Professional Documents
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Gynaecology
AN ILLUSTRATED COLOUR TEXT
Commissioning Editor: Ellen Green
Project Development Manager: Jim Killgore/Helen Leng
Project Manager: Nancy Arnott
Designer: Sarah Russell
Obstetrics and
Gynaecology
AN ILLUSTRATED COLOURTBtt
CHURCHILL
LIVINGSTONE
EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2003
IV
CHURCHILL LIVINGSTONE
An imprint of Elsevier Science Limited
The right of Joan Pitkin, Alison Peattie and Brian Magowan to be identified
as authors of this work has been asserted by them in accordance with the
Copyright, Designs and Patents Act 1988
ISBN 044305035X
Note
Medical knowledge is constantly changing. Standard safety
precautions must be followed, but as new research and clinical
experience broaden our knowledge, changes in treatment and
drug therapy may become necessary or appropriate. Readers are
advised to check the most current product information provided
by the manufacturer of each drug to be administered to verify the
recommended dose, the method and duration of administration,
and contraindications. It is the responsibility of the practitioner,
relying on experience and knowledge of the patient, to determine
dosages and the best treatment for each individual patient.
Neither the publisher nor the authors assumes any liability for
any injury and/or damage to persons or property arising from
this publication.
Cover image
Infertility: false-colour hysterosalpingogram of the abdomen of a woman
suffering from blocked fallopian tubes.
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Science Photo Library
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V
Preface
Obstetrics and gynaecology is a dynamic women-centred and to provide similar in the clinician by the woman is a
and rapidly changing speciality. Great standards of care worldwide. Nowhere privilege to be valued and respected.
advances have been made in prenatal else in medicine are we faced with the This book aims to encompass the
diagnosis, the management of infertility exhilaration of the arrival of new life; breadth and depth of our speciality in a
and contraceptive techniques. The equally, our speciality remains the vivid, easy-to-use fashion. Based on a
introduction of minimally invasive highest area for litigation - an added double-spread format for each topic, the
surgical procedures has reduced bed burden for clinicians - so that audit, subject comes alive through the
occupancy and analgesic requirements clinical governance and an evidence- generous use of illustrations but retains
allowing women to return home more based approach are especially pertinent. considerable up-to-date detail and covers
rapidly. Service delivery development, There continues to be areas of great some topics overlooked in other texts.
required to meet improving NHS controversy surrounding the speciality, The use of tables and 'key-point' boxes
standards, has seen the introduction of a especially assisted conception, facilitates easy reference. We hope it will
new multidisciplinary approach, new termination of pregnancy and hormone be instructive and enjoyable to read.
roles for midwives and the emergence of replacement therapy. In no other branch
the gynaecological nurse practitioner. of medicine are such private and
Obstetrics and gynaecology is both intimate details discussed regarding London Joan Pitkin
rewarding and demanding. Maternity dysparunia, vaginal discharge and 2003 Alison Peattie
care challenges all of us to be more psychosexual problems. The trust placed Brian Magowan
VI
Acknowledgements
We would like to acknowledge all those
who have lent material, the secretarial
support received and the patience of the
publishers and our long-suffering
partners.
Contents
Index 162
2 OBSTETRICS
Urinary tract
The anatomy of the renal tract changes
in pregnancy. Cellular hypertrophy
causes a 1 cm increase in renal length.
The diameter of the ureters is
increased due to the relaxant effect of
progesterone on the smooth muscle
and in later pregnancy there may be
ureteric obstruction due to uterine
enlargement. Increased filtration of
glucose may lead to glycosuria as the
proximal tubular ability to reabsorb
glucose is overloaded. The patient is
aware of urinary frequency due to
increased renal blood flow and the
pressure of the pregnant uterus on her
bladder in early pregnancy. There is a
diuresis immediately following delivery
of the placenta as the vascular bed is
contracted down by nearly 500 ml.
Table 2 lists the changes in values seen
during pregnancy.
Gastrointestinal tract
Progesterone causes smooth muscle
relaxation and thus decreased gut
motility with adverse effects for the
mother. The resultant constipation can
be very uncomfortable and may be
exacerbated by treatment with oral
Fig. 1 Maternal systems changed by pregnancy.
iron therapy. Straining at stool may
Normal pregnancy - physiological signs and symptoms 3
Antenatal care
Aims of antenatal care murmur, hypertension, size of
The main aim of antenatal care is to mother (large with risk of
have a healthy mother and a healthy gestational diabetes, small with risk
baby at the end of the pregnancy. of IUGR), pelvic mass, uterine size
Antenatal care thus becomes risk not in keeping with dates.
assessment - trying to identify from the
patient's history and from examination Clinical examination
whether there are any factors which may Few women have had any medical
have an adverse effect on the patient or examination since starting school and
her fetus during the pregnancy and the routine examination to exclude disease
correction of these problems, should cover cardiovascular,
respiratory, renal and locomotor
Pattern of antenatal care systems. Clinical examination to
The traditional pattern for antenatal care exclude breast disease is supplemented Fig. 1 Lateral palpation of the pregnant
was laid out in the early 20th century in pregnancy by an examination of the abdomen.
with monthly visits until 28 weeks' nipples so that the woman who wishes
gestation, visits every 2 weeks until to breast feed may be prepared, with
treatment for inverted nipples as flat, one on either side of the
36 weeks and weekly visits until
appropriate (nipple shields or massage). maternal abdomen (Fig. 1), The fetus
delivery. This entails 12 to 14 visits per
The presence of varicose veins should be is then gently ballotted between the
pregnancy and is probably more than is
managed by adequate support hosiery hands to ascertain the fetal parts.
necessary to enable detection of the
during pregnancy to prevent worsening The lie may be longitudinal (most
major complications of pregnancy such
varicosities with the possibility of commonly), oblique or transverse
as hypertension and fetal growth
thrombophlebitis. (see p. 53). The volume of amniotic
restriction. The usual aim is to hold the
fluid is described as clinically
booking visit early in the pregnancy - if
normal when fetal parts can be felt
possible in the first trimester - to enable Palpation of the pregnant through a fluid cushion, increased
advice to be given on diet smoking, abdomen (clinical polyhydramnios) when
alcohol, and medication, much of vvhich This skill is developed with much fluid prevents determination of the
might be more appropriately dealt with practice but a structured approach will fetal parts, or decreased (clinical
under pre-conceptual counselling (see ensure maximum information is oligohydramnios) when fetal parts
p. 6). A detailed history' is usually taken obtained. can easily be felt through the
at this visit enabling identification of
• Inspection - look for the degree of abdominal wall.
factors which would place the patient at
distension; the presence of umbilical • Presenting part - both hands are
higher risk of perinatal mortality:
eversion suggests excessive used to palpate the lower pole of the
distension (consider twins or uterus and determine what fetal part
Epidetniological factors
polyhydramnios). Watch for fetal lies there (Fig. 2). It is usual to
• teenager - at risk of hypertension,
movements (presence confirms this decide whether the presenting part
intrauterine growth restriction
is distension due to pregnancy and is engaged (widest presenting
CIUGR)
not an ovarian cyst). The linea alba diameter has passed through the
« elderly primigravida (over 35 years)
may become pigmented during pelvic inlet) or not engaged.
- increases in fetal chromosomal
pregnancy - called a linea nigra, Alternatively with a cephalic
abnormalities, perinatal mortality,
• Fundus - determination of the presentation you may say how
and obstetric intervention.
position of the fundus (uppermost many fifths of the head you can feel
part of the uterus) is with the ulnar (Fig. 2).
Past obstetric history
border of the left hand palpating • Fetal health - auscultation for the
• previous stillbirth or neonatal death
gradually down from the fetal heart with a Pinard's
(NND)
xiphisternum. stethoscope or Doppler hand-held
• previous fetal abnormality
• Symphysis fundal height (SFH) - device completes the examination.
