. T. pallidum
from 0 to 400/0. A primary chancre develops at the site of inocula- haemagglutination assay (TPHA) - remain reac-
Signs and symptoms tion after an incubation period of approximately tive even after treannent. They are useful only for
WartS may appear as single or multiple fleshy Prevention 21 days. The adjacent lymph nodes are enlarged the diagnosis of the fIrst infecrion. Negati ve TPHA
lesions. On non-hairbearing skin, they are of a soft Male sheaths (condoms) reduce the infection rate and nonsuppurating. serology in the presence of syphilis may occur in
consiStency, but on skin with hair they are firm and of new sexual partners, but are not completely very early infection and in the immune-deficient
keratinised. They have a broad base and may be effective in preventing transmission, as the area of Secondary syphilis patiem with HIV infection. Reagin tests such as
pedunculated or pigmented. Occasionally, they may the venereal disease reference laboratory (VDRL)
skin and mucous membranes infected with HPV After 2-3 months, fever, headache, malaise and test and rapid plasma reagin (RPR) test are non-
cause pain or pruntuS, or be Enable WIth bleeding.
may be quite extensive and include scrotal skin, general aches and pains may precede or accom- specific for syphilis, and biological false-positives
Large wartS may make intercourse difficult ~r
painfu4 and may affect urination or defecanon if perineum or inner rh ighs. pany the signs of secondary syphilis. The most occur. However, these teSts show a significam fall
common symptom is a generalised, symmetrical in titre or become nonreactive in response to treat-

*
they obsrruct the urethra or anal canal respectively.
maculopapular rash on the face, palms and soles. ment and are useful in follow-up management.
I I Diagnosis Sy p hilis Other signs include condylomata lata; patchy . Screening for syphilis generally involves a com-
alopecia; oral, pharyngeal or genital ulcers; or bmanon of TPHA and RPR. Syphilis serology in
Direct examination of anogenital wartS is crucial widespread lymphadenopathy, If untreated these the asymptomatic patient, however, can be inter-
for clinical diagnosis. Confirmation by histOlogical clinical signs resolve spomaneously, leading to preted only with the aid of a comprehensive histo-
examination may be required, especially if the latent syphilis.
antenatal screening. ry of past infection and treatment for syphilis.
lesions are atypical, ulcerated, attached to under-
Treatment is with parenteral penicillin (unless
lying srructures, or exhibit frequent recurrences The female partner of a man diagnosed with Latent syphilis there is penicillin sensitivity). Alternative options
(to exclude malignancy). . syphilis presents for advice.
The presence of perianal or anal canal wartS is This is indicated by positive syphilis serology in mdude erythromycm and doxycycline.
A young woman has noticed a painless ulcer
not in itself evidence of anal receptive intercourse. the absence of symptoms or signs of the disease.
In her vulval area.
However, proctoscopy should be offered to those
who have perianal wartS or those who have been Tertiary syphilis Health maintenance
engaging in anal sex. After approximately 3 years or more, te rti~ ry Contact tracing is essenlial for all STis
Epidemiology and some Infections are required by
syphilIS may present with gummas in any o r~an law to be notified.
Management Or with cardiovascular or central nervous sys~e~
Syphilis was epidemic in late fifteenth-century
Europe. Reported syphilis peaked around the disease.
Management depends on the type, number and
Second World War and decreased with the advent
distribution of wartS, available resources, the

ME
3 Sexua lly transm itted infections
Women's health : a c o re curr icul um

floxacin can be used in cases of penicillinase- Diagnosis had three phases: men having sex with men, intta-
* Gonorrhoea resistant Neisseria gonorrhoeae. Follow-up IS
recommended 1 week afrer eompletmg a treat-
Samples should be taken from the endocervix, ure-
thra and urine. Chlamydial tests include culture,
venous drug users and heterosexual transmission.

Pathophysiology
ment regimen to ensure cultures are negatJve. immunofluorescence and detection of antigen or
Common clinical presentations
nucleic acid. First-catch urine tests by polymerase The humatl immunodeficiency virus is a retrovirus
A 25-year-old woman presents with Infertility Outcome chain reaction (peR) or ligase chain reaction which can be found in the blood, vaginal fluids or
and tubal blockage. (LCR) are alternatives to swab tests. N on-culture semen of infected people. The virus can be trans-
In 60-80% of cases, pelvic infection in women
An asymptomatic woman presents with her under the age of 25 years is caused by gonorrhoea tests may give false-positive results and should be mitted to others during sex, by sharing needles and
partner. He Is complaining of urethritis. or Chlamydia. This can lead to infertility, chrOille interpreted with caution. syringes, through a contaminated blood tratlsfu-
A woman presents with a mucopurulent pelvic abscess and pelvic pain. . sion and by vertical transmission in childbirth or
Without treatment, gonorrhoea m men causes Management during breastfeeding.
vaginal discharge.
prostatitis, vesiculitis and epididymitis. In the new- 1. Check for other STIs as Chlamydia may occur
born, ophthalmia neonatorum (conJunCtlVltIS concurrendy with gonorrhoea. Signs and symptoms
within 21 days of birth) is a notifiable disease. 2. For local infections, give azithromycin 1 g orally
Epidemiology The initial illness usually occurs within 2 weeks of
as a single dose (category B1 in pregnancy), or
infection and has symptoms similar to those of
Gonorrhoea is the second most commonly re- doxycycline 100 mg twice a day for 10 days

*
ported notifiable STI in Australia. The prevalence (category D in pregnancy), or erythromycin glandular fever: headaches, fever, swollen glands
is influenced by the spread from asymptomanc 800 mg twice a day for 10 days (cate- and body rash. After a dormant phase, the sympto-
people and others with at-risk behaVIOur.
C hlamydia gory A in pregnancy). matic carrier state occurs once the immune system
3. Where there is PID, azithromycin and metron- is affected. There are a wide range of clinical mani-
Pathophysiology Common clinical presentation idazole are recommended, followed by doxy- festations including fatigue, fever, weight loss,
cycline. diarrhoea and glandular swelling. Autoimmune
Gonorrhoea is caused by the gram-negative diplo- A 19-year-old woman presents for colposcoPY
deficiency syndrome (AIDS) has severe effects on
coccus N eisseria gonorrhoeae. It is contagrous and because of an abnormal cervical smear test.
Outcome s the immune system, causing the body to be over-
spread mainlv by coitus. . Chlamydia Infection was also found as part of
It affects 'mucosal and glandular strUCtures m In women, upper genital, peritoneal, joint and whelmed by infections and cancers. The most com-
a routine screen. mon of these are pneumonia, Kaposi's sarcoma
the genital tract, reCtum, oropharynx and conJunc- ocular manifestations can occur, and Chlamydia
tivae. The incubation penod IS usually 2-7 days infections are associated with tubal blockage and in- (rare .in women) and lymphoma.
but can be longer. fertility. In men, Chlamydia may cause epididymitis.
Epidemiology Diagnosis and ma nagement
Signs and symptoms In industrialised western society, virtually all Health maintenance Antibodies to HIV appear approximately 3 months
In more than 60% of women, the condition is Chlamydia trcu:.hom atis infections are sexually Scree ning for other STis is important. afrer infection and remain throughout life.
asymptomatic: hence contact .tracmg 15 lIDpOrtant. transmitted. Chlam ydia is the most common STI as several may co-exist . After the primary infection, the viral load stabi-
The most common symptom IS cervlcms and a dis- in Australia. In many deveiopmg. countnes? a- :r lises at a 'set point'. The disease is monitOred with
coloured vaginal discharge. .. . choma is endemic and child-to-child trans.truSSlon HIV/viral load and CD4/CD8 lymphocyte counts.
Other presentations include vulvms, dysuna,
dyspareunia, pharyngitis, pam on defecatlon, rec-
tal bleeding and heavy, pamful pen ods. In men,
classical symptoms include urethral discomfort,
is common.

Pathophysiology
* HIV/AIDS
Rising viral load and falling lymphocyte count
indicate the need for antiretroviral therapy.

Chlamydia trachomatis is an obligate intracellular Treatment


dysuria and a yellow urethral discharge, while parasite. If symptoms occur, these usually appear
25% of males are asymptomanc. woman whose partner Is an Antiretroviral therapy is consrandy changing. It is
1-3 weeks afrer exposure. ~.I I...I,nv,.... ,'''. drug user has a postlve test to HIV common to use a combination treatment with
Diagnosis and management attar presenting for routine STI screening. three drugs. Specialist assisrance should be sought
Signs and symptoms
Diagnosis is confirmed by demonstrating the organ- to investigate and plan management.
In 70-90% of wo men, the infection is asymptO-
ism in culture. Appropriate swabs are taken from matic. Whete there are symptoms, they are likely
the endocervix, urethra, anus, throat or abscess. Epidemiology Specific considerations
to be mucopurulent discharge and/or cervlCltl~
A presumptive diagnosis can be made by finding postcoital bleeding and lower abdommal pam. Women represent 6% of adult cases of human 1. Fifty per cent of HIV-positive women have a
gram-negative intracellular diplococa m smears. 10-150/0 of cases, there may be pelVIC mflamm a- immunodeficiency virus (HIV) in Australia. In the high risk of HPV and therefore are at an
Most gonorrhoea infections are sensmve to developed world, the epidemiology of HIV has increased risk for cen·i. cal cancer.
penicillin. Spectinomycin, ceftnaxone or orclpro- to ty disease (PID).

WE
3 Sexually transmitted intec llon>
Women's health : a core cur riculum

d her partner and other children and imiquimod should not be used during preg- would be valuable in monitoring any increase in
During vaginal intercourse, women a,re at high- ch ec ke d , an . d . d 'f nancy. The baby can acquire the genital wart virus cases in other countries with a lower prevalence.
h ld be screened for infeenon an vaccmate I
2. er risk than men of acquiring HI\ mfeenon ~o~ualready infected. The main risk for the neonate from the vagina during childbirth; rarely, this can Screening should be offered to pregnant women
after appropriate counselling is given about the
and several other STIs, probably mcluding cause neonatal laryngeal warts. Genital warts are
is at delivety. The combination of liTIIDunoglobulm
HSV-2 infection, gonorrhoea and Chlamydia. and immediate postparrum vaccmatlon prevents not considered to be an indication for performing limitations of the testing and the implications of
3. Reproductive issues: pregnancy outcome ma~ a caesarean section. the results. HIV transmission to the fetus can be
the majority of perinatal transmiSSIOns. markedly reduced by the use of antiviral medica-
be affected by an HIV diagnosIS, whether It IS
made before or during pregnancy. Chlamydia Syphilis tions during the pregnancy and a caesarean section
delivery; in developed countries, breastfeeding the
Mother-to-fetus infection can occ~ at the time of All pregnant women should be screened for infant should also be avoided.
Counselling and testing for HIV birth by direct transmission. The mfant may de- syphilis because it is easily treated, whereas
It is essential that the patient give informed con- velop conjunctivitis or pneumonltls: the nsks are untreated syphilis in pregnancy causes potentially
Health maintenance
sent before any testing and after explanaoo n about thought to be up to 250/0 and 15% respeenvely. If severe disease in both the mother and the fetus. As
a general rule, tetracyclines should not be used in
the possible results. Explam a mother tests positive for Chlamydra dunng preg-
th e implications of th'
Antenatal screening may consider-
that there is a 3-mon WID . d ow' fr om exposure to nancy the risk to the neonate IS reduced by a pregnancy. If the nonspecific screening test is p.osi- ably reduce the risk of vertical trans-
antibody development, and therefore a repeat test cours~ of antibiotics. Erythromycin is the first drug tive, exposure to syphilis should be confirmed mission of Infection to the fetus and
neonate.
will be necessary before a negaave test can be con- of choice. Azithromycin or alilOluCillin are mdicat- with a positive T. pallidum haemagglutination
firmed. Confidentiality issues are. Important. ed if erythromycin is not tolerated. assay (TPHA). There is a high incidence of syphilis
A positive result may have. imphcanons for life alilong Aboriginal women, and a number .of babies
insurance and immigranon, In addinon to ralsmg Bacterial vaginosis (BV) with congenital syphilis have been born in recent Further reading
serious social and psychologlcallssues. Although not a sexually transrrutted infecti.on, BV years. These women should be rescreened in the
Bowde n FJ, Tabrizi SN, Garland SM et al 2002 Infectious

-. . -.
Wherever possible, partners should be
is a common cause of vaginal discharge. It IS char-
acterised by an imbalance in the normal vagtnal
flora, with a decrease in LactobaCIllus spp and an
third trimester to exclude recent infection. If there
has been no antenatal screening, mother and baby
should be screened at the time of birth and fol-
dise ..... 6: Sexually transmitred lniections: new
di agnostic ap proaches and treatments. Medical Journal
of Australia 176 (11):551-557.
involved in the counselling process. increase in Gardnerella spp, Mycoplasma spp and lowed up in the posmatal period. Maternally
anaerobic bacteria. Epidemiol.ogl cal srudles sug- acquired antibodies will be detectable in non- Brown ZA, Selke SA, Zeh j et al199 7 Acquisition of herpes
gest an increased risk of rruscarnage, preterm infected infants for some months afrer delivery. si mplex virus during pregnancy. New England journal

* delivery and low-birth-welght mfa~ts amo ng of Medicine 337:507-515.


Advice from the pathologist, paediatrician, obste-
women with BY. However, the mecharusms are not trician or sexual health service can be obtained if
Sexually transmitted completely underst.ood and inter:enti.on studies there is doubt about interpreting neonatal syphilis
Crum Cp, BerkowitZ R5 2002 H uman papilloma viruses:
Applications, caveats and prevention . Journal of
infections and have not been sh.own to be effecnve m reduang serology. Penicillin is the drug of choice for treat- Reproductive Medici ne 47 (7):519-528; discussion
preterm delivery. There is insuffiClent eVidence to ment of the pregnant woman. 528-529.
pregnancy recommend routine screenmg 10 average-nsk
Sexual health: at hrtp :liwww.health.qld .go.l.au1scxhealth
pregnant women. Gonorrhoea
Sisk EA, Robertson ES 2002 Clinical implications of hwnan
Common clinical presentations 'Herpes A baby passing through a birth canal infecred with papilloma virus infection . Frontiers in Bioscience
A pregnant woman seeks advice afte' recently gonorrhoea may develop conjunctivitis or a pha- 7:77-84.
Vertical transmission and perinatal infection w ith
tyngeal infection. Gonorrhoea should also be sus-
having casual unprotected Intercourse. HSV are most likely to occur \\~th vagmal dehvery Stanberry LR, Rosenthal SL 2002 Genital herpes simplex
pected with a 'sticky eye' in the neonate.
A pregnant woman's antenatal screen test is at the timE of primary or active maternallnfecnon. virus infection in the adol escent: special consideration
The risk of neonatal infection is about 41%. 10 Ophthalmia neonatorum (conjunctivitis within
positive for syphilis. for management. Paediatric Drugs 4 (5):291-297.
babies born to women who acqUIre infeenon 21 days of birth) is a notifiable disease.
At 39 weeks' gestation, a woman notices for the first time near the onset.of labour, and Whitely Rj, Kimberlin S\V, Roizman B 1998 Herpes
painful vulval blisters. Chlamydia simplex viruses. Clinical Infectious Diseases
bo ut 30/0 in women with
aCaesarean
established Infecnon.
26:541-553.
section may be m . d'leate d'm pr.oven
Conjunctivitis can occur in 30-50% of neonates and
active primary HSV maternal infection. About pneumonia in 10-20% of neonates born through an Zur Hausen H 20Q2 Papilloma viruses and cancer: from
Consideration should be given to the effect of the 15% of neonatal infeCtlon results from posmatal infected birth canal to a mother with Chlamydia. basic studies to clinical application. Nature R~t'Ws.
Cancer 2 (5):342-350.
infection on the mother, the ferus and the neonate. traIlSmission from oral lesions.
HIV
Genital warts
Hepatitis B Universal screening may be cost-effective in some
These can increase in pregnancy: Excision can some- countries, aIld testing .of pooled antenatal sera
The woman who is hepatitis B surface antigen pos- times cause scarring. Podophyllin, podophyllotoXlD
itive (HBsAg+ve) should have her liver enzymes

ME
Women's health: a core curriculum

c . It may be caused by a Chlamydia


Lower abdominal pain
Questions infection,
d. It should be treated with saline eye
Edited by Vivienne O'Connor
1. Which of the following statements Is
incorrect? drops.
a. An Increase In vaginal discharge e. The mother should be tested for
indicates the presence of an STI. vaginal infections. Pelvic pain Ian Jones
b. An increase in vaginal discharge Endometriosis Vivienne O'Connor
may be related to the use of 3 . Which statement is incorrect? Pelvic Inflammatory disease Vivienne O'Connor
hormone therapy.
( f0P.. n ulcer of the vulva can be caused
c . An increase in vaginal discharge / V by use of steroid cream.
could suggest cervical cancer.
b. An ulcer of the vulva is painless if
d . A positive culture for Gardnerella
caused by syphilis.
vaglnalls does not Indicate a
sexually transmiHed Infection. c. An ulcer of the vulva could be a
e. There may be an Increase in vaginal vulval malignancy. Learning objectives
discharge during pregnancy. d. An ulcer of the vulva is painful if
caused by the herpes virus. ....,. Knowledge Skills
2. Which of the following statements is
not true of '~ic ky eye' In the neonate? e . Delivery by caesarean section
A~ the end of this chapter, the student At the end of this chapter, the student
a. It can be caused by a herpes should be considered for primary will be able to: should learn how to:
infection . herpetic infection of the lower
genital tract close to term. Pelvic pain • explain the concept of endometriosis in
It Is always due to gonorrhoea.
a clear and understandable way
list the differential diagnoses of acute
pelvic pain and of chronic pelVic pa in address the psychological component
of chronic pelvic pain .
outline the investigation and
management of a patient with acute
pelvic pain
• outline the Investigation and Attitudes
management of a patient with chronic
pelvic pain At the end of this chapter, the student
• discuss the psychosocial context of should reflecl upon:
chronic pelvic pain
• the association between chronic pain,
Endometriosis low self-esteem, sexual abuse and
outline the causation theories of domestic violence.
endometriosis
describe the natural history of
endometriosis
outline a plan of investigation and
management of endometriosis
Pelvic Inflammatory disease
recognise the relationship between
pelvic Inflammatory disease and STis
• describe the consequences of
untreated pelvic inflammatory disease
• outline an Investigation and
management plan for acute and
chronic pelvic inflammatory disease.
4 Lo w",r abdomi nal pain
Women's health: a co re curricu lu m

* Pel vic pain


• complication of an ovarian cyst: rupture,
haemorrhage into a cyst, torsion
• ovulation pain
Signs and symptoms
A detailed assessment of the pain is required,
including:
Natural history
In the acute situation, a diagnosis is usually made
based on the history, examination and investiga-
Common clinical presentation tions, and most often the problem is treated and
• retrograde menstruation • character, site, intensity, duration, periodicity,
Lower abdominal pain (LAP) is a common • primary dysmenorrhoea resolved. In the chronic situation, management
gynaecological and obstetric problem , radiation, onset also depends on the underlying cause and is more
• trauma to the upper genital tract following • aggravaring and relieving features
Associated symptoms may Include nausea, likely to be long-term.
vomiting, vaginal discharge, vaginal bleeding, instrumentation. • effeCts of micturition, defecation, vomiting,
painful menstruation, dyspareunia : abdominal The non-gynaecological causes of acute LAP coughing on the LAP
bloating, and urinary and bowel symptoms, • associated features of nausea, vomiting, sweat- Health maintenance
include: ing, urge to pass urine or faeces Recognition of past sexual abuse or
1 • effect of any pain relief administered previ- domestic violence and appropriate'
• cystitis
• ureteric colic
MIJC ously for this pain counselling may reduce the risk of
Pathophysiology • relationship to last menstrual period (LMP),
development of chronic pelvic pain ,
• acute appendicitis
LAP may originate from the genital tract organs, the menses, micturition, defaecation, move-
the bowel or the urinary bladder. It may also be • diverticulitis

*
ment, coitus, previous pregnancy or surgical
referred pain from the musculoskeletal system or • bowel obstruction
procedures

~'
other intra-abdominal structures higher up m the • mesenteric thrombosis.
• p,ast obstetric and gynaecological history Endometriosis
abdomen, or the pain may be psychosomanc. The , • past medical, surgical and psychiatric history
pain may be physiological, resulnng fr?m ovula- Chronic LAP Common clinical presentation
social history, including marital, sexual and
tion (mittelschmerz), premenstrual pelvIc vascular Chronic LAP is often more difficult to diagnose occupational history A 25-year-old woman complains of very painful,
congestion, retrograde menstruaClon or prllllary than acute pain. Gynaecological causes include: • history of physical or mental abuse, including periods and abdominal pain in the week
dysmenorrhoea. An underlymg depressIOn? anXI- domestic violence before menstruation,
ety state, sexual problem, or domesnc vIOlence • chronic pelvic inflammatory disease (PID) • orthopaedic and postural problems
should always be kept m mmd as a prtmary or sec- • endometriosis/adenomyosis • history of previous trauma
ondary component of the pain. . ' • ovarian masses, both benign and malignant • medication and medication allergies,
A working knowledge of the mnervanon of the
• complications of uterine fibroids Epidemiology
pelvic viscera assists in evaluating the cause of Physical exa mination
lower abdominal pain. The embryoruc ongm of a pelvic vascular congestion syndrome. The prevalence of endometriosis is unknown,
particular organ determines its nerve supply. Less common gynaecological causes of chronic What is the general appearance of the patient? Is since the pathological findings and symptoms are
Sensory impulses travel via both the somanc and LAP include: ofren not aligned: a woman with extensive disease
she shocked, distressed, tense, anxious, moving
may be asymptomatic and vice versa. The point at
the autonomic nervous systems. , about or lying still with her pain?
Diagnostic laparoscopy is a valuable tool U1 the • un ruptured ectopic pregnancy which a possible physiological problem becomes
Examine the vital signs and then perform a pathological may be different for each woman.
investigation of chromc L<\p' HO,wever, the poor • lo,,\'-grade PID general examination, including abdominal and
correlation of the laparoscoplC findings Wlth the • polycystic o\'ary disease musculoskeletal examinations. If appropriate, Pathophysiology
degree of pain, the high proportion of normal varicose veins in the broad ligament perform a pelvic e::amination: observe signs of
findings, and the finding of [runor adheSIOns and
• prolapsed ovaries intO the pouch of Douglas trauma, discharge, bleeding, foreign bodies, tissue The precise cause of endometriosis has not been
minimal endometriosis connnue to cause confu-
• genital prolapse, coming through the cervix, polyps, malignancy determined. The main theories include retrograde
sion for the clinician.
(unlikely to cause acute pain), and take appropri- menstruation, coelomic metaplasia, an altered
Non-gynaecological causes include: autoimmune response to menstrual blood in the
ate specimens for pathology (see below). Perform
Differential diagnosis a bimanual pelvic examination, checking for cervi-
peritoneal caviry, or a combination of these.
• appendiceal abscess Oestrogen is important in maintaining the pres-
Acute LAP • intra-abdominal adhesions cal excitation on moving the cervi..x. Then check ence and prol iferation of the tissue - endometri-
• di, cniculitis uterine size, consistency, tenderness, mobility, osis is not seen before adolescence and settles after
The gynaecological causes of acute LAP include:
• irritable bowel syndrome shape and consistency. Palpate each of the fornices menopause,
• threatened, incomplete and septic abortion • Crohn's disease, inflammatory bowel disease and the adnexa for masses, tenderness and fixity, Endometriotic tissue containing glands and
ectopic pregnancy _ AD malignancy of the small or large bowel , Based on the history and examination, make a epithelium are found in sites outside the endome-
acute salpingitis E:.p.;\" \'t;t'{ bladder dysfunction, urinary tract calculi list of differential diagnoses and give feedback to ttial cavity of the uterus. The precise definition of
tubal or ovarian abscess 0 - , the patient on these. Appropriate investigations endometriosis has varied over time and this has
osteoarthritis, lumbar disc protruslOn, other
• endometritis I- On \ musculoskeletal disorder. will assist you in refining your diagnosis. led to difficult;, in interpreting research results.
• pelvic peritonitis

81
4 Lo wer a bdominal pa in
Women 's health: a core c urriculum

ness~ tenderness in the adnexa and on moving the Further reading


The histological confirmation of endomeuiotic tis- Health maintenance
cervIX. There may be vaginal discharge, abnormal Abbott J, Hawe J, Shaltoot N et al 2002 Pelvic pain scores
sue is suggested as the gold standard. Recently it Use of the oral contraceptive pill bleedUlg or dyspareunia. However there is not in women without pelvic pathology. Journal of the
has been suggested that the degree of pain is more minimises the risk of developing good evidence to relate these non~pecific symp- American Associarion of Gynecologic LJparoscopisrs
likely to be associated with the depth of invasion endometriosis. toms to PID. 9(4):414-417.
into the tissues.
Natural history Campbell J, Jones AS, Dieoemann J et al 2002 Intimate

*
bulL The most frequent sites affected include the
parmer violence and physical health consequences.
, r"'-'''' I c pouc~, pelvic side-walls and adnexa. Archives of Internal Medicine 162(10):1157-1163.
I' f'H."~ The-large bowel and bladder may also be involved, Pelvic inflammatory Early diagnosis and treatment can resolve the
problem. Where the disease has been present for
and endometrioric tissue has been found at distant Endometriosis Association of Victoria websitt: at
sites, including the lung (causing haemoptysis),
disease longer or there IS recurrent disease, the risk of http://ww\v.en dometriosis.org.au.
tubal damage Ulcreases.
and within abdominal scars. Common clinical presentation wngstreth GF, Drossman DA 2002 New developments tn
Impact and outcomes the diagnosis and treatment of irritable bowel
Signs and symptoms A 22-year-old woman is admitted to the syndrome. Current Gastroenterology Reports
emergency deportment with severe lower Tubal and pelvic organ damage can result in 4(5) :427-434.
The most frequent symptom is pelvic pain. This abdominal pain and greenish vaginal anatomical distortion and the development of
may presently acutely with an accident to an discharge. adheSIOns. The sequelae are an increased risk of Ross J 2001 Pelvic inflammatory disease: extracts from
endometriotic cyst on the ovary, but most com- 'clinical evidence' . British Medical Journal
ectopic pregnancy, infertility and chronic pelvic 322:658-659.
monly pr€sents as a chronic problem. Endo- pam. PID has high morbidity: about 20% of
metriosis may also present with dysmenorrhoea and affected women become infertile, 20% develop Ross J 2002 An update on pelvic inJlammatory disease.
dyspareunia. Epidemiology chroruc pelvic pain, and 10% of those who con- Sexually Transmitted Infections 78( 1):18-19.
Abdominal and pelvic e.,xarnllation reveal ren-
The exact incidence of PID is unknown because it ceive have an ectopic pregnancy.
derness in the pouch of Douglas, uterus and Simms I, Warbunon F, Westrom L 2003 Diagnosis of pelvic
cannot be diagnosed reliably from clinical symp- mflammatory disease: rime for a rethink. Sexually
adnexa. Rarely, this may be associated wirh the pal-
toms and signs. Direct visualisation of the fallopian Health maintenance Transmitted Infections 79(6);491-494.
pation of endometrioric nodules. Endometriosis tubes by laparoscopy is the best single diagnostic
may also be diagnosed during investigation for sub-test, but it is invasive and not used routinely in clin- Education about responsible sexual VaUe RF, Sciarra JJ 2003 Endometriosis: !Teaonent
activity and prevention of STls should strategies. Annals of the New York Academy of
fertility. ical practice. PID is most common in young women reduce the risk of acute pelvic
under 25 years of age following a sexually trans- Sciences 99 7:229-23 9.
inflammatory disease and Its
Naturo l history mitted infection. It may also present afrer vaginal sequelae.
This is variable and individual. Women may have douching or surgical inrervention, such as afrer a
endometriosis in mild or severe fonus that may be termination of pregnancy or insertion of an
asymptomatic or cause severe problems. The latter intrauterine contraceptive device (IUD).
may resolve with time, remain static or progress.
. (S Us:' hw.. t athoPhYSIOl09y Qu estions 2. Which of the following statements are
Im pact/outcomes \'/., U M ost cases seem to resulr from infection ascending true of ectopic pregnancies?
from the cervLx. Initial epithelial damage caused 1. Which statement Is incorrect?
This depends on the effect on the woman's quali- by bacteria (especially Chiarnydia trachomatis and a . Ninety-five per cent occur in the
ty of life and her needs. Management is directed Neisseria gonorrhoeae) allows the opporrunistic a. Chronic abdominal pain can be fallopian tube.
towards these needs - resolution of pain, entry of other organisms. In mild cases, these are caused by endometriosis. 0 PID is the most important tactor in
I decrease in menstrUal bleeding and the desire to the predominant pathogens; in severe or recurrent b. Chronic abdominal pain, by the aetiology.
I . ~l1ecome pregnant. Management options include disease, rhe aetiology is often polymicrobial, with definition, has been present for at c . Bleeding is usually the first symptom.
~(. Jurgery (most often by the laparoscope) to remove the primary pathogens being mixed _vith other least 6 weeks.
_ } the lesions and restore the anatomy to as near a conun.ensals and anaerobic genital flora. d. The diagnosis is ruled out by a
c. Chronic abdominal pain may be the negative pregnancy test. ~IJ\) '
normal state as possible. A complere pelvic clear- result of childhood sexual abuse.
ance (removal of the urerus, tubes and ovaries, and e . Va ginal Candida infection increases
other endometrioric deposits) is the last resort and Signs and symptoms d. Chronic abdominal pain can be due the risk of ectopic pregnancy.
to PID resulting from a previously
is not guaranteed to resolve all rhe problems in the The symproms and signs of PID may be minimal, undiagnosed chlamydial infection.
long term. Medical options (where pain is rhe pri- so a high index of suspicion is necessary, particu-
mary concern) are directed rowards the use of lady for chlamydial disease. In the acute situation, e. Twenty per cent of women with PID
analgesics, hormone stabilisation and oestrogen marked abdominal pain may be associated wirh a have difficulty conceivi ng .
( re~~~~;::1 : up prr ession.
r- fever, abdominal guarding and rebound render-
Iy ""\"~ 'V I \~ ,U'f-.fAc.~
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~
~~o~
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vv
f(C)~~lt~ ,,'-.(. - r; vv4 '1 f'l\ .
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_
\ \vJ.. '_ 4--CoC1:'0 \ l ~ '" wv'<'\NJ
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b v'-*
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,.l.U .l( .
tl U. Cl- V'w'f
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Contraception
Beverley Vollenhoven and Gareth Weston
Edited by Beverley Vollenhoven

Learning objectives

Knowledge Skills

At the end of this chapter, the student At the end of this chapter, the studen t
will be able to: should learn how to:

Reversible contraception explain to a woman the efficacy,


benefits, risks and side effects of various
explain the methods of reporting forms of contraception
contraceptive efficacy
describe how e ach method of
describe the various methods of contraception works
reversible contracepti on In terms of
efficacy, benefits, risks and side effects counsel a woman about emergency
contraception
discuss the suitability of these methods
for women at different ages, women counsel a woman and her partner
with medical problems, women with about permanent contraception ,
multiple sexual partners and for
II breastfeeding mothers
Emergency contraception
Attitudes
evaluate the available types of
emergency contraception AI the end of this chapter, the student
• discuss the suitability of these methods
should reflect upon:
for women of different parity and sexual
behaviour the need to tailor contraception to the
individual
Irreversible contraception
the need for contraception in minors
• evaluate the types of irreversible and the mentally/physically
contraception challenged,
• list the likely reasons for requesting
reversal of sterilisation,