• preterm labour or precipitate labour
measured with a tape measure from Maternal reporting on fetal
caesarean section
the fundus through the umbilicus to movements may replace listening
• pregnancy complication likely to be
the upper border of the symphysis for the fetal heart.
repeated - pre-eciampsia, IUGR,
abruption, postpartum haemorrhage pubis. The measurement in
(PPH). centimetres in the third trimester Presentation of the findings
corresponds approximately to the It is usual to start with a one-line
Maternal medical history number of weeks' gestation summary of your history details - for
m cardiac disease, diabetes, thyroid (+ 3 weeks). example: Mrs X is a 30-year-old, para
disorder, drug misuse, renal » Lateral palpation - to determine 2+0 at 36 weeks with raised blood
problem, thromboembolic disorder, the lie (longitudinal axis of the fetus pressure. On examination the
hypertension, epilepsy (see p. 25) with respect to the longitudinal axis abdomen is distended compatible with
« factors on examination: cardiac of the uterus) both hands are placed pregnancy and old striae are noted.
Antenatal care 5
closer to labour she may have worries she wishes to discuss. • There are seven key findings on palpation of a pregnant abdomen.
Some draw up a birth plan which needs careful discussion of
6 OBSTETRICS
Pre-conceptual counselling
Pre-conceptual counselling is helpful in a wide variety of
circumstances. There is potential for general advice, an
opportunity to plan care in those with background medical
disease, a chance to review those with previous obstetric
complications and a discussion with those at increased risk
of fetal anomaly. In reality, what should ideally be pre-
conceptual counselling is often carried out in the first
trimester of the pregnancy.
General
Mothers at extremes of reproductive age are at increased risk
of obstetric complications, particularly hypertensive
disorders, and they carry an increased perinatal mortality.
Smoking also increases the perinatal mortality and should
ideally be stopped. Alcohol may reduce fertility and is also a
potential teratogen. Poor nutrition is rare in the UK, but Fig. 1 Spina bifida - large lumbosacral myelomeningocele. Folic
significant maternal malnutrition is associated with acid should ideally be started pre-conceptually.
intrauterine growth restriction (IUGR) and subsequent risks
to the offspring of coronary heart disease, non-insulin-
dependent diabetes and stroke (Fetal Origins Hypothesis).
Daily folic acid taken from before conception reduces the
recurrence risk of neural tube defects in those who have had
a previously affected child (Fig. 1). A pre-conceptual
prophylactic dose for all pregnant women probably also
offers some protection. There are, at present, no known
teratogenic effects from folate.
Medical
Chronic maternal disease may have a deleterious effect on
fertility that may lessen as the disease process itself
improves. Maternal disease can affect the fetus, and the
pregnancy itself may affect the disease. See particularly SLE
(p. 24), Diabetes (p. 28), HIV(p. 16), Renal disorders (p. 26),
Fig. 2 Anticonvulsants are associated with neural tube defects,
Thromboembolic disease (p. 42) and Thyroid disorders
cardiac and craniofacial defect. The figure shows a unilateral cleft lip.
(p. 27).
It is rare to advise against pregnancy in those with cardiac
disease, although those with fixed pulmonary output may be
advised that the risks to their own health are too great (e.g. possible recurrence risks and a plan for the next pregnancy
in those with pulmonary hypertension). Active SLE nephritis are useful. It is also an opportunity to identify those with
is associated with significant maternal and perinatal abnormal grief reactions who might benefit from further
mortality, and in particular with a risk of pre-eclampsia. counselling before considering another pregnancy.
Those on warfarin for valvular problems or venous Pre-eclampsia tends to improve with subsequent
thromboembolic disease are at increased risk of teratogenic pregnancies, with the possible exception of severe pre-term
problems (particularly midfacial hypoplasia). Consideration disease. The incidence of proteinuric pre-eclampsia in a
should be given to timing of pregnancy and whether a second pregnancy is 10-15 times greater if there was pre-
change to heparin, at least in very early pregnancy, is eclampsia in the first pregnancy compared to those with a
appropriate. As anticonvulsants for epilepsy may also be normal first pregnancy. It has been suggested that low-dose
teratogenic (Fig. 2), seizure control with a single drug regime aspirin taken from early pregnancy (< 17 weeks and
is ideal or, if seizure-free for 2-3 years, drug withdrawal may probably from the first trimester) may reduce the incidence
be considered (this may have implications for the patient's of IUGR or perinatal mortality in those with previous severe
work and/or driving licence). Pre-conceptual folate disease. Studies in this area have provided conflicting
supplements should be given because anticonvulsants lead to evidence.
a reduction in serum folate. Those who have had a previous difficult instrumental
delivery usually have a much more straightforward delivery
Obstetric next time around, but may occasionally request an elective
Women who have experienced obstetrical difficulties in a caesarean section. This is controversial, and careful
previous pregnancy are often anxious to talk these through consideration of the advantages and disadvantages is
and consider the likelihood of recurrence. This is frequently required (see p. 56). In general, those with a previous
a listening exercise so that anxieties and occasionally anger caesarean section for a non-recurrent indication, e.g. breech,
can be expressed, especially in cases of previous fetal or fetal distress or relative cephalopelvic disproportion
neonatal loss. An explanation followed by discussion of secondary to fetal malposition, should be offered a trial of
Pre-conceptual counselling 7
labour, but repeat elective caesarean section may be commonest being A F508), and again subsequent invasive
considered in certain circumstances. fetal testing if both parents are carriers.
In situations where there has been previous IUGR or an
intrauterine death, subsequent management depends on the Lifestyle education
cause and the estimated likelihood of recurrence. More Smoking is associated with low- birthweight babies, probably
intensive antenatal monitoring is usually offered and the related to fetal hypoxaemia and ischaemia from both carbon
outcome is usually good, particularly when the loss was monoxide and nicotine. Although there is no evidence to
'unexplained'. support association with fetal abnormality, long-term follow-
up has demonstrated intellectual and emotional impairment.
Risk of fetal anomaly Smoking is also associated with an increased risk of
Those who have had a previous baby with a fetal anomaly abruption, preterm labour, intrauterine fetal demise and
are often anxious to know the risk of this happening again sudden infant death syndrome. Alcohol and drug misuse
and whether any prenatal testing can be carried out. This also carry significant fetal risks and, in the ideal world, all of
discussion has usually taken place after the problem these substances should be avoided in pregnancy.
pregnancy, but further discussion is sometimes welcomed. Those whose work environment exposes them to
A couple who have had a previous Down's syndrome radiation, hazardous gases or specific chemicals should be
baby, or fetal loss from Down's syndrome, carry a risk of appropriately counselled. There is no evidence that VDUs
0.75% above their baseline age-related risk (p. 11). Down's, are harmful, or indeed that work itself is harmful to the
however, may rarely also be inherited from a parental mother or fetus. The mother should be advised that she may
translocation (e.g. 14 : 21) or mosaicism, which increases this continue working providing she is not unduly tired.
recurrence risk significantly. The complexities of these issues Moderate exercise is likely to be of benefit and should be
often require specialist advice from a clinical geneticist encouraged, but should probably be avoided if there are
[Fig. 3). This also applies to many other abnormalities, for complications, e.g. hypertension, multiple pregnancy,
example congenital heart disease: while in general the cardiorespiratory compromise, antepartum haemorrhage or
recurrence risk of this is ~ 5%, it is dependent on the family preterm labour.
history, drug history and whether the anomaly was isolated
or part of some other syndrome. Other structural Drug treatment in pregnancy
abnormalities, for example Potter's syndrome or It is never possible to confirm the safety of any drug in
diaphragmatic herniae, usually carry a low recurrence risk. pregnancy; one can only report on problems that seem to
There may be a family history of certain conditions, and have arisen. As a general principle, all drugs should be
others have a racial predisposition, e.g. Tay-Sachs disease in avoided in pregnancy unless clinical benefits are likely to
Ashkenazi Jews or haemoglobinopathies in those of outweigh the risks to the fetus. A useful treatment, however,
Mediterranean origin. Invasive fetal testing may be should not be stopped without good reason.
appropriate after parental gene testing if both partners are The major body structures are formed in the first 12
homozygous for a recessive condition. It is possible to test weeks (organogenesis) and drug treatment before this time
for some of the trinucleotide repeat disorders (e.g. myotonic may cause a teratogenic effect. If a drug is given after this
dystrophy, Huntington's chorea or fragile X syndrome) but time it will not produce a major anatomical defect, but may
the ethics of such testing is complex and it is not necessarily affect the growth and development of the baby.
desirable in every couple. Other autosomal recessive Drug-related teratogenic problems were highlighted by the
conditions are also amenable to testing, e.g. the screening of drug thalidomide introduced in West Germany in 1956 to
saliva for the commoner mutant alleles of cvstic fibrosis (the combat morning sickness. By the end of 1961, thalidomide,
sold under 51 brand names in at least 46 countries, was
identified as a human teratogen and removed from the
market. More than 10 000 infants worldwide were born with
malformations attributed to the use of thalidomide in
pregnancy.