..if
5 Con traception
Women's health: a core cu rri culum

o There may be a slightly increased risk of breast


Facfs
A wide range of contraceptive options is available 1. Highly eNectlve contraception In motlvoted cancer, but only of localised disease, and this may • COCP does NOT cause weight gain.
women (annual failure rate 0.1%) be due to acceleration of the onset of existing
for couples. Different methods . may be used. by • Prolonged COCP use does NOT cause infertility.
couples at different stages of the1l" lives. Providing 2. Reduced risk of: cancers. Some studies show no increased risk. • 'Pill holidays' are NOT required to reduce risk of
• Iron-deficiency anaemia • EndometriosiS endometrial/uterine carcinoma.
information, education and advice for couples on
• Dysmenorrhoea • Fibroids Pill administration
all aspectS of contraception is an important role • Endometrial cancer Contraindicotions
• Menorrhagia • History of thromboembolism
for the health professional. • Functional/simple • Ovarian cancer The woman should be advised that she must take
There are twO methods of reporting contracep- • Bacterial 51ls • Suspected breast cancer
ovarian cysts seven active pills before the COCP will be effective • Smokers :>35 years old
tive efficacy: • Premenstrual syndrome (efficacy is immediate if she starts active pills on • Markedly impaired liver function tests/jaundice
1. The Pearl inde-x gives the number of failures day 1 of her cycle). This contraceptive method • Cerebrovascular/cardiovosculor disease
BOX 5,1 Benefits of the COCP may fail to be effective if a pill is missed by > 12 • Acuie/chronic/cholestallc liver disease
per 100 woman-years of exposure (usually
based on 1 year of exposure). hours (particularly if this increases the pill-free Relative contraindications
2. The life table analysis calculates a failure rate interval), if the woman has vomiting and/or diar- • Migraines
The following types of preparations are available: rhoea, or if there is a drug interaction. Drugs that • Uncontrolled hypertension
for each month of use, with comparison of con- • Epilepsy (need 50 ~g EE/day)
rraceptive methods by cumulative failure rates o low-dose (<50 ,t.g EE) or high-dose (;;<50 ft.g EE) may interfere with the COCP include antibiotics, • Sickle cell disease
for any specific length of exposure. monophasic (same daily dose of E and P) anti epileptic medications, antituberculous drugs • Active gallbladder disease
o biphasic (two-step P dose) and antifungals.
If there is risk of failure, an additional contra-
*Reversible contraceptive triphasic (two-step E dose, three-step P dose).
The mechanisms of action of COCPs are:
ceptive method should be used until seven active
pills have been taken after the risk ceased.
BOX 5.2 Facts abo u t lhe COCP and its
contralndications

methods o suppression of follicular selection and ovula- - or within 3 hours - every day); with obesi-
tion at h'·pothalamus/pituitary (E and P) Health maintenance
ty, there is an even greater risk of failure (2 pills
Common clinical presentation o endometrial atrophy, thickening of cervical Women on the combined oral a day should be taken) .
mucus, and reduced tubal motility (P). contraceptive pill should ovoid o Other potential problems include follicular
A 25-year-<lld woman requests 0 reversible
smoking to minimise the risk of venous CYStS (20%, usually asymptomatic) and an
method of contraception ond would like to The benefitS of COCPs are given in Box 5.1. thromboembolism.
know her options. increased risk of ectopic pregnancy (relative,
due to effect on tubal motility).
Side effects/risks
o There is an increased risk of venous throm- Progestogen-only p ill (POP) / Inje ctable progestogens
Combined oral co ntraceptive pill boembolism. The incidence is 3-4 in 10,000 minipill
women using the COCp, compared with 1 in Depo-Provera (depot medroxyprogesterone acetate,
(COCP) This is an oral pill with no oestrogen and a small DMPA) is a highly effective contraceptive, admin-
10000 women who don't use it. In pregnancy
This is a daily oral pill containing oesrrogen (E) - th~ risk of venous thromboembolism increases dose of progestogen (e.g. 30 ~g levonorgestrel, istered as a 3-monthly injection. It works in the
ethinyl oesrradiol (EE) - and a progestOgen (P). 30 times. There may be a greater risk with a 350 ft.g norethisterone). It actS by changing the same way as the COCP and is commonly used for
ProgestOgens used in COCPs include: COCP using a third-generation progestogen, nature of the cervical mucus and the endomet- women who have difficulty complying with an
o If the woman is over 35 years old and IS a rium, which prevents implantatio n; 40 % of OCp, or for women for whom oestrogen is con-
first generation: norethisterone and its deriva- smoker, there is also an increased risk of car- women on the POP continue to ovulate. traindicated:
tives diovascular disease (lower with third-genera- It is mainly indicated for women who are breasr- The main problems with this drug are the
o second generation: norgestrel group - levo- feeding because, unlike the COCp, it has no effect short- and long-term side effectS, as follows:
tion Pl·
norgesrrel, the most androgenic of the available o There is a dose-dependent increase in cere- on breast milk. It should also be used by women for
brovascular disease if EE ",50 mg/day. o irregular vaginal bleeding. Of the women using
progestOgens . whom oestrogen is contraindicated (e.g. past histo-
third generation: desogestrel, norgesnrnate and If the woman has wei !-controlled hypertension, this drug, 20% have prolonged regular or irreg-
o o ty of deep vein thrombosis - DVT).
gestOdene. These have beneficial effectS on the COCP is not contraindicated. ular bleeding episodes, 40% amenorrhoea and
lipids and reduced effects on carbohydrate For the woman with well-controlled diabetes 40% scant regular periods. This is the most
o
Si de 'effectsj p ro b Iems
mellirus, the COCP is not contraindicated, but common reason for ceasing the drug. This
metabolism
o fourth generation: cyproterone acetate, dros- some preparations may cause reduced glucose o There may be irregular vaginal bleeding (this irregularity can be treared by giving low· dose E.
tolerance. causes 20% of users to cease). o weight gain (6 kg after 4 years of use) due to
perinone. These are amiandrogens and benefit
The COCP may accelerate gallbladder disease. o The POP has an increased risk of pregnancy increased appetite
women with mild hirsutism and acne.
o The COCP may increase the risk of cervical compared with the COCP (shorter half-life of o delayed return to fertility - up to 1 year after
Drosperinone is also a mild diuretic, and min- cessation (20% of users)
cancer. 19 hours, and must be taken at the same time
imises bloating and breast tenderness.

81
ttl'
Women's health: a core c urriculu m
5 Contraception

• possible osteoporosis with long-term use (sup- that is more common in users of inert IUDs
plemental E may be required if use is long-term (less likely with Cu IUDs) : if it occurs, remove
or from a young age). the IUD and treat with penicillin G 500 mg qid
for a month.
• There is a 30% miscarriage risk if pregnancy
Health maintenance occurs. Remove IUD immediately.
Hormonal contraception has definite • The absolute risk of ectopic pregnancy is not
health benefits, especially reducing increased by IUDs, only the relative risk.
the Incidence of heavy painful
menses, endometriosis, and endo- Contraindications
metrial and ovarian cancer.
An IUD should not be used in the foUowing con-
ditions:
• risk of endocarditis
Implantable progestogens • surgery (contraindicated)
Implanon (desogestrel) is a single-rod implant and • copper allergy and Wilson's disease (if intend-
is effective for 3 vears. The indications are the ing to use copper IUD)
s~e as for DlItrPA. It is highly effective, with • immunosuppression (relative)
irregular bleeding as a major side effect. Fertiliry • pregnancy.
rerurns immediately upon removal and there is no
adverse effect on bone density. Post-insertion
Check strings in siru with a speculum examination
Intrauterine device (IUD) after the next period. The woman should check
the stri ngs after each period.
There are three types of intrauterine devices:
inert IUDs; e.g. Lippes loop (plastic), stainless Barrier methods
steel IUDs (mainly in China/SE Asia)
copper IUDs (CuT380A is effective for 10 These include both male and female condoms and
years and multiload Cu375 for 5 years) the diaphragm. Condoms have the added benefits
hormone-releasing IUDs (Mirena, with levo- of protecting from STls and pelvic inflammatory
disease (PID) and reducing the incidence of cervi-
norgestrel coating, lasts for 5 years) . Mirena
cal cancer.
IUDs are also an effe ctive treatment for menor-
rhagia (9 7% reduction of menstrual blood loss Diaphragms need to be properl y fitted over the
cervix to be effective. Insert up to 6 hours before
at 1 year).
intercourse, and remove at least 6 hours after-
wards. There is an increased risk of vaginal irrita-
Mechanism of action
tion and urinary tract infections. Spermicides
The sterile inflammatory response interferes with inactivate sperm in the vagina, work for up to
sperm motiliry and therefore prevents fertilisation. 8 hours and can protect against STIs (including
The IUD also prevents implantation. H1V), but can cause allergic reactions. Condoms
(male and female) protect from STls as well as
Side effects/problems providing a contraceptive effect, but can reduce
• Menorrhagia/dysmenorrhoea may occur (15%) sensit:iviry in intercourse.
with copper and inert IUDs. FIGURE 5 . 1 Common methods of contraception:
• There is a slightly incre ased but not long-term Natural family planning
: - mo~oPhasic oCP; B - triph asic OCP; C - POP (minipill); D - postcoi tal contraception '
risk of intrauterine infection after insertion Narural methods of contraception involve avoid- in - ma e condom; F - female condom; G - diaphragm; H - IUD s; I - Implanon rod and'
(IUDs are not protective like OCP'progesto- ing intercourse during the fertile parr of the men- sertlon trocar. (Pho to co urtesy Peter Fa rk os/Ro yal Darwin Hos pital)
gens or barrier methods). The)' are contraindi- strual cycle (i.e. peri ovulation) .
cated in women who are at ris!·: of bacterial The rhythm/calendar method entails absti-
endocarditis. Actinomycosis is an infection nence from intercourse for 1 week before and
5 Co ntraceptio n
Women 's health: a core curriculum

ovulation (i.e. subtract 14 days from the Transcervical sterilisation Kaunitz AM 1992 Oral contraceptives and gynaecological
1 week after ovulation (i.e. on days 8-21 of a cancer: .an update for the 1990s. American Journal of
expected date of the next menses and add 5). This technique aims to destroy the proximal Obstetncs and Gynecology 167:1171.
28-day cycle). It is only practical if the woman has The failure rate is 2-30/0. section of the fallOPian tube by inserting a spring Kovacs G 1994 Steroidal contraception 1995. Royal
regular cycles. The cervical mucuS method 4. Mifepristone (RU486) - not yet available in
hysteroscop lcaUy. It can be performed with IV Austrahan College of Obstetricians and Gynaecologists
involves abstaining from intercourse when cervical AuStralia: 10 mg is administered as a single sedanon/paracervical block. Other methods Contmumg Education, resource unit 114.
mucus is increased in volume, thin and clear (peri- dose. It can be used within 5 days, and is as llldude heat, chemicals, and plugs used to block Schwing! PJ, Guess HA 2000 Safety and effectiveness of
ovulatory change). The symptothermal method effective as POEC, but the onset of menstrUa- the tube hysteroscopically. vasectomy. Fertility and Sterility 73:923.
entails daily measurement of basal body tempera-
ture to detect the 0.3°C temperature rise that tion is delayed. Shearman RP 1995 Contraception and sterilization. In:
marks ovulation, together with observation of Further reading Whitfield CR (ed) Dewhurst's textbook of obstetrics &
mucus changes.
* Irreversible American Fertility Society Guideline for Practice 1994
Contraceptive choices.
gynaecology for postgraduates. Blackwell Science
Oxford, pp 568-579.
SperoH L, Darnel' P 1992 A clinical guide for
'

Health maintenance contraception Cheng L et .1 1999 Interventions for emergency contracepnon. Lippincott Williams & Wilkins
contracepoon. In: The Cochrane Database of Baltimore. '
Barrier contraceptive methods protect Systematic Reviews (The Cochrane Library 3). Online.
against sexually transmitted infection. Common clinical presentation Ava,lable : hrrp:llwww.update-sorware.comlcochr<lue Yusuf F, Siedlecky S 1999 Contraceptive use in AustralW.:
Consider investigation for STI in a eVidence fro m the 1995 National Health Survey
woman who requests emergency A couple with three children have decided that Glasier AF 2003 Ferrility control. In: Shaw RW Sourrer WP. Australian and New Zealand Journal of Obstetri'cs and
their family is complete, They would like advice Stanton SL (eds) Gynaecology, 3rd edn. Churchill ' Gynaecology 39:58.
contraception,
about methods of sterilisation. LlYIngstone, Edinburgh.

* E m erg~ncy
contracepti on
vasectomy
This is safe, cheap and has lower morbidity than Q uestions 4, Which of the following are forms of
female sterilisation. The failure rate is 1 in 2000 emergency contraception?
1. Which of the following is an absolute
if twO consecutive semen analyses 2-4 weeks a, EE 100 >lg with levonorgestrel 500 >lg
Common clinical presentation contraindication to the COCP?
apart and at least 8 weeks post-procedure show given 12 h apart ('\\.\..~(>-t.)
azoospermia. Early complications include haema- a. Simple migraine
• A 26-year-old woman hod unprotected b . 1,5 mg levonorgestrel .
intercourse 24 hours ago. She asks your advice
toma, infection, sperm granulo mas, epidi- b. Well-controlled hypertenSion
about the use of emergency contraception dymo o rchitis and congestive epididymitis c, Previous pulmonary embolus c . IUD '
(1-6% of men). There is no epidemiological evi- d, Past history of ChOleCystectom y /
and her opNons. d , MifeprlstonEj
dence of increased autoimmune disease, athero-
sclerosis, prostate cancer, impotence or testicu- e. Menorrhagia
e. All of the above
lar cancer after vasectomy. Rever al of vasectomy 2. Which is the most common side eHect
Methods has a 50% success rate if done within 10 years. of all P-only contraceptives? 5. Which of the following women may
There are four emergency contraception methods. a. Weight gain request reversal of a tubal ligation at a
later date?
1. Yuzpe method: 100 p.g EE and 0.5 mg levo- Tubal ligation (TL) b. Irregular bleeding
norgestrel are given 12 h apart with an anti- Tubal ligation is highly effective (1 in 200 lifetime c. Mood disturbance a . A woman in a stable relationship
emetic. The failure rate is 2-3% if given within failure rate) and involves blocking the fallopian d.Headaches b. A womon who had the procedure at
72 h. Nausea is a common side effect related
tubes by diathermy, clips, rings or transection (all e.Acne 40 years of age . - /
to E. can be pedormed laparoscopically as day proce-
2. Progestogen-only emergency contraception dures) . An increased risk of ectopic pregnancy is 3. Which of the following contraceptive
c A woman who had her last child ~
(POEC): twO doses of 0.75 mg lcvonorgestrel 5 years ago
are given 12 h apart. As there is no E, there is
less nausea/vomiting. This method is more suc-
cessful than Yuzpe (1.1% failure if given within
associated with TL using diathermy. Successful
reversal rates vary with the method of 11. used
(80% with clips); a request for reversal is more
methods does not give protection
against bacterial STls?
~I UDs
d. A woman who underwent the
procedure at the time of a
/
Likely if the woman is dO years old, single or in an b, COCP caesarean section
72 h) and better tolerated. It can also be given
unstable relationship, if TL is performed im-
as a single 1.5 mg dose with the same efficacy. mediately postpartum or at caesarean section, c. Depo-Provera e . A woman who had her last child
3. Copper IUD insertion prevents implantation if d. Condoms 3 years ago
inserted within 5 days of the most likely day of or after the death of a child.

w.,
.,
*6
Health education before and
during pregnancy
Lucy Bowyer and Ratnasari Padang
Edited b y Lucy Bowyer

Learning objectives

Kno wle dge Sk ills

At the end of this chapter, the student At the end of this chapter, the student
will be able to: should learn how to :

Counselling before pregnancy: general outline to a woman the requirements of


a normal, balanced d iet and how It
discuss the prevention of anaemia, should be modified in pregnancy
rubella infection and neural tube
defects in pregnancy counsel a woman about the prevention
of neural tube defects with folic acid
Identify women w ith lifesty le issues that supplementation
have an impact on pregnancy
counsel a woman about the risks of
identity preexisting medical conditions smoking in pregnancy and encourage
that have an impact on pregnancy or her to quit
may be affected by pregnancy explain to a patient the difference
• list appropriate pre-pregnancy between a screening and a diagnostic
investigations test

Women with genetic concerns • explain to a woman the principles of


screening for Down syndrome
indicate the prevalence, mode of
• counsel a woman who has a positive
inheritance and populations at risk for antenatal screen test for Down syndrome
Down syndrome , thalassaemia and
cystic fibrosis interpret a family pedigree with
conventional symbols.
• identify the underlying genetic or
biochemical abnormality leading to
each of these disorders
A ttitudes
• describe briefly the clinical
manifestations of each disorder At the end of this chapter, the stUdent
critically appraise the screening and should reflect upon:
diagnostic tests for Down syndrome
different cultural and personal belief
outtine the screening and diagnostic systems Influencing patient preferences
tests for thalassaemia and cystic fibrosis . in the uptake of prenatal screening .

w,
6 Health educ a ti on befo re a nd du ring
. pregna ncy
women's health: 0 core c u rriculum

* Counselling before
pregnancy
may also be conducted for infectious diseases that
can have an impact upon the progress of preg-
nancy, such as HIY, hepatitis B and C, and syphilis.
should
.th be. planned
Wl al
. and managed m· conJuncnon
. .
an mfecnous diseases consultant to reduce
vClth load and maximise the CD4 count (see
apter 10).
Diet Smoking, alcohol and
Common clinical presentations
A well-balanced diet is particularly important in recreational drugs
A healthy 30-year-old woman is planning to pregnancy. There is some evidence that multivita-
conceive and requests advice about diet and min and mineral supplements may reduce fetal Smoking is harmful to the reproductive system
alcohol In pregnancy. abnormalities in pregnancy. In particular, the rou- and to the ferus. It can reduce fertility and there-
A 28-year-old woman with type 1 Insulln- tine supplementation of folic acid is recom- fore It may be harder to conceive. Smoking during
dependent diabetes mellitus Is considering mended, as discussed below. Soft cheese should pregnancy leads to an lilcreased risk of miscar-
pregnancy but has heard that diabetes poses be avoided in pregnancy due to the risk of Listeria ?age, pcieterm delivery, small-for-gestational-age
a higher risk of fetal abnormalities. infection from unpasteurised dairy products. ~s an an mcreased rate of antepartum haemor-
FIGURE 6.1 The felus affected by lumbo-sacral
Calcium requirements are higher in pregnancy, so m yelo-menlng ocele r ge and abrupnon. Posmatal smoking increases
• A concerned mother of one child who was
pregnant women should be advised to maintain a the risk of sudden infant death syndrome (SIDS).
very small at birth wishes to have another
regular intake of calcium-rich foods, such as dairy All smokers should be advised of the risks that
child. She smokes 20 cigarettes a day. second most common fetal abnormality after car-
productS, fish and tofu/soy productS. Coffee, tea> smoking carnes for their pregnancy - in particu-
• Having previously had a baby with spina and caffeine-containing drinks should be kept to a diac anomalies. The neural tube develo sand lar, the rISks of miscarriage and abruption - and
biflda, a 33-year-old mother would like to minimum throughout pregnancy because a h.igh begms to close during the fifth week of gesrfnon at should be encouraged to stop smoking with .
minimise the risk of recurrence. intake of caffeine has been linked with reduced a rune when some women mav not be aware t1~ey programs and support information. qwt
fertility and increased risk of miscarriage. are pregnant. Therefore It IS advised that folic acid f It IS possible that even moderate consumption
be taken before mtended conception. Women who o alcohol reduces fertility Uensen et al 1998).
fa~e never had an affected pregnancy should take a 1herefore, If there IS a delay in conceiving alcohol
General advice Iron-deficiency anaemia o c aCId dose of 500 /-lglday and women with re- s ould be avoided. Fetal alcohol syn~ome is
Although it used to be most unusual for the aver- Iron-deficiency anaemia is more common among vlously affected offspring should take 5 mg/dar: clearly assOCiated with excess alcohol intake but it
age healthy woman to ask for medical advice women with heavy mensrrualloss, vegetarians and IS unclear at what level alcohol causes feral dam-
before planning a pregnancy, nowadays many vegans. Pregnancy and lactation demand at least Vi ral screening age. It IS probably adVisable to limit alcohol intake
women will consult their general practitioner for a 1000 rug of iron per day. In addition to the physio-
Infection with both rubella (German measles) and to one or [WO uruts per week during pregnancy
check-up before trying to conceive. This is a great logical anaemia of pregnancy (caused ' by the
~arlcella (chickenpox) can cause fetal abnormali-
Cenam recreational drugs, particularly ~he
opporrunity to make sure that the woman is in haemodilution of a relatively greater increase in
~mphetarrunes and cocaine, are very harmful to
general good health and to give advice that \~~U plasma volume compared with red cell mass), a es m the first and second trimester of pregnancy.
~though most girls are vaccinated during child-
fi e developmg ferus. Organogenesis occurs in the
optimise healthy conception. Once the woman is woman who is iron-deficient at the start of preg-
pregnant, the time available for investigations and nancy is likely to feel tired and symptomatic ood or adolescence agaiIlSt rubella, they may not 6 rst 12 weeks of embryonic development crable
.1) and It IS dunng this time that the ferus is most
the consideration of options is limited. ~av ~ ~en exposed to varicella. A positive child-
through the pregnancy (Hercberg 2001) . iron
deficiency is generally easily treated by iron [to story of chickenpox is usually memorable. vulnerable to teratogens. However, after the first
3 months .of pregnancy, certain drugs, infections
History replacement (e.g. with a ferrous sulphate supple- . not, Immunoglobulin G (IgG) titres for both
VLrUses should be checked. Low-level · . and radianon can still be harmful to the develop-
There are certain factors that cannot be altered: ment) throughout pregnancy; the addition of vita- rub II . di unmuruty to
. e a may m cate the need for repeat vacu·na- ment
v' d of the U· ferus. Most area health servICes
. pro-
age, genetic background, race, social class, and min C helps the absorption of iron. Women who non I e counse mg to advise doctors or mothers
bl' and. a \' accme
. f or · .
chickenpox is now avail-
previous medical and obstetric history. Pre- are iron-deficient should be retested after replace- a e. Smce both viral diseases can have a profound about the potential effects of teratogenic agents.
conception counselling should always start with a ment therapy has begun to ensure that absorption
thorough medical histOry, including family and is adequate.
ar
eFe~ pon fetal development (not to mention the
High-risk pregnancies
c ml~l manlfestanons of adult chickenpox), it is
social background, and diseases. The histOry will seosl e to vaccmate vulnerable women before
direct the focus of further counselling. Folic acid and the prevention of Diabetes
pregnancy.
neural tube defects Women who are HN-positive carry a risk of uP Women with .type 1 (insulin-dependent) diabetes
Investigations to.30 01o (dependent upon the population) of trans :ve a higher mCldence of fetal abnormalities than
Folic acid supplements may halve the risk of neu-
Pre-pregnancy investigations should include a full mltnng the vu:
'Ii . al inf"
ecnon vertically to their ferus - e general population. Those who receive pre-
ral rube defects (NTDs) in the ferus, such as spina
blood count (FBC) as well as rubella and varicella bifida (Fig 6.1) and anencephaly (MRC Vitamin [datment With antiviral agents can significant!; cdonbcepnon counselling have a lower incidence of
immunoglobulin titres. The FBC may reveal iron- Srudy Research Group 1991). The incidence of re uce the
worn . nskd to around 2% . If an ruLITU ..
v-posmve la encore lated co mp 1·Icanons
. at all stages of
deficiency anaemia and other conditions such as NTDs is 1-2 per 1000 live births, making it the an mten s to get pregnant, the pregnancy pregnancy.
thalassaemia and sickle-cell anaemia. Screening

Wi
6 He a lth education b e fore and d u ring pregnancy

Women's heallh : a c ore curriculum

to conceive are advised co take 5 mg of folic acid Antenatal care not diagnostic for the abnormality (Newberger
Complete 2000). It 15 tmportant to provide both pre- and
Organ Differentiation daily. Around the world, many different models exist for
(weeks) formation (weeks) post-test counselling. A positive screemng test
the care of pre~ant women during pregnancy and generally mdicates that a diagnostic test should be
Spinal cord 3-4 20 other chroniC diseases and previous delivery.. It 15 Important that women be given dIscussed.
3 28 pregnancy problems appropnate adVICe at the beginning of pregnancy Diagnostic tests accurately identify fetuses with
Brain about a SUItable model of care for their individual
3 20-24 Pregnancy outcomes for women with renal, thy- abnormalities .. A .diagnostic test has a high speci-
Eyes needs. Women with high-risk medical or obstetric fiCity and senSIOVlty, but the invasive nature of the
4-5
roid and heart disease, hypertension and asthma backgrounds should be triaged to hospital care
Olfactory are significantly improved if they receive pre- test poses a ruk to the pregnancy. Thus diagnostic
apparatus WIth a consultant obstetrician and may need to be tests are not commonly offered as first-line tests to
3-4 24-28 conception counselling. seen m consultation with other specialists_ The
Auditory Outcomes for women with problems in previous the general population, but rather to those with
apparatus maJonty of women will have a low-risk pregnancy nsk factors such as advanced maternal age or bigh-
pregnancies, such as miscarriage, preterrn labour or and may choose lIlldwifery care, obstetric medical
5 24-28 nsk screenmg results. Prenatal diagnostic tests
Respiratory stillbirth, are discussed in Chapters 7, 11 and 13 . care,. or care shared by a general practitioner and
system mclude chonoruc villus sampling (CVS), anmio-
6 a lIlldWlfe or obstetrician_ Those who develop centeSIS, cordocentesis and ultrasound_
Heart Social issues problems during pregnancy, whether maternal or
3 24 fetal, should be. offered the appropriate care.
Gastrointestinal Women who are well supported in pregnancy by Down syndrome (trisomy 21)
system Many countries, mcluding Australia, offer success-
12 their partners, families or friends have a lower risk - Down syndrome is the most commonly recognised
Liver 3-4 ful homeblrth models to low-risk women .
of posmatal depression and anxiety. Because many chromosomal cause of mental disability, with a
Renal system
Genital system
Face
4-5

3-4
5
12
women in wealthy countries are unlikely co have
more than twO babies, they rely on information
from friends, family and professionals to cope
with a unique and unfamiliar experience. Isolated
* Women with
genetic conce rns
prevalence of 9.2 cases per 10,000 live births_
There IS a strong association between the inci-
dence of D O,""ll syndrome and advancing maternal
8 age (Table 6.2)_
Limbs 4-5 women, single mothers, teenage mothers and
TABLE 6.1 Differe n tiation of fG t al tissue (weeks those with a history of mental illness may require
from conception) (From Hanrettv 2000. p 16) additional professional support to deal with the A 40-year-old woman is pregnant and Maternal age at Incidence of Down
demands of pregnancy, particularly if they are concerned about the risk of having a child delivery (years) syndrome
The first trimester is the critical period of obliged to work in later pregnancy. Social support with Down syndrome.
organogenesis during pregnancy, but good diabet- ,is also vital through labour: studies have shown that 20 I in 1500
A consanguineous Lebanese couple book an
ic control is essential both pre-concepnon and women who are well supported by a parmer, fami- antenatal appointment. 25 I in 1350
throughout pregnancy to reduce the risk o f fetal ly member, friend or doula (labour support person)
A father-to-be has a brother with cystic "brosis 30 1 in 909
anomalY fetal macrosomia, growth restriction and have a lower incidence of caesarean section and
preter~' labour. Blood glucose levels of women perceive less pain in labour_
and wishes to know the risk of his child being 35 1 in 384
with diabetes should be controlled more strictly affectGd.
36 1 In 307
during pregnancy than at any other time in order
37 1 In 242
to reduce the incidence of fetal abnormahoes: fin-
38 1 In 189
gerprick blood sugar levels should ideally be kept Prenatal screening versus
between 4 and 8 mmoVL. These patients should be 39 1 in 146
diagnostic testing
managed in conjunction with a diabetes physician
40 1 In 112
and should have overall control monitored with Prenatal diagnosis is. the science of identifying
41 1 in 85
haemoglobin Ale (HbA1J levels_ structural and funcoonal abnormalities in the
developmg fetus. It offers an opportunity to influ- 42 1 in 65
Epilepsy ence the mCldence and severity of various genetic 43 1 in 49
Women ,vith epilepsy, particularly those caking diseases wlthm the community. For some women
44 1 in 37
anriconvulsants, have three times the risk of fetal and theu partners, prenatal diagnosis is nor
structural anomalies (Fig 6.2) compared to normal acceptable for personal or religious reasons, while 45 1 In 28
women. These women should be assessed before FIGUIlE 6.2 A unilateral cleft lip: such cronio-
for others It will be an integral part of the preg-
nancy. TABLE 6.2 InCidence o f Down sy ndrome by
conception to review and possibly change their facial defects are ossocloted with antlconvul- maternal age (Adapted from Cuc kle et 01
anticon,: ulsants to the least reratogenic regimen. sants. as '.'iell as neural tube and cardiac . Prenatal. screening rests identify a fetus ar 1987)
Because many anticonvulsants are folate antago- defects ,From Pitkin et 01 2003. P 6. Fig 2) Increased nsk of having an abnormality, bur are
nistS, women taking such medication and planning
Wi
6 He alth ed ucation b efore a nd during pregnancy
Women's health: a core cu rri culum

Counselli ng thalassaemia minor generally have clinically


Down syndrome is caused by the presence of insignificant microcytic anaemia.
Consultation with a genetic counsellor is advisable
an extra, partial or whole chromosome 21. The
before any prenatal diagnostic test. If diagnostic Carrie r sc reeni ng and
majority of cases (950/0) are conce1ved by non-
tesong reveals a fetal abnormaliry, the parents prenatal d ia g nos is
dysjunction of maternal chromosomes dunng
should be given assistance to address any concerns
meiosis, the minority by unbalanced translocaoon In the mother, thalassaemia is diagnosed by mean
and help them make a decision whether to termi-
or mosaicism. nate or continue the pregnancy. corpuscular haemoglobin concentration (MCHC)
Down syndrome is usually identified soon after and haemoglobin electrophoresis. Prenatal diagnosis
birth by a characteristic pattern of dysmorphic fea- mvolves DNA analys1s of fetal cells from either first-
tures, including a flat fac1al profile, hypotorua, Tha iassaemia trimester CVS or second-trimester amniocentesis.
slanted palpebral fissures and loose skin on the
back of the neck. It is associated Wlth a w1de spec- Thalassaemias are autosomal recessive inherited
trum of phenotypic marUfestations. Affected mdi- disorders characterised by a reduction in the syn- Cystic fibrosis (CF)
viduals have mild to severe mental retardaoon, thesis of globin chains (0 or ~; Table 6.3) . This
results in reduced haemoglobin synthesis and a CF is the most common potentially fatal cause of
with IQ scores ranging from 25 to 75. In the severe chronic lung disease in Caucasian young
absence of severe congenital heart dlsease, life hypochromic microcytic anaemia. Of the total
FIGURE 6.4 Image o f a mniocentesis needle Australian population, 1% are estimated to be car- adults. With an incidence of 1 in 2500 live births
expectancy of Down syndrome individuals 1S in Australia, the carrier frequency is 1 in 25 and
good, with over 50% living longer than 50 years, In situ riers of the thalassaemia trait. Alpha(o)-thalas-
saemia is most common among patients from transmission is autosomal recessive. The most
but morbidity is high. common gene mutation is 6F508, which is respon-
protein A, PAPP-A). Increased nuchal translucency China and Southeast Asia. Adults normally have
SIble for 75-88% of cystic fibrosis cases in north-
Prenatal scree ning te sts thickness low PAPP-A and high ~HCG serum level four copies of a globin genes. Absence of all four
ern-hemisphere populations.
are all ~ssociated with the fetus having an ct globin genes is lethal and results in hydrops
Abnormalities in the epithelial cell membrane
Although the risk of having a child with Down increased risk of DO\>.1l syndrome. The combina- fetalls. Beta(~)-thalassaem ia is the result of
syndrome increases considerably afrer the age of reduced or absent ~ globin chain synthesis. It is result in altered chloride transport and water flux
tion of NfS and serum markers detects over 80%
35 most babies with Down syndrome are born to most co mmon in patients from the Inruan subcon- across the cell. Viscous mucous secretions predis-
of Down syndrome cases (compared :mth 70% pose to glandular obstruction and tissue damage.
w;meo under 35 years of age, since more women detection rate if NTS is used alone), WIth a false - tinent and Mediterranean countries (Italian, Greek
under 35 have babies. Screening is performed dur- and Lebanese). Paoents With CF suffer from chronic lung disease,
positive rate of 5%. gastrojmcstinal and nunitional abnormalities and
ing the firSt and second trimesters. . The second trimester maternal serum (MSS) Children who inherit beta-thalassaemia major
The first trimester screerung IS performed are normal at birth, but at 6 months of age, when infertility. The median lifespan increased from
screening for Down syndrome is performed
berween the 11th and 14th weeks of gestation, Hb synthesis switches from Hb F to Hb A, they 1 year in 1950 to 31.1 years in 1996. The chief
berween 15 and 20 weeks' gestation, and measures
using a nuchal translucency scan (NTS; Fig 6.3\ develop severe transfusion-dependent anaemia. determinant of morbidi~ ' and mortality is the rate
serum alpha-fetoprotein (AFP), unconjugated oest-
of progression of lung diSease.
with or without biochemical screenmg of maternal rio~ 0 and ~ HCG. Down syndrome is associated Numerous clinical problems ensue, including
serum (~HCG and pregnancy associated plasma with high ()HCG and low levels of AFP and uncon- growth failure and bony deformities. The clinical Prena ta l diagnosi s
jugated oestrioL The test can detect 70% ~f affected course is modified by transfusion therapy, but
pregnancies with a false-posmve rate of 5 Vo. transfusional iron overload (haemosiderosis) often Population carrier screening is usually applied to
results. Death usually occurs berween 20 and 30 high-nsk populations by performing common
years from cardiac failure. Patients with beta- mutation DNA analysis. Newborns are screened as
Pren a t a l d iagnos is part of the Guthrie test, when the baby is 3 days
Definitive prenatal diagnosis of Down syndrome ~ globin Hb A Hb A, Hb F old. Those with a positive result are then referred
requires culture of fetallplacental cells and karyo- genes (%) (%) (% ) for diagnostic genetic testing. Prenatal diagnosis is
typing of fetal chromosomes. Karyotypmg IS rou- Normal 97-99 1-3 performed by D A analysis of fetal cells, usually
tinely offered to all women who are 35 years or obtamed by CV5 at 10-12 weeks' gestation. For
Thala ssaemia major ~o~o o 4-10 90-96
conclusive genetic testing, definitive knowledge of
older, and to those with risk factors such as a ~.~. 0- to 4- 10 90-96
known translocation. the type of both parental mutations is required.
Thala ssaemia minor ~~. 80-95 4-8 1-5
Amniocentesis (Fig 6.4) is usually performed 80- 95 4-8 1- 5
W Fa m ily ped ig ree
berween 15 and 18 weeks' gestation. The risk of ~o = absent ~ glpbin chain synthesis
miscarriage associated with amniocentesis is ~. = .educed synthesis A family pedigree summarises a complex family
approximately 1 in 200. CVS can be performed m Hb A = a,~,; Hb A, = a,5, history LOto a sunple and concise format (Mueller
the first trimester, usually around 11 weeks' gesta- Hb F (fetal Hb) = =1' & Young 1998). The construction of an accurate
FIGUR E 6.3 Ultrasaund Image af fetus tn
sagittal section, with nuchal translucenc y tion. The risk of miscarriage associated with CVS family pedigree is a fundamental component of
TAB LE 6 .3 Haemoglobin and beta·tholassoemio clinical genetic services and of human genetic
measu rement marKed by calipers . is approximately 1%.

'#
Women's health: a co re curric ulu m
6 Hea lth edu cation b efo re and d uring p reg nan cy

research. Table 6.4 summarises corrunon pedigree Health maintenance


symbols and definitions, and Figure 6.5 gives an Questions
example of a pedigree of a patient with cystic Folic acid supplementation is recom-
c. carries a risk of miscarriage
mended for all women considering
fibrosis. pregnancy. Ideally It should be com- Comp lete the follow in g statements with d. Is more accurate if combined with a
me nced 3 months before conception th e correct answer.
blood test /'
Symbols Definitions and continued for at least 3 months . 1. Folic acid:
e. detects thalassaemia . ../
Smo king Is harmful at all stages of
a . is advised as Soon as pregnancy is
0 .0. 0 pregnancy, and strategies should be
_,e,. Male. fema le. sex unknown

Affected individuals
employed to encourage smokers
to quit.
diagnosed
b . is adVised in a dose of 5 mg per da y
for all pregnant women
4 . Individuals with thalossaemla minor:
a. are at risk of having a fetus with
thalassaemia major
~~ Carriers c . reduces the Incidence of /
References anencephaly In pregnancy b . require constant b lood transfus ions
JZ10 Deceased individuals Cuckle HS, Wald NJ, Thompson SG 1987 incidence of
d . is not necessary for women with
through their lives
Down's syndrome. British Journal of Obsterrics and epilepsy c. have a chromosomal abnormality
58 Stillbirth (write below the symbol) Gynaecology 94:387-402.
e. helps women with diabetes have d . have more than 50% norma l adult ..,.
p Pregnancy (write Inside the symbol) Hanrctty KP 2003 Obsterrics illustrated, 6th eeln . Churchill better glucose control . haemoglobin
Livingstone, Edinburgh.
~.~. Proband: an affected Individual 2. Smoking : e . are at risk of an affected pregnan cy
coming to med ical attention Hercberg S, Preziosi P, Galan P 2001 Iron deficiency in if their partner does not carry the
Independent of other family Europe. Public Health -urritioo 4(2B):537-545. a . reduces the chance of conception gene.
m embers
Jensen TK, Hjolland NHI, Henriksen TB er al 1998 Does b . reduces the chance of miscarriage
5. Cystic fibros is:
~D~O Consultand: an individual
seeking genetiC counseling/testing
moderate alcohol consumption afieer fe rtiliry? Follow-
up srudy among couples planning first pregnancy.
c. redUces the chance of premature
blrfh a. is more common In people of
British Medical Journal 31 7:505-510.
d. increases the growth o f the fetus Mediterranean descent
~ Spontaneous abortion (SAB) (If
ectopic. write ECT below symbol) MRC Viramin Srudy Research Group 1991 Prevention of b IS more common in people from
neural rube defects: results of the Medical Research e. reduces the risk of SUdden Infant
.......
..
death syndrome. northern Europe /
Allected SAB (write gender below Council Vitamin Srudy. Lancer 338(8760):131-137 .
Mo le/f"emofe the symbol) c. occurs as a result of extra
M ueller RF. Young ID 1998 Emery's elements of medical 3 . Nuchal translucency ultrasound : chromosomes
L;A Termination of pregnancy (TOP) genetics, 10th edn. Churchill uvingstone, Edinb urgh. a . is a d iagnostic test
d. creates neurologic a l abnormalit ies
Affected TOP (write gender below Newberger DS 2000 Down syndrome: prenaraJ risk b . is m ore accurate tha n
Mole/ Female the symbol ) assessment and diagnosis. American Famil y Physician amniocentes is e. is usually diagnos ed in the fetus by
62 :825-832. a blood test.
TABLE 6.4 Common pedigree symbols and def-
initions (From Mueller & Young 1998) Pitkin J, Peattie AB, Magowan BA 2003 Obstetrics and
gynaecology - an illustrated colour teXr. Churchill
uvingsrone, Edinburgh.

FIGURE 6. 5 Pe d igree o f a p a tient with cystic


fibros is

-4
/
Antenatal care
Edited b y Sandra Carr

Lifestyle issues in pregnancy Penelope Black and William AW Walters


Antenatal care - first trimester Stephen O'Caliaghan
Ectopic pregnancy, miscarriage Lijliana Milkovic-Petkoyic and Thomas Tait
Antenatal care - second trimester Warwick Giles
Antenatal care - third trimester Andrew Bisils

1
Learning objectives

Knowledge • discuss the effect of ectopic pregnancy


on future fertility
At the end of this chapter, the student
w ill be able to: Mfs~ ge

• discuss lifestyle Issues in pregnancy define miscarriage and the types of


miscarriage
F~ trimester
indicate the prevalence of miscarriage
summarise early embryonic and
placental development list the common causes of miscarriage
• discuss the minor complications of early describe the Invesllgatlons for first-
pregnancy and their management trimester vaginal bleeding and oulline
management options
• describe the clinical and laboratory
diagnoses of pregnancy Se~d trimester
oulline the role of first-trimester outline the management of second-
ultrasound trimester minor complications
describe the antenatal screening tests describe the maternal and fetal
performed at the first antenatal visit screening tests performed in the second
list the models of antenatal care trimester
E, c pregnancy outline the clinical evaluation of the
pregnant woman at each antenatal visit
• discuss the epidemiology of ectopic
pregnancy Third trimester
• list the sites of ectopic pregnancy describe briefly the physiological
discuss the pathophysiology of tubal changes in the uterus before labour
damage in ectopic pregnancy outline the management of minor
discuss the investigations commonly complications of late pregnancy
utilised to diagnose ectopic pregnancy summarise the health education
• oulline the emergency treatment for Information to be given in preparation
ectopic pregnancy for birth, breastfeeding and parenting
(Continued over)


7 An te na ta l c are
Women's health : a core curricul um

unpaid leave, is usually of 12 months' duration. At to inferior vena caval occlusion. Contact sports
• perform and interpret a urinalysis the completion of maternity leave, the employee is and recreational activity with an increased risk of
(Learning objectives continued) entitled to resume employment at the same level of falling should be avoided. Exercise may contribute
• perform a clinical o~stetr!c examination
seniority within the organisation concerned. In the to the management of gestational diabetes by
of a woman in the third trimester.
• describe the principle of the birth private sector, maternity leave entitlement varies increasing glucose utilisation.
plan considerably and the o rganisation's human
Attitudes resources officer should be approached for Occupational work
list the signs of commencement of
At the end of this chapter, the student detailed information.
labour. Evidence suggests that physically demanding work
should reflect upon : Additional entitlements for many parents
and prolonged standing are associated with preterm
Skills include the maternity allowance, family payments
pregnancy and birth as a physiological
and the baby bonus payment. Parental leave may birth and reduced birth weight (Berkowitz &
At the end of this chapter, the student process Papiernik 1993). Shift and night work, and high
also be available for parents to enable them to care
should learn how to: • the role of the health professional to cumulative work fatigue scores may also be associ-
for a newborn or adopted child. Paternity leave
provide support and education (paid or unpaid) of 1 week may be available for ated with preterm birth. However, long working
perform a pregnancy test hours and preterm birth are not associated.
• the role of medical screening in fathers at about the time of the birth of their child.
explain to a woman the physiologic~1 . Exposure to toxic chemicals and radiation in the
antenatal care
basiS of minor pregnancy complications work environment is best avoided during pregnancy.
and suggest management options • the opportunity afforded by pregnancy Seatbelts
to encourage women to Improve It is a legal requirement that all motor vehicle driv-
use the correct technique to measure general health and lifestyle. Sexual activity
arterial blood pressure ers and passengers, including pregnant women,
wear seatbelts. During pregnancy, the lap belt Variable changes in sexual feelings are normal in
should be worn low under the enlarging abdomen pregnancy, ranging from a significant increase to a
and over both anterior and superior iliac spines decrease in desire. While sexual intercourse is not
and the symphysis pubis. If a shoulder harness is contraindicated at any time during normal preg-
used, the straps should be placed so that they pass nancy, it is best avoided when the membranes have

* lifestyl e issues in
pregnancy
Birth and parentin g education
Antenatal education programs are provided in mosr
centres for pregnant women and therr support
diagonally across the body between the breasts. It
is important to avoid placing the lap belt over the
anterior abdominal wall and the underlying
uterus, as should an accident occur, the forward
ruprured prematurely or when antepartum haem-
orrhage has occurred. In women with threatened
miscarriage, it may be wise to advise against sex-
ual intercourse for several days after symptoms
people in the second half of pregnancy. Programs for momenrum of the uterus against the seatbelt at the and signs have disappeared.
Common clinical presentation primigravid women usually consist of ~ 2-hour ses- time of impact may result in trauma to the uterus.
sions over 6 weeks. The aim is to proVide educanon In particular, placental abruption and fetal death Die t
A 23-year-<>ld woman in the loth week of her about pregnancy, labour, birth, breascieedin.g and
first pregnancy attends the antenatal clinic may occur. A small increase in energy requirements occJ.Jrs dur-
early parenting. The courses include strategies for
with her husband to ask whether she needs to encouraging suppornve farruly relanonships and ing pregnancy (71-120 kcal per day). The birth
. alter her lifestyle In preparation for the birth of Air travel weight of the baby is related to maternal nutrition.
promoting healthy lifestyle b.ehavlOurs for pregnant
the baby. women and their farrulies (Kitzman et al 1997). Provided the pregnancy is uncomplicated, there is During famine, the mean birth weight may fall by
no reason for restricting air travel unless the 550 g. Protein requirements increase in the final
Social and psychological support woman is at or beyond the expected date of deliv- 12 weeks of pregnancy, with 12 g nitrogen being
ery. However, individual airlines have their own required for the growth of maternal and fetal tissue.
Health education for While it is logical to expect that social sUjJPort dur- Additional folate, riboflavin and polyunsaturated
restrictions, which impose an upper limit (e.g.
optimal pregnancy ing pregnancy should be benefiClill, there IS very lit- 36 weeks' gestation) for international flights. fatty acids promote fetal wellbeing. A balanced diet
Pre-conception counselling and antenatal <:are pro- tle definite evidence to support this concept. It has Pregnant women should consult the airline before rich in fruit and vegetables and containing three
vide excellent opportUnities for lIDprovmg the not been shown to prevent preterm birth or low ved making arrangements to fly. serves of dairy products each day is ideal.
health of women before and during pregnancy. For birth weight but may be associated WIth lIDpro
example, controlled trials have demonstrated that fetal growth and reduced lilCldence of pregnancy- Exercise Weig ht
behavioural strategies to stop smoking durmg induced hypertension in a high-nsk pregnancy. In the absence of medical or obstetric com plica- The average weight gain in pregnancy is 10-14 kg.
pregnancy are successful (Dolan-Mullen et al
nons, 30 minutes of moderate exercise a day is rec- Low pre-pregnancy weight «50 kg) increases the
1994) and that pre- and peri-conceptional folic Maternity leave for employees
ommended for pregnant women. After the first risk of intrauterine growth restriction (IUGR),
a .d supplementation can prevent recurrence of Government organisations provide materni1
trimester, exercise in the supine position should be while excess weight gain during pregnancy is asso-
f~~ neural tube defecrs (Enkin et.al 2000). Such leave, part of which may be on full or: reduce avoided to prevent supine hypotension secondary ciated with large r infants. Obesity increases the
interventions can have a flow-~n etfect m lIDprov- salary. In Australia, the £ull enm1ement, lilcluding
ing the health of children and ,amllies.

Wi
7 Antenalal core
Women's health: a core curriculum

risk of complications, including gestational dia-


betes, hypertension, dystocia and thromboembolic
Opiates
Maternal withdrawal from opiates is associated
* Antenata l ca re
first trimester
Clinical and laboratory diagnOSis
Most women suspect pregnancy when their men-
with spontaneous abortion, hypoxia, passage of strual period is delayed. The expected date of
disease after caesarean secoon. Welght-reducmg
meconium, FDIU and hyperactivity of the new- delivery is calculated as 40 weeks from the first day
diets should not be commenced or continued dur- Common clinical presentations
born. Therefore, maternal stabilisation on of the last menstrual period. If the menstrual cycle is
ing pregnancy, and a dietician should manage
methadone should be encouraged in opiate users A healthy 20-year-old woman seeks advice megular, this date may be inaccurate, in which case
extremes of weight control. because she and her partner have been trying early ultrasound detennination of gestation is more
during pregnancy. ta have a child and it is now 7 weeks since her reliable (±S days). Common early symptoms of
Alcohol last menstrual period . History reveals that this pregnancy include fatigue, breast tenderness,
Alcohol is teratogenic, and ingestion of large Amphetamines waman has epilepsy and has been taking anti- nausea ('morning sickness') and frequency of
amounts of alcohol causes the fetal alcohol syn- Amphetamine use in pregnancy has been associ- epileptic medication for the last 5 years. unnaaon.
drome characterised by pre- and posmatal growth ated with IUGR and placental abruption. A 36-year-old woman Is concerned about the Diagnosis of pregnancy is possible with highly
restriction, dysmorphic facial features and mental chance of having a child with some form of reliable pregnancy test kits, for use by either the
retardation. Ingestion of smaller amounts of alco- Dental care congenital malformation , because at age 40 woman or the doctor. The kits use a monoclonal
hol (twO drinks per week) reduces adverse fetal Recent evidence suggests that periodontal disease her mother had borne a child with Down syn- antibody to detect the presence (or absence) of the
effects while five or more drinks per week in pregnancy may be a risk factor for preterm drome who died soon after birth. beta subunit of human chorionic gonadotrophin
throughout pregnancy appears to be the threshold delivery and low birth weight (Offenbacher et al ' (HCG) and may be positive a few days after the
for increased risk of fetal anomalies (Ouellette et al 1996). These complications can often be prevent- first mIssed menstrual period. Formal laboratory
1977). There is no known safe level of alcohol ed by nonsurgical procedures such as professional testing may also be used to test the level of serum
intake in pregnancy. Development of the embryo, HCG in a quantitative assay if necessary.
teeth cleaning to remove plaque and local irritants.
Precautions should be taken to avoid invasive fetus and placenta
Smoking dental procedures and reduce any risks associated
Minor symptoms/complications
The blastocyst forms at the 32 -cell stage after fer-
An increased frequency of low-birth-weight with the administration of medications or diag- tilisanon and consists of an inner cell mass - the VlItUally all women experience some minor com-
infants, prematurity and spontaneous abortion are nostic radiation. Maintenance of oral health in precursor of the embryo - and the trophectO- plications of pregnancy, and for some women
well-documented, dose-related complications of pregnancy is helped by a diet high in protein, cal- derm overlying the embryonic pole, wIDch these symptoms can be most distressing. An aver-
maternal smoking. Other associations include pla- cium, phosphorus and vitamins A, D and C. mteracts WIth the uterin e lining to facilitate age of 24 symptoms have been found to be ex-
cental abruption, fetal death in utero (FDIU), implantation 7-14 days after conception. The perienced by pregnant women, the most common
premature rupture of membranes and sudden Pets being urinary frequency, fatigue, pelvic pressure,
first 8 weeks is. the embryonic period, by wIDch
infant death syndrome (SIDS) (Brandt 1987). msomrua and lower backache (Zib et al 1999).
Pregnant women should be advised that domestic arne the begmmngs of all the essential structures
However, the incidence of congenital anomalies The most dlStressmg symptoms of the first
cats might have toxoplasma infection, wIDch can are present. The neural plate begins developing
is not increased with maternal smoking. trimester are usually nausea and vomiting wIDch
be transmitted to humans through contact With dunng the 3rd week and the heart begins beating
are related to increased HCG and proge;terone.
infected cat'S faeces. Toxoplasma may be transmit- about 21-22 days post-fertilisation. These struc-
Drugs These are more severe in multiple pregnancy.
ted to the fetus and can result in mental retard- tures grow and develop in their complexity during
Relief measures include frequent small meals,
ation, seizures and b.lindness, and in some cases the fetal penod, from the 9th week until birth
Marijuana foods low m fat, eating dry carbohydrates before
infant death. Other common pets do not pose any (Lipson 1994).
nsmg, and oral vitamin Bl . When nausea and vom- \v-ll
The use of marijuana may be associated with serious risks.
Placental growth and development involve
growth of. the cytotrophoblast (individual cells),
lUng are severe, it is known .as hyperemesis grav 0 ... 1",\\
IUGR, an increased risk of prematurity and darum and can lead to Slgnificant dehydration IT -.;f.'I\T¥"'",u,
not treated appropriately with rehydration and ~ ~Vt
With mvaSlOn of the maternal spiral arteries to
delayed mental development in the newborn.
mcrease the maternal blood supply to the placenta
and branch 109 of the villous structure of the pla-
annemenc drugs such as metocloprarnide. The \0"
Cocaine ~rmCJples of management for all minor com plica- ~
centa to maximise the surface area for nons of pregnancy are to exclude more serious
Cocaine use has been linked to maternal medical maternal-fetal exchange at the terminal villi. underlying pathology, reassure the woman and
complications including stroke, seizures, acute . With the advent of modern molecular genetics, provide supportive therapy.
myocardial infarction and arrhythmias. Cocaine SQenasts are beginning to elucidate the mecha-
has also been implicated in IUGR, premarunty, OlSrns mvolved in the development of early fetal
spontaneous abortion and placental abruption.
Routine blood and
anatomy. JUSt how does a fetus know where to
Furthennore, prenatal exposure to cocaine is as- grow its eyes? Which is the head end of the body?
other investigations
sociated with necrotising enteroco.litis and abnor- ~ch IS nght and left? These are intriguing ques- At the first antenatal visit, a thorough medical,
mal behavioural development in the newborn nons (Sharpe 1999). famlly, obstetrlc, gynaecological and social history
(Cunningham et al 1997).

Wi
7 Antenatal ca re
Women's health : a c ore cu rr ic u lum

is taken and physical examination performed. The


Diagnostic tests
Chorionic villus sampling at 10--13 weeks involves
* Ectopic pregnancy Consequently, . risk factors include sexually
transrmtted mfectlOns, pnor ectopic pregnancy,
prIor tubal surgery, hormonal factors such as
principle of care is to identify a baseline so as to
monitor the impact the pregnancy may have on raking a transvaginal or transabdominal SamPle, diethylstilbestrol exposure and progestogens, con-
maternal wellbeing. It must be remembered that under ultrasound guidance, of chonomc villi for A 26-year-old woman presents with amenor- rraceptlve faLlures . (e.g. intrauterine devices),
genetic testing to identify chromosomal abnormal- rhoea and pelvic poln. mcreasmg age and cigarette smoking. Proliferation
the majority of pregnant women are healthy. The
ities and some hereditary conditions. Amniocentesis A young woman presents with bleeding In
of refluxed endometrial tissue arrested within a
purpose of antenatal care is to promote health and
is most commonly performed in the second early pregnancy. tube could provide the epithelial characteristics of
manage complications. Blood tests that are rou-
trimester and is described under second-trimester a uterine environment, and this is the pathophysio-
tinely ordered include full blood count (FBC), A pelvic ultrasound scan is performed at
care in this chapter. logical explanation involving endometriosis
blood group (ABO and Rhesus), red. blood cell 6 weeks' gestation and no Intrauterine gesta- (Hunter 2002). There is also an increased risk with
antibody screen and serology for syphihs, hepaDtls tion sac is seen.
Models of antenatal care assisted reproduction techniques (NF). .
B (and, for women at risk, hepatitis C), human Extensive investigation has been conducted at
and education A 35-year-old woman uncertain ot her last nor-
immunodeficiency virus (HIV) and rubella. If the cellular level to study decidualisation and
mal menstrual period complains of severe
these tests identify a problem, they enable treat- Women in Australia are able to choose different abdominal pain and collapses. Implantation in ectopic pregnancy (Lemus 2000).
ment to be given to improve outcome. For ex- models of care for their pregnancy and birth: home
ample, if red blood cell antibodies are detected in birth with a midwife or doctor, birth centre Diagnosis
the mother's blood during pregnancy, further attached to a hospital, shared care with family .
practitioner at a public or private hospital, team Ectopic pregnancy is frequently misdiagnosed at
investigation and appropriate treatment can
reduce the effects of Rhesus isoimmunisation. midwifery care or private obstetric consultant care. Epidemiology the mmal visit. At present, we rarely see patients
The role of the health professional is to present the who present m shock because of ruptured ectopic
A sterile mid-stream urine (MSU) sample is also Ectopic pregnancy remains a major health concern
options and discuss with the woman and her part- pregnancy. The main symptoms are delayed per-
collected and sent for culture and sensitivity, as for women of reproductive age and a common
ner those that best suit her individual needs. IOd, abnormal bleeding or pelvic pain, initially uni-
asymptomatic urinary tract infection is more cOm- cause of pregnancy-related deaths. In developed
lateral but It may become more generalised.
mon in pregnancy and may lead to pye\onephritls counm es, the mCldence of ectopic pregnancy has
Individual needs On examination, the patient should be assessed
if untreated. increased six-fold over the last 20 years, although
for signs .of shock, such as pallor, tachycardia and
Australia is a comple.x, multifaceted society. There ill recent years there is some evidence of reduction .
hypotenSIOn. O n abdominal examination there
might be unilateral or generalised guar~g and
are groups of women within our society who, for a The incidence of ectopic pregnancy in the general
First-trimester ultra sound variety of reasons, will reqwre speaal conslderanon populanon IS 1 m 200; in a high-risk population it
pentorusm. On vaginal. examination, there may be
Fetal imaging with ultrasound in the first trimester when they present for antenatal care. They may be can be as high as 1 m 30. With IVF, there is a risk
bleedmg, a closed ce rvIX, a small uterus for gesta-
is performed to establish gestational age, to illves- indigenous or from a non-English-speaking back- of ectopic pregnancy in 5% of pregnant cycles and
nonal age, an adnexal mass (with or without ten-
tigate vaginal bleeding or to screen for Down syn- ground. They may be very young, depressed, vic- of heterotopIc pregnancy (co-existing intrauterine
derness) and cervical excitation.
drome. High-resolution ultrasound, parucularly tims of domestic violence or soaally disadvantaged. and ectopic pregnancies) in up to 3% of pregnant
Currently, transvaginal ultrasound scan (TVS)
with a high-frequency transvaginal imaging probe, The history taken at the first antenatal visit should cycles (Lemus 2000).
and senal j3HCG determinations remain the two
is able to date the pregnancy accurately (±5 days) identify any factors that need consideration when most important diagnostic tools. The absell ce of an
and identify the presence of a fetal heartbeat from providing care for the individual woman so as to Sites mtrauterine gestation sac on TVS when ~HC G is
6-7 weeks amenorrhoea. This demonstrates a live enhance her care and her e."'qJerience of pregnancy. The fallopian tube is the most common site for above 1500 IU/mL is strongly associated with
fetus, whether the pregnancy is intrauterine or ectopic pregnancy (97%): 810/0 ampulla, 12% in ectopic pregnancy.
ectopic, and shows whether the pregnancy is sin- the lSthmuS, 5% fimbrial end, 2% interstitial seg- Clinical findings are associated with a higher
gleton or multiple. ment (cornual). Other sites include the ovary, probabIlity of ectopic pregnancy, even when
Early presentation for antenatal care
Ultrasound can also be used routinely as a cervL"<, broad ligament and peritoneal cavity. j3HCG and TVS are below algorithm threshold. In
allows accurate establishment of
screening test for chromosomal abnormality such gestational age, baseline health
these situations, findings of free fluid in the pouch
as Down syndrome (trisomy 21) by measuring assessment and timely lifestyle Pathophysiology of tubal damage of Douglas (POD) and adnexal mass on TVS are
fetal nuchal translucency, ideally together with modifications to optimise maternal useful. A f)HCG rise of at least 60% over 48 hours
Ectopic pregnancy is believed to be due to
first-trimester biochemical assay of the two hor- and fetal outcome. and progesterone values over 25 nglmL are pre-
endothelial tubal damage secondary to salpingitis,
mones: free j3HCG and pregnancy associated dictors of VIable pregnancy, but do not determine
disturbed mbal oocyte transport or proliferation of
plasma protein A (pArP-A). Such a test has an the site of pregnancy.
refluxed endometrial tissue arrested within the fal-
85-90% detection rate for trisomy 21 (and also lopian tube. History of salpingitis often cannot be
for some of the other major chromosomal disor-
Emergency trea tme nt
obtalned, . but deciliatlon is frequently found or
ders) and can be used as a population-screening there IS histologic evidence of previous salpingitis W hen a patient has haemorrhagic shock, she must
test for women who have been counselled and (Speroff et al 1999, Guyton & '-fall 2000). be operated on as soon as possible by the most
choose to have this test (Spencer et al 2003).

i:'
7 Anlenatal core
Women's health: a core c urriculu m

Suspected ectopiC pregnancy

Patient haemodynamically unstable

Deteriorating clinical Signs/unstable -

~HCG levels
failing/patient stable .
FIGURE 7.1 Unruptured tubal p regnancy (Reproduced wi th permission from observe
Belscher et 011997, P 172. plate 5)

shorter hospital stay, lower analgesic requirements


expedient method. Open laparotomy is often and quicker postoperative recovery compared
preferable, after securing IV access and blood for with laparotomy. Laparoscopic salpingectomy or
blood group, crossmatch, FBC and ~HCG, even salpingostomy can be performed. There is no dif-
before blood and fluid have been replaced. ference in the intrauterine pregnancy (IUP) rate
following these twO procedures if the contralater-
Management and implications al tube is healthy. Failure to completely remove
A:; diagnosis becomes possible at increasingly trophoblast and recurrent ectopic pregnancy is
earlier gestation, it is possible to observe the higher after salpingostomy (RCOG 2002).
ectopic pregnancy when indicated and await natu- In selected cases - e.g. asymptomatic patient, FIGURE 7. 2 Management of suspected e c topiC p regnancy
ral resolution. The success rate of expectant man- no free fluid in POD and small tubal ectopic on
agement is up to 700/0 in selected cases with low TVS, and low (lHCG - it is possible to give
~HCG, no haemoperitoneum and a tubal mass methotrexate, an antimetabolite that prevents the
growth of rapidly dividing cells by interfering with complex.. With the aid of methotrexate, a more Fertility outcomes
less than 2 cm. Rupture of ectopic pregnancy can
DNA synthesis. It can be administered systemic- conservanve approach has recently evolved. Other
still happen and expectant management has a poor If infertility has not been a problem, the rate of
ally or by local injection under TVS or laparo- forms of therapy for cervical pregnancy include
efficacy. Follow-up requires measurement of IUP followmg an ectopic is 85%, with 7.5% recur-
scopic guidance and has a 7+-84 0.0 success rate
(lHCG until it disappears, which might take up to emb.ohsation, Foley catheter tamponade and rence and 7.5% infertility. Future fertility is unre-
(Buster & Heard 2000, Sowter et al 2001). These
50 days. Operation is indicated as soon as there is SUction curettage (Tulandi & Sarnmour 2000). All lated to size of ectopiC, haemoperitoneum or tubal
patients require (lHCG follow-up.
deterioration in clinical symptoms/signs. Non-tubal ectopiC pregnancies are rare, and non-senslOsed Rh-negative women should receive ruptur,e. It is significantly affected by the presence
Today's surgical approach is by laparoscopy. standardisation in diagnosis and management is 250 IU (50 !-!g) of anti-D IgG. of penadnexal adhesions.
Laparoscopy is associated with less blood loss,
7 Antenata l ca re

Women's heolth: a c ore curriculum

On vaginal examination, the internal os of the Expectant management may be a solution for
embryo/placenta to develop normally. This is fol- WOmen in the first trimester. In a randomised con-
The patient should be involved in the selection cervix is open and often products of conception
lowed by haemorrhage into the decidua basalis, trolled trial, up to 80% of patients were managed
of the most appropriate treatment. She should be are present in the canal.
which causes necrotic changes at the site of pla- Septic miscarriage presents with fever, bleeding expectantly,. but they needed regular follow-up,
reviewed in a follow-up clinic and have appropri- centation. At the same time, there is a fall in
ate counselling regarding future fertility. Support and srgruficant tenderness in the lower abdomen and some soli needed surgrcal evacuanon. Medical
oestrogen and progesterone concentrations, caus- and uterus. evacuation is an accepted alternative using miso-
for the grieving process related to pregnancy loss ing decidual sloughing. All these changes result in
should be provided if necessary. . in complete miscarriage, products of concep- prostol (RCOG 2003).
vaginal bleeding and uterine irritability, leading to oon are passed and on pelvic examination the Women with recurrent miscarriages should be
uterine contractions and expulsion of the products cervix is closed. An ultrasound scan reveals an referred to specialised recurrent pregnancy loss