Other drugs known to cause fetal abnormality include
anticonvulsants, warfarin and isotretinoin, a vitamin A
derivative, which is highly teratogenic and can produce
almost any type of malformation in small doses. Ionising
radiation kills rapidly dividing cells and can produce virtually
any type of birth defect depending on the dose.
Alcohol is able to cross from the maternal circulation
through the placenta into the fetal circulation and is
potentially teratogenic. Fetal alcohol syndrome is discussed
on page 44.
Pre-conceptual counselling
• Folic acid reduces the incidence of neural tube defects.
Certain medical disorders, particularly structural cardiac disease and
renal failure, may have major implications for mother and baby.
Fig. 3 Atrioventricular canal defect in a baby with Down's
syndrome. There is a large ventricular septal defect (VSD) and no • Screening for structural or genetic fetal abnormality may be possible.
identifiable atrial septum.
8 OBSTETRICS
Fig. 3 Karyotyping for Turner's syndrome, (a) 45, XO karyotype. (b) Fetus with Turner's Fig. 4 FISH analysed cell showing trisomy
syndrome. 21 (Down's syndrome).
Fetal abnormality
The finding of some 'abnormality5 in consequences. It is our role to advise,
pregnancy transforms what was guide and respect their final wishes,
previously an exciting and joyous event irrespective of our own personal views.
into an extremely worrying and
distressing time. This remains true Screening for fetal abnormalities
even when the potential risks are Structural anomalies are best seen on
small; for example being recalled with ultrasound scan and many clinicians
an abnormal level of a-fetoprotein advocate that all mothers should be
(AFP), or with the finding of a choroid offered at least one detailed ultrasound
plexus cyst on routine ultrasound scan. at around 18-20 weeks or earlier. This
The very greatest of care should be has the advantage that previously
taken in explaining any findings to unsuspected major or lethal anomalies
parents. Tact, understanding and (e.g. spina bifida, renal agenesis) can be
reassurance (if appropriate) are offered termination, and it also allows Fig. 1 Echogenic focus in the left ventricle
paramount. The advice given to planned deliveries of those conditions of a four-chamber cardiac view.
parents is of such importance that it which may require early neonatal
will frequently be necessary to involve intervention (e.g. gastroschisis, (increased synthesis). Even if the scan
senior members of the obstetrics team transposition of the great arteries). It is normal, raised AFP is still a marker
as well as members of other has the disadvantage, however, that for later pre-eclampsia or intrauterine
specialties, particularly paediatricians, many defects are not identified (it is growth restriction.
clinical geneticists and radiologists. likely that < 50% of cardiac defects are Increased nuchal translucency (NT)
The aims of prenatal diagnosis are recognized) and the false reassurance is also a marker for structural defects
fourfold: provided by this scan may become a (4% of those > 3 mm), particularly
source of parental resentment. cardiac, diaphragmatic hernia, renal,
• the identification at an early
Furthermore, problems may be abdominal wall and other more rare
gestation of abnormalities
uncovered; for example one of the 'soft abnormalities. The overall survival for
incompatible with survival, or likely
markers' (see below), the natural those with NT > 5 mm is = 53%.
to result in severe handicap, in order
history of which is uncertain. This may
to prepare parents and offer the
generate unnecessary anxiety and Aneuploidy — soft markers
option of termination of pregnancy
increase the number of invasive These are structural features found on
« the identification of conditions
diagnostic procedures (and thereby the ultrasound scan which in themselves
which may influence the timing, site
loss rate) in otherwise healthy are not a problem, but which may be
or mode of delivery
pregnancies. pointers to chromosomal problems.
« the identification of fetuses who
Chromosomal abnormalities are Examples include choroid plexus cysts,
would benefit from early paediatric
much more difficult to identify on mild renal pelvic dilatation, an
intervention
scan. While around two-thirds of echogenic focus (Fig. 1) in the heart
• the identification of fetuses who
fetuses with Down's syndrome will ('golf-ball'), or mild cerebral ventricle
may benefit from in utero treatment
look normal at 18 weeks, most with dilatation. They are found in
(rare).
Edwards' or Patau's syndrome do show approximately 5% of all pregnancies in
It should not be assumed that all some abnormality, even though these the second trimester and are the cause
parents are going to request are often not specific or diagnostic. of a lot of parental anxiety. If isolated,
termination of pregnancy even in the In the absence of routine ultrasound the risk of chromosomal problems is
presence of lethal abnormality. Many scans, it is possible to screen for open low, but if more than one is found, or
couples have opted to continue neural tube defects by measuring the if there are any other structural defects,
pregnancies in the face of severe maternal serum AFP at 16 weeks. AFP the risk is very much higher.
defects that have resulted in either is an alpha-globulin of similar
intrauterine or early neonatal death, molecular weight to albumin, which is Congenital heart disease
and have expressed the view that they synthesized by the fetal liver. Any This is the commonest congenital
found it easier to cope with grief break in the integrity of the fetus malformation in children and affects
having held their child. Others say that allows the AFP to escape into the about 5-8:1000 live births. Of defects
they were glad of the opportunity to maternal circulation and therefore be diagnosed antenatally, about 15% are
terminate the pregnancy at an early elevated on serum testing. Those with associated with aneuploidy, most
stage and that they could not have levels greater than 2.0-2.5 multiples of commonly trisomies 18 and 21.
coped with going on. More the median should be recalled for an The four-chamber view of the heart
controversial still are the problems of ultrasound scan, giving a sensitivity for can be used as a screening test (Fig. 1)
chronic diseases with long-term picking up neural tube defects of and will identify 25-40% of all major
handicap and long-term suffering for around 85%. Raised levels are also abnormalities, particularly ventricular
both the child and its parents. The found following first trimester septal defect, ventricular hypoplasia,
parents themselves must decide what bleeding, or with intrauterine death valvular incompetence and
action they wish to take - it is they (fetal autolysis), abdominal wall arrhythmias. In addition, viewing the
who will have to live with the defects, or multiple pregnancy aorta and pulmonary artery increases
Fetal abnormality 11
Lung disorders
Pulmonary hypoplasia
Liquor is important for alveolar
maturation, particularly in the second
trimester when the alveoli are forming.
Without liquor there will be
pulmonary hypoplasia. Severe
oligohydramnios occurs with very
preterm pre-labour membrane rupture
or Potter's syndrome (see above).
Fig. 7 Dysplastic renal scan. Note the enlarged kidney containing fluid-like cysts, (a) Ultrasound. Pulmonary hypoplasia also occurs with
(b) Postmortem specimen.
diaphragmatic herniae as there is no
room for lung expansion.