* Miscarriage
of conception.
As many as 50-60% of embryos miscarried in
the first trimester will have a chromosomal abnor-
maliry. Autosomal trisomies are the most common,
empty uterine cavity.
Missed or delayed miscarriage is often diag-
nosed when a first-trimester ultrasound scan
chrucs. Low-dose aspirin, heparin and supportive
~e are cornerstones of management. Cervical
illcompetence can cause miscarriage of a fetus in
the second trimester. Often spontaneous rupture
Common clinical presentations reveals an absence of fetal heartbeat. Clinically, the
involving chromosomes 13, 16, 18, 21 and 22 in woman loses the symptoms of pregnancy. On of the membranes occurs, leading to fetal loss.
A pregnant woman presents with unexpected 50-60% of cases, and with karyotype 45XO pres- Trauma to the cervix is the most significant risk
bleeding at 8 weeks' gestation .
exammaoon, the uterus is smaller than eXJlected
ent in 70/0 of cases. The prevalence of major chro- for length of amenorrhoea and the cervix is closed. factor. Diagnosis can be made if an ultrasound
A pelvic ultrasound scan in early pregnancy mosomal abnormalities in the general population For most women, the diagnosis will be clear shows a characteristic appearance of 'funnelling'
reveals no fetal pole within the gestation is 3% but in a parent with twO or more miscar- following history, examination, urine pregnancy and shortening of cervical length.
sac. riages it is up to six times higher. test and TVS. For some, it will be difficult to dis- Treatment usually consistS of the insertion of a
Other caUSes of miscarriage include factors such cervical suture, with bed rest and close observation
Fetal heart activity cannot be demonstrated on tinguish between ectopic pregnancy and early mis-
a transvaginal ultrasound scan performed at as age (paternal as well as maternal), uterine abnor- for signs of infection. Transabdominal cervico-
carnage, so quantitative estimation of serum
malities such as bicornuate/subseptate uterus, and an ISthmiC cerclage is sometimes indicated in the
an estimated 8 weeks' gestation. ~HCG is required in cases occurring early in the
incompetent cervix. Thrombophilias, antiphospbo- management of previous recurrent second-
first trimester. trlIDester loss and preterm delivery. Occasionally, a
lipid syndrome, immunological conditions (e.g. sys-
temic lupus erythematosus) and other diseases (e.g. woman may be managed conservatively with strict
Definition and epidemiology Ma nagement bed rest.
diabetes mellitus and coeliac disease) are also associ-
. Early pregnancy loss will evoke a range of emo-
in Australia, a miscarriage is defined as the eXJlul- ated with miscarriage (Rosevear 2002, Kutteh 2001, Early pregnancy assessment units provide care by a
oons ill different women and can significantly
sion of the products of conception before Salit et al 2002). Infections (e.g. toxoplasmosis, ure- suppomve, multidisciplinary team and have been
affect them and their families. Women need to be
20 weeks' gestation. This defiuition may vary in aplasma urealyticum, Chlamydia, cytomegalovirus, found to improve the quality of outpatient care informed of the available support and foll ow-up.
different countries. Miscarriage is now the pre- herpes simplex) and environmental toxins, such as (Nardo et al 2002). N on-sensitised Rh-negative Often the ome of presentation is not the appropri-
ferred terminology to abortion, which is reserved cigarette smoke, high-dose radiation and cytotoxic women reqwre 250 IU (5 0 ~tg) of anti-D IgG ate nme to counsel but the woman must be man-
for therapeutic termination of pregnancy. drugs, have also been implicated. wlthin 72 hours. If a live ferus is seen on ultrasound aged with empathy and reassured as far as possible.
Spontaneous miscarriage occurs in 1O-20°;\) of scan and the cervLx is closed, the woman is reassured After one rruscarnage, the risk of another is the
all clinical pregnancies, and perhaps as many as DiagnOSis and follow-up is organised. Patients with complete same as for the general population. After two mis-
60% of conceptions are lost. This equates to only nnscamage may need ~HCG follow-up. carnages, the risk is 25% and after three, 30%.
The classic clinical presenration is with lower
a 25% chance of successful pregnancy per ovula- Surgrcal evacuation of the uterus with suction
abdominal pain and per vaginam (PV) bleeding.
tion in fertile couples. The incidence of miscar- curettage was standard treaanent until recendv. This
With threatened miscarriage, the typical his-
riage for women aged 35-40 is 21 % and for option may be preferred for patients wh; have
women over 40 is 41 %. Eighty per cent of miscar- tory is one of vaginal spotting with minimal pelviC
?eavy bleeding or who wish to avoid the inconven-
riages are diagnosed between 8 and 12 weeks' ges- or lower back pain. On vaginal examination, the Ience of not knowing when a miscarriage will take
tation. Missed or delayed miscarriage is the failure cervix is closed. An ultrasound scan reveals a live place. Senous complications include perforation,
to expel the productS of conception after death of intrauterine fetus. cervical tears, mtra-abdo minal trauma, haemorrhage
the embryo. Recurrent miscarriage refers to three Inevitable miscarriage is characterised by lower
and mtrauterille adhesions. All at-risk women
consecutive pregnancy losses before 20 weeks of abdominal pain and vaginal bleeding. On vaginal undergoing surgical uterine evaluation should be
gestation. This affectS 1 in 200 couples, or 1 in examination, the lower uterus appears to be bal- screened for Chlamydia trachomatis.
500 pregnancies (Speroff et al 1999). looning, while the internal os is closed. ProductS of
Tissue obtained at the time of miscarriage
conception have not been passed. should be exammed histologically to confirm
Aetiology and pathophysiology Incomplete miscarriage presents with a history
productS of conception and to exclude ectopic
of increasing bleeding, cramping lower abdorrunal
Most spontaneous miscarriages result from the pain and passage of some products of conception. pregnancy and gestational trophoblastic disease.
death of the embryo or the failure of the

':5
7 Ante nata l c are
Women's health: a core c urri c ulu m

* Anten atal care -


second trimester
• Blood pressure Is checked. Normal blood pressure
Is accepted as <140/90 mmHg using the phose V
Korotkon sounds (disapperance of sounds) (Brown
a b

et 012000). ---'t-- _
• The woman is asked it the baby is moving regulorl y
Common clinical presentations and otten. She is asked to report sudden changes
' ..
in the fetal achlty. In the third trimester, she will tee I ---·::·h:·· .. ·
A woman at 26 weeks' gestahon In her first
the baby roll over and kick several times a day. ~ "'"

'y
pregnancy Is referred to the antenatal clinic by
her general practitioner for apparent slowing • symphysis-fundal height (SFH) Is measured (gener-
ally, fundal height In cm ±3 = weekS of gestation).
of fetal growth .
Fetal size, lie, presentation and descent.of the pre-
A 37-year-old woman at 16 weeks' gestation senting port ore assessed . Fetal growth IS evaluated
asks if her age poses any risk to her by comparison with previous SFH measurements.
The fetal heart rate is checked with a Pinard stetho-
pregnancy.
scope or Doppler ultrasound . FIGURE 7.3 (a) Progressive Incre ase of fundal height . (b) The lie a f the baby. Th is refers to the
A 22-year-old woman at 24 weeks' gestation • Urine is tested tor proteinuria to screen for Infection relationship of the long a xis ot the fetus to the u t erus: longitudinal is n ormal (Based o n Hanretty
presents to the antenatal clinic with a history of and preeclampsia. 2003. pp 59, 75)
a previous intrauterine death . • Information about pregnancy and motherhood Is
provided, and the woman 's ability to cope With the performed between 15 and 20 weeks will give a mal glucose tolerance then undergo a full 2-hour
A pregnant woman who has a long-term
transition and her need tor social support IS ,
history of essential hypertension presents to the 70% pick-up rate for Down syndrome, with a 5% formal glucose tolerance assessment.
assessed .
antenatal clinic at 25 weeks' gestation. false-positive rate. If the calculated risk is greater Most women will be offered an ultrasound at
BOX 7.1 Procedure at each antenatal v isit
than 1 in 250, the woman sho uld be referred for around 18 weeks' gestation to check the anato my
genetic counselling and amniocentesis to assess of the ferus and the number of feruse s, and to con-
fetal karyotype. firm the gestational age of the fetus. After 20
Follow-up antenatal care Amniocentesis is the removal of a sample of weeks, ultrasound is unreliable in confirming ges-
Antenatal care in the second trimester is based on amniotic fluid under ultrasound guidance. It is usu- tational age of the pregnancy. Ultrasound is also
monitoring maternal health and feral wellbemg, ally performed between 14 and 18 weeks. It is used to assess fetal wellbeing if there is any evi-
and providing education and support to the 1. Inspection - abdominal contour, operation offered to any woman at increased risk of chromo- dence of delayed fetal growth or other indicators
woman and her parmer. Care also alms to prevent, scars, striae, pigmentation, tetal movements somal abnormality, e. g. over 35 years of age. This of maternal/fctal compromise (see Chapter 8).
identify and manage any obstetnc and/or medical 2. Palpation procedure carries a 0.5-1 % risk of miscarriage. In some centres, women will have a FBC at
problems that arise, including SOClOeconomlC and • Fundal height. The uterus is first palpable at . In the mid-second trimester many women are 28 weeks. In Rh-negative wowen., an antibody
around 12 weeks' gestation, reaching the umbili- screened for gestational diabetes using an oral 50 g screen should be performed at 28-30 weeks and
psychological issues. . cus at 20 weeks. Thereafter SFH rises by 3-4 cm
In the second trimester of pregnancy, until glucose load with measurement of the blood glu- they should receive 650 IV of anti-D IgG at 28 and
In each 4-week period.
28 weeks ' gestation, a woman will have regular cose concentration at 1 hour. Women with abnor- 34 weeks if no anti-D has been detected.
• Fetal lie. Using both hands to gently compre~
monthly antenatal check-ups with her pregnancy the abdomen longitudinally, determine the lie o f
carer. Randomised controlled tnals m developed the long axis of the fetus in the uterus.
countries have shown that a decrease m antena.tal • Presentation. Using ooth hands, determine the
visit frequency is not associated with any neganve presenNng fetal part and assess descent Into the
maternal and perinatal outcomes. However, some pelviS. The one-hand Pawlic's grip is more
women feel less satisfied and their expectanons of uncomfortable for the woman.
care are not fulfilled (Villar et al 2003).. .. • Auscultation. Usten to the fetal heart over the
A comprehensive history taken at the first VISit area of the fetal shoulder. This area is deter-
mined by Identltying the posit1on of the fetal
will alert the carer to any problems. At each sub- back and limbs. The back Is telt as a smooth,
sequent visit, the woman is asked about her gen- firm elevation . Fetal limbs are felt by gilding the
eral wellbeing and fetal acnvlty. hands over the surface of the abdomen, seek-
ing the mobile Irregularit1es. The fetal heart Is
heard directly using a Pinard stethoscope or
Screening/investigations Indirectly using Doppler ultrasound. The normal
If no first-trimester nuchal fold translucency risk fetal Mort rate is 110-150 bpm.
assessment for Down syndrome has been conduct- FIGURE 7.4 A bdomi nal palpation (Based on Hanretty 2003, p 76)
ed, the woman should be offered maternal serum BOX 7.2 ObstetriC abdominal examination
screening (for ~HCG, AFP and oestriol), which if

'*
1 Ante n atal care
Women's health : a co re curricul'Jm

• Nausea and vomiting (usually resolving by early In


the second trimester, but may con~ nue) .
* Antenatal care
third trimester
The enlarging uterus can produce the following
symptoms:
• gastro-oesophageal renux due to reloxatlon of the
Physiology
Further breast enlargement occurs during the third
trimester and colostrum production commences.
• Con~ p~on due to Increased progesterone sphincter. The woman should be advised to eot
(smooth muscle relaxes in gastrointesMal tract). frequent, small meals, to ovoid caffeine ond spicy
The uterus contracts irregularly throughout preg-
Relief measures Include Increasing Huld and ~bre food and to toke antacids If severe nancy, but in the third trimester it contracts more
intake, exercise. mild laxatives or stool softeners. Common clinical presentations • Increasing difficulty w~h breathing due to enlarge- frequently in preparation for the labour.
• Varicosities due to progesterone-mediated smooth • A 25-year-old woman at 34 weeks' gestation In ment or the uterus. This can be especially evident Contractions commence as painless tightenings
muscle relaxation of the veins, Increased blood vo~ her first pregnancy wishes to discuss how she
at night. Sleeping in a supported lateral position but become more painful closer to the onset of
ume, stasis ond Increased pelvic pressure. Relief con help labour. The cervix undergoes a process of ripen-
measures include frequent posl~on changes, ele- will manage pain during labour and birth .
• oedema ond potenHol median nerve compres- ing. This involves breakdown of collagen so that
vation of legs , exercise , avoid ing lengthy periods of A 3D-year-old woman at 32 weeks' gestation In sion, leading to cor pol tunnel syndrome . Lower
standing, and support stockings . with the pressure of the amniotic sac and the pre-
her second pregnancy wishes to talk about limb oedema Is reloted to water retentlon ,
• Headaches, often worse In those women who have increased blood volu me and prolonged standing. senting parr, the cervix assumes a more anterior
having her baby naturally this time, as the
a pre-pregnancy history of migraine. Consider Reller measures Include wearing support hose and position in the vagina, becomes shorter (effaces)
previous birth was by elective caesarean
anaemia, hypoglycaemia. Relief measures Include regular exercise. Median nerve compression In the and dilates. As a result of this, women will notice
rest, hydr~on, simple analgesia and cold packs. section because the baby was very small. carpal tunnel by oedema may require physiother- an increasing amount of discharge or the loss of a
apy rererral and wrist splints
A 37-year-old woman at 41 weeks' gestation In discrete mucous plug.
BOX 7 .3 Minor complications o f pregnancy In the her firsl pregnancy presents to Ihe cliniC. She Is .. • supine hypotension due to aortocovol compres- The precise trigger for rhe onset of labour is
now 7 days beyond her expected dale of sion
second trlmester nor known but the following are important events
• postural hypotension due to obstructed venous
delivery.
return from the lower limbs
leading up to it. Oesrrogen promotes the develop-
menr of gap junctions between myometrial cells,
• urinary frequency due to pressure on the bladder.
Education • loin pain secondary to varying degrees of ureteric
thus facilitatin coordinated contractions in
The second trimester of pregnancy is often a time obstruction labour. estrogen r motes t e pro uction
when the woman is feeling well. :Morning sickness The third trimester of pregnancy is a time of • back and pelvic pain from the descent of the
of prostaglandins from the membranes. Another
has passed and she starts to fee l the baby move increasing anticipation about the. birth of the baby. feta l head and fhe relax oMan of pelvic ligaments. placental hormone, corticotrophin-releasing hor-
and experience the growth. of . the uterus, but It is important that those carmg for pregnant ReUef measures Include sleeping In the lateral mone (CRH), is produced in increasing amounts.
without the later physicallimltanons of the heavy women allow adequate space and time for. the position, massage, heat pocks and peM c rock The action of progesterone is removed, possibly
woman and her partner to voice all their quesoons exerc ise. through a change in receptor subtypes. Fetal mat-
gravid uterus. It is during the second mmester
that the woman co=ences parent educauon in preparation fo r birch. The principles of man- uration also seems to contribute to the onset of
BOX 7.4 Minor complications of pregnancy In the labour (Challis 2001).
classes. She is usually starting to explore what It agement remain to: third trimester
will be like to be a new mother. She may relate
stories she has been told by family and friends • monitor the progress of pregnancy . Preparation for birth
about birth and parenting. This can be a frighten- • provide advice, reassurance and educanon about
ing as well as joyous time. Each woman's expen- pregnancy, labour and planning for a parennng trauma. Pelvic fl oor exercises antenarallv are All women will have many questions about the
ence will be unique. Her background, culture and role, including factors influencmg the overall believed to reduce longer-term problems with anal signs of labour, the length of labour, what con-
social supportS strongly influence how she per- health and wellbeing of women and thelf families incontine nce, stress incuntinence and geni ral tractions feel like, pain llJanagement options, who
• identify women ar risk of maternal and fetal prolapse (Tindall 1991). There is also greater will care fo r them, or otller1toncems about labour
ceives her parenting role.
complications during pregnancy . emphasis on assessment of antenatal depression or based on their own pa~t experiences or those of
• manage any obstetric and/or medical problems posmatal depression. others. Every woman f.;hould be encouraged and
arising during pregnancy, mcluding soaoeco- supported to explore fhe changes occurring in her
nomic and psychological factors. Investigations body and her life during pregnancy, and to prepare
In the third trimester, antenatal visits will be for birth and parenthood. A birch plan facilirates
formightly from 28 to 36 weeks, and ~en weekly Many health centres will perform an FBC at the documenration of how the woman would Like
to 41 weeks. At each visit, the woman will have the 28 weeks' gestation and an antibody screen at her labour and birth care to be conducted. Writing
systematic assessment outlined in Box 7.1. Blood 36 weeks if the woman is Rh negative. There is these thoughts encourages her to think about her
pressure is of greater slgruficance m the third no good evidence to supporr the use of a routine expectations and makes them explicit for the mid-
trimester because this IS when preeclampSia IS third-trimester ultrasound scan, which should wives and doctors caring for her. A birth plan is
most lik~ly to occur (Brown & Whirworth19 99). be done only if fe tal growth problems are sus- usually written at around 36-37 weeks. It may
The focus of education moves to preparaoon for pected fr om the history or examination (Larsen document simple requests such as her preference
labour. One area receiving increasing attention IS et al 1992, US Preventative Services Task Force for analgesia or the presence of support persons,
the prevention and management of major perineal 1996). or it may make exp licit her wishes about medical

lit
7 An tenatal care
Women's health: a core curriculum

pregnancy loss - management. Online. Available: years prospe 've experience_ BJOG: an international
Enkin M, Keirsc MJNC, Neilson J et al 2000 A guide to
intervention, Once documented, this plan can be http://www.rcog. org. ukJguidelines. journal of obst ' d .ecology 110(3):281-286.
effective care in pregnancy and childbirth, 3rd edn.
discussed with the doctors and midwives cating Chapter 6, Dietary modification in pregnancy. Oxford
Rosevear S 2002 Handbook of gynaecology management. Speroff L, Glass R, Kase N 1999 Clinical gynecology,
for her. University Press, Oxford, pp 38-39. Blackwell Science, Oxford. endocrmology and infertility, 6th edn. Lippincotr,
A woman should be advised to stay at home until Williams & Wilkins, Baltimore,
Farquhar C, Jamieson M 1997 IntrOduction to obstetrics
the contractions ate regulat and becoming more fre- and gynaecology. Department of Obstettics and
Salir G, Younis J, Hoffman R er al 2002 Trombophilia is
quent, for example once every 7-10 minutes, She common in women with idiop~thic pregnancy loss and Tindall V 1991 Gynaecology - illustrated textbook.
Gynaecology, Univorsiry of Auckland/National Gower, London.
should contact her health service when the mem- is associated with late pregnancy wastage. Fertility and
Women's Hospital, Auckland.
Sterility 77(2):342-347.
branes ruprure, or if she is bleeding, experiencing Tulandi T, Sarnmour A 2000 Evidence-based management
reduced fetal movements or is feeling distressed. Haorerty KP 2003 Obstetrics illustrated, 6th edn. of ectopiC pregnancy. Current Opinjon in Obstetrics
Sharpe PT 1999 Homeobox genes and determination of
Churchill Livingstooe, Edinburgh. and Gynecology 12:289-292.
embtyonic body plan. 10; Rodeck C, Whitrle M (cds)
Hunter RH 2002 Tubal ectopic pregnancy: a patho- Fetal medicine - basic science and clinical practice.
US Preventative Services Task Fotce 1996. Guidelines for
physiological explanation involving endometriosis Churchill Livingstone, London. clinical prevention.
(review). Human Reproduction 17(7): 1688-1691.
Antenatal education prepares the Sowter M, Farquar C, Petrie K 2001 A randomised trial Villar J, Carta Ii G, Khan-Neelofur D et al 2003 Panerns of
couple for childbirth, breastfeeding Kitzman H, Olds DL, Henderson CR Jr et al1997 Effect comparing single dose systemic methotrexate and routine antenatal care for low-risk pregnancy. 10: The
and parenting . of prenatal and infancy borne visitation by nurses on laparoscopic surgery for the treatment of unruprurcd Cochrane Database of Systematic Reviews (The
pregnancy outcomes, childhood injuries, and repeated tubal pregnancy. British Journal of Obstetrics and Cochrane Library). Online. Available:
childbearing: a randomised clinical trial. Journal of the Gynaecology 108:192-203. http: //,,".\"W. update-sofrware.comlcochrane.
American Medical Associatioo 278;644-652.
Spencer K, Spencer CE, Power M, Dawson C, Nicolaides Zib M, Lim 1., Walters WAW 1999 Symptoms during
References
Kurreh W 2001 Recurrent pregnancy loss: an update. KH 2003 Scree.ning for chromosomal abnormalities in normal pregnancy: a prospective controlled stUdy.
Current Opinion in Obstetrics and Gynecology the first trimester using ultrasound and maternal serum Australian and New Zealand Journal of Obstetrics and
Beischer NA, Mackay EV, Colditz P 1997 Obstetrics
and the newborn; an illustrated textbook, 3rd edn. 11:435-439. biochemistry in a one~stop clinic: a review of three Gynaecololgy 39(4):401-410.
WB Saunders, Sydney. Larsen T, Larsen JF et al 1992. Detection of small-for-
Berkowitz GS, Papieroik E 1993 Epidemiology of pretenn gestational-age fetuses by ultrasound screening in a
high-risk population ; a randomised conrrolled srudy.
birth. Epidemiologic Review. 15:414-443.
British Journal of Obstetrics aod Gynaecology
Brandt EN 1987 Smoking and «productive health. 99(6):469-474.
PSG Publishing, Littleton (MA).
QuestIon s b. Hepatitis B serology
Lemus J 2000 Ectopic pregnancy: an update . Current
Opinion in Obstetrics and Gynecology 12:369-375. c . HIV serology
Brown MAo Whitworth JA 1999 Management of 1. Which of the following statements Is
hypertension in pregnancy. Clinical and Experimental correct? d. Thyroid function tests (TFTs)
Lipson T 1994 From conception to birth - our most
Hypertension 21:907-916.
important journey. Millennium Books, Sydney. a . Behavioural strategies to stop e. Rubella serology '/
Brown MA, Hague WM, Higgins J et al 2000 smoking during pregnancy are
Nardo L, Rai R, Backos M etal 2002 High serum
The detection, investigation and management of
luteinizing hormone and testosterone concentrations
unsuccessful. 3. Which of the following statements is true?
hypertension in pregnancy: full consensus statement
do not predict pregnancy outcome in w omen with b. Social support during pregnancy a . All fetuses with Down syndrome look
(Australasian Society for the Study of Hypertension in
Pregnancy). Australian and New Zealand Journal of recurrent miscarriage. Ferrility and Srerility prevents preterm labour. abnormal on a scan at 18 weeks'
Obstetrics and Gynaecology 40(2);139-155. 77(2):348-351. gestation.
c . Air travel during pregnancy is
Offenbacher S, KatZ V, Ferrik G et al 1996 Periodontal contraindicated after 28 weeks' b. All cases of spina bifida will have an
Buster J, H eard M 2000 Current issues in medical
infection as a possible risk factor for preteon low birth gestation. elevated maternal serum alpho-
management of ectopic pregnancy. Current Opinion in
weight. Journal of Periodontology 67:1103-1113.
Obstetrics and Gynecology 12:525-527. fetoprotein (MSAFP) blood test result .
d . Government organisations provide /
Challis JRG 2001 Characteristics of parturition. 10; 'Creasy Ouellette E.M, Rosen HL, Rosman NP, Weiner L 1977 12 months' maternity leave. c. Most cases of Down syndrome are
Adverse effectS on offspring of maternal alcohol abuse detectable by first-trimester /
and Resnick, Maternal fetal medicine - principles and e. Treatment of periodontal disease
during pregnancy. New England Journal of Medicine
practice. WB Saunders, Philadel phia. shOUld be delayed until after screening with nuchal translucency
297:528-530. ultrasound.
Cunningham FG, MacDonald PC, Gant NF et al 1997 parturition.
RCOG (Royal Conege of Obstetricians and Gynaecologists, d. A scan at 18 weeks should be done
Wtlliams' obstetriCS, 20th edn. Appleton & Lange,
UK) 2002 Clinical green top guidelines: tubal Which of the following blood tests is
Stamford, Connecticut, pp 959-960. only on women who are at high risk
pregnancies - management. Online. Available:
not routinely performed at the first of fetal malformations.
Dolan-Mullen P, Ramirez G, Groff JY 1994 Obstetrics: a http://Www.rcog.org.ukJguidelines.
antenatal visit for all women?
meta-analysis of randomised trials of prenatal smoking e. Amniocentesis can detect the vast
RCOG (Royal College of Obstetricians and Gynaecologists, a. Full bload count
cessation interventions. American] ournal of Obstetrics majority of fetal malformations.
UK) 2003 Clinical green top guidelines: early
and Gynecology 171: 1328-1334.

'*

Women's health : a co re curricu lum
7 Anten atal care

4, Which is the most like ly diagnosis in a


woman with a quantitative flHCG of
a , Ser ia l measurement of maternal
weight is essential in assessing fetal
~hlCh of the following substances is
~;;~;ot associated w [fh the onset of c . Oestrogen
3000 IU/mL, an empty uterus on wellbeing , parturition? d . Gamma-amlnobutyric acid
transvaginal ultrasound scan and light
b . Psychosocial issues have little a. Corticotrophin-releasing hormone e , Oxytocin
vaginal bleeding? bearing on the provision and
a, A live intrauterine fetus outcome of management In the b , Prostaglandin
second trimester of pregnancy.
b, An incomplete miscarriage
c, Antenatal care in the second /
c , A pseUdo-pregnancy
d , An ectopic pregnancy
trimester aims to identity and
manage any obstetric or medical 1\+ D\I\...u..k- o~ ~ :
problems that develop during this
e, A delayed (missed) miscarriage ti me. ~ -e.J-t"nI 'Y"" fo.. 'l ~ roJ-f,.?
d . Ul trasound aHer 20 weeks is very
5, A 40-year-old woman who has had a
tubal ligation presents with a posit ive
pregnancy test and 7 weeks '
reliable In the calculation of the
gestational age of the fetus , CD rY\'l4~~~
amenorrhoea , Which of the following e, A maternal blood pressure of
statements is correct? 150/95 mmHg is normal.
~ Ce.k
a , This is a folse-positive test and the 8, With respect to screening tests in the
patient should be reassured, second trimester, which of the
b, The woman should have a following statements [s correct?
transvaginal ultrasound scan and a , Measurement of the symphysis-
quantitative BHCG,
c , The woman should be advised to
terminate the pregnancy,
/ fundal height is not a screening test.
b , Screening for gestational diabetes Is
not carried out In the second
d, The woman should be advised to trimester.
return in 2 w eeks for a repeat test c. An Rh-nega tive woman in whom no
and evaluation , anti-D was detected in the first
e , The woman is probably extremely trimester does not need to be tested / '
for anti-D at 28 weeks ,
pleased to be pregnant.
d , Materna[ serum screening may be
6, Which of the following statements oHered to assess the risk of Down
about spontaneous miscarriage Is syndrome .
true? e , Umbll[ca[ artery Doppler evaluation
a , It is commonly due to an inherited is a useful screening tool for
chromosomal abnormality, intrauterine growth restriction.

b . It occurs aHer fetal viability, I. e . Wh ich of the following is an essential


24 weeks' gestation. and routine port of the assessment
c. There is decreased risk if the woman during an antenatal visit in the third
is ove r 40 years of age , trimester of pregnancy?

d , It is most commonly due to sporadic a , Dipstick testing of urine


chromosomal abnorma lity. b. Weight measurement ../
e, It is frequently recurrent, c. Blood pressure measurement

7, Which of the following statements d . Che ck ing the amount of oedema in


about antenatal care In the second the lower limbs
trimester is correct? e, Assessment of amniotic fluid volume

WI
J
The fetus
Martha Finn

Learning objectives
Knowledge • critique the view that one can ha ve a
perfect baby every time
At the end of this chapter, the student outline the merits of a day-assessment
will be able to: service versus hospital admission
Fetal growth expla in the rele vance of ·t he cerebral
palsy statement.
discuss the importance of accurately
dating a pregnancy
describe the physiology of amniotic
flu id and the causes ot reduced or Skills
excessive fluid volume
At the end o f this chapter, the student
• list the causes of a small-for-dates and a should learn how t o :
large-far-dates tetus
list th e maternal and fetal causes of establish gestational age using
In trauterine growth restriction menstrual and ultrasound data
evaluate th e ro les o f palpation and ta ke a n antenatal histo ry a nd p erform
ultrasound in Identifying the small-fo r- an antenatal exami nation with
dates fetus particular reference to reco rd ing and
interpreting symphys is-fundal height
discuss the perinatal mortality and measurements
mo rbidi ty associated with intrauterine
growth ,estrlctlon listen to the fetal heart using a Pinard
stethoscope or handheld Doppler
discuss the importance of timing and
location of delivery explain to a woman the significance of
evaluate the Impact of intrauterine a fetus that appears small for dates .
growth restriction on the newborn, th e
child and later adult years
• describe the risks associated with
accelerated fetal growth Attitudes
Assessment of fetal wellbeing
At the end of this chapter, the stUdent
indicate the rates of stillbirth, cerebral should reflect upon :
palsy and b irth anomalies
• summarise fetal adaptations to acute the value of prenatal education and a
and chronic hypoxia healthy IifeSfyle in pregnancy
• c riticall y appraise the methods tor • the Impact of intense fetal monitoring
assessment of fetal wellbeing in n ormal on the wellbeing of the pregnant
and complicated pregnancies woman and her fam ily.
8 Th e fe tus

women 's health: a c o re curricu lu m

re~fncy such as anticonvulsants, warfarin,

*
below her gestational age in weeks. The liquor vol-
indicates the median and normal range of gesta-
. eta- . ockers and angIotensin-conve rting enzyme ume was normal throughout and the fetal umbili-
tion in weeks. This method may suggest a small
Fetal growth fetuS but it cannot differentiate between the phys-
mhibltors. Other
. al' f causes of fetal growth resrncnon
.. cal artery reSistance was also normal. The mother
sueh as Vlr m ections (e.g. rubella and cyromegalo- had a spontaneous onset of labour and deLivered a
i.I"i..i.i,i;ii,ii4.il.i@g,it#!j[.j,~. iologically and pathologically small fetus. Plotting
serial SFH measurements on a graph gives the vhlrusl)d bas well as chromosomal abnormalities healthy 2600 g baby at term. There were no
A pregnant woman at 36 weeks' gestation has s ou e conSidered. neonatal complications.
health professional and mother a better under-
a symphysis-fundal height of 32 em. Is this The finding of morphological abnormalities on The abdominal circumference is the single
standing of the growth of the baby (Fig S.l) .
baby small for gestational age and what are ultr.asound mcreases the suspicion of fetal aneu- most mformative meas urement of fetal size
An ultrasound examination will confirm if the
Ihe Implications for the mother and baby? baby is indeed small or large for gestational age:
plOldy. A sonographically normal fetus with earl - r~flecnng the size of the liver and its glycogen sup~
onset second -tnmester fetal growth resrnctlon . Y p y. An eval uanon of the ratio between the head
A pregnant woman at 32 weeks' gestation has physical variables of head circumference, abdomi-
may, h owever, have a 25% risk of aneuploidy. mcurnference and ,abdominal circumference may
a symphysis-fundal height of 36 em. What are nal circumference and femur length are plotted on
the standard 3rd to 97th (or 10th to 90th) per- The Rattern of fetal owth cannot be inferred mdlcate a relanve head sparing' effect, which is
the differential diagnoses?
from a sm . e measurement 0 e SIZe. owever due to preferennal cardiac output to the brain .
the growth-restricted fetus (asymmetric growt~
centile chartS. These measurements represent the
an. ev uanon 0 et we eing may help distin~
fetal size and thus one snapshot in time.
gmsh
all between
wth the healthy fetus and the poten- ~~tncnon). How:e~er, this feature may be absent if
An important objective of antenatal care is to mon- a y gro . -restricted fetus. Valuable information growrh-Impamng msult to the ferus occurs at
itor fetal growth and thus identify the fetus that is
The small-for-dates fetus may be gamed from assessment of liquor volume an earher gestanon when the fetus is incapable of
not realising its full growth potential (intrauterine When the pregnancy is judged clinically small for - the blOphyslcal profile score (BPS), 1elil cardio~ mounnng such a compensatory response (symmet-
growth restriction) or the fetus that is exceeding its gestational age, a search should be made for rocorsp11,Y and fetal um6mcal artery - reSlStanCe tiC growth restriction).
growth potential (accelerated fetal growth). Both physiological and pathophysiological causes. The (see sessment 0] fetal wellbeing).
conditions are associated with significant maternal mother's physique and ethnic background may Fetal growth may be observed only by serial Management of the
and fetal morbidity and mortality. suggest that a small baby may be of appropriate m::surements of fetal size at intervals of at least growth-restricted fetus
size for her. Pathological factors associated with ~eaIilikS. Anormal growth rate may be obseryc d in
Establishment of gestational age fetal growth restriction include smoking, hyper- y smaJJ; average and large letu~. In the While clinical practice places emphasis on the
tension, diabetes mellitus, autoimmune disorders pregnancy shown In figure S.2, the mo ther was s~all fetus, it is important to realise that any ferus
Acrurate establishment of gestational age is crucial and recurrent antepartUm haemorrhage. Growth
CaucaSian, 160 em tall and weighed 57 k wether of small, average or even above-avera ~
SymphYSIS-fundal height was consistently 4 c~ Size, may demonstrate a decline in growth (gro~
to identification of the small- or large-for-dates restriction has also been associated with alcohol,
fetus. The gestational age is calculated from the cocaine, opioid abuse and medications used during
first day of the last menstrual period. Menstrual
2
cycle length and recent oral contraceptive use
influence the reliability of this date. If the ultra- 50 0
I
sound estimation of gestational age, based on 38
I
crown-rump length in the first trimester or bipari-
45
90th cen11le 6
I ~

etal diameter at 20 weeks' gestation, is within 5 or


10 days respectively of the menstrual dates, the E 40
B
50Ih eenflle
loth cen~le
13
~
4
~
~
~