Genitourinary abnormalities pregnancy. If there is survival beyond
the neonatal period, there may be later Diaphragmatic hernia
Renal dysplasia (Fig. 7) Stomach, colon and even spleen can
problems with raised blood pressure
Multicystic dysplastic kidneys (sporadic and progressive renal failure. Long- enter the chest through a defect in the
inheritance). The kidneys have large, term survival is rare. diaphragm, usually on the left. The
discrete, non-communicating cysts with heart is pushed to the right and the
a central, more solid core and are Pyelectasis lungs become hypoplastic. The
thought to follow early developmental Renal pelvic dilatation may be incidence of aneuploidy is 15-30% and
failure (Fig. 7a). If the cysts affect only unilateral (79-90%) or bilateral. It is there is an association with neural
one kidney, the other is normal, and probably caused by a neuromuscular tube defects, congenital heart disease
there is adequate liquor, the prognosis defect at the junction of the ureter and and renal and skeletal abnormalities.
is good. If the cysts are bilateral and the the renal pelvis, and presents with The overall survival of those diagnosed
liquor is reduced, the prognosis is poor. increasing pelvic dilatation in the antenatally is -20% with a better
presence of a normal ureter. As there prognosis for isolated left-sided
Polycystic kidney disease is an association with postnatal UTIs herniae. Polyhydramnios, mediastinal
and reflux nephropathy, it is shift and left ventricular compression
Adult polycystic kidney disease (AD). reasonable to start all neonates on are poor antenatal prognostic factors.
The corticomedullary junction is prophylactic antibiotics and arrange Postnatally, those that survive undergo
accentuated and the condition is postnatal radiological follow-up. Even surgery to reduce the hernia and close
relatively benign, often not producing in those with mild dilatation (> 5 mm the diaphragmatic defect.
symptoms until the fifth decade of life. and < 10 mm) there is vesicoureteric
Many individuals have ultrasonically reflux in 10-20%, although only a
normal kidneys at birth. There are at Cystic fibrosis
small proportion require surgery.
least two genes on different The UK gene frequency is 1 : 25 (i.e.
chromosomes, however, so that DNA heterozygote frequency), giving an
Posterior urethra I valves estimated overall couple risk for a live
studies are only possible in families Folds of mucosa at the bladder neck
with multiple affected members. birth around 1 : 2500. Clinically there
prevent urine leaving the bladder. The is respiratory, gastrointestinal, liver and
fetus is usually male, there is often pancreatic dysfunction and
Infantile polycystic kidney disease (AR). oligohydramnios and on ultrasound
There is a wide range of expression azoospermia is the rule. The prognosis
there are varying degrees of renal is very variable and although death in
with the size of cysts ranging from dysplasia. There is a chromosomal
microscopic to several millimetres the 20-30 age group still occurs, the
abnormality in 7% of isolated defects, prognosis is improving and many now
across. Both kidneys are affected, and and in one-third of those with other
there may also be cysts present in the live considerably longer. The health of
abnormalities. It may be possible to an affected sib is not a prognostic
liver and pancreas. Ultrasound features insert a pigtail shunt between the
of oligohydramnios, empty bladder guide to the health of other sibs. Four
bladder and amniotic cavity to relieve mutant alleles account for 85% of the
and large symmetrical bright kidneys the obstruction, but the long-term
(Fig. 8) may not develop until later in gene defects in the UK (the
prognosis is still poor as the renal commonest being AF508) and
damage may not be reversible. antenatal screening for these is
possible using saliva specimens, with
Potter's syndrome chorionic villus sampling (CVS) being
There is bilateral renal agenesis which performed if both parents are gene
is associated with extreme carriers.
oligohydramnios and leads to the
Potter's sequence of pulmonary
Other disorders
hypoplasia (see below) and limb
deformity (due to fetal compression). Cystic hygroma (Fig. 9)
The condition is lethal. The recurrence Cystic hygromas are fluid-filled
Fig. 8 Infantile renal cystic scan. Note risk is approximately 3% although AD swellings at the back of the fetal neck
anhydramnios and bright real echoes from the forms with variable penetrance have and probably develop from a defect in
microscopically small cysts. been described. the formation of lymphatic vessels — it
Fetal abnormality 13
Fetal abnormality
• Not everybody wishes prenatal diagnosis, and not everybody wishes the option of termination if
there is a severely abnormal fetus.
m Ultrasound scanning is the best screening tool for structural abnormalities but will still miss many
problems, particularly cardiac defects.
14 OBSTETRICS
Infections in pregnancy
Infections in pregnancy are important
because of potential risks to the fetus.
A number of agents are known to be
teratogenic, particularly in the first
and early second trimesters. Others
carry the risk of miscarriage,
premature labour, severe neonatal
sepsis or long-term carrier states.
Infection risks
Occupation
Fig. 1 Hepatosplenomegaly (a) and
Farm workers thrombocytopenia (b) occur with
A chlamydia (which causes congenital CMV infection.
miscarriage in sheep), toxoplasma
(which causes abortion in cows and
sheep) and listeria can all cause those in contact with small children listeria. Those made from
miscarriage in humans. (Fig. 1). Serology is of little benefit as pasteurized milk are safe.
Working with farm animals should the presence of antibodies does not Raw eggs. These must be avoided
therefore be avoided when pregnant, necessarily denote immunity (see as there is a risk of salmonella
particularly in the lambing and Table 1). If hands are washed well (remember puddings).
calving seasons. At these times, basic and often, the risk of transmission is Meat or pate. Undercooked meat
hygiene precautions should be very small. may transmit toxoplasma or rarely
observed by everyone else on the listeria.
Food
farm to prevent transmission. Fruit. This should always be
The following foods carry potential
washed before eating as it may be
infection risks in pregnancy:
Nurses contaminated with salmonella,
Nurses may be concerned about • Soft cheeses. Unpasteurized milk toxoplasma or one of several
cytomegalovirus (CMV), particularly and its products may contain intestinal parasites.
Key. CHD, congenital heart disease; CMV,.cytomegalovirus; CP, cerebral palsy; IUGR, intrauterine growth restriction; TOP, termination of pregnancy
infections in pregnancy 15
Specific infections
General principles
The fetus does not make IgM until
beyond 20 weeks' gestation. Absence
of fetal IgM at birth does not mean
that infection has not occurred and
IgG is usually passive (i.e.
transplacental from the mother) unless
the baby is older than 1 year. Evidence
of infection does not imply damage.
Fig. 2 Microcephaly in association with Fig. 3 Jaundice and sepsis with perinatal
Chickenpox congenital rubella infection. Now rare in group B B-haemolytic streptococcal
Chickenpox at term (see Table 1 for countries with childhood vaccination infection.
programmes.
early pregnancy). Severe and even
fatal cases of chickenpox can occur in
neonates whose mothers develop neonatal infection (~ 40%) and this Listeria monocytogenes
chickenpox from 7 days before to 1 may be localized or systemic, This is a rare bacterial infection
month after delivery (usually 2 days occasionally including encephalitis. transmitted in food (usually soft ripe
before to 2 days after). This is because The risk of infection is greatest with a cheeses, pate, cooked-chilled meals
the baby is born before maternal IgG primary infection, but can occur with and ready-to-eat foods that have not
production has increased sufficiently recurrence, although this risk been thoroughly cooked). Following
to allow passive transplacental decreases with time from the first an initial gastroenteritis, which may
protection. The baby should be given attack. Antenatal screening at 36 be fleeting, bacteraemia results in
varicella zoster immunoglobulin weeks does not predict transmission, bacilli crossing the placenta leading to
(VZIG) as soon as possible if maternal and indeed, 70% of neonatal amnionitis, preterm labour (which
symptoms develop. infections occur to mothers with no may result in stillbirth) or
overt signs of infection. Membrane spontaneous miscarriage. There may
Hepatitis rupture in the presence of a primary be meconium, neonatal jaundice,
Hepatitis A has not been associated infection (i.e. within 6 weeks of conjunctivitis or meningoencephalitis.