V
correct interpretation is that the ultrasound sup- E 35
g 32
7
.
~

portS the menstrual dates. Otherwise an amended B' ~ 30


1/ V - -3_
expected date of delivery may be calculated based
~
30 E /' ....,.V - - SO'Ue
C ~ 28 J .. - .. - ~'-
/' .cr
on the ultrasound date. " 25
c:
.
~ 26 o Fetus

1
';;; E
c
24
V /'
Screening for abnormal ~ 20 o /' /'
Q. ~ 22
fetal growth E < / V V
?; 15 20
/ /'
The uterine fundus is first palpable at 12 weeks' 18
10 /'
gestation, reaching the umbilicus at 20 weeks and
16
the xiphisternum at 36 weeks. Determination of
fetal size and growth by this method is, however, o 16 20 24 28 32 36 40 44 14
24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
prone to inaccuracy, owing to the variation in Weeks
Weeks
maternal bodily habitus. FIGURE 8.1 Assessment of fetal growth bY
M easurement of the distance between the serial SF H measurements (FrOm Llewellyn -Jones FIGURE 8 . 2 Normal a
JOW t h of a physiologica lly small fetus
uterine fundus and the symphysis pubis (sym- 1999, p 46 , Fig 6.16)
physis-fundal height, SFH) in centimetres (:t3 cm)

w;
-,I
Women's health : a c o re curriculum
8 Th e fe tu .

restriction) if exposed to an unfavourable Asian nulliparous woman with an SFH measure-


intrauterine environment. In the pregnancy shown ment of 29 cm at 32 weeks' gestation. Ultrasound 2

in Figure 8.3, ultrasound monitoring of growth confirmed a small baby. The liquor volume was ~

was commenced because of a bad obstetric history reduced (amniotic fluid index, AFI, 6 em) and the 8
with fetal demise at 35 weeks' gestation, due umbilical arrery resistance was high (>97th per- 36
~

to abruptio placentae. Clinically the subsequent centile). The mother was admitted to hospital and
baby appeared to be growing appropriately. An given steroids to promote fetal lung maturity. 134 ~
~

ultrasound examination at 34 weeks, however, Twice-weekly amniotic fluid measurements were g 32 V-


demonstrated no fetal growth in 4 weeks. On hos- low-normal (AFI 8 cm). Doppler measurements j 30
pital admission a day later, severe bradycardia were unchanged. Daily cardiotocograph record- E
V :,...-
~
--,.....
---"""""
~ 28
occurred, necessitating delivery by emergency ings were normal. Two weeks later, however, there ..
~ 26
./ V - ,~

caesarean section and neonatal resuscitation. The was no demonstrable growth, oligohydramnios V- ./ o Fews
~ 24
baby spent a week in neonatal intensive care but and absent end-diastolic flow on Doppler assess- o :,...-
.
/

:ll22 ./
subsequently did well. ment. The mother showed evidence of severe /
/' ./
If one snapshot in time shows the fetus to be preeclampsia. A caesarean section was performed. 20
truly small for dates but the fetus is surrounded by The baby weighed 1600 g, was hypogiycaemic at 18
V
normal amniotic fluid, is active, morphologically birth but required minimal oxygen supplement- .. 16
~
r-
normal, and has normal umbilical arrery resist- ation, fed well and rapidly gained weight. 14 I
ance, the mother may be reassured that the fetus A decision to deliver a growth-restricted fetus
~a~VD~~~RDM~38~3838~~U
appears healthy. A repeat ultrasound to assess must balance the risks of prematurity and con-
Weeks
growth may be performed a minimum of 2 weeks tinued fetal compromise in utero. While severe
later. The liquor volume may be evaluated more JUGR poses a significant risk for the fetus, peri- FIGURE 8.4 Fetal growth restriction In a woman with severe preeclampsia
frequently, as fluid changes are more dynamic and natal monality and morbidity is dominated by
may demonstrate a compromised fetus earlier. The gestational age at diagnosis and delivery. When
mother should be assessed for risk factors and her delivery is deemed appropriate, consideration Profound fetal distress warrants deliyery by emer-
gency. caesarean section. Lesser degrees of com- An expedited delivery, particularly if compli-
blood pressure monitored weekly. must be given to the timing, mode and location of
Growth restriction is one manifestation of the delivery. The gestational age and degree of pronuse and later gestation allow consideration of cated by operanve illtervention, may create con-
rnducnon of labour. SIderable anxiety. Neonatal complications may
preeclampsia. Figure 8.4 shows the case of a small compromise dictates the urgency of the delivery.
Deliverr of a pre term compromised baby lead to separation of mother and baby, and diffi-
42 should be ill a umt WIth neonatal intensive care. culty ill bonding. Every effort should be made to
In-u~ero transfer of a baby to such a unit should be illvolye the mother in the care of her infant
consIdered, as well as administration of exogenous mcluding feeding of expressed breast milk. Parent~
40
38
sterOIds to promote pulmonary maturity. may rncur significant exp~nses either travelling
36 ~
~

daIly to the neonatalrntensive care unit or staying


f34 ~
~

v
.-/ Impact of growth restriction away .from home in temporary accommodation.
i The finanCIal pressll!e to return to work may also
i
E
~ 28
32
30

6 V-
V-
Ov-
VV
/
V/
--.-
- -00Ye
- - --97'U1
The neonatal complications of intrauterine growth unpact on the family. Early involvement of the
reStrlctIOn lllclud,e antenatal or intrapartum SOCIal worker should be encouraged.
mtrauterrne hYPOXIa, WIth risk of fe tal death, and In the short term, other family members may
~ 26 --O---Feb.4 fetal distress rn labour requiring instrumental feel neglected. It IS unponant that siblings of the
~ 24
V ./
or 0peranve delivery or neonatal resuscitation. mfant be mcluded in the management plan. Older
o
:ll22
cf V V Neonatal hypogiycaemia may occur as the glyco- children ,may have been anticipating the new
< ~
/' V gen-depleted lIver fail s to maintain normogiy-
20 arnval WIth excitement and then acutely feel the
./ caeOlla. When pre term delivery occurs, additional
18 disappOIntment If the baby dies Or requires inten-
problems such as pulmonary immaturity further SIve neonatal care.
16 complicate neonatal life.
14 Long-term chronic childhood illness may be
Childhood complications include failure to
~a2VD~~~RDM~38~38.~~U stressful for the whole family. A supportive gen-
Lhnve, chronic lung disease and learning disability.
ow bmh weIght has been associa ted with later eral ?racnnoner and ease of access to specialised
Weeks

FIGURE 8.3 Intra ute rine g rowt h res triction of a 'no rm a l-size' fe tus (aBdult onset of hypenension and diabetes mellitus paediatrIC servICes are irnponant. Early recogni-
arker et aI 1993). non of and attennon to learning disability should
help such chIldren to maximise their potential.

Wi
8 The tetu s
Women's health : a core curricul um

8 cm. If this is found, an anatomical screen is per- 42


Prenatal education formed to exclude a gastrointestinal obstruction, 40

Prenatal education should promote a healthy which may occur anywhere from the mouth to the 38
lifestyle, involving diet and exercise, immunisation ileo-caecal valve and inhibit fetal absorption of 36 ~
~

against rubella, and avoidance of smoking, alcohol amniotic fluid . Anencephaly is associated with a
and recreational drug usage. During a preconcep- neurological inability to swallow. Placental or cord
K 34 0
~
~

/"
V

tion counselling session or fIrst antenatal visit, the haemangiomas may be other causative factors. No ~ 32
......V
~
/"
general practitioner has the opporrunity to re- cause is found for many cases of polyhydramnios. .! 30 , - - 3_
...... ...... - -50_
inforce these values, check immunity to rubella, Accelerated fetal growth may be identifIed by e
E
28 ,
~

...... .-/ I --0-_.


_ .. - 91"Al1o
advise folic acid supplementation and optimise serial ultrasound measurements (Fig 8.5). In asso- ~ 26
~

treatment of preexisting medical conditions. ciation with polyhydramnios, this should prompt 0
~
V ..... V
E 24 ,
One of the greatest risk factors for develop- investigation for diabetes mellitus or tighter 0
:822
:0 ......
ment of intrauterine growth restriction is a history maternal blood glucose control. Glucose crosses « / .....- ......
20
of a previously affected baby. The recurrence risk the placenta, and the hyperosmolar state induces ......
is 25%. If the growth restriction was severe fetal polyuria and production of fetal insulin, a 18 --
enough to warrant delivery before 34 weeks' ges- growth-promoting hormone. Polyhydramnios is 16 --
tation, the recurrence risk may reach 50% . Early associated with preterm labour, preterm rupture . 14
referral to specialist antenatal care and ultrasound of the membranes, cord prolapse, postpartum 24 2S 26 27 28 29 30 31 32 33 34 35 36 37 38 39 4D 41 42
confirmation of gestational age are important. haemorrhage and fetal malpresentations. Macro- Weeks

Clinical evaluation of fetal growth should be sup- somia is associated with intrauterine asphyxia, FIGURE 8.5 Fetal growth ac c eleration In a woman with diabetes mellitus
ported by serial ultrasound examinations in the obsuucted labour, birth trauma to mother and
third trimester to allow prompt recogrunon and baby, shoulder dystocia and caesarean section,
with its attendant maternal complications. The Management of the growth-restricted fetus after 24 completed weeks' gestation or weighing
management of fetal compromise.
fetal hyperinsulinaemia places these babies at risk is a balance between the risks of preterm delivery over 500 g up to 28 completed days of life. The
The large-far-dates fetus of neonatal hypoglycaemia. and continued fetal compromise in utero . Australian definition refers to births after
Figure 8.5 shows growth acceleration that Management of the large infant includes consider- 20 weeks' gestation and/or weighing over 500 g.
When the uterus is clinically larger than expected is associated with maternal diabetes mellitus. Poly- ation of maternal diabetes mellitus fetal Structural In developed counmcs, the perinatal mortality
for dates, the possibility of a big baby must be con- hydramnios was present from 34 weeks. The abnormalities associated with polyhydramnios and rate for babies over 1000 g is usually less than 6
sidered. The differential diagnoses include mcor- mother had previously given birth to three large an assessment of the safest mode of delivery. per 1000 births, whereas in developing countries it
rect dates, twins, polyhydrarrmios, uterine fibroids babies (>4000 g) by normal delivery with no ranges from 30 to 200 per 1000 births. Such vari-
or exuauterine masses. complications. Labour was induced at . 38 weeks'
A large-for-gestational-age fetus is defined as gestation. An obstetrician was present ill annclpa-
having a weight greater than the 95th percentile tion of shoulder dystocia. A baby of 4100 g was
for gestational age. The fetuS may be phYSIOlogI- delivered after a labour of 6 hours. The baby was
* Assessment of
fetal wellbein g
ation reflects the health of the general population,
access to and quahty of antenatal care, the inci-
dence of birth anomalies, and quality of intra-
parrum and neonatal care.
cally normal or may have accelerated growth put to the breast immediately and did not develop 1\vo per cem of children are born with major
(macrosomia), which is associated with maternal hypoglycaemia. malforrnauons (life-threatening or requiring major
diabetes mellitus or a congenital fetal abnormality surgery). Chromosomal abnormalities, single gene
(Beckwith-Wiedemann syndrome). Summary • A tetus Is determined to be small tor gesta- mutauons, and environmental and teratogenic ex-
Incorrect dates and twins can confidently be tional age on ultrasound. Is th is likely to be a
The clinical finding of a uterus that appears small posures account for 40% of major malformations.
excluded by referring to the morphology or or large for dates should prompt re-evaluation .of healthy, small tetus or a growth-restricted tetus?
earlier dating ultrasound scan. A fibroid or ovar- A pregnant woman at 39 weeks' gestation has Threats to fetal wellbeing
the gestational age and a search for maternal nsk
ian cyst can usually be seen at 18 weeks' gestation relt reduced tetal movements in the previous
factors. An ultrasound examination is performed Both maternal uteroplacental and fetal conditions
and may become larger as the pregnancy pro- to confirm that the fetus is truly discrepant for ges- 48 hours.
gresses. Polyhydramnios may be clinically sus- may cause an imbalance between fetal oxygen
pected if the abdomen is particularly distended tational age.
For the fetus identified as small for dates, fur-
demand and supply. Maternal conditions such as
and tense, and fetal parts are difficult to identify. hypertension or microvascular diabetic disease impair
ther evaluation of fetal wellbeing is necessary to
When the uterus is recognised as large for distinguish the healthy small fetus from the com- placental. perfusion, leading to lUGR. Fetal hyperin-
Perinatal mortality sulinaenua may also be associated with accelerated
dates, an ultrasound is performed to determine promised and potentially growth-restricted fetus.
fetal size suucrure and amount of amniotic fluid. Serial evaluation of fetal measurements at 2-week- The international definition of perinatal monality growth. Maternal hypethyroidism affects fetal
Polyhyd:amnios is defined by an AFI of more ly intervals determines the pattern of fetal growth. refers to stillbirths and neonatal deaths occurring basal metabolic rate by transplacental transfer of
than 20 em or a fluid pocket depth of more than

Wt
Women's health: a core c urri c u lu m
8 The fetus

antithyroid antibodies. Intrauterine infection rnay normal umbilical artery resistance more reliably
cause fetal anaemia (parvovirus). Isoirnrnunisation predicts that a growth-resrricted fetus is not
may also cause fetal anaemia. It is irnporran.t to mon- hypoxaemic. The positive predictive and negative
itor the fetal response to such threats and detect early predictive values of absent end-dias.tolic flow
signs of compromise. velocity for fetal death are 40% and 95% respec-
tively.
Clinical assessment One of the adaptive fetal responses to hypox-
of fetal wellbeing aemia is reduced cerebral resistance to blood flow.
This is a reflection of the redistribution of cardiac
Maternal assessment of fetal movements provides output preferentially to the brain and myocard-
a simple assessment of fetal wellbeing. UltrasOlwd
ium. Identification of decreased middle cerebral
evaluation of fetal growth, activity, amniotic liquor
artery resistance in the presence of increased
volume and fetal perfusion provides valuable clin-
umbilical artery resistance is consistent with fetal
ical information in a high-risk pregnancy or sus-
hypoxaemia.
pected fetal compromise. More detailed analysis
of fetal acid-base status and hypoxaemia may be Further fetal decompensation occurs when the
cardiac output falls. H ypoxaemic cardiomyopathy
made by invasive tesring.
results in fetal acidaemia. Doppler venous indices __
Amniotic fluid volume reflect ventricular function, and abnormal patterns
herald imminent fetal demise.
The volume of amniotic fluid re.tJecrs YIerjpr per-
fusion and the physiological processes of fail Fetal blood sampling
sWaIIOwing, fetal cardiac function and rsal fu lJc-
non. Reduced utenne perfUSion, secondary to Cordocentesis involves taking a blood sample from
nypertension, microvascular disease or placental the fetal umbilical artery to evaluate blood gases and
acid-base status. It may be of value in compromised
infarCts, results in redistributed fetal cardiac Out·
put. This leads to poor renal perfusion and low preterm fetuses, where perinatal mortality is domi-
renal output. Thus oligohydramnios suggests a nated by gestational age at diagnosis and delivery:
compromised fetus. Intervention on behalf of the very early preterm
Evaluation of liquor volume is one component fetus should cautiously be considered at the point
of the BPS, which considers fetal tone and move- where decompensation begins but before the blood
ment, fetal brearhing pattern and liquor volume. gases (determined by cordocentesis), cardiac func-
Scoring 2 for each normal variable, a healthy baby tion (determined by cardiotocography) and perhaps
will achieve at least 6/8 over 30 minutes' observa-Doppler venous indices have deteriorated too far.
tion. A still fetus with oligohydramnios is an omi- Fetal scalp sampling in labour is performed
nous finding. Fetal cardiotocography may also be where there are clinical signs of fetal compromise,
a component of a modified BPS . e.g. a non-reassuring fetal heart rate pattern.
t~tl Evaluation of fetal venous pH and base excess
Um bilic al arterial resistance - "'" \ \J 1..1\- aUows continuation of conservative management
or prompt delivery. Use of this modality has helped
Resistance to blood flow in the fetal umbilical to reduce, without neonatal compromise, the rate
artery may be measured by Doppler studies (Fig of caesarean sections amibuted to 'fetal distress'.
8.6). Umbilical artery resistance closely refleCts
placental villous resistance. Umbilical artery Cardiotocography
downstream resis.tance increases once approxi-
mately 30% of the villous vessels are affected. Doppler recording of fetal baseline heart rate and
Increasing flow resistance reduces diastolic flow variability is the basis of non-stress cardio tocO-
velocity in the umbilical artery, leading in the graphy. The baseline fetal heart rate falls with
extreme cases to absent or reversed end-diastolic increasing gestation and becomes more variable
velocities. with the later development of fetal vagal tone.
While absent end-diastolic flow velocity has There is insufficient evidence regarding the relia- FIG URE 8 .6 Feta l umbilica l o rte r D I
been shown to correlate with fetal hypoxaemia, bility, validity and suitability of electronic fe tal ~ Osp lta l) y opp er patterns (Photos courtesy Peter Farkos/RoyOI Darwin
Women's health: a core curricu lum
8 The fotu.

monitoring as a tool for assessing feral wellbeing, uteroplacental function, e.g. hypertension or dia- The International Cerebral Palsy Task Force
except in [Wo circumstances. A ferus with a base- betes mellitus, may also be thus monitored. ing difficulties - may reflect physiological irnma-
(MacLennan 1999) considered three essential cri-
line hearr rate within the normal range (110-150 tunty. Nevertheless, the document gives valuable
teria to be necessary to amibute the cause to Intra-gwdance to expert opinion when counselling in
bpm), moderate baseline fetal hearr rate variability Cerebral palsy pa~ hypoxia:
(6-25 bpm) and no decelerations is not at risk of this area. By defining intrapartum causes of cere-
Cerebral palsy, a nonprogressive abnormal control • evidence of a severe metabolic acidosis in intra- bral palsy, it should help to focus research on the
acidaernia (Fig 8.7). At the other extreme of fetal
heart rate patterns, a fetus with a bradycardia or
absent fetal hearr rate variability in the presence of
of movement or posture, develops in 2-3 per 1000
live births during the first years of life. It has long
partum fetal or
samples
mr early neonai'at' blood many antenatal causes of cerebral palsy and their
prevennon, ill addition to the prevention of dam-
persistent late or variable decelerations has evi- been associated with intrapartum adverse events. • earl agrng Intrapartum hypoxia, which has been the
dence of potentially damaging acidaernia. Recently, however, it has been recognised that .~~~~~~~~~~ mam emphasis to date.
The majority of the above tests of fetal well- about 90% of cases can be amibuted to intrauter-
being may be performed in a day-assessment set- ine events preceding labour, e.g. IUGR, fetal coag-
ting. This allows close surveillance of the pregnan- ulation disorders, multiple pregnancy, anteparrurn Health maintenance
cy, while causing least disturbance to the woman's haemorrhage, chromosomal and metabolic abnor- A healthy lifestyle involving diet and
family life. Maternal causes of compromised malities, coagulation disorders and infections. Weaker. criteria that together suggest intra- exercise and avoiding smoking
parrurn tllIung but by themselves are nonspecific alcohol and recreational drug ~se
include: prOVides a favourable environment
for fetal growth. Pre-conception
• a sentinel hypoxic event occurring immediately treatment of medical conditions
before or during labour optimises fetal growth and wellbeing .
• early evidence of multisystem involvement
early imaging evidence of acute cerebral abnor-
mality.
References
Implementation of the International Cerebral
Palsy Task ~orce guidelines is limited by the lack of Barke r D]p, Glud<man PD, Godfrey fG\.f er 0.1 1993 Fetal
nutntJon and cardiovascular disease in adult life.
resources !n smaller hospitals to ascertain the Lancet 341:938-941.
degree of metabolic acidosis and to perform early
neonatal brain imaging. The consensus document Llewellyn-Jones D 1999 Fundamentals of Obstetrics and
does not address the association between preterm gynaecology, 7th eeln. Mosb» Lo ndon.
birth below 34 ~veeks' gestation and cerebral palsy. Macwnan A 1999 A template for defining a causal
This IS a difficult area, as signs of neonaral relanonship between acute intrap artum eVents and
encephalopathy - such as difficulty initiating and cerebral pals}': internarional consensus stare-mem
International Cerebtal Palsy Task Force. British '
marntauung respiration, abnormal tone and feed- j\·ledical kumal 319,1054-1059.

d . It would be wise to consider early


1. A 22-year-old woman presents ot delivery.
34 weeks' gestation in her first e. She may have twins .
pregnancy. Her pregnancy appeors
clinically smoll for dotes. Which of the
following is correct? 2. Intrauterine growth restriction is
associated with:
a. Her dates may have been incorrect. /
b. She could have polyhydramnios. a . maternal weight loss in pregnancy
FIGURE 8.7 Normal ontenotal cardiotocograph pattern (Courtesy of Peter Farkas /Ro yal Dar win
c. A single ultrasound examination can b . fetal talipes equinovarus-
Hospital)
determine fetal growth.
-~ £)n aternal preeclampsia
,/

"·k
to

Women's health: a core c Uiri culu m


*9
Medical disorders in
c. A fetus with a normal cardio- .
d. reduced fetal umbilical artery tocograph is likely to be aCidotiC.
resistance
e. all of the above.
d. The use of fetal scalp sampling for pregnancy
acid-base status in labour has been
associated with an increase In Edited by Martha Finn
3. A 35-year-old woman with diobetes caesarean section rates.
mellitus is at risk of having:
e. All of the above.
a . a macrosomic baby
Hyperemesis gravidarum Regina Wulf
b . a growth-restricted baby 5. Which of the following statements
about cerebral palsy are correct? Anoemia Petra Porter
c. a traumatic delivery associated with Isoimmunisation Louise Komman and Helen Savoia
shoulder dystocia a. Cerebral palsy occurs In less than 5
Abnormal glucose tolerance Helen Lammi
per 1000 births.
d. a baby that succumbs to Hypertension Mark Brown
intrauterine asphyxia
e. all of the above.
/ b. About 10% of cases of cerebral
palsy may be attributed to
intrapartum hYPOXia.
Thromboembolic disease Petra Porter

4. Which of the following is correct in the c Severe metabolic acidosis In labour Learning objectives
. should be an essential criterion to
assessment of fetal wellbeing?
diagnose an Intrapartum event as
Knowledge outline a plan for the diagnosis and
a. Amniotic fluid volume reflects causal to cerebral palsy. management of a microcytic anaemia
uterine perfusion and the processes in pregnancy
of fetal swallowing, fetal cardiac
d. Intrauterine growth restriction may At the end of this chapter, the student
function and renal function .
imply a cause of cerebral palsy will be able to: Isolmmunisat/on
other than acute intrapartum
b. Isolated abnormal fetal umbilical hypoxia. Hyperemesis gravidarum identity the common antigens that ma y
artery Doppler resistance reliably cause haemolytiC disease of the
predicts a hypoxaemlc fetus . e. All of the above. indicate the prevalence of morning newborn
sickness and hyperemesis gravidarum
describe the pathophysiology of fetal
• discuss the differential diagnosis of anaemia and cardiac failure in
hyperemesis gravida rum Isoimmunisation
describe the Investigations required to describe the pathophysiology of
assess the severity of hyperemesis neonatal anaemia and jaundice
gravidarum
• outline the Investigations and
outline a management plan for severe management prinCiples of
hyperemesis gravida rum isoimmunisation
Anaemia • discuss prevention strategies, the value
define anaemia in pregnancy of screening and effectiveness of anti-D
immunoglobulin
indicate the pregnancy demands for
iron and identify dietary sources of iron, Abnormal glucose tolerance
folate and vitamin BI2 describe the physiology of glucose
describe the pathophysiology of homeostasis in pregnancy
anaemia in pregnancy define gestational diabetes mellitus
describe the common causes of describe the population at risk for
anaemia, their prevalence and gestational diabetes
management
• discuss the implications of abnormal
• outline the diagnostic tests performed glucose tolerance for the mother, the
to Identity the cause of anaemia fetus and the neonate
discuss the value of routine versus outline the principles of management of
selective iron supplementation gestational diabetes
(Continued over)

II.F
9 Medical d isord e rs in p regn a ncy
women's health : a core curr icu!u rn

(learning objectives continued) Ski lis


At the end of this chapter, the student
* Hyperemesis
gravidarum
increased thyroid-stimulating activity and elevated
serum thyroxine levels have been reported in more
than 70% of patients with HG. Hyperthyroidism
• discuss the Importance of maintaining usually resolves early in the second trimester, sub-
normal pre-pregnancy blood glucose should learn how to:
siding along with the hyperemesis. PSjCchosocjal
levels in women with established diabetes
clinically assess the degree of dehydration stress is not a cause of hyperemesis but can
in a woman with hyperemesis gravidarum A 30-year-old woman at 8 weeks' gestation Is
Hypertens ion
unable to eat or drink owing to severe nausea
affiavate It and should be taken into consideration
• define the subtypes of hypertension In perform and interpret a ward urine dipstick and vomiting. She fells dizzy and weak, passes in e overall management of the woman with HG.
pregnancy and discuss the clinical examination only small amounts of dark urine twice dolly Women who have experienced HG in a previ-
implications of each interpret blood biochem istry of a woman and is unable to look after her other child or to ous pregnancy or who have experienced nausea
• list the maternal risk factors for develop- with severe prolonged vomiting do any housework. She also experienced while taking oral contraceptives are more likely to
ment of preec lam psia nausea and vomiting In her previous suffer from HG.
counsel a woman regarding the
significance of hyperemesis gravldarum pregnancy.
describe the pathophysio logy of Physiology
preeclampsia take a nutritional history from a pregnant
outline the investigations performed to woman and offer appropriate advice. The pyloric glands of the stomach produce gasrric
about iron and vi tamin supplementallon secretions high in potassium (15 mEq/L) and with
assess maternal and fetal wellbeing in a Morning sickness
hypertensive pregnancy explain the role of postpartum passive
significant sodium content. The secretion from the
immunisation to the Rh-negative mother Nausea and vomiting are cornmon in early preg- parietal cells is isotonic but contains chiefly
discuss the statement that hypertension in
pregnancy, in particular preeclam~sia , is a who has no ant ibodies detected in nancy and are referred to as morning sickness, but hydrochloric acid. It also has a significant potas-
common cause of maternal mortality and pregnancy symptoms are restricted to the morning in only sium content (5-8 mEq/L). In the formation of
af perinatal morbidity and mortality explain to the Rh-negative mother the 2% of women. Up to 85% of pregnant woman are hydrochloric acid, sodium bicarbonate is rernmed
implications of a posllive anlibody screen affecied, and symptoms are commocly expen- to the extracellular fluid (ECF). C.!(!!,tinued vomit-
• outline a management plan for a patient
admitted with preeclampsia test in pregnancy ence from the 4th to the 12th week of Ereg- ing thus leads to aemia, hYE.0natraemia,
explain to a woman the value of a glucose n~. Although the symptoms may be traulITe- ~oraemlc alka losis an a decreass in FeE
Thromboembolic disease some, they rarely require investigation or dru& v Alkalosis shiftS more potaSSium into the
screening test in pregnancy
• discuss the significance of thrombo- ~eraa In general, first-trimester nausea has no cells. In adclition, the concentration of body fluids
counsel a woman with gestational increases because of insensible water loss with no
emboliC disease in pregnancy diabetes mellitus about her long-term a verse effect on the roWer or ferns.
• identify the common symptoms and signs health risks
replacement. In some patients who have been
of deep vein thrombosis and pulmonary Hyperemesis gravida ru m vomiting for a long period of time, the pyloric
clinically assess the woman who presents sphincter rela;'(es and large quantities of alkaline
embolism with hypertension in pregnancy Hyperemesis gravidarum (HG) is excWiye pq:g- duodenal contents are lost. These patients will
• outline the investigations used to Identify counsel a woman about appropriate nancy-related nau(;f and /gr vomiting that usually have bile in the vomirns.
DVT and PE In pregnancy therapy for deep vein thrombosis and prevents ad uate fo and fluid intake and is asso- Urine output is reduced. This occurs by hyper-
describe the management of deep vein pulmonary embolism in pregnancy. oate with ei t oss a mare t an 5% of body osmolar stimulation of antidiuretic hormone
thrombosis and pulmonary embolism in mass. It occurs in ess than 3% 0 pregnancies. secretion and reduced glomerular filtration, asso-
pregnancy Attitudes Symptoms usually begin at 4-6 weeks' gestation and ciated with reduced ECF volume. Urine specific
identify women who may need prophylaxis peak between 9 and 13 weeks. In 10-20% of cases~ gavity is incregsed. Initially the urinepH IS atka
for thromboembo lic d ise ase in pregnancy
or the puerperium.
At the end of this chapter, the student
should reflect upon:
symptoms may last the entire pregnancy. The inabil-
ity to retain food and fluids leads to de!tndration,
~6ecause the kidneys excrete bicarbonate in an
attempt to correct the alkalosis. As the condition
the value of indivldualisation of care for nutritional deficiency and metaboGc lIDb ceo p!:o~esses, however, the jlQtaSSium defiaens
each woman In pregnancy causes an ina ro riate acidifica .on of the urfue
Aetiology and the urine comes more acidic.
the maternal anxiety engendered by the
label of 'high-risk pregnancy ' The cause of HG is not well understood. Human
chorionic gonadotrophin (HCGl. which rises to a Clinical picture
the maternal guilt of having a condition
that may adversely affect the fetus. peak at 12 weeks' gestation and falls thereafter, The reduced ECF volume and hypokalaemia cause
bas been held responsible. The HCG level is ex- thirst, malaise, dizziness when tanding and ~
tremely high in women with molar pregnancies ~ ~ati0!1 is associated With postural
and twin pregnancies, conditions associated with hRr0tensJOn and fever. Hyponarraemi!, may cause
HG. High levels of HCG are also associated with ~s, convUl5iOm and reSplIatory arre t.
-
Iltt
Women's health : a core curriculum
\ 9 Medical disorders In preg nonc y

should be further investigated by microscopic exam-


ination of a midstream urine sample. A urine dip-
stick is used to check for specific gravity, ketones,
and the selective serotonin (5HT3) receptor antag-
onist, ondansetron, are most co I use an
have not een associated WI te ato enie e
* Ana emia
protein and urine acidity, as severe dehydration is AI " es suc as pow er (1 g
associated with high specific gravity and the produc- dally) and Vltamtn B. (30 mg pyridoxine daily) • A 32-year-old nulliparous woman presents at
tion of ketones. The haematocrit is increased as a have also proved to be effective and can be tried 14 weeks ' gestation to receive the results of her
result of a concentrated blood volume. T here are where oral therapy is possible. S stemic steroids Initial antenatal screentng blood tests. Her
blood eleCtrolyte changes, e.g. decreased sodium, (hydrocortisone, prednisolone) have e e haemoglobin is 90 gIl.
p~ chloride and ~ esium are common, as fully H.sed in patients f Of whom annemegc therapy
A 24-year-old woman presents at 29 weeks'
well as elevared'1iver, enwmes such as asparrate has failed. Parenteral therapy haS a role to play in gestaHon with tiredness. She is a vegan and
transaminase (AS 1j, alarune transaminase (ALT) severe HG.
has two young children at home.
or bilirubin. Overr jaundice is rare. Thyroid function It is imporrant to remember that a woman who
teStS should be checked in women with clinical signs has been hospitalised for a prolonged period with
of hyperthyroidism, in which an increased T4 con- HG, who is dehydrated and confined to bed, is at
centration and reduced thyroid-stimulating hor- increased risk of venous thromboembolic disease, The majority of hereditary haemolytic anaemias
mone (fSH) may be found. An ultrasound should be and tlJ.£Qmboprophyl~s (lffilZ-Wo!eCJJ lar-weit t and homozygous haemoglobinopathies are identi-
performed to identify a rwin or molar pregnancy. _. heoiif and compressIOn stockings) shoUld e fied before pregnancy. At the . t antenatal visit,
co~ensa: the most common cause of anaemia IS nutrltto .
Tre a tment der cases of nausea and vomiting in preg- CJc"caslonatIy heterozygous haemoglobinopadlfeS
nancy have not shown a long-tenn adverse out- and, very rarely, a panCytopenic bone marrow
In the eighteenth century, it was believed that HG come for the fetus. In sev . ed
was caused by a 'fullness of the vessels of the uterus' aplasia or leukaemia are identified. The ~
Diagnosis maternal naus v ttn and we
of nutritional anaemias are due to iron deficiency.
and it was treated by venesection. Today, once the erus IS at ris of &9wth restriction, whieh may
diagnosis is made, trea . 0 .
lead to preterm delivery and its complications. ft is rare today, with food forrification and vitamin
care with correction a both flu ' 01 supplemenration for prevention of neural tube
irn c deficienCies. Summary defeers, to see folic acid deficiency or the haema-
Hospitalisation is necessary in severe es. tological manifestations of vitamin Bu deficiency_
Adequate fluid, eleCtrolyte and vitamin adminis- Screening beyond the first trimester is directed at
tration will prevent life-threatening complications. identifying iron deficiency anaemia.
First-line management includes intravenous rehy-
m anon WIth normal saline or H artmann'S solution Physiology
WIth potasSlUm chlOride su pplementarion. It is
irnporrant not to correct severe hyponatraemia toO Plasma volume begins to increase by the sixth
Investigations rapidly, as this may also precipitate central pontine week of gesration, peaJdJ]g at around 30 weeks,
myelinolysis. Fluid and electrolyte regimens With a total of 1.2-1.3 litres extra by term. The
e oss 0 should be re-evaluated daily, based on serum urea erythrocyte mass mcreases more slowly and' pro-
tic! ta oscur and eleCtrolyte concentrations. A woman who has pomonately less than the plasma volume, resulting
As psVchological factors may influ- in a net dilutional effect. This is referred to as the
bo y a our ue to rapid fat oss and ketosis may been unable to eat sufficiently for weeks is at risk ence the severity of hyperemesis
be noted. Excessive salivation (ptyalism) with con- of significant malnutrition. V~it~";!;
m~in~ s~~,IOiOj~ gravidorum . early adaptation to the phYsiological anaemia of premqnQ'. The lowest
srant spitting is found in many women. The urine tion, es eciall of the water-s e vitamins su pregnancy and a pos itive outlook pregnancy haemoglobin (Hb) occurs at 25-26
is usually dark, and urinary frequency is reduced as amm I, IS lIDporrant to Rrevent evelop- should be encouraged. weeks' gestation. A haemoglobin less than 110 gil
to two to three times daily, as the body tries to ment of werrucke's encephaloE!athy. in the first trimester or less than 100 gIL in late
retain as much water as possible. Oral lIwd and food should be withheld for second and third trimesters should be considered
Symptoms of hyperthyroidism are similar to 48 hQurs and then a bland carbohydiate diet cOm- as anaemia and investigated furrher.
those of normal pregnancy (heat intolerance, pal- menced WIth small and frequent meals. Antiemetics Mild agaemia, although a marker for poor
pitations, tiredness), but the presence of goitre, are tndlared tor S~ptoIllS that are inr:;:;lctable nutritional status, rarelfuhas untoward effects dur-
tremor and signs of eyelid lag or exophthalmos despite adequate hidranon. t hey shoUld be iJruL ;f ~egnancy. When e haemoglobtn IS 60 70
should alerr to the possibility of associated hyper- witl£:caunon, especiaIIy dUring the first 10 weeks of , ~e mother is at risk for high-ournut cardiac
thyroidism. n
pregnancy. necessary, melowest effecnve dose IS
failure and extreme tati~T'" At these levels the
Symptoms and signs of a urinary tract infection administered. Metoclop rarnide, phenothiazines
1'eWs'is at the lower limit ~ adequate o"lgen;tion_
9 Modlcal disorders In preg nancy
women's health: a core curr ic ulu m

Screening for anaemia


with the beta-thalassaemia trait have a 250/0 prob-
ability of propagating a major thalassaemia. This is
a transfusion-dependent condition that has high
* Iso im munisa ti on
A full blood examination (FBE) estimates haemo- Common clinical presentations
morbidity and mortality. Parents should be given
globin concentration, platelet and white blood cell A woman presents with an Inevitable miscar-
the option of prenatal diagnosis.
counts. In addition, the red cell size (mean corpus- riage at 10 weeks' gestation. Her blood group
cular volume, MCV) and the red cell Hb concen- Sickle cell syndrome Is Rh(D)-negatlve.
tration (mean corpuscular Hb concentration,
MCHC, and mean corpuscular Hb, MCH) are It is important to screen all high-risk ~oup s, such A woman presents to the antenatal clinic at
as black people of A1ncan Orlgtn, , ans, Saudi. 27 weeks' gestation. The routine antibody test
calculated. . performed at 26 weeks' gestation showed a
Microcytic anaemia (MCV <80 femtolitre s ArabIans artdivfediterranean eo Ie, or sickle cell
traIt. SICkle ce . soluble titre of 1 In 128 of antl-Rh(D) antibodies.
(fL)) is commonly found in Iron defiCiency
Further questioning reveals that atter a previ-
anaemia and thalassaemia. Provided the platelet
ous ectopiC pregnancy she had not received
and white blood cell count are normal, the first Rh(D) Immunoglobulin. There Is no record of
investigation of microcytic, hypochrorruc (low an earlier antibody titre in this pregnancy, as
MCHC) anaemia is directed at Identifymg \ron she was travelling overseas In the earlier
deficiency, by estimati pg sepJI~ ferpryn concentra- weeks of her pregnancy.
tion. Tests of serum iron and \ron-bmdin~g~­
rare mfliienced b dietary mtake and pre an ,
an us are not recomm n e . erum er-
riM IS nsmpaJ (especuiIly when the M CH IS very Approximately 170.0 of Caucasians are negative for
low, with a riilldly depressed MCV), haemo obm the Rh(D) arttigen and are termed Rhesus negative
electrophoresis is performed to Iden carner (Rh(D) negative). This blood type is rare in people
statesof haemoglobinopathies. . of Asian or Australian Aboriginal origin. Rh(D)-
A macrocytic anaemia (MCV > 100 fl.) ~s asso- positive individuals may be heteroz)'gous or.~
ciated with folic acid and vitamin B12 dettclenCies. homozygous for the D antigen. A heterozygous, ( f ,
Anaemia associated with macrocytic red blood father has a 500.0 chance of passing on the D anti- f (I
cells (RBCs) and hypersegmented polymorphs Thalassaemia gen. If a w oman is Rh(D) negative and her partner 'l
should be investigated to detennme erythrocyte Alpha-chain haemoglobin production is under the is heterozygous, each fents bas a 50 % chan ce of ,CfJ·
folate levels. Serum B12 levels are difficult to mter- control of four genes and beta-chain produ~on being Rh(D) positive or Rh ipl peg3 ~. ••
pret in pregnancy and are commonly phYSIOlogi- under the control of only twO genes, one inhented M ore than 40 dillerent red cell antigens have
cally low in the second half of gestatlon. from each parent. Thus thalassaemia may have been reported to cause haemolytic disease of the
major and minor forms. The major fonns are ferus/newborn (HDN) . However, o.!llx 3gri-R h (Q.),
Iro n -deficiency a naemia usually identified before pregnancy as severe trans- anti-Rh(c) and 3nrj- Ke l! cause seriolIS feral prob-
fusion-dependent anaerrua. The common . -
Summary lems. Other antibodies (Rh E, C, e), Duffy (Fya),
Women are prone to iron deficiency, which is
aggravated by menstrual loss and short intervals
. efe resul ' e unde d The most common cause of anaemia in pregnancy tGcId aka) and Lutheran (Lua) are common but
between pregnancies. In the non-~regn.ant state, .either alpba or beta sbaLJli.. Un . . is nutritional deficiency. With changing migration usually cause only mild to moderate HDN .
uses an uru:natched excess of the other leadin patterns throughout the world, it is important to
approximately 1-2 mg elemental . \ron IS needed
mem(lU)e e an mcrease e e ~ - screen for haemoglobinopathies. Pathophysiology
each day. An additional 2-3 mg \ron per day 1S
ity and reS111ring.JO a c orne emo ~c anaenua. ~ During pregnancy, fetal cells may cross the placenta
needed in pregnancy (apgror4 atelv 900 mg m
total per pregpanf)' The ad tionaJ \ron IS used
T he populanons most affected Y beta-& ilas
and enter the maternal circulation, exposing the
saemia minor are from the Mediterranean regIOn,
both to increase e maternal red blood cell mass mother to 'foreign' red cell antigens that the ferus
where the carrier rate may be as high as 1 m 7 llldi- A healthy diet generally meets the
(400-500 mg) and liver stores (250-300 mg) and has inherited from the father. This fetomaternal
viduals . Alpha-thalassaemia minor is more com- physiological demand for Increased haemorrhage (FMH) is most likely to occur at deliv-
for fetal haematopoiesis. mon in sub-Saharan Africa and Southeast Asia- ~ iron in pregnancy. Oral supplement-
Oral iron is absorbed in the stomach and duo- ery (60% of pregnancies) but may also occur spon-
women with bo th the alpha and beta tram, ee g- ation may be considered to maintain
denum, in a mildly acidic medium. Thus enteric-
n1.hf: taneously during pregnancy and in association with
coated or sustained-release iron preparatlons are
inefficient. Iron absorption is inhibited by antaCids
nancY js generally well tOlerated .
iC@jiifjed as £}rner It ISjffipera rjy e
father of~e
that:-
mot e r A

. d also be screened With. hae . 0 -


maternal iron stores .
threatened or complete miscarriage, after trauma
and after invasive procedures such as amniocentesis,
and enhanced by ascorbic acid, and therefore Iron chorionic villus sampling (CVS), external cephalic
is beg ral ~en °0 20 empty stomach . The iron ~varr:
g 0 Ul concentration an aem 1-
trophoreslS. s is Im portant because twO peop e version (ECV) or abruptio placentae .
;J;fe for absorption is termed th e elemental \ron.

'0
Women's health: a core curriculum
9 Me dica l disorders In p regnanc y

Exposure to foreign fetal red-cell antigens may d


result in the development of maternal antibody. 1.0
fetal cells in maternal blood, is used to determine
Development of isoimmunisation deBend.s. on a the volume of FMH and thus the dose of anti-D
0.7
number of factors, indudiIlg the anagentClty of ""a that should be administered after sensitising
tl:ie anagen, the dose of antigen to whiCh the 3. 0.4 events ill the second and third trimester and after
mother is exposed and the responsiveness of her E
<: 0.3 Severelyaffec ed delivery. Anti-D immunoglobulin should be given
--.;
as. dose to the sensitising event as possible and
immune system, and ABO com,anbiliry between
the mother and the ferus. (D) IS the most ~ 0.2 ~-- .... -----.......... Within 72 hours. It may still have an effect up to
'6 9-10 days after the event.
immunogeruc ot the red-cell antigens. A single preg-
~ 0. 1 -----.. --. Administration of Rh(D) immunoglobulin to
nancy with an Rb(D)-positive, ABO-compatible <:
t» 0,07 Moderately affected ------- all Rh(D)-negative women who have not devel-
fetus initiates immunisation in about 1 in 6 Rb(D)- '0
'6 0.05 oped anti-D antibodies at 28 and 34 weeks' geSta-
negative women.
Antibodies of the immunoglobulin G (w;i).. "
~ 0,03 non and after each sensitising event reduces the
class are act;i.vely transferred from mother to fetus.
0 development of sensitisation to less than 0.20/0
0.02 Normal '. (NHMRC 1999).
The anl0unt of antibody transferred is small in the
first 12 weeks of pregnancy, increases slowly
between 12 and 24 weeks and thereafter increases 33 35 37 39 41 Health maintenance
exponentially until te=. HDN occurs when the Maturity (weeks)
life span of the infant's red cells is shonened by
the action of a specific antibody derived from the FIGURE 9.1 Optical density of a mniotic fluid In the ~l1e~jgz~~t~%~8~;t?4~f;rere
~Iven ~~~_
mother by placental transfer. Antibody-coated red
cells are removed from the circulation by the fetal
liver and leading to anaemia I he illcreased
prediction of hoemolytic disease of the newborn
(Bosed on Symonds & Symonds 2004, p 59. Fig 4.16)
s ou d be
ftSM~&gi~t i €h
weeks' ~estatIO!1 . This considerably
bre own 0 aemo 0 U1 resu ts in ingeased Preventio n of Rhesus reduces In t1Sk of Isolmmunisation .
pigment in the amniotic fluid. Anti-Kell antibodies isolmmunisation
appear to work differently, bY causm anaemia ri-
maril via su ression of
ra er an ~ aemo ~IS.
III mUd ises of RNathe ferns may be born
ucnon
* Abnormal g lucose
tolera nce
without major clinical problems, and simple post-
natal observation of the mfant may be all that is
required. In other cases, phototherapy or an Common clinical presentations
exchan~transfusion ma~ be required for ~~ When screened at 28 weeks' gestation, a
h}'.llC,rb bmaemta. EarL QUShof severe :Ce 33-year-old primigravida has impaired glucose
rna res@t ill te@ anaemia in utero which le~
increase e 0 oeisis (enlarged
~.~o~::~~~~~~~~~~§e~n~~~iY~
ine transfusion can be pe orme Intrauterine
tolerance.

A woman gives birth to a 4500 g baby. Whot


" \ liver an spleen), cardiac decompensation and transfusions are usuauy stopped around 34 weeks' are the Implicati ons for the mother ond
'""'" ~ h:;drops fetaljs (so-called immune hydrops) with gestation and the fetus delivered at 36-37 weeks. In subsequent pregnancies?
ascites, pleural and encarclial effuSions and~-
0,
\dL

~
~amruos. ntreate us results '
deaai. The affect on the erus of jsoimmunisation
tal
less severe disease, where the maternal blood tieres
do not rise above 1 in 16, or where the aD 450
results do not require additional intervention, deliv- • threatened or spontaneous mjscarriage, ~~ Epidemiology
~'\lI\rt cisWiD.y increases in severity with subsequent preg- ery is usually planned for 37 weeks' gestation. stye procedures, trauma, placental abruption
nancies. (increased risk of F~ Gestational diabetes mellitus (GDM) is defined as
Noninvasive methods of determining fetal
anaemia are increasingly being researched. The • routinely at 28 a nd 34 weeks' gesra&K>n carboh drate intolerance of variable severi with
Investigations most promising appears to be the peak systohc routinely ~ty if the baby is Rh(D)- onset durin e .
The presence of re! Ifll antibodies.t n m~ternal flow in the middle cerebral anery. Liver length, pOSlt!ve. In Australia gestational diabetes is fo~nd in
blood is deteged b_ a, _ indirect ano JpbUlin test spleen perimeter and fl0'.·' velocity changes in 6-8% of all pregnancies. There is an increased risk
The dose of anti-D given must be sufficient to
(lAn. Antibody levels are monitored by either other fetal vessels have all been reponed m women WI th a famil y history of djabet4i, a~-
remove all fetal cells from the maternal circula-
titration or quantitation. Once the titre eXceeds (Divakaran et al 2001) . sto of estational d ' c~
tion. The Kleiliauer-Betke test, which identifies
hypen eosion, e ore pregna;cy, older
.- cytv-(,o~ ~~ ~\­
~~ ~AAhj l~ 1~, D'''_ _
~I.U'< ~ \. '"
. ., .1' """"""",I ( L ~
Ct'l1 I 1M~",,\ ~"""'- f
CJI'vt q.), ~~'" :L L'f"), '7 ~
I
Women·s health: a cor e curricul um
9 Medic al diso rders In p regn a ncy

maternal age, a previous magosgmjc infiJlt or develo ~ment of raised baemnocri r wd neopalil' Diagnosis
Wlexplained fetal demise. Some ethnic groups (e.g. hi'Perb'irubinaemja. _ nn a!jties in babies of WOmen wi th pre-
indigenous Australians, Pc:!:::an and Indian Admissions to neonatal intensive care WlitS If a screen test is positive, a confirmatory test is pregnancy diabetes. In all women with abnor-
women) are at pamCularly ~sk of developing occur more ofren and perinatal mortality is reqUired. Common diagnostic testS include either: mal glucose tolerance in pregnancy, fetal growth
GDM. should be assessed clinically and by regular
increased. Neonatal complications include hypo-, • ~ 75 g glucose tolerance test that yields a fast-
glycaemia and hypocatcaemla, the latter bemg ultrasound to Identify growth restriction or
Ing glucose greater than 5.5 mmol/L or a
Pathophysiology attributed to reduced parathyroid hormone syn- 2-hour result of greater than J.-;nmollL
accelerated growth. Fr eks onwards,
cardlo" c a h , be er
Normal pregnancy is characterised by hyperplasia thesis. Compared with infantS of similar gesta- (Hoffm~ et al1998). A 2-hour cut-off level of ,as
9 mmo'!~ IS used in New Zealand. t ere IS an Increased rlS 0 sudden intrauterine
of pancreatic beta cells, increased insulin secretion tional age, infantS of mothers with diabetes have
fetal death. However, the cJinical effectiveness
and insulin sensitivity in early pregnancy, followed less surf~ctant production and are at increased risk • A 3-hour 100 g glucose tolerance test, taken
of thIS approach is not weJl established.
by a progressive increase in insulin resistance. of respiratory distress syndrome. after .overnight fasting and carbohydrate load-
Induction of labour rna be c ' red after 38
Placental diabetog~c bormones, such as growth mg, IS more commonly used in the United
States. wee s gestation In women with 0 0
hOnnone, progesterone and corticotrophin, lead Signs and sy mptoms tro e " , VI ence that peri-
to changes in maternal carbohydrate metabolism natal mortiih1y IS Increased in the presence of
during pregnancy. These hormones rise linearly A woman with gestational diabetes is usually Therapy
asymptomatic and diagnosed after screening for weJJ-controJled gestational diabetes.
during the second and third trimesters ill orCJef..u, Good glycaemic control is important in labour.
sup~owing ferus consrandy with sufficiwt the condition. Alternatively, she may have symp- '
toms of hyperglycaemia (polyuria, polydipsia) or a Lower insulin requirements are common in
n~ - glucose and am;;o ac~. The mot.Mr labour, and hypoglycaemia should be avoided.
~ from carbobydiaL tg _ w!:!abfjIWTI, large-for-gestational-age ferus.
Elecrroruc fetal monitoring is advisable.
utilisinr. free fatty acids, triglycerides and ketones Close neonatal fo Uow-u is iill artant arti-
Screening
fanue . .
~rmal pregnancies, blood glucose levels fall There is controversy regarding which women
e a: or e eteenon 0 emia and
:.:,splratory stress syn orne. Breastfeeding IS
by 10-20% owing to ' increased storage of tissue should be screened and how to screen for gesta- acdvely eHEolliaged.
glycogen, increased peripheral glucose utilisation, tional diabetes. Some guidelines recommend uni-
decreased hepatic glucose production and fetal Prog nOSis
versal screening of pregnant women, and others
glucose consumption.
suggest testing only high-risk groups. Approx- Most women become euglycaemic after delivery
In estational diabetes, there is gr-eater insul ' ,
resi rure m sec e
imately one-third of women with gestational dia-
betes will be missed if risk factors alone are used to
as somatomamrnotrophic hormone produced b; ..
p~ Hyper ycaemia is associated with an the placenta has a short half-l ife.
. increase in maternal and fetal complications. The guide screening. Women with abnormal glucose tolerance
maternal same!.e of gestational diabetes include The optimum time for screenin is 24-2 have a 30-70% increased risk of recurrent gesta-
an mcrease risk of pregnancy-mdu ed hyperten- weeks' estanon, w en insulin resistance increases. tional diabetes, ,the higher rate being reported in
sion and preeclampsia, premature delivery and t e present orne, ere is a ac of high-qu ty the non-CaucasIan population . Higher pre-preg-
caesarean seenon. evidence regarding important health outcome nancy weIght and a, hIstory of a large infant are
Women wuh pre-pregnan~ diabetes have an measures related to screening for gestational dia- assocIated, Ith an Increase d risk of recurrence.
increased risk of fe@ congen! abnormatities, in betes. The Australasian Society for Diabetes in The nsk of developing type 2 diabetes meJlirus is
particular cardiac detects and neuraJ rube deteers. Pregnancy (Hoffman et al1998) recommends uni- up to 50% over the following 5 years. There is
Later UiItuences on me tHus depend on the degree versal screening. emergrng eVidence thar the incidence of obeSity,
of maternal hyperglycaemia. An oral glucose challenge test performed at insulin reSIStance and diabetes is increased in the
FetalJlyperglycaemia stimulates hyperinsulin- offsprmg.
24-28 weeks' gestation is used to screen for gesta-
aemia, which leads to stora e of excess energy and
aces erate gro . S IS maru es S as mago-
tional diabetes. Two variations are described with The
W~)[Denla
2r~~, ~~~endati~~ f screen
~: f VEt; : pbetes -at
positive resultS:
somla, With resuTting increased rates of shoulder 6 weeks postpamun and ths! rg cgntinue to
dystoCla. and birth trauma. • a serum glucose level greater than 7.8 mrnoVL section screen tor diabetes at least every two years
Polyhydramnios IS caused by hyperosIDplar 1 hour after a morning nonfasting 50 g glucose (Hoffman et aI 1998). Women who have had ges-
fetal 01 ria and may precipitate reterm labour. load tational dIabetes should maintain ideal body
e mcrease c rate an 0 en • a serum glucose level greater than §Jl. mrnoVL Fetal monitoring weIght and exercise regularly to decrease the risk
requirementS may partly :=rlain e !perease risk 1 hour after a morning nonfasting 75 g glucose An ul of future diabetes , There is no strong evidence that
or llltrauterme asphYXla:tiey also lead to tlie load. gestational diabetes predisposes to a later risk of
hypertensIOn.

I'F
9 Medica l d isor d ers in pre gna nc y
Women's hea lth : a c ore curricu lum

accompanying evidence o f maternal cerebral, but once preeclampsia has begun it runs a pro-
Contraceptive advice should be given in the Type of Characteristics
renal, hepatic or clotting abnormalities, or fetal gressive course until delivery.
puerperium, and women should be advised to hypertension
De !l~VO trt~2ttitl§I~!l arlsln~
growth r estriction.
plan future pregnancies with careful attennon to 1. Preeclampsia Clinical assessment
Offer 20 weeks' gestatlo n, In developing countries, preeclampsia remains
good pre-conception blood glucose controL rmorl'Hng Fo normal within 3 one of the most common causes of maternal death Preeclampsia is detected initially in most cases by
monmspoi!Od@tD and a common cause of death in young women. the presence of hypertension arising after the
and ane or more or: Death may occur from acute hypertensive crisis, 20th week of pregnancy. It does nor occur before
Health maintenance p~a - ~3()() mg/dafr
spat urine albumln:creOflnn e
mkam£Ti' acute pUiIDOnary~edema, acute
ure, 'ver failure, haemorrhage or co::.:a~,."
o _ __
the 20th week, except in the rare case of hyda-
tidiform mole. S~s are not always present,
In women with diabetes mellitus, nor-
ratio (ACR ) ~30 mg/ mmol or but may comprise severe headaches, convulsions.
malisation of blood glucose levels d ipstick proteinuria persistenHy
Ii'i1Iie developed workI; maternal mo .ty is now
before pregnancy reduces the risk of uncommon, although occasional cases still occur s~e, re eated visual scotoma (all manifesta-
~3 gIL
fetal congenital abnormalities and despite the best possible management. Perinatal tions of cere r lnvo vemenc), severe epjga§qjc
facilitates optimal control during Rena/Insufficiency - pl~ or right upper quadrant pain (reflecting hepatic
creanmi'ie ~1;I!l ~ mollL mortality is of the order of 20-35 per 1000 cases.
pregnancy. Identification of abnormal ischaemia With pOSSi ble subcapsular haematoma
glucose tolerance in pregnancy ~as Uvw distiase - AST >50 IU/L
and/or severe epigastric/right of the liver or even li ver rupture), ~ (due
lifelong implications for a woman s to acute renal failure) , bleeding ~use d by dis-
upper quadrant pain
general health. se minated intravascular coagu \:tion (DIC::) ,
Neurol0fl.'cal Qr51~b2~i- -
convulsions (eclampsia); lower abdominal ~ain ca used by abruptio-pTa-
hyperrenexla with clonus; centae" re duced G I wgyemen n or fetal denuse.

*
S' g hegdgches with hyper- -rIi'most cases, however, clinicians must search
re for evidence of maternal or fetal abnormalities in
Hype rtension Haema/olog/cal dlsturbances preeclam psia. Routine h sical examination
0 : sho uld include assessmeot 0 e 0
haemo~
Common clinical presentations fe e ra e, e etecnon a epl!lastric or ri~t
2. Gestational De nova h~ensl o n after
A primigravida presents In the antenatal clinic upl'er quaarant tenderness, and assessment ott:e
hypertension 2 weeKS' eSlanon~ 1
at 36 weeks' gestation with 0 2-<:1ay history of a~...QI!'Ler eature o f
multi Ie re an connective tis- reflexes, parucUlariy Identification of clo ous as a
headaches, a blood pressure of 160{1 05 and preecfgmgs o , re~ sue or ers a esl ear re ancy sysro c P warmng SIgn of unpendlOg eclampSia.
2+ proteinuria . no rmal wtthln 3 months post-
p~
> mm g, ck race an pass! m
boptlilias. Smokiflg appears to reduce e llkeb-
om- In general, only a few laboratory tests are
required for the full assessment of preeclampsia
Two days after a normal delivery of her second
3. Chronic h15tcr01' developing preeclampsia but babies of (Table 9.2). Fetal growth is best assessed by
baby, a mother feels nauseous and unwell,
and proceeds to have a tonic clonic seizure. hypertension smokers tend to be small for gestational age. Test Significance
a . EssenHal BP ~ 140 mmHg systolic and/or Underlying renal disease also increases the risk
A 38-year-old woman with chronic high blood hypertension ,,90 mmHg diastolic ~ when there is preexisting r enal impairment, Hoemoglobln Haemolysls: bleeding
pressure o n antihypertensive medication wants ceoti on or in the nrst half of Hoematocrit Haematoc rit , 0.40 renects plosma
hypertension or proteinuria. The placenta appears
to know what medication Is safe to take during pr~rran<N' W1TI'!a ar- volume contraction
en secondar1§use or evi- to be the culprit in causing p reed ampsia, with
pregnancy. dence of WHire:coar hyper- other maternat organs such as the kidrieys perhaps Platelets Platelet count < 150 x ]09 is abnor-
tension mal, probably due to Increased
being amplifiers of the disease process.
plotelet ocHvatlon
b . Secondary H~Cill!ilgll gl.li! to renal or PreeclamJsia is characterised by the patho-
Creatinine Plasma creoHnine ,,90 ~mol/L
hypertension a renal d isease physiologic triad of: reffects Impaired GFR
Definitions TABLE 9.1 Cla ssific ati on system fO I h y pe rten - Uric acid Plasma uric acid ~0 . 35 ~mol/l
H ypertension occurs in about 10% of pregnancies sive pre gn an c ies renects Impaired rena l tubular func-
and is defined as an absolute blood pressure Hon
greater than or equal to 140/90 nunHg. It IS clas- Hypertension in pregnancy Aspartale AST , 50 IU/L Indicates hepatic dys-
sified as follows (see also Table 9. 1) : function in preeclampSia
The development of elevated blood pressure after Proteinuria A s~gt wlgmlilgW Utig~ cltu Ig;tir;n:a:e-
• arising de novo during pregnancy (gestational 20 weeks of pregnancy without evidence of mat- atinlne ratlo e Fn~~
hypertension or preeclampSia) ernal organ dysfuncti on is known as gestational creQflHioe In I
• present befo re pregnancy (chronic, usually teln excreHon.
hyp ertension . Preeclampsia also refers to hyper-
essential hypertension) . TABLE 9.2 Laboratory In v e stigation of
tension d evelo ping in the second half ? f preg-
• preeclampsia superimposed on chrom~ hyper- p reeclampsia
nancy, but this more serious disorder . mcludes
tension.

lit
Women's health: a core curriculu m
9 Medical dis o rders in pregn ancy

ultrasound, and fetal wellbeing by a combination • inability to control blood pressure in a subsequent r.re~ancy. Women who have
oTCaraTotocography and ultrasound assessment of inadequate letal grgwth. presented at or beor?S weeks of gestation may Health maintenance
bio~:fiKal profile and utenne mea resIStance. It have a highet risk of recurrence. Early presentation for antenatal care
slio be stre sed that none of the assessments of AntihYJ1ertensive m edications are usual ly
fetal wellbeing provide any long-term certainty given if e systolic blood pressure IS persIs- . The traditional view has been that preeclamp- facilitates identification of chronic

about fetal outcome. tently ~ao mmHg a1lti


Oi diaseotOmSl!re
~o mm g, aIthough t~ choice 0 the exact
sIa IS not assOCIated WIth long-term health risks for
the mother, although gestational hypertension _
hypertens ion and risk factors for
development of preeclampsia .
Regular antenatal care allows early
blood pressure level at which treatment . is particularly when recurrent - prediCts a greater
Eclampsia likehhood of later essential hypertension.
detection and management of the
required remains controversial. For such chronic often asymptomatic hypertensive
treatment, several agents may be used, However, it is now thought that long-term cardio- disorders of pregnancy.
including methyldft};a, o~re nolol, labetalol and vascular and cerebrovascular risks are increased in
clonidine as hrst- e agents. ~ hen addltlonal women with preeclampsia or geStational hyper-
treatment IS reqUIred, hydralazine, nifedipine or
prazosin may be added. Angiotensin-converting
enzyme (ACE) inhibitors, angiotensin II (~
receptor antagonists and ~ are ~y
tensIOn.