with significant complications in delivery) is considered by many to be Diagnosis is made by blood culture
pregnancy. All mothers should be the only indication for caesarean or by culture of liquor or placenta.
screened antenatally for hepatitis B section, providing the operation is Treatment is with high-dose
virus as vertical transmission can carried out within the first 4 hours. It amoxicillin or erythromycin.
occur. The initial serological response is possible, however, that caesarean
is with HBsAg, followed by HBeAg, a section is appropriate in recurrent B-haemolytic streptococci -
marker of high infectivity. herpes if active lesions are present. group B
Transmission is most likely to The very small risk of fetal infection Between 5% and 20% of women carry
occur with acute infection (especially in this situation must be weighed this organism in the vagina. It is
third trimester), or in the presence of against the risk to the mother of associated with preterm rupture of the
HBeAg. The risk of maternofetal caesarean section. membranes. About 50% of babies
transmission for mothers who are become colonized at delivery but only
HBeAg +ve is 90%, falling to 10% in Rubella about 1% of these develop infection.
those with antibodies to the HBeAg. Rubella infection is discussed in The mortality from infection may be
The baby should be given hepatitis B Table 1 but its importance lies in its up to 80%, with 50% of those surviving
immunoglobulin i.m. at birth as well potential for prevention through meningitis having subsequent
as active hepatitis B immunization, vaccination. Immunity from natural neurological impairment (Fig. 3).
the latter repeated at 1 month and at infection is lifelong. Seroconversion Antenatal screening is not indicated in
6 months. and lifelong immunity occur in about the UK (initial screen positives may
With hepatitis C, vertical 95% of vaccinated individuals, and as become negative and vice versa) but
transmission is related to viral load but the benefits of herd immunity have those with known infection should
is unlikely in the absence of detectable been clearly demonstrated, many receive intrapartum antibiotics (e.g.
RNA. There is no evidence that countries now immunize all amoxicillin or erythromycin). There
treatment during pregnancy reduces preschool children. Rubella antibodies is no evidence to support antenatal
the chance of transmission and are commonly checked at booking, treatment of asymptomatic carriers,
ribavirin is probably teratogenic. and postnatal vaccination is offered to as carriage is rapidly re-established
Caesarean section or breast feeding is those with low titres. following treatment.
unlikely to alter the incidence of
neonatal infection. Hepatitis E infection
in pregnancy, whilst uncommon, Infections in pregnancy
carries a 30% maternal mortality rate • CMV, toxoplasmosis and rubella are teratogenic.
and possible risk of fetal loss.
• Parvovirus B19 may lead tohydropsfetalis.
• Primary varicella zoster and herpes simplex infections just before the onset of labour may
Herpes simplex virus
result in serious neonatal morbidity and mortality.
An acute attack of primary herpes
shortly before delivery may lead to a
16 OBSTETRICS
Clinical features
Pneumocystis carinii pneumonia (PCP) presenting with
dyspnoea on exertion and a non-productive cough, Kaposi's
sarcoma (which is rare in women) and cervical carcinoma
are agreed AIDS-defining illnesses when present in HIV-
positive individuals. Viral load (monitored by HIV-1 plasma
RNA) is the most important prognostic marker of risk of Fig. 2 HIV entry into a CD4 lymphocyte.
progression. Those with a low (< 500 x 10G/1) CD4 count (a
T-cell subset) need antiretroviral therapy (Fig. 3).
Early symptoms and signs of progression include malaise, may represent a neoplastic process such as a lymphoma.
weight loss, fevers and night sweats. Persistent generalized
lymphadenopathy is common throughout the course of the Obstetrics
disease and has no prognostic significance, but asymmetrical The vertical transmission rate is somewhere between 13 and
or atypical lymphadenopathy needs further evaluation as it 30% before treatment, with 90% of all infants infected
Fig. 1 Numbers of people living with HIV/AIDS, numbers of new infections and numbers of deaths due to HIV/AIDS in 2000.
Human immunodeficiency virus (HIV) 17
perinatally being born in sub-Saharan AZT therapy antenatally Avoid use of fetal scalp
results in two-thirds' electrode and fetal blood
Africa. There are obvious advantages to reduction sampling in labour - these
the mother in knowing her HIV status interventions bring maternal
and fetal blood
during pregnancy (Fig. 4). into contact
A very small minority of women
Caesarean section (C/S) -
may wish to terminate their pregnancy meta analysis suggests Douches to the birth canal
but knowledge of HIV status allows an overall that C/S lowers may limit spread - under
transmission. In women investigation
informed decision about future on antiretrpviral therapy,
the rarity with which they
pregnancies. Antenatal testing thus has transmit HIV to their babies
advantages and should be on offer to questions the need for C/S Avoid breast feeding -
halves the rate of
all patients, though uptake of testing is transmission. Where there
low in the UK compared to France and is high infant mortality
associated with malnutrition
Sweden. A 1997 survey of children Delay ARM (artificial and infectious disease,
rupture of membranes) - WHO/UNICEF support breast
born in the UK and developing AIDS more than 4 hours from feeding by the baby's own
found that 53% of the maternal ARM there is increased mother, regardless of her HIV
rate of transmission status
infections were diagnosed only once
the child developed AIDS. Only 4.5% Fig. 4 Reducing vertical transmission from mother to baby.
were diagnosed during pregnancy.
Most women who know they are HIV- gynaecological manifestations of HIV, organisms to bypass normal defences
positive act to reduce the risk of termination of pregnancy and infection but are also a potent source of virus in
vertical transmission (Fig. 4), so uptake control. those who are seropositive. Vigorous
of testing antenatally must be more treatment of STDs would help to
universally encouraged. Gynaecological manifestations of reduce the worldwide progression of
There are also advances in the HIV HIV infection.
treatment of HIV in adults, including Immunosuppressed HIV-positive Pelvic inflammatory disease has not
combination drug therapies, leading to patients are at increased risk of genital been found to occur more often in the
increased benefits to the woman tract malignancy and an annual HIV-positive patient but may be more
herself in knowing that she is HIV- cervical smear is probably appropriate. severe and ideally requires inpatient
infected. The use of triple therapy Cervical carcinoma is an AIDS-defining therapy to prevent peritonitis and
(generally consisting of two nucleoside diagnosis but the malignancy may be abscess formation.
analogues and a protease inhibitor) multifocal with lesions of the cervix,
hopes to prevent emergence of drug- vagina, vulva and perianal area. Human Termination of pregnancy
resistant strains due to incomplete papilloma virus (HPV) types 16 and 18 Once pregnancy is confirmed a full
suppression of replication (note: have oncogenic effects which may be discussion of the risks to mother and
protease inhibitors are teratogenic). enhanced in the HIV-positive patient baby should be available. Though
who also has a higher prevalence of some patients who are HIV-positive
Gynaecology such infection. may wish termination, others will
There are three areas where HIV- The risk of developing neoplasia is proceed successfully with their
positive status impacts on gynaecology: directly related to the degree of HIV- pregnancy. Proper disposal of the
induced immunosuppression as products of conception, handling them
measured by decreasing CD4 as high risk and sending for
lymphocyte number and advancing incineration in line with all
clinical disease. contaminated hospital waste, is
There is a strong association important.
between HIV and other sexually
transmitted diseases (STDs), Infection control
particularly those involving genital Gynaecological and obstetric practice
tract ulceration, such as chancroid, exposes practitioners to bodily fluids
syphilis and genital herpes. These infected by HIV so universal use of
disrupted mucous membranes allow safe handling techniques is logical.
• Reduction of vertical transmission can be achieved by two-thirds with the use of AZT therapy
and by half with avoidance of breast feeding.
Fig. 3 AZT (zidovudine), an antiretroviral « Low rates of diagnosis of HIV antenatally limit the ability to reduce vertical transmission.
drug.