Gestational hypertension * Thromboembolic


d isease
a~ the first two groups cause a fetal
hypotension syndrome and diuretics reduce an .- Common clinical presentations
already impaired maternal blood volume.
HELlP syndrome Blood pressure ~170/110 mmH re uires acute
A 33-year-old woman presents at 34 weeks'
gestation In her third pregnancy for routine
HEllP syndrome (haemolysls, elevated liver treatment er to revent mate oke antena tal review. During the consultaHon she
enzymes and low platelets) IS a subcategory of an~r e ampsla. IS setting, in~s complains of a swollen . sore left leg. .
preeclampsia. Although sometimes regardedas a hy r azme or mtravenous labetalol are most com-
separate entity, HELLP simply refers to a severe mo@y used. o@ IiiJedipme 15 al 0 usefUl. One week after an emergency caesarean
form of preeclampsia in which the hepatic and MagnesIum sulfate is the dru~hoice for section under general anaesthetic for fetal '
co nvulSion prophylaxis. It is a stered to distress. a 25-year-old woman presents to the
platelet abnormalities dominate. Clinicians should
continue to look for all the other potential those \~omen who have already bad a conYUl- emergency department with breathlessness.
complications of preeclampsia in such women. sion an IS otherwise reserved for women who A 34-year-old woman presents to her general
have severe ttIfi'ptomatic preeclampsia, hyper- pracHtroner for advice about her next preg-
Prevention ~Ia or 0 er diIIj@ evidence of cereOraJ Chronic hypertensio n nancy. During her third pregnancy, she was
involvement. d iagnosed with deep vein thrombosis and
Unfortunately no set of tests has reliably predicted In most cases, this is due to essential hypertension treated with low-molecular-weight heparin unNI
the development of preeclampsia. Low-dose a.nd, unlike preeclampsia or gestational hyperten- 6 weeks postpartum . .
Postpartum m anagement
aspirin reduces the risk of developin~reeclamp­ ~I~n, It IS apparent in the first half of pregnancy. It
~ but apprOlamately 100 women ne thiS treat- Recovery should be anticipiued over 5-7 days fol- IS unp ortant to exclude 'white-coat' hypertension
ment to prevent one case (Knight et al 2000). It is lowing - delivery in most women. OccasIonally, with 24~hour ambulatory home blood pressure
best reserved for women considered at highest panents may take up to 3 months for all the fea- Thromboembolic disease encompasses thrombot-
morutormg before making a certain diagnosis of
risk; such as those who have expenenced a tures to resolve, and a few patients will have essential hypertension. IC events (deep vein thrombosis - DVT
generally of the lower limbs, superficial throm~
~ious fetal loss due to preeclampSIa or who proteinuria that takes up to a year to disappear The main risks of chronic hypertension in
have prevlOus0 re;i1llred very earty de!ivery completely. pregnancy are : bophlebitis and thrombosis of other venous
because gf t hiS g]wrWr - systems such as hepatic or portal veins) as well as
As~s~~~~~~~~~~~~ fetal growth resrriction embolic phenomena, both venous and arterial
months os artum i ato . ressure
Treatment sh ave returned to normal within 3 months. • accelerated maternal hypertension (pulmonary embolus - PE, cerebral and other
If it oss not, t s s ou prompt a seare or • superimposed preeclampsia (in about 25% of end-artery systems). This chapter discusses only
underlying essential or secondary hypertension. cases). DVT and PE and their relationship to pregnancy.
Urinalysis and urine mjcroscooy should be nor- P~on= embolism is a mabor cause of
mal, certainly by 12 months postpartum, if not Wire ;! rnriljr;r, and bVi mdE are major
• progressive evidence of maternal gcva n dys- n
before. this is not the case, a pnmary underly- contributors to maternal morbidity. Pregnancy,
fu~ worserung renat or hepatic function, ing renal disease should be sought. DVT and PE are closely linked, as pregpancy is a
worsening thrombocytopenia, development of As a general rule, preeclamosia or gestational rothrom botlc state WIth an increase in coa 1-
neurological symptoms or signs hypertension will recur in about 15% of women [Jon actors, eVI ence 0 0 asmino-
gen activation, and impairment of yenous retur. p
..-
Women's health : a core curriculum
9 Medical disorders In pregn a n cy

in the lower limbs. Pregnancy may be associated Pulmonary embolism after consultation with a haematologist. Patients References and further reading
with other risk factors, imrnobilisation (hospitali- Without a c10ttrng tendency usually have postpar-
sation) and surgery (caesarean section). tum prophyl3.XJ.s but not necessarily antenatal Cousins L 1987 Pregnancy complications among diabetic
prophylaxis. women: revieW 1965-1985. Obstetrical and
Deep vein thrombosis Gynaecological Survey 42(3):140-148.

The prevalence of DVT is less than 3 per 1000 preg- Prophylaxis without DVT Divakaran TG, Waugh J, Clark TJ et aI 2001 Noninvasi ve
nancies. Thrombosis often startS in the calf but only techniq ues to detect fetal anemia due to .red blood cdJ
TbromboEfog,hv w with heparin in £!3!gpaocy alloinununizarion: a systematic review. Obstetrics and
thrombosis above the knee produces dots large mQ be o$r;;C;; ummen WIthOut a hiStory of Gynecology 98:509-517.
enough to create a significant risk of pulmonary DVT/PE who have a thrombophilia or possibly a
embolism. Alone, superficial thrombophlebitis in strong farruly hiStory. Some obstetric units offer Hod M, Orvieto R, Kaplan B 1994 Hyperemesis
the leg or thigh is unlikely to generate aPE. prophylaxis post-caesarean section for all patients gravidarum: a review. Journal of Reproductive
Medicine 39:605 .
DVT occurs with e uaI Ere uen in each whereas others offer this intervention only wher~
. ester but other rIsk factors coexist. Hoffman 1., Nolan C, Wuson JD et aI 1998 Gestational
Ri,tJ$..factors may h.e considered in two grQ'1PS: diabetes mellirus - management guidelines [consensus
DVTs occur in the e eg or ater y. is sug- ~le and a~le. The former include statement], the Australasian Diabetes in Pregnancy
gested by signs and symptoms that include pain, maternal age over 35 years, high Parity, ~: SocJ<ry. Medical Journal of Australia 169:93-97.
swelling, oedema, heat and redness. As swelling is a persona:t or £3illlly hiStory of throm1Josls, _
Knight M, Duley 1., Henderson-Smarr D], King JF 2000
common symptom in late pregnancy, it has poor bophilia syndrome or malor surgery. Av~e Ann·platelet agents for preventing and treating
sensitivity as a sole symptom. Unilateral or early- nsk factors that demand arrenoon indu~­ preeclampsia. In: The Cochrane Database of
trimester bilateral swelling should be taken seriously. ~n, Immobility, pree~lampsia and r;:,a~ok Systematic Reviews (rhe Cochrane Libtary), issue 2:
In re an there should I w res old Intercurrent liifecoon or Illness. Multiple ns CD000492. Online. Available: http://www.update.
factors fiiitlier Ihtrease an individual's risk of somvare.comlcochrane.
for eJ<! u n . iagnostic investigations are the
same as for non-pregnant panents except for the thromboembolism, and prophylaxis should be Langer 0, Conway D, Berkus M et aI 2000
value ot the D-difiler test: the D-diriier IS usuany cOrISidered. .
A comparison of glyburide and insu/in in women with
elevated In pregnancy and especially postparnun. gestational diabetes mellirus. New England Jourrul of
Ultrasound - usuaJIy compreSSlOn Ultrasound - is Heparin Medicine 343 (16): 1134-1138.
e Low-molecular-weight heparip is becgmipg tb e NHMRC 1999 Guidelines on the prophylactic use of Rh D
stanfod anticoa@l4iit used during pregnancy immunoglobulin (anti·D) in obstetrics. Online.
~a In the noo-pregnant state. It is..wgrs expell- Available: http ://www.health.gov.au/n/unrc.
slve 9ut regtllres little monitorin~and is assocj<u:-
Queenan J 1999 Management of Rh-immunized
ed .lYlth a reduction in the side eeets comwpolJl pregnancies. Prenatal Diagnosis 19:852-855.
seen~th untracoonated he~.e. o§.t eoporo-
~ om60cytog;rua and be . Symonds EM, Symonds 1M 2004 Essential obstetrics and
gynaecology, 4th edn. Churchill Livingstone New
~~ ,

The risk ot thromboembolism is


increased in pregnancy. cabi mu,st
b~ laken 10 address avoid a e
tacrg!s such a s immoclIi$gfj on,
Inre li on and dehfcdrallon, which
p rdmo te venous s asis and platelet
activation. Prophyl axIs should be
consIdered in indivIduals c onsIdered
at Increased risk . There shOUld be a
loW IhresMold for Inyestjggljpo pf
venous I romboemboJism a n d
prompttrealmen t .
...

It..
Women's health: a core curriculum 9 Modic al disordors in p reg nonc y

Questions b , Is managed with


iron per day -
¥a mg elemerJ.Ial
~
@ n creases perinatal morbidity .,/' 11 , Therapy for pulmonary embolus In
d , can be prevented / pregnancy:
Select the correct answer(s), 12\15 characterised by low seru n V '
r;l associated with an increased a, is commenced using ther;!lpeutic
1. Which of the following are Important In V ferritln, ~aesarean section rate, -V'" doses of warfarin ./
the investigation of severe hyperemesis d. commonly causes a macrOcyti /
gravidarum? /. anaemia 9, Preeclampsia: /
@ AurinedipstiCk examination ~~ _ e. is associated with increased fetal a, is characterised by convulsions ./' c. itially involves intraVenous / '
(§) Haematocrit ./' ~M-~",",) loss , b, should be treated with aspirin in all . /
unfractionated heparin

(9 Thy roid function tests ~\RI"~roJ(!"", \so


patients d. always requires the addition of a / "
Which of the following statements
d. HCG estimation /' regarding isolmmunisation is true? Pc\;s defined as hypertension plus . / vena caval filter

G
~~I _
An ultrasound examination VI""""\J#J'f,
, W-Qol(.) Ib.\AII Rh(D)-negative women should
I V have their red-cell antibodies
/ \ : Iorgan Involvement In pregnancy
e . with heparin puts the fetus at risk as ~
d, is always associated with growth./' It crosses the placenta.
2. Which of the following are recognised
checked at 26-28 weeks' gestation , / restriction of the fetus

complications of hyperemesis b. h(D)-negative women who have o n e . can be safely treated with ACE / 12. Thromboprophylaxls in pregnancy
ectopic pregnancy should be given .' inhibitors. should be:
gravidarum? /
Rh(D) immunogobulin,
a Dehydration 10, Deep vein thrombosis In pregnancy: a , offered only to women with a history"'"
. V c, A woman who is Rh(D)-negative / of pulmonary embolus
esophageal bleeding (with no red-cell antibodies) and \AcXPa, occurs in 1 in 100 pregnancies ../

~
, Intracranial bleeding gives birth to an infant who is Rh(D)-
b. is diagnosed with D-dimer ../ ered when there are multiple ris k /
... positive does not need anti-D
immunoglobulin, fC:I may be treated with low-molecular· , / '
,""w eight heparin c.
f ctors
Iv en to patients with a ./'
d , If an Rh(D)-negative woman's ./'
hrombophilia syndrome ../'
partner is Rh(D) positive, the babY"" d, is always associated with a .,,-
3, Physiological anaemia of pregnancy: wil l certainly be affected by HDN . thrombophilia syndrome ~ @ With SUbcutaneous heparin
a. esults from Increased plasma ./' e , he disease process is likely to be e . is treated for 12 weeks w ith w~. e, with low-dose warfarin , ./'
olume more severe if a woman has had
b, results from decreased RBC mass . /
antibodies In her previous
pregnancy,
~~ b~~
c. is greatest at term /'
7, Gestational diabetes: ~\\) f- V/~'f\ \J ~~ r,
d, results from decreased plasma
volume and Increased RBC mass
/'
a, occurs In 25% of pregnancie J ~ ~'\\- _(u-Avw- '
G )esults from decreased iron stores, """ ( 9ma y recur in subsequent .,/'
pregnancies
4, Microcytic anaemia: 01ncreases the risk of preeclampsi /

~
a. results from low vitamin B12 . / f treated, Improves maternaY-
urvival
b. has an MCV >100 fL '/ ./'
, ccurs more frequently in women /
c , requires further Investigation with
with a higher body mass index . /
serum Iron and Iron-binding
before pregnancy.
capacity ~i\."V\ ' .
d . esults from Iron deficiency ,./"/ 8. Abnormal glucose tolerance during
pregnancy:
e, causes significant fetal morbidity,
~ccurs because of increased ins;:!Ln
5, Iron deficiency in pregnancy: / ~(eslstance V
a, results from increased maternal RB @ ncreases the risk of later type 2 ./
mass diabetes '"

ItA
Infections in pregnancy
Michael Humphrey and Ajay Rane
Edited by Vivienne O'Connor

Learning objectives
Knowledge Other infections
summarise the eHects of other common
At the end of this chapter, the student infections on the mother and fetus/
will be able to: neonate
• discuss the time sequence of fetal • outline the diagnostic procedures for
organ development In relation to each infection in pregnancy
possible teratogenic Influences
describe available tests to confirm fetal
Rubella Infection
describe the consequences of maternal outline management options for each
rubella Infection in pregnancy Intection
discuss the Importance of pre- Chorioamnionitls
pregnancy counselling, antenatal
screening and primary prevention by oulline the aetiology of preterm
vaccination prelabour rupture of membranes and
preterm labour
Hepatllts B
list the common causative organisms tor
list the modes of transmission of chorioamnionitis,
hepatitis B
• describe the consequences of maternal Skills
hepatitis B Infection
At the end of this chapter, the student
• describe the serological tests for
should learn how to:
hepatitis B
• outline a management plan for an • explain to a pregnant woman the results
infant at risk of hepatitis B of rubella and hepatitis B antibody
screening tests
Urinary tract Infection
instruct a woman how to collect a
• state the significance of urinary tract midstream specimen of urine.
infection (UTI) and asymptomatic
bacteriuria in pregnancy
explain the predisposition to UTI in Attitudes
pregnancy
At the end of this chapter, the student
describe the clinical and should reflect upon:
microbiological diagnosis of UTI
outline the management of UTI in the maternal anxiety engendered by an
pregnancy uncertain prognosis, particularly when
tetal or neonatal infection may not be
• list appropriate antibiotics used for evident for several weeks after maternal
treatment of UTI in pregnancy exposure,

\ NV\ 'tf
10 Infecl lons In pregna nc y
Women's health: a core curriculu m

* Rubella
Common clinical presentations
Impact/outcomes
If a woman believes that she may have been
exposed to the 'wild' rubella virus in pregnancy, she
Time period
0-2 weeks
Susceptibility
High rate of lethality
Usually not senstlive
Events
From fertilisation to complete implantation of blastocyst
In endometrial stroma
Uteroplacental clrculo~on established
should have paired sera examined 10-14 daYs 3-8 weeks Organogenesis Embryonic development In a cepholocaudal fashion
A pregnant woman Is concerned because a a~ looking for a ch3llge in rubella IgM and IgG Rme of greatest susc epHbllity Susceptibil ity stgrts with ayes and brain , then movin
child at her doughter's preschool has a rash . antibodies (lgM rises 7-10 days after primary infec- ac1 ; Ss own peak o f towards lower limbs g
A woman discovers that she Is pregnant shortly tion). As laboratories may use different types of susca AgePifS causing serious defects Include viral Infeetons
rubella antibody testS (enzyme-linked immunosor- qlcohol, maternal diabetes, med!cgt1ons '
after being vaccinated against rubella.
bent assay - EUSA, haemagglutination inhibition 9-40 weeks FunetonaJ maturation Fetal development can be affected by agents such as
and immunofluorescent antibody assays), it is wise Suscepltblllfy decreases alcohol or clggrette products
to test the paired sera together in the same labora- Effeas depend on dose a nd duration of exposure
Epidemiology tory. Rubella immune serum globulin does not
TABLE 10.1 Fe tal susceptibility to damage during development
appear to be a useful post-exposure prophylaxis.Jn

*
Rubella is a ribonucleic acid virus causing a
v ess assoaate Wl a e macular the event of a s~cant rise in rubella antibodIeS
rash. It commonly occurs ill childhood but can withill the fuSt lU weekS of Dreftang.. termina- inf..:,cnous Datie ; the patient with chronic he~t Uri na ry tract infecti o n
tion of pregnancy shoUld be offete to e woman. ons~d the pL-ant woman most likelY to q~_ s-
cause fetal abnormalities if it occurs in a woman at
less than 115' weeks' ~estation. Vaccinaoon IS usu- IDlt the mfecnon to her baby. Vertical transmission
Cammon clinical presentations

*
a1.Ifcarned out ill ch dhood. While rubella vacci- IS less likely when the anti-HBe antibody is found.
nation should be avoided during pregnancy, the A pregnant woman presents·with high fever. dysuna
recorded cases of accidental vaccination of women
He patiti S B Impact/outcomes and frequency, rigors and uterine controetons. .
in early pregnancy would suggest that the li:ts. Infection may produce a variety of clinical states A pregnant woman has recurrent urinary tract
attenuated virus in the vaccine is not teratogenic. varymg from ~ severe systemic icteric illness t~ Infections ond is found to have asymptomatic
A pregnant woman is found to be an asympto-
asympt0m.anc mfection, and resulting in a spec- bacteriuria.
matic carrier of hepatitis B. raising questions of
Pathophysiology trum of disease from full recovery and long-term
possible transmission to her baby and to
If a maternal viraemia occurs during the first mununlty to progressive liver damage and an
health core professionals.
a'ii'esrer of pregnancy (viraemia occurs 5-7 days mfecnve carner state. It does not a~pear to be ter- Pathophysiology
after exposure), there is an approximate 20% risk of ato!';1ms but fetal loss can occur, as WIth any other Urinary tract. infections are more common in
feb e I.llness 10 pregnancy. women than m men, owing to the shorter female
rransplacental fetal infection le a $ ous=ge Transmission of this deoxyribonucleic acid (DNA)
or to one or more con*,erutal ab~tles. r he"fat- virus is predominand;l via sexual or blood (via urethral length, whIch makes bacterial contarnina-
ter may IOvolve eyeJectS leadiIlg to vision loss,
Management non of the urethra and bladder a common occur-
injecting drug use) contact and by vertical trans-
hearing loss, cardiiC"defuctS, intellecruafdI.Saljility N~wborns at risk of vertical ttansmission of he a- rence With sexual activity. The majority of urin
mission to the neonate. tract mfccnons are due to Escherichia coli ary
and befui'y!ouraI abn ormalities (the congenital tms B should b$ Efven nepanps 1$ Iwwppe glbb-
rubella syndrome). iVGteu"r jofectjoo in later uIin (HEIGl within 12 hours of birth and a The combination of decreased ureteri~ muscle
Diagnosis
pr~ ns;y has a lower incidence of fetal problems, subse uent course of active he and s Bva~cination tone and peristalsis, altered bladder tone and
e.g. thrombocytopenia and vasculitis (the expanaedThree antige,!).s are measurable in ass~ation with shou e commenced wit lD o ur mcreased bladder capacity (due to the high levels of
congenital rubella syndrome). The maximal risk to.the hepatitis B virus: the ~ (HBeAg), the b,fuE; Breastfeeding is not contraindicated under progesterone and rela.--..:in. in pregnancy and to
the fetuS occurs in the ~t weekSif§,~:cy,
8 core antigen (HBcoreAg), and the surface antiv.en m ese CIrcumstances. uretenc compresSIOn by the gravid uterus at the
ana armost
is nonexistent1)x 16 weeks~ gesr;r;ox;.(HBSAg). pelvIC brun) leads to u . stasis and vesicoureteric
A positive test to the surface antigen (HBsAg) reflux. Conse uencl , e re ant wo gil
Signs and symptoms denotes ~t or present contact with the virus, and nsk
tra .
of bo tomatIc an .
c~
.
the anti-HBs antibody is found m unmune and Universal. vaccination programs should
Infection with the RNA rubella virus usually pro- all but eliminate congenital rubella
immunised individuals. Unlike the HbsAg, which is
duces a mild febrile illness with a fleeting rash and are of major importance in red'uc-
associated with the viral protein coat, the e antigen
1~-14 days atter exposure. 109 the Impact of hepatitis B on the Signs and symptoms
(HBeAg) and the core antigen (HBcoreAg) are asso- neonate. Pre- re non e vaccination
ciated with the viral DNA The H&oreAg is USIl- Presentations vary from a severe febrile illness with
Natural history sh re
alll. confined to infected hepat~and is rarel.Y and wom ilistrertebral angle and suprapubic tenderness to
lmmuni follow io a rubella infection is u uall found in se~ and the ann - core antibody is tQ..Cllbe lla dl!rj o g pregnancy should be e . ncling of SIgnificant bacteriuria in an asyrnpto-
~e ong..an c · 00 vacclOanon programs are usuaJ]y the ~o appear in an infection. The find- offered postpartum Immunlsaft on. manc mdivldual. The most cornmon presentation
ing of ~Ag in serum often denotes the h.ig];!Y
e most cost-effective means of preventing the consiStS of frequency, dysuria., urgency and nocturia.
congenital rubella syndrome.
Women's health : a core curriculum
10 Infections in pregnancy

Diagnosis * Varicella zoster virus VZV =q~~ in the Seriparrum period sho!!ld
begixen
eriCOUraged.
va
and reastfeeding should be * Cytomega lovirus
Common clinical presentatio n

*
A pregnant woman who Is not Immune to
varicella zoster virus has Significant contact A pregnont chlldcare worker asks about the
with a child who develops the rash of chicken- Pa rvovirus 8 19 consequences of contact with a child Who Is
pox 1 day late I. known to Chronically excrete cytomegalovirus
In her urine.

Management • A fetal death, secondary to the development


Treannent of any pregnant woman with UTI should Pathophysiology of hydrops fetalis, occurs after a minor mater-
nal febrile illness. Pathophysiology
include advice about ~ fluid intake .and ~ The varicella zoster virus (VZV),. which causes
Ce~ (250 mg or y 6-hourly), ~­ chickenpox and herpes zoster (shingles), ~ Cytomegalovirus (CMV) is a member of the her-
toin (50 mg orally 6-hourly; best tolerated rn the risks for both the mother and the feros if infeCtlon pes virus group and is the virus most freQuemly
~olide form) or amoxicillinJ~otasSlUm clavu- occurs dUTIn¥ pregnan~ The usual rncubauon Pathophysiology transmitted to a feI!!S. Illf.;,crious CMv max.,be
l~te.J.2501125. mgoratiy 8-houry) are the most penod IS 10- 4 days, Wl infecoVIty lasont.from. Infection with parvovirus BI9 causes a cornmon fo~nd in wine" s~~ blood, := sem,!!1 and
app ro~riate anoblOocs, and should oe contmue~ 1 to 2 days before the rash appears un@ an esions childhood febrile illness known as fift breast mill<, and rh s eddiiiiOf ~rus may rake
for at east 10 aay:;. 1 fie rising i denc; of E. co!t
reSIstance to amoXlcillin makes an rnappropn-
ate anoblooc to use ruane, UDJess the orgarusm IS
known to be sensitive. .
-
are crusted.

Im pact/outcomes
e
drome .
ema infectiosum or s a syn-
orne rop et spread leads to symp-
toms 4-20 days later and, classically, the illness
place Intermittently, WltbOiltanY detectable si,l2!s
and Without causing symptoms.

Symptoms and signs


PregIlant women presentin~ with a seve(e febrile lasts 1-3 weeks wjth a cbamgerjsdc rcd ra§h l1fi
. ess and ossible sepocaerrua sha uldlJe treated the cheeks and a lace-like rash on the trunk au
d
m rn a lliiiEs that may tade and reappear. Up to one-third
oTaaUits with this infection are asymptomatic,
Diagnosis
Parvovirus B I9 IgG and IgI\1 antibodies measure-
ments will show a rise in titre in the presence of
infection.
-
Impact/outcome
Primary CMV infection occurs in 1-3% of ~regnant
Management wmIlen. andis US~y asymptomatic. It IS, owever,
Impact/outcomes the most impoltan use or COD enital viral infec-
No treatment or vaccine is available. .' . 4 ecnOlL ~
Subsequent to the sue
in
shoul
e
esta
a ro am of re
e
eatment of UTI dur-
Management Outcome /impact
risk 0 e
infectiog maY lea to a gene
rh~ wirh an SAM nsk 0 compllcat1ru16
'7
infecoon in

recurrence . A varicella-seronegative pregnant wOII,lan \1{ho within the first few years of life, Indu~ h~g
"'OC'CaSi'onally, recurren! infectjQn~ make propby- has a sl .{icant e osure to VZV mEe ~ISlOn = M!tm@' and vatyJ,ng degre_ of=---
laxis a~ODriate Wlth rutrofurantorn (50-100 mg s ou e oHered zoster unmune J? 0a (ZIG) tal retardation. Alternatively, rhe infant may be
oraJIy ~ynor dle remamder of tln!-pregnancy. within 72 hours of exposure. Varlce a~se~oneg­ ~ with no symptoms at birth, and subse-
atIve pregnant women who have a slgmflcant quently may deVelop hearing and mental or coordi-
Health maintenance exposure to VZV and do not receive ZIG, or nation problems. There appears to. be little risk of
who have risk factors for severe adult dlsease, CMV-related complications for women who have
The association between urinary tract should be considered fur prophylactic Ora ', ac:y-
infection and preterm labour is been infected at least 6 months before conception.
c~ Pre gnant women ;to ,develop yap cella
sufficient to warrant mlcroblolo~ical
examination of a midstream urine pneumonia Qt.p,her compcatlo ns of VZV (e.g. Management
specimen in the event of any urinary ha1iTIorrhagic rash, neurolOgical SignS) s~
sympfomatology. Asy,!,pton;atrc ge offered intravenous a9,c1ovlI, as sh,?uld preg- In rhe event of a CMV-specific antibody rise in a
bacteriuria should be Identrfled of fhe nant wo men receIvmg systerruc comcosterOid pregnant woman, amniotic fluid viral culture and
first antenatal visit. therapy who develop otherwise uncomphcated fetal blood antibody testing have been used to
VZV infection. Babies born to women WIth attempt to diagnose fetal CMV in fection, but nei-
ther test is reliably accurate. &, more th::~ 50% of
Women's heallh: a coro curriculum
10 In fe c tion s In pregnanc y

feruses are unaffected by intrauterine infection and


there is nQ known curative or pr0;fjylactic treat- is appropriate; clindamycin 600 mg intravenously,
men;, tegrlinaoon of pregnanCJ:, in e IDscance of given slowly 8-hourly, can replace the amoxicillin
pnmary maternal infection is controversial. and metronidazole in women hypersensitive to
penicillin.

* Toxopla smosis Outcomes Ur ent delivery of the baby should be consid-


ered: vagill IS e, as caesarean sec-
nonin ese CIrCUmStances may lead to serious
intraperitoneal sepsis.
Common clinical presentation
A pregnanl velerlnary nurse quesllons Ihe
safety of conlacl wilh cols. Symptoms and signs
These may include maternal fev" and/or
~ fetal tachycardia, uterine pain and ten _
:jJt: Health maintenance
Women known to be at risk of giving
birth to a baby with GBS colon isation
Pathophysiology ~~ Pf'~ labour and ~ or puruJem shOUld be treated with intravenous
amn10_ -- . ---- antibiotics In labour; potentially this
means thai 20-30% of labouring
DiagnOSis women will be exposed to antibiotics,
with the ~Isk that this Will lead to on
Full blood examination reveals a leuk~osis with a increase in the incidence of antibiotic-
Ma nagement neutroph jlia, and a cervical swab reve .targe num- reSislant bacteria .
bers of le~~es and pathogenic pacteQ!!, with an
Treatment of the carrier State is not successful absence? Ctobacilli. Occasionally, microscopy
in eradicating the organism. The incidence of neQ- and culture ot ammotic fluid obtained by amnio-
Impact/outc ome ?x
natal disease is sigpificantly reduced iprr3P?,!,J?" centesis may be needed to confirm the diagnosis. Further reading
anti blogCi : intravenous Gasta"we pe pJCdhn
2 x 106 u, followed by 1 x 106 U 4-houdy until Impact/outc ome Freij B], South MA, Sever]L 1988 Maternal rubella and
dslli:;ry; or clinctamycm 906 mg 8-hourly or e:rytli-
the congenital rubella syndrome. Clinics in

Prevention
rornycin 500 mg 6-hourly in the event of pemcillin
hypersensitiviry. In the absence of a rapId dia!;00s-
tic test, the current a roach to the use of
seS emia ~ the feros, preterm
ae
r
Chorioamnionitis ma'y cause pneumonia and/or
and ~I;I,­
septicimia in the mgther. ere is eVl ence
that chorioamnionitis i a risF factor for cerebral
Perinatology 15(2) :247-257.

Heuchan AM, Isaacs D 200 1 The management of varicella-


zoster virus exposure and infection in pregnancy and
the newborn period. Australasian Subgroup in
parrum antiblottcs IS to treat orne whose
• The mo$u is at risk of significant postpar- Paediatric Infectious Diseases of the Australasian
babIes are at en n reterro labour.
rum endomC1J1!J!;" Sociery fot Infeerious Diseases. Medical ]oumal of
prolonged ru&; rure of membranes, kndWIi CBS car- Australia 174: 288- 292.
~ fever ill our).
Managem ent Vierorian Medical Posrgraduate Founda tion Therapeutics

* Group B Streptococcus * Chorioamnionitis


Aggressive antibiotic therapy is used to treat Commicree 1997 (on behalf of the Vierorian Drug
Usage Advisory Co mmittee) Anribiotic guidelines, 10th
chi5noamnionitis as soon as the infection is diag- edn.
nosed, and the antibiotics should be continued
after delivery. A combination . of gemamr!;,in Wong SF, Chan FY, Cincotta RB, Tils. M 2002 Human
Common clinical presentation Some days after prelerm prelabour rupture of
(~day intravenously as a sin e dose), parvovirus B19 infecrion in pregnancy: should
amoxicillin (1 g mtravenous y - ourly) and screening be offered to the low-risk population?
A pregnanl woman wilh previously membranes and maternal fever, a woman Australian and New Zealand Journal of Obstetrics and
me2".oructaZole (500 mg intravenously 12-:hourly) Gynaecology 42(4) :347-364. . .
documented Group a Streptococcus (GaS) develops fever, abdominal pain and uterine
colonisation wishes to minimise her baby's risk contractions, and a fetal tachycardia develops.
of neonatal GaS disease.

Pathoph ysiology
Epidemiology
Between 10% and 30% of wo men are asympto-
ma~y colOlllsed With Group B Streptococcus mem ranS§,.

I"~
women 's health : a c o re cu rriculum

c, should have a caesarean section to


Preterm b irth
Questions minim ise the risk of vertical
transmission of hepatitis B Regina Wulf
Select the correct answer(s).
r'd.\h ould have a program of hepatitis
1. A woman who consults her doctor \.:.;..a Immune globulin and active __ Ed ited by Martha Finn
after discovering that she was hepatitis B vaccination within ..r
Immunlsed against rubella 3 weeks 12 hours of birth to minimiSe the risk
after conceiving should be offered: of vertical transmission of hepatitis B

a . termination of pregnanc/y e . should be given acyclovir during


labour to minimise the risk of
@ eassurance vertical transmission of hepatitis B.
c . paired rubella IgM and IgG
antibody titres 2 weeks apart 3. Urinary tract Infections in pregnancy
are common because :
d . an 18-week gestation anomaly
a. Immunity is reduced in pregnancy
scan Learning objectives
b . the glomerular filtration rate is
e . chorionic villus sampling. reduced in pregnancy
2. A woman who is HBeAg positive: c . the vaginal bacterial flora become Knowle dge describe the investigations to confirm
more pathogeniC in pregnancy the diagnosis
a. should be isolated from her baby at At the e nd of this chapter, the student
birth to minimise the risk of vertical d. reduced bowel mobility leads to an list the investigations to screen for
Increased Incidence of gram- will b e ab le 10 : infection
transmission of hepatitis B
negative bacteraemio outline a plan of management for the
Pre/erm labour
b . should bottle-feed her baby to
minimise the risk of vertical
~ inary stasis is increased in mother and fetus
transmission of hepatitis B V~egnancy. . / define preterm birth
• desc rib e the outcomes for the
discuss the importance o f prematuri ty to fetus/neonate .
perinata l mortality a nd morbidity
• li st the causes of preterm birth
Skills
discuss the diagnosis of preterm labour
At the en d of this chapter. the student
outline the investigations and sh ould learn how to:
management options for preterm labour
discu ss the role of taco lysis and Counsel a woman about the risks of
corticosteroids preterm labour and its management.
Pre term prelabour rupture of the
membranes (PPROM)
Attitudes
• define PPROM
• discuss the prevalence of spontaneous At the end of th is chapter, the student
rupture of the membranes and the should reflect upon :
prevalence in preterm births
• the significance of preterm birth for
list the causes of PPROM families and soc iety.
Women's health : a co re curricu lum
11 Pre lerm b irth

* Preterm labou r neoplasia) is associated with an increased risk of


cervical incompetence.
If the diagnosis is unclear but the clinical pic-
ture suggests threatened preterm labour - e.g.
costeroids is administered (two injections of beta-
methasone given 24 hours apart). Corticosteroids
Common clinical presentation trregular utenne contractions and lUldilated or
Consequences of preterm birth effacing cervix --:- prediction of labour is impor-
should be administered with caution to women WIth
A 25-year-old woman presents at 28 weeks'
The ma jor risks of pre term birth include ~ tant. One predicove test is based on detection of diiibetes mdlitus, as thIS may prec!pltate sliiIiificant
gestation with irregular uterine contractions .
fibronectin, a glycoprotein produced by the chori- hrer!ycaemla.
Her previous baby was born at 24 weeks' death due to eXtreme illlffiaturtty, and rejpiaatoD'
distress syndrome, as the lungs are un er evel- orne cells and released when the interface between ~ use of prophylactic antibiotics for prema-
gestation and died a few hours after birth. ture labour without ruptured membranes has been
Postmortem examination was not performed . oped and surfactant is deficient. The developing the chorion and decidua is interrupted, either
investigated in a large multicentre ITial, the ORA-
fetal organs, particularly the brain and bowel mechanIcally or owing to infection. Detection of
CLE II srudy (Kenyon et a! 2001). Although there
mucosal are susceptible to hypOXIa. III the late sec- fibronectin has a poor positive predictive value for
was a reduction in maternal infection, it failed to
Ond trimester and early thlrd trimester, the delivery within 14 days (less than 40%) bur the
negative predictive value is as high as 97% and this demonstrate any benefit Or harm with respect to
vascular subependymal plate below the cerebral neonatal outcome.
ventricles is particularly sensitive to changes in may be useful in determining the need to transfer oco! 'c ents su
oxygen tension, and these fragile vessels may bleed the woman to a tertiary referral centre. cated or tene
into the ventricles, causing ventricular dilatation on. ey are e to success e
and scarring. Developmental arrest of the rapidly Management
"CeniiCar dilatation' Or if preterrn
growing bowel mucosa leads to necrotising entero- Unfortunately, therapeutic agents designed to sup- I our occurs early in the second trimester. They
colitis. press labour have not been effective in prevention of may act by beta S)'ID"bathetic agonist activiry (salbu -
The preterm baby has relatively low stores of preterm bmh (delivery before 37 weeks' gestation). taIIiol or ntoanne), y reducrng myometrial inrra-
Risk factors fat and without this insulation is prone to The management of threatened pretenn labour is cellular calcium levels (calciwn channel blockers
~E.2:$S!l!;~' In the pre term infant, the tmmature therefo~e auned at prolongmg the pregnanCY to such as nifeclipine), by smooth mUScle relaxation
Preterm labour is preceded by spontaneous rupture stores, leading to ~ allow mne for adiIllnistration of corncosteroids (glyceryl trinirrate) or i.illiibition of prostai:landjc
of the membranes in one-third of cases. It is thera- to The mother. 10 treat [lJe undeclymg cause and to producuon (mdomeiIi'acin). Despite being predomi-
peuticall, induced in the maternal or fetal interest ow tr the mo er 0 e a cenITe. ~ta 2 agonises, the sympathetic agonises are
in another third (e.g. in the presence of hyperten- I" Suppression of labour IS con IT e owever assoaated WIth the severe maternal side effeces of
sive disorder or fetal growth restriction). The cause where continuation of pregnancy may prove dele: tachycardia, pulmonary oedema and myocardia!
of up to one-third of pre term labours is unknown. to mother or fetus, as may occur in the case infarcoon. Maternal anxiery, tremor, hypotension

~ir[ad~tion.
th~e~~~~~~~~~~~~:i~~~ 7
Women at increased risk of reterrn labour are placental abruption, chorioarnnionitis or fetal and hypokalaemia are also co=only experienced.

f:
those w 0 ave a distress.
Particular care needs to be taken if :; ~­
Cortico teroid adminisITation is desjgned to ex.l§pni condipoqs,. e.g. bearCdis or
a neonatal unit creates a distance between the promote fetal lun!! ma~:~~ stimplati on pf mulaple )lEegnapcy. Ntfedi~lDe 15 as ective in
mother and her new baby. Every effort should be ~veolar cells to prOOuCl' _ • __ t, a surface ten- short-term sugll~~~ ~ lour as nrod%ie "SUt
made to involve the mother in the care of her sLOn-[owenng agent, which will allow optimal lung wiailess severeJide ;ifern, and haS secom~ the
infant to promote bonding. expansLOn after delivery. Administration of cortico- drug of liiSt choice,
steroids berween 29 and 34 weeks' gestation has ."Women who present with cervical dilatation
Diagnosis been shown to halve the incidence of respiratOry dis- WIthOut utenne conrractions or rupture of the mem-
tress syndrome and its sequelae of neonatal death branes rna
and intraventricular haemorrhage. Steroids ar~ most ce
se consIdered for erne en cervical
e. owever, s carnes e ris 0 mem rane
ner to leon. beneficja! if delivery has not occurred wit h; 4~ pe oration and subsequent chorioarnnionitis if the
hours of adIl1iI1istratlOn or u~ to 7 days pOst-admin- cervix is very thin and the membranes are bulging
~ I here IS now evi ence that the use of through a dilated cervix.
repeated doses of corticosteroids can have the
ad~erse effect of .fetal. growth restriction, with up to Proph yl axis
25 Va reducoon m birth weIght, and reduction in
bram weIght and head circumference (National Preven= of prereun hju b is di ffi~ but e s
tion regarding a healthy lifestyle and pepmpr effrr-
Institutes of Health 2001). Myelination of pyra-
~dal ITaces and other myelinated nerves may be ave ITearment of iD1ecuon rnay play a role. In
Impatred. Insulin reSIstance may be induced and a w2IT?en who nave l1aa a hiStory conslstent with
reduced cortisol response at the age of 3 years has cemcaJ mcoms;renc(j ;r9ett!a$c cem@ cer-
been observed. Nowadays, a single course of corti- cllli e may be pegnne a U Q' 8esta~n, once
a live fetus has been visualised on ulITasound. In

'EE
11 Pre te rm b irth
Women's health : a core cur riculum

preterm PROM, as the reduction in amniotic fl uid The interpretation of an elevated leukocyte
women who have an increased risk of cervical restricts lilllb aria Chest movements. count and C-reactive protein can be difficult in
incompetence, transvaginal ultrasound may be use- preterm births pregnancy, as they are physiologically elevated.
ful ra measure cervical length and predict preterm Diagnosis Fetal hean rate monitoring may identify fetal
birth. A shortening cervix may prompt the insertion compromise due to cord compression or infection.
of a cervical cerclage. The diagnosis of preterm PROM is based on the
Aetiology Cardiorocographic recording is unfortunately less
history, physical examination and identification of
reliable in very preterm pregnancies, as the central
Prognosis Spontaneous rupture of the membranes at term is amniotic fluid. In 90% of cases, the patient's his- nervous system is still immature. The relatively
usuauy caused by a narurat weaJ<erung ot the mem- tory alone is correct, but urine leakage and later physiological development of the parasympa-
An accurate assessment of gestational age, taking increased vaginal discharge may be mistaken for thetic system results in a greater sympathetic sys·
menstrual and ultrasound data inra consideration, is branes or by the force of contractions. In ~
essential. This will determine the likelihood of via- p@M; an iriHatdiMEOt i piUe~ weakens the preterm PROM. tem influence with higher fetal hean rate and less
c.l:iorioamnion. Bacteria and macropllages prOduce To confirm the diagnosis a steri le sllcmlum variability in the preterm infant.
bility, and hence suitability for resuscitation, and the
examination IS performed. Digital examination
prognosis for the infant if born at an early gestaTIon. protease, phospholipase, elastase, cytokines and If expectant ;;;rcgemem is chosen, the w~
eicosanoids, which lead ra uterine irritability, cervi- Should be avoided, as this increases the risk of is nospltaJiSed ancorticosteroids and anrik .
The paediatric and obstetric team should deade if
delivety at the current hospital is safe or if transfer cal ripening with membrane weakness and rupture. infection. ~ol of liquor cannot be identifie ~ a . erO! ave teD sho':Y!Uo
ra another centre is more appropriate. This will A previous histOry of pretenn PROM is the mOst a IS from the osterior forrux an improve fetal outcome by reduang the mCldepce
depend on the progress of labour, the availability of common risk factor for reterm PROM. smeared on a s e. is owe to and then
Ofli y:wt me:rrafie S!ease mtraventIicular
neonatal intensive care support, and expernse 1Il the CervtcovaguuTIS ue to s transDll c- examined under a light microscope for the appear- Memo age an necrotlSrng enterocolitis in the
management of very preterm babies. Preterm labour , a e w c ance of feming, which is characteristic of amni- event of preterm labour. Steroids have not been
is a highly stressful event for most parents. ococcus is strongly associated with otic fluid. Another method employs nitrazine, an shown to increase the risk of fetal or maternal
Counselling about the possible neonatal outcome of P . Uf1Ilary tract ection may to altint that c'tinges colour from renow to blue at a infection. The effectiveness of steroids has not
the fetus and the discussion of management options c orioamnionitis if the woman becomes septi- p above 6. As the vaginal pH dunng pregnancy been assessed in the very preterm fetus.
is 4.5-5.5 and the pH of amniotic fluid is about
is very important. caemic. Cc;rvical incompetence, polyhydramnios
and mul1l.le PlIfanClesaISo preref'se to weak- Ul nim~jne wi". cbange.j o ft Recent .evidence. has shown that the ~
If It co mes 10 anTIbIOTICS IS benefiCial 1Il preterm PRO even if

* Preterm prelabour
rupture of me mbranes
ening of e me ranes by pressure e ecr. Cigarette
s~ diinng pregnancy IS be\leved t o co:~
~ tbeJDemhrane jnteeQry thrQugh effe_~
carbon monoxide. The association between low
contact With arnmonc £Jill.
positive resuI
Lscmen ~, ' e .
ommately, ~
a occur from contamination

bacterial vaginosis, an ~ , as they all increase


es 0 va en on et al

socioeconomic StatuS and preterm PROM probably the vaginal pH.


Common clinical presentations reflects the presence of one or more of the above Ultrasound examination can be helpful to Prognosis
support the diagnosis in the presence of oligo-
A 35-year-old woman presents at 29 weeks' risk factors. Ax less than 24 weeks' gestatio ~ the outcome is
hydramnios and to confirm the fetal presenta-
gestation with a history of waking up In a pool
tion. A finding of normal liquor volume, how- usually poor. Pulmonary hypopasia as a conse-
of Muid. She hod two previous preterm deliver- Sequelae of preterm PROM quence of madequate alveolar growth and in utero
Ies at 36 and 34 weeks' gestation.
ever, does not exclude a diagnosis of ruptured
of preterm PROM is chest compression in chronic oligohydramnios
membranes.
A 22-year-old woman presents at 32 weeks' ges- leads to poor oxygenation. In survivors ener-
tation In her first pregnancy feeling generally Management alised develo mental dela , dela ed motor
unwell. She describes a constant malodorous ogment, cere ~riit p y and chIomc lung dise.ase
wetness far 5 ·days. The baby Is less active than Management will depend on w tational .ffiie, the rnafn0ccur as oog-term problems.
usual. On examination. her blood pressure Is presence of iIlfection, and fetal and maternal welJ- cases where preterm PROM occurs very
110/65, temperature 38.4·C and her abdomen b3. At 34-36 weeks' gestaTIon, de4yerv may J?e early in the second trimester and is likely to be
soft but mildly tender. Speculum examination apnriate as a balance between fetal maturity associated with in utero fetal death or chronic
reveals a closed cervix and a pool of liquor In an e nsk of infection. oligohydramnios, termination of pregnancy may
the vagina. The liquor has an offensive odour. At less than 34 weeks' gestatign agd in the be considered and the parents need in-depth coun-
The baseline fetal heart rate is 180 beats per absence of SignS of maternal or fetal infection or selling.
minute. cord com ression directed Overall, the risk of expectant management
must not be underestimated and close observation
can make the difference between a healthy moth-
Prelabour rupture of the fetal membranes (pROM) er and fetus or high maternal and fetal morbidity.
is defined as ru turf of membranes that oc Parents should be involved in decision making
reterm pre our ruo- after counselling by a senior obstetIician and a
or preterm PROM) is

lij
Women's health: a co re c urricul um

paediatrician. The management of preterm PROM


is still controversial and more research 15 needed to
optimise outcomes.
References
Kenyon SL, Taylor DJ, Tarnow-Mordi W 2001 Broad-
specaum antibiotics for spontaneous preterm labo ur:
the ORACLE II randomised trial (ORACLE
Coll aborative Group). Lancet 357(9261):989-994.
* 2
Maternal and perinatal mortality
Gerard Gartlan and Clement Chan
Health maintenance Kenyon SL, Taylor DJ, Tarnow-Mordi W 2002 Antibiotics
Attention to oral hygiene and avoid- for pretc:rm prelabour rupture of the membranes: Edited b y Lucy Bowyer
ance of STis minimises the risk of short-term and long-term outcomes (ORACLE
chorioamnionitis and preterm labour. Col.laborative Group). Acta Paediatr Suppl
91(437):12-15_

Narional Institutes of Health 2000 Antenatal corticosteroids


revisited: repeat courses - consensus development
co nference statement, August 17-18. Obstetrics and
Gynecology 98:144-150.

RCOG 1999 Antenatal corricosceroids to prevent


tospiratory distress syndrome. Royal Co llege of
Obstetricians and GynaecologistS Guidelines 7,
Leaden.
Learning objectives
Knowledge Skills

At the end of this chapter, the student At the end of this chapter, the student
will be able to : should learn how to :
d. exclusion of parents in deCision /
Questions making , as this can be very /
Maternal mortality take an obstetric history, with attention
stressful
Select the correct answer(s). to areas that may affect maternal
e . emergency cervical cerclage. define direct, indirect and incidental health
1. Preterm birth is associated with : maternal mortality
break bad news

~
_ drug abuse /' 3. Common risk factors for preterm PROM compare the maternal mortal ity rates In
are: different regions of the world interpret the grass findings of a
pregnancy ultrasound scan
b. ervical dilatation withou V a. previous preterm birth "", list the main risks of pregnancy to the
mother detect a fetal heartbeat with a Pinard
contractions / Ci\ b. oligohydramnios /\1"" stethoscope or fetal Doppler device.
describe preventative management to
c. reduced fetal movements '" f' ~L C sexual intercourse /'
"Iv- ;~R'<I'o~ . .." reduce these risks
€ ) ntracranial haemorrhage / /~~~~Ci garette smoking during pregnancy describe the physiological changes of Atti tudes
~sPiratory distress syndrome. e. dyskaryosls an Pap smear. / pregnancy that may adversely
At the end of this chapter, the student
influence the health of women with pre-
4, The following may be part of the existing disease should reflect upon:
2. The management of preterm labour

~
agement of preterm PROM '
• discuss areas of obstetric care where • the respons ibility of managing a
Includes. a . trauterine transfer if nOMOnatal 1- improvements can be made pregnancy
~ccurate estimation of fetal ,,/" eds are available .."" discuss improvement of care tor women
. • the foct that every pregnancy carries
gestational age X admlnistration of antibiotiCS only If with high-risk pregnancy
some risk to the life of the mother
& dmlnlstration of Intravenous "f. p- ~J there ar~ signs of Infection Perinatal mortality
~l'f ~t(~~ ~7 ./~' ounseiling
the varying standards of obstetric care
antibiotics ..,. define stillbirth, neonatal death and In the world and the high maternal
c admlnistralion of repeated courses use of corticosteroids / ' vi' perinatal mortality mortality rate in developing countries

of corticosteroids xpectant management. indicate the perinatal mortality of • the impact of a maternal death on
developed countries family, friends and medical personnel
• list the major causes of perinatal the impact of perin atal death on a
,rtaHty. mother and her family.

.Ii
12 Materna l and perinatal morta lffy
Women's health : a co re curriculum

It then remains fairly constant until term. Blood


* Materna l mortality e.g. heart disease, diabetes mellirus and ~ Triennium Total Maternal Maternal

-
confinements deaths mortality ratio pressure usually falls slightly in the second
disease. (per 100,000 trimester and then returns to normal levels in the
In some countries, including Australia and New confinements) third trimester. Durin labour cardiac ou ut rises
Common clinical presentations
Zealand, details of a third group - incidental 1964-66 667,649 275 41.2 b e- a our eve s thus
A multiparous woman In spontaneous labour deaths - is collected for statistics but excluded placing a considerable load on the m~ocardium.
at term becomes shocked and dyspnoeic In 1967-69 713.064 237 33.2
from international comparisons. Incidental mater- The increase in blood volume and cac q ac output
the second stage of labour. nal deaths ace those occurring during pregnancy 1970-72 790,818 244 30.9
Two weeks after delivery a woman Is read- but to which the pregnancy has not contributed 1973-75 726.690 137 18.9 Number of deaths
mitted with leg pain , followed by a sudden significantly, e.g. road accidents, malignancies. 1976-78 678.098 106 15.6 Cause of death By
episode of chest pain, shock and death specific Total
6 hours after admission. Maternal mortality in Australia 1979-81 682.880 98 14.4
cause
1982-84 713,985 94 13.2
A 35-year-old -primigravida , 8 weeks
pregnant. The main causes of direct maternal deaths in CardIovascular disease 10
develops lower abdominal pain·. which does Australia (1991-96) ace given in Table 12.1. The 1985-87 726.642 86 11.8
Cardiomyopattw 1
not settle with paracetamol. Four hours later principal causes in eaclier decades were haemor- 1988-90 754,468 96 12.7
she loses consciousness and dies. rhage, infection and preeclampsia, but blood trans· Myocardial Inforction 1
1991-93 769.253 84 10.9
fusion, oxytocics and antibiotics have reduced th~. Card iac arrhythmia 1
1994-96 767.448 100 13.0
Pregnancy~nduced 1
TABLE 12. 2 Moternal deaths In each triennium . hypertenSion
Number Australia. 1964-96 (From NHMRC 1996. P 21)
Rates and definitions Cause of death
of deaths Preeclampsia 1
Maternal mortality in Australia and in countries of 8 incidence of haemorrhage and infection. Improve- Dissecting caronary artery 1
P.lILmonary embolism aneurysm
similac social and medical background is approxi- ments in the health of the general population,
Amnioftc ftuid embolism 8
mately 8-10 per 100,000 births. The rate is a antenatal care and awareness of preventing direct Mitral and aomc valvular 2
measure of the quality of obstetric care for the Preeclampsla. prognancy~nduced 6 disease
causes of maternal mortality have resulted in a sig-
mother. hypertension nificant fall in maternal deaths (Table 12.2). As a Eisenmenger's syndrome 1
World Health Organization (WHO ) figures EctopiC pregnancy 5 result, indirect deaths, pacriculacly from heart dis- Septol defects 1

-
(excluding incidental deaths) for other regions ace: 5 ease, have become more prominent (Table 12.3).
Sepftcaemia Infec:tlon 2
• Southern and eastern Europe: approximately Termination of pregnancy 3
30 per 100,000 Physiolo gical changes during Pneumonia 1
Ruptured uterus 2
• Southeast Asia: approximately 60 per 100,000 p regnancy Sepffcaemia 1
• Africa: approximately 940 per 100,000. Prima!:X e2!!Eartum haemorrhage 1
Supervision of pregnancy requires appreciation of Cerebrovascular disease 2
Spontaneous abortion 1 the changes in maternal physiology and the poss-
Comparison between countries depends on accu- Cerebral haemorrhage 2
rate statistics and similar definitions. T~ Plac,!;,ta pra2.:as 1 Ible nsks when there is preexisting maternal dis-
Suicide
ease. 2
defines maternal morcali as' e death of a Placental abru.!2l!,on 1
w2 man w e pregnant or within 42 days of the Blpolor mood swings 1
Intracranial haemorrhage 1 Cardiovascu lar system and blood
terrrunanon 01 pregnancy, irrespective of the dura- Postpartum depression 1
1 composition
n on and rhE site or the pregnancy, from any cause Ruptured artery MIscellaneous 4
related to or aggravated by the pregnancy or its ThrombOHc thrombo~e2nla 1 The plasma volume incteases by 50% from the 6th
management' (WHO 1993). Su0 deaths can be to the 34th week of gestation and then remains Ruptured artery 2
Thrombocytopenia 1
classified as: fairly constant until tene. The red cell mass Diabetes 2
Ana~!!§lg;u:I~
1 increases continuously through pregnancy and is
• direct deaths resulting from obstetric complica- Tolal Indirect deaths tram 20
46 r<used by 20-35% at term, resulting in a relative all causes
tions of the r egnant state, e.g. e~Jit;L, Tolal
haemoclilution. Total blood volume increases ro Note. Each death has been attributed 10 a single couse as
mromboembo m, postpartum haemorr ge, Nole: Each death has been attributed a single couse. os
decided by the relevant state or terrttofV maternal mortalty
40% above non-pregnant levelS. Iron reqUIre- decfded by the r vont state Of teffltoly maternal mortc'lty
ruptured uterus - committee. In a ;Cnffl.cant number. mult1p6e tactors were present ments also Increase because of tile increase in red c Ol'TYT'dtee. In a slgnlftcant number. muffip6e factOf'S were prec..ent.
indUect deaths resultin~ from preexisting dis- cell mass and fetal consumption. TABLE 12.3 Indirect maternal deaths by
ease or disease that eve loped dunng7the TABLE 12.1 Causes of direct maternal deaths principal cause. Australia 1994-96 (From
. Cardiac output statts to rise early in the first
pre~an~ bur w~ch may have ~~~ a~a­ in Australia 1991-96 (From NHMRC 1996. P 22) tnmester and at 24 weeks has increased by 40% . NHMRC 1996. p 23)
vat~by1fie Pl1YslOloi§l meetS Jw;mancy,

1"
12 Matarna l and pari natal mortality
Women 's health: a core cu rri c ulu m

Health maintena nce neonates from 400 g birtb weight, or of at leaSt 20 rates, with the neonatal deatb rate decrease being
Ilred jspgses t 9 cardiac fai lure jn the }¥gw an w jth weeks' gestation wben birtb weigbt is unavailable the more marked. Figure 12.2 grve the main causes
underlying cardiac disease. The development of Antenatal patients must be assessed as well as neonates up to 28 days after birth. ' of permatal mortality in WeStern AuStralia. The
anaemfa in pregnancy further increases the work- carefully and women with high-risk preg-
nancies (e.g. those with heart disease, three main causes are similar in all States, but a
load 0 the heart. diabetes, renal disease or pregnancy- Rates and prevention in Austra lia nanonal report using the more recently introduced
"toag\ilauon factor production is increased in induced hypertension) referred to Tbe AuStralian perinatal mortality rate decreased AUStralian and New Zealand Antecedent Classi-
Rre specialist units. Adequate facilities for . from 22.6 per 1000 births in 1973 to 8.5 per 1000 ficanon of Perinatal Mortality is not yet available.
delivery and the care of mothers should births ill 1999 (FIg 12.1), This fall can be attributed Tbe development of neonatal intensive care
be provided according to their risk.
to a combination of lower fetal and neonatal death , services bas been largely responsible for the
Careful postpartum observation and
early ambulation are important in all
women, with prompt intervention to man-
age abnormalities such as postpartum 25r-----------------------------=========
haemorrhage, deep vein thrombosis,
puerpenum. e me an! pressure 0 e uterus puerperal depression ond psychosis. 20
on mE m:n: ve.ins and illtenor vena cava further
a§&ravates venous stasIb produces oedema in the
l~ and increases the nsk of tfrrombo-em botism.
Renal and endocrine system
Renal plasma flow and giomem la [ fi ltration rate
* Perinatal m o rtality
increase early in pregnancy, rising up to 30%
above pre-pregnancy levelS by rrud-pregnancy and
A woman at 32 weeks' gestation reports that
then remaining sta!ile for the remamder of the
~~73~--~19~7;6--~1~97~9~~~;---~~--~~~--L-----L-----1-~
she has not felt fetal movements for 3 days.
pregnancy. G IL!;!u;co~s!.!ie~~l5i.lo.il~Uu.ll.lo!;;.I.I.:~.w.~1lS
pregnancy, WI relative resistance to insulin. An ultrasound at 28 weeks' gestoNan reveals an 1994 1997
LevS[ or adrenocomcOtroPIC hormone (ACrB) abnormal fetal heart and evidence of fetal Year
and unbound cortisol are increased. Thus preg- hydrops. . _. - - Fetol deaths -0- Neonatal deaths Perinatal deaths
nancy IS a prodiJhefiC State. A newborn baby becomes cyanotic with
FIG URE 12.1 Fetal neonatal and . t I
feeding . Sul livan 2001. p 37'. Reproduc e d !::'fI~~ a ,death ;~~es In A ustralia . 1973-99 (FrOm Nassar &
rml SSlon 0 e A ustralian Insti tute of Health and We lfare)
M ental state

P ~OI dDlClthl, modmod WI'IIffIek:I c kJl:all'lcct1on, Wemlln Au.l1* 1999


Definitions
~~-----------------------------------
25
~~ -------- ----------------------------

WIthin 28 so (WHO 1993).


erma mo ity is a measure of the Standard
of obstetric and neonatal care in a community, and
analysis of the causes directS attention to areas that
need better care, The Australian Bureau of Statistics
and other countries with a low perinatal mortality
~~~~ E2 ~;i ~ The mai n c a uses a f perin a tal mo rtali t y in Western Au strallo, 1999 (Based on Gee &
rate use a wider definition of perinatal mortality
than the WHO. In Australia, the definition includes
. W"'-o)
-7
~~ ~,~~~J -) ~~
~;;¥\n ~~\\k '7/400~
1,,'1 V'J'f\1wt >tI OOO~
/1M>
-
A+J!) -;,- 19 ~ ~ ~~'or\ ~f. ;;, l-%~ ~
~ ~. }c :fJ ~~ W'( \.0 1-~ ' ~ \o;y~
~ \,..,'y 0--. . ~\ "'..,.~ ($h\1 ",-,(\"'\,...) , ~
-, ~~ \"t\. 1IV\e' 0 ~ ~'\~
~c.. ~ >8" ~) -
Women's health: a core curriculum

decrease in neonatal deaths associated with pre-


mature birth. However, the prevention of prema-
all mothers. Many abnormalities are not necessarily
fatal, making a decision about continuation of the
labour and delivery
pregnancy difficult for the mother and her advisors.
ture labour still offers wide scope for reducing
perinatal mortality. Perinatal deaths can be further
Improvement in intrauterine procedures, neonatal Edited by Beverley Vollenhoven and Martha Finn
management and operations will save some of these
reduced throu renataI counselIm materna!"
babies, but fetal abnormality will continue to be a
an etal ScreenIpg, an Wlprovemenrs to care or
WO=men with hi -riSk pre anCles. Pre-concep- major cause of perinatal mortality. Normal labour Andrea Barkehall-Thomas
tion a VIce s 0 ill U e genetIc counselling and Prolonged and dysfunctional labour Andrea Barkehall-Thomas
testing, immunisation against rubella and treat- References Active management of labour Roslyn MacKenzie
ment of preexisting disease (e.g. HIY, syphilis), Buist A 1997 What's new in postpartum depression. Operative vaginal delivery Andrea Barkehall-Thomas
together with strict control of diabetes mellirus Resource Dlanual 5, resource unit 144. Royal Prolonged pregnancy Nader Gad
Ausualian and New Zealand CoUege of Obstetrics and
and administered drugs.
Antenatal care should ensure avoidance of ter- Gynaecology.
atogenic drugs and subStances, and adequate man- Gee V, O'Neil MT 2001 Perinatal statistics in Western
agement of diseases acquired in pregnancy such as Australia: seventeenth annual report of the Western
toxoplasmosis and varicella. Women with high-risk Ausualian midwives, 1999 - notification system.
pregnancies (those with cardiac and renal abnor- Department of Health, Penh. learning objectives
malities as well as diabetes) should receive optimum Nassar N, Sullivan EA 2001 Australia's mothers and babies,
antenatal care, sometimes in dedicated antenatal 1999. Perinatal Statistics Series no. 11 AIHW cat. no. Knowl edge Operative vaginal delivery
clinics. Intrapartum deaths and morbidity may be PER19. Australian Institute of Health and Welfare,
• Indicate fhe local prevalence of
reduced by better fetal monitoring techniques, Canberra. At the end of this chapter, the stUdent operative vaginal delivery
with both current equipment and furure improve- be able to:
W ill
NHMRC 1996 Report on m",ernal deaths in Australia, list the indications for each type of
ments. 1994-96. Nation"l Health and Medical Re.earch operative vaginal delivery
As a result of increased screening for fetal abnor- Normal labour
Council.
mality using genetic, biochemical and ultrasound define labour • describe the risks associated with each
techniques, early termination of some pregnancies WHO 1993 Geneva inrernational statistical classifiGltion of mode of operative delivery for mother
will lower the incidence of babies born with abnor- disc'ase5 and related health problems, tenth revisio n, describe the stages of labour and fetus
malities. However, termination is not acceptable to vol 2. World H ealth Organization, Geneva. Prolonged pregnancy
outline normal progress of labour
review the maternal physiological • define the terms post-dates pregnancy,
changes in labour post-term and post-maturity
• describe fetal adaptations to labour • discuss the fetal effects of prolongation
of pregnancy
describe the options for pain
management during labour present a plan for management of
2. Which of the following are prolonged pregnancy.
Questions major contributors to perinatal
• outline the various models of care and
options for place of birth
1. Which of the following are the main mortality?
Abnormal labour

~
Down syndrom7 e
causes of maternal mortality in Sk ill s
developed countries?
-I-
list the likely reasons for the failure to
b . Prematurity progress adequately In the first and At the end of this chapter, the student
. Pulmonary embolism . / should learn how to:
second stages of labour In nulliparous
b Amniotic fluid embolism \I'" c Unexplained intrauterine
and multiparous women
care for a woman during the birth of
death ./
c Haemorrhage ~ outline a plan for management of slow her baby
d. Syphilis infection progress in a nullipara and a multipara
d. reeclampsia , /
e. naesthesia 'I- 0 aemo Philia ..,. Active management of labour
demonstrate the use of a partogram
demonstrate the mechanism of birth
describe the principles of active using a doll and pelvis .
management of labour
explain to a woman the risks of
critically appraise this model of care prolonged labour
(Continued over)

'IE
Women's health: a c ore cur Ficulum
13 Lobo ur a nd d e livery

(Leornlng objectives continued) Attitudes Process progress of the labour accelerates to a minimum
establish the date of delivery using At the end of this chapter, the student of 1 em dilata