18 OBSTETRICS
Delivery
If labour ensues, a controlled delivery with intact membranes
and a short second stage offers the best outcome for the
infant. The preterm breech presentation risks delivery of the
small trunk through an incompletely dilated cervix resulting
in fetal head entrapment. In these circumstances it may be
best to deliver by caesarean section, between 26 and 34
Fig. 1 Management plan.
weeks' gestation - though the evidence for this is limited.
The lower uterine segment will be poorly formed in these
circumstances, so a longitudinal incision in the lower uterine
Complications include:
segment may be needed (de Lee incision).
• infection
• antepartum haemorrhage
PPROM • fetal compromise.
Premature rupture of the membranes (PROM) is when the The presence of complications makes a more active
membranes rupture before the onset of labour. In 80% of approach to delivery appropriate. If there are no
patients labour ensues within 24 hours. Once the complications it is acceptable to wait up to 96 hours for
membranes are ruptured the barrier to ascending infection is labour.
gone and if labour does not follow within 24-48 hours,
induction of labour to prevent chorioamnionitis in the Making the diagnosis
mother and systemic neonatal infection is usual. After palpation of the abdomen to confirm the fetal lie,
Preterm PROM (PPROM) is when the membrane rupture presentation and size, a sterile speculum examination is
occurs before 37 weeks and induction of labour may not be performed to observe the cervix for amniotic fluid leakage -
the optimal management. It occurs in 2-3% of pregnancies unless there is obvious liquor at the vulva or on a pad.
and accounts for about one-third of preterm deliveries. A Amniotic fluid has a characteristic odour and presence of
more conservative approach may be used dependent on the vernix caseosa is diagnostic. A high vaginal swab should be
gestation (see Fig. 1). In uncomplicated cases: taken to check for infection or amniotic fluid aspirated and
< 34 weeks - benefits of in utero development outweigh the sent for microscopy and culture. If doubt exists the patient
risks of ascending infection and a conservative approach is may be asked to wear a pad whilst ambulant and check the
appropriate. Pulmonary hypoplasia and skeletal deformities pad for presence of liquor. If there is still doubt, then an
may be seen due to oligohydramnios following spontaneous ultrasound scan to measure the amniotic fluid index and a
rupture of the membranes (SRM) in extreme prematurity. check for the presence of fluid below the presenting part will
Pulmonary hypoplasia after SRM occurs in 50% of cases less refute the diagnosis.
than 20 weeks but in only 3% over 24 weeks. Two doses of
corticosteroid given 12 hours apart are associated with increased Management of chorioamnionitis
fetal surfactant production so long as there are 24 hours after Labour should be induced with Syntocinon and a
the completion of the dose before delivery. The use of continuous CTG is needed. Caesarean section is only
antibiotics prophylactically is of unproven benefit for the fetus. performed if clinically indicated as there will be an increased
34-37 weeks - no suppression of uterine activity and if risk of postoperative pelvic sepsis and subsequent tubal
no evidence of infection conservative management. The risk blockage. Intravenous antibiotics should be broad spectrum.
of respiratory distress syndrome (RDS) in the infant is about
5% and this dictates conservative management. Antibiotic
therapy may be given to reduce maternal infection but it
may be preferable to treat infection if detected rather than
subject all patients to therapy. Induction of labour at 36 Preterm labour and PPROM
weeks avoids the continued risk of ascending infection,
• Preterm labour accounts for 75% of perinatal mortality.
whilst the chance of RDS is small.
• Most preterm labour is due to unknown reasons.
> 37 weeks - if no labour ensues within 24-48 hours of
membrane rupture then induction of labour avoids the m Rupture of the membranes is associated with ascending infection.
development of infection with the associated morbidity.
20 OBSTETRICS
Hypertension
Hypertension in pregnancy may be or phaeochromocytoma). Gestational
coincidental (usually background hypertension and pre-eclampsia
essential hypertension) or related to [hypertension and proteinuria) only
pregnancy (gestational hypertension, very rarely occur before 20 weeks
pre-eclampsia or in association with (unless associated with trophoblastic
eclampsia). disease).
« Hypertension in pregnancy is
Essential hypertension
defined as a diastolic blood pressure
This is commoner in older women
(BP) > 110 mmHg on any one
and the prognosis overall for
occasion or > 90 mmHg on two
pregnancy is good. The main risk is
occasions > 4 hours apart.
from superimposed pre-eclampsia
• Severe hypertension is a single
(which is more common with pre-
diastolic BP > 120 mmHg on any
existing essential hypertension). The
one occasion or > 110 mmHg on
hypertension itself is rarely of Fig. 2 Uterine artery Doppler notching at
two occasions > 4 hours apart.
significance, although there might be a 24 weeks is predictive of pre-eclampsia
In normal pregnancy the BP will fall slightly increased risk of placental and IUGR in high-risk mothers.
during the first trimester, reaching a abruption. Those women who are
nadir in the second trimester and already taking antihypertensive drugs, uterine artery Doppler notching
rising slightly again during the third and who have mild to moderate (Fig. 2) at 24 weeks are at increased
trimester. It should be measured in the hypertension (140/90-170/110), may be risk of developing pre-eclampsia.
sitting position with an appropriate able to discontinue the medication in
size of cuff (Fig. la). Although pregnancy. Those with more severe Primary placental pathology
controversial, it is suggested that the hypertension should continue. There is a lack of trophoblast
phase IV Korotkoff sound (i.e. Appropriate preparations include infiltration of placental arterial walls
'muffling' rather than 'disappearance') methyldopa, B blockers (e.g. labetalol) leading to failure of arterial dilatation,
should be taken when reading the or nifedipine. Diuretics and ACE and acute atherosis with aggregates of
diastolic pressure. inhibitors may cause fetal compromise fibrin and platelets blocking the
Raised BP at booking (e.g. before and are contraindicated. arteries.
16 weeks) is usually due to chronic
hypertension [usually essential Gestational hypertension and Secondary effects
hypertension, only rarely renal disease pre-eclampsia (gestational These are summarized in Table 1.
hypertension and proteinuria) It is an extremely variable and
• Gestational hypertension: see unpredictable condition, and
definitions above, but note that progression is often more rapid the
some authorities also consider an earlier in pregnancy it occurs. Some
incremental diastolic rise of > 25 have minimal symptoms and then
mmHg above the level recorded at have fits, others look worryingly
booking to be significant. unwell and are fine. The purpose of
« Gestational proteinuria: > 300 mg/ antenatal screening is to prevent both
24 hours (= '+' or more on Dipstix the maternal complications (cerebral
testing). injury, multisystem failure) and fetal
complications (intrauterine growth
Pre-eclampsia is a multisystem restriction (IUGR), intrauterine death
disorder of unknown aetiology specific and abruption) of severe disease by
to pregnancy characterized by timely delivery of the baby. Treatment
hypertension, proteinuria and often of the mother with antihypertensives
fluid retention. Those with bilateral masks the sign of hypertension but
does not alter the course of the first trimester) may reduce the 1.8% with a neonatal death rate of
disease, although it may allow incidence of IUGR or perinatal 34/1000. In the developing world,
prolongation of the pregnancy and mortality in those with previous incidences of 20-80/10 000 maternities
thereby improve fetal outcome. The disease. Studies in this area have have been quoted, with a maternal
only true 'cure' is delivery of the provided conflicting evidence. mortality around 10%.
placenta.
The patient should be turned onto
Severe disease
Management of gestational her side to avoid aortocaval
The aim is to:
hypertension compression. An airway and high-
The following may be used as « Reduce diastolic BP to < 100 mmHg flow O2 should be given.
guidelines: with labetalol, hydralazine or MgSO4 should be given immediately
nifedipine. by intravenous injection to terminate
• If the BP is found to be elevated at • Consider delivery, the timing of the convulsion and then by
an antenatal clinic, it should be which depends on maternal well- intravenous infusion to reduce the
rechecked after 10-20 minutes. If it being, and fetal gestation and well- chance of further convulsions.
has settled, no further action is being. Delivery is the only thing that MgSO4 can depress neuromuscular
required. will improve the course of the transmission, so the respiratory rate
« If the BP is elevated on two or more disease. and patellar reflexes should be
occasions > 4 hours apart, fetal size • Assess fluid balance. There is monitored.
should be appraised clinically and increased vascular permeability and « Consideration should be given to
enquiry made about maternal well- a reduced intravascular urgent delivery if the fit has
being. Serum urate (rises with pre- compartment - giving too little fluid occurred antenatally.
eclampsia). U & Es, and platelets risks renal failure and giving too • Consideration should also be given
(which fall with pre-eclampsia) much risks pulmonary oedema. to paralysis and ventilation if the fits
should be checked twice weekly Urine output should be measured are prolonged or recurrent.
along with BP recording and urine hourly, and SaO2 also monitored.
Dipstix measurement (Fig. Ib). U & Es, liver function tests (LFTs),
HELLP syndrome
Advice should be given to present if albumin, urate, haemoglobin (Hb),
HELLP is an acronym from
unwell, or if there is frontal haematocrit, platelets and clotting
haemolysis, elevated liver enzymes
headache or epigastric pain. should be monitored. Central
(particularly transaminases) and low
« If there are abnormal blood results, monitoring with a central venous
platelets. It is a variant of pre-
the diastolic is > 100 mmHg or has pressure (CVP) or Swan-Ganz line
eclampsia, affecting 4-12% of those
risen from booking by > 25 mmHg, is often helpful in oliguria to
with pre-eclampsia/eclampsia and is
or there is clinical suspicion of IUGR, differentiate intravascular depletion
commoner in multigravidae. There
poor fetal well-being or maternal from renal impairment.
may be epigastric pain, nausea,
compromise, arrangements should « There is very good evidence
vomiting, and right upper quadrant
be made for a cardiotocograph supporting the use of
tenderness. There may be acute renal
(CTG) and ultrasound assessment of anticonvulsants in established
failure and disseminated intravascular
fetal size and liquor volume. Also eclampsia, and magnesium sulphate
coagulation (DIC), and there is an
arrange BP recording and Dipstix is known to be significantly more
increased incidence of placental
three times per week, with at least effective than phenytoin or
abruption. There is also an increased
weekly measurement of serum diazepam in preventing further
incidence (although still rare) of
urate, U & Es, full blood count, and convulsions. Although the use of
hepatic haematoma and hepatic
platelets. magnesium sulphate in severe pre-
rupture leading to profuse
eclampsia has been shown to be
intraperitoneal bleeding. Management
It is important to consider the overall effective in preventing eclampsia,
is to stabilize coagulation, assess fetal
picture rather than make decisions on treatment is not without risk.
well-being and consider the need for
the basis of a single parameter. It is Eclampsia is said to have occurred delivery. It is generally considered that
appropriate to admit the mother for when there has been a convulsion. The delivery is appropriate for moderate to
more intensive monitoring if there are UK national incidence is 4.9/10 000 severe cases, but management may be
symptoms or if she has significant maternities with 38% antepartum, 18% more conservative (with close
proteinuria or severe hypertension. intrapartum and 44% postnatal. Of monitoring) if mild. Postpartum
Oral antihypertensives may be these, 38% occur before proteinuria vigilance is required for at least 48
considered and plans can be made for and hypertension have been hours. The incidence of recurrence in
delivery. documented. The maternal mortality is subsequent pregnancies is about 20%.
The decision to deliver and the
method of delivery are dependent on
Hypertension
many of the above factors. There are
advantages to conservative • Pre-eclampsia is a multisystem disorder, and a major cause of fetal and maternal morbidity and
management up to 34 weeks if BP, mortality.
laboratory values and fetal parameters • Medication, including antihypertensive agents, does not alter the progress of the condition; the
are stable. only cure is delivery.
It has been suggested that low-dose • HELLP syndrome is a variant of pre-eclampsia and is an acronym from haemolysis, elevated liver
aspirin taken from early pregnancy enzymes (particularly transaminases] and low platelets.
(< 17 weeks and probably from the
22 OBSTETRICS
Fig. 3 The amniotic fluid index plotted Fig. 4 Doppler ultrasound of the umbilical artery, (a) Normal, (b) Absent end diastolic
against gestation showing normal range blood flow.
(mean ± 2 standard deviations).
The fetal head circumference is identify those at risk of hypoxia survival rates of infants at the gestation
measured to try to get around the (Fig. 4b). It is likely that the hypoxia the pregnancy has reached once tests
problem of variations in the biparietal precedes the Doppler changes. This become abnormal.
diameter (BPD) due to different head can give further information to aid a
shape depending on fetal position (e.g. decision on whether to deliver a small
fetus early to achieve a better outcome.
Management
dolicocephaly or the more oval head
Delivery of the baby removes the
shape in the breech infant). This is
infant from a hostile intrauterine
plotted against the abdominal
Biophysical profile environment but the mode of delivery
circumference on the charts and the
This looks at five variables (fetal has to be decided upon. A caesarean
pattern of growth noted. Curve a
movement, tone, reactivity, breathing section offers immediate extrauterine
depicts asymmetric IUGR and curve b
and amniotic fluid volume) considered conditions but there is a higher risk of
shows a small for dates fetus.
to be of prognostic significance in respiratory distress syndrome in babies
Ultrasound is also used to measure
assessment of the high-risk pregnancy. born by caesarean section compared
the amount of liquor around the fetus.
Comparison of this profile with with babies born vaginally at the same
This varies with the gestation but also
antenatal CTG for care of high-risk gestational age. Vaginal delivery,
changes with IUGR when, due to poor
pregnancies does not result in however, is recognized to be stressful
perfusion of the fetal kidneys, there is
improved outcome for the baby so the for the infant and if there are already
less liquor than usual at that gestation.
test is not universally used, though it signs of fetal compromise, it is not
The volume is assessed by measuring
often produces useful information. reasonable to induce labour. There are
the pools of liquor without limbs or
no scientific studies to give an answer,
cord in them. Pools between 3 and
Monitoring and each case is assessed individually
8 cm are normal but are not thought
Once the small infant has been in the light of all the facts to try to
to give a very representative overall
identified there is usually a period of decide on the best method of delivery.
picture of the volume, so an amniotic
monitoring to try to assess the optimal Antenatal corticosteroid therapy has
fluid index measuring the greatest
time to deliver the baby. Twice weekly been shown to reduce the incidence of
pool in each quadrant of the uterus
measurement of amniotic fluid volume respiratory distress syndrome.
may be preferred (Fig. 3). The amniotic
(plotted against the chart - see above) Maximum benefit is achieved for
fluid index has been plotted against
and CTG may be supplemented by babies delivered more than 24 hours
gestation to give a normal range.
Doppler studies. Abnormalities in any and less than 7 days after
Alterations in fetal umbilical blood
of these tests may make the commencement of the medication. In
flow may occur as an early event in
obstetrician feel that the extrauterine elective preterm deliveries it is usual to
conditions of placental insufficiency.
environment may be safer for the baby. give corticosteroid therapy between 24
Doppler ultrasound (Fig. 4) of the
The decision is based on the likely and 34 weeks' gestation.
umbilical artery is used as an
assessment of downstream vascular
resistance (i.e. placental resistance) and
may help to identify placental
insufficiency in high-risk pregnancies
(e.g. IUGR, PET). The Doppler probe
is directed at the umbilical cord and Small for dates fetus
detects velocity (the Doppler shift - the
• Asymmetrical growth restriction is associated with low amniotic fluid index and raised perinatal
effect noted as an ambulance with its mortality, and may necessitate early delivery.
siren on passes and you note a change
• Ultrasound measurements of the fetal abdominal and head circumference plotted on growth
in the tone). charts allow detection of the fetus whose growth pattern deviates from the normal.
Figure 4a shows the normal pattern
• Symphysis-fundal height is better than abdominal palpation alone in detecting low birth weight
obtained with flow during systole and
for gestation.
diastole indicated and below the line
• Doppler ultrasound gives additional information when monitoring the high-risk pregnancy.
the continuous venous flow. Reduction
of end diastolic blood flow may
24 OBSTETRICS
Respiratory disorders
Breathlessness due to the physiological
increase in ventilation is a common
symptom in pregnancy. This is due
partly to low pCO2, the effect of
Those with asymptomatic bacteriuria progesterone, and partly to a raised
should be treated as there is a
30-40% risk of developing diaphragm, which occurs even before
symptomatic infection the uterus causes direct physical
pressure. A normal chest X-ray and
Fig. 4 The genitourinary system in pregnancy.
physical examination virtually excludes
a pathological problem in the absence
of other symptoms.
Asthma is common. In most, the
Primary biliary cirrhosis Chronic renal impairment
disease is unchanged, but it may
This is variable in severity. The The fetal prognosis with chronic renal
improve, or less commonly,
prognosis for mother and fetus is disease in pregnancy is best if maternal
deteriorate. Treatment is similar to that
good in mild disease. It may present renal function and BP are optimized. If
in the non-pregnant patient. Inhaled
during pregnancy for the first time in a the plasma creatinine is < 125 umol/1,
B-sympathomimetics and inhaled
similar way to intrahepatic cholestasis the maternal and perinatal outcome is
steroids are safe. Oral steroids may be
of pregnancy. usually good. If it is > 250 umol/1,
indicated.
there is usually amenorrhoea and if
Renal disorders (Fig. 4) pregnancy occurs there may be a risk
Thrombocytopenia
In pregnancy, there is an increase in of renal deterioration (therefore
the size of both kidneys and dilatation consider termination of pregnancy). Maternal thrombocytopenia in
of the ureter and renal pelvis. This is Between these levels, women should pregnancy
greater on the right than on the left be advised that pregnancy may cause In the second half of 8% of normal
because of the dextrorotation of the their renal function to deteriorate and pregnancies there is a mild
uterus. There is also an increase in that there are also risks to the fetus thrombocytopenia (platelet count
creatinine clearance because of the (mainly IUGR). Pre-existing 100-150 x 109/1) which is not
increased glomerular filtration rate hypertension, proteinuria and a pre- associated with any risk to the mother
(GFR) (maximal in the second pregnancy GFR < 70ml/minute are or fetus. Pre-eclampsia (see p. 20)
trimester). Urea should be < 4.5 also associated with a poorer maternal should be excluded.
mmol/1 and creatinine < 75 umol/1. and fetal outcome. Some renal diseases Autoimmune thrombocytopenic
carry a worse prognosis than others purpura is the commonest cause of
Infection (specialist advice is required). thrombocytopenia in early pregnancy
Urinary tract infections (UTIs) occur in Close fetal monitoring is important (but can also arise in later pregnancy)
3-7% of pregnancies and if untreated in the third trimester. It is difficult to and may be acute or chronic.
may lead to septicaemia and
premature labour. Asymptomatic
bacteriuria should be treated in all
pregnant women, as there is a 30-40%
risk of developing a symptomatic UTI.
Pyelonephritis should be treated
aggressively.
Obstruction
Acute hydronephrosis is characterized
by loin pain, ureteric colic, sterile urine
and a renal USS showing dilatation of
the renal tract greater than normal in
pregnancy (Fig. 5). If the symptoms are
not settling and the USS does not
demonstrate the cause of the
obstruction, a limited intravenous Fig. 5 Ultrasound of left kidney with ureteric obstruction and
urogram (IVU) should be considered. calyceal clubbing. There was a calculus in the lower third of the ureter.
Medical disorders in pregnancy 27
Antiplatelet antibodies may be restlessness. It is usually due to Graves' Inflammatory bowel disease
detected. These may cross the placenta disease but may occur secondary to Fetal loss rate is similar to that of the
and cause fetal thrombocytopenia, toxic thyroid adenoma or multinodular normal population providing that the
although this is rarely associated with goitre. Untreated thyrotoxicosis is disease is not active at the start of the
long-term morbidity (cf. alloimmune associated with approximately 50% fetal pregnancy. Flare-ups of the disease
thrombocytopenia). No treatment is mortality and a risk of maternal thyroid occur most commonly in the first
required in the absence of bleeding, crisis at delivery. Well-controlled trimester. There is no evidence of fetal
providing the platelet count remains hyperthyroidism is not associated with problems with prednisolone or
above 50 x 109/1. If the platelet count an increase in fetal anomalies but there sulfasalazine and these should be
falls below this level, steroids and is a tendency for babies to be small for continued at the minimum dose
immunoglobulin can be given. gestational age. Graves' disease usually necessary. Constipation should be
improves during pregnancy. avoided and the mother should receive
Fetal (alloimmune) Carbimazole and propylthiouracil cross folic acid supplementation.
thrombocytopenia the placenta and can potentially cause Acute episodes of inflammatory
This is a rare disorder in which there fetal thyroid suppression. In low doses, bowel disease present with abdominal
are maternal antibodies to fetal however, this is rarely significant. pain, diarrhoea and passage of blood
platelets (similar to Rhesus disease Radioactive iodine is absolutely and mucus p.r. Patients should be
except for platelets rather than red contraindicated, and surgery is indicated admitted and fluid and electrolyte
blood cells). The maternal platelet level only for those with a very large goitre or balance checked. Stool samples should
is normal, but there may be profound poor oral compliance. be sent for culture to exclude
fetal thrombocytopenia and antenatal gastroenteritis. Treatment is with
or intrapartum intracranial bleeds. The Postpartum thyroiditis topical steroid enemas, oral
diagnosis should be suspected when a This occurs following 5-10% of all sulfasalazine and prednisolone daily. If
previous child has had neonatal pregnancies, with initial the patient deteriorates, the possibility
thrombocytopenia and maternal hyperthyroidism followed by of intestinal perforation or toxic
antiplatelet antibodies have been hypothyroidism (at around 1-3 months, megacolon should be considered.
identified (often to the HPA-la which therefore may be confused with Colostomies and ileostomies may
antigen). Treatment is usually with depression) and then recovery. become temporarily obstructed during
antenatal immunoglobulin and elective Symptoms of hyperthyroidism may be pregnancy. Vaginal deliveries are
caesarean section. treated with propranolol (antithyroid preferable to caesarean section (as
drugs accelerate the appearance of there is a risk of adhesions from
Thyroid disorders hypothyroidism). Hypothyroidism may previous surgery), although care is
1% of pregnant women in the western be treated with thyroxine as above, needed with operative vaginal
world are affected by thyroid disease, withdrawing it around 6 months deliveries if the disease involves the
with hypomyroidism being commoner postnatally. A small proportion may perineum. Although sulfasalazine
than hyperthyroidism. The fetal require long-term treatment or may crosses into breast milk, there is no
thyroid gland is active and secretes develop hypothyroidism later in life. evidence of any neonatal problems.
thyroid hormones from the 12th week.
It is independent of maternal control, Gastrointestinal disorders Coeliac disease
although maternal thyroid hormones Presentation may occur in pregnancy
do cross the placenta. Peptic ulceration with non-specific gastrointestinal
Ulcers are rare in pregnancy but, when symptoms, anaemia and weight loss.
Hypothyroidism present, tend to improve. If ulcer Diagnosis is by duodenal biopsy via
This may present with fatigue, hair loss, symptoms occur, first-line treatment is endoscopy. Treatment is with gluten-
dry skin, abnormal weight gain, poor with simple antacid/alginate free diet and vitamin supplementation.
appetite, cold intolerance, bradycardia compounds. If not resolving then Patients with known coeliac disease
and delayed tendon reflexes. If ranitidine, an H2 antagonist, should be should be encouraged to comply with
untreated, there is double the rate of started. Those with problematic a strict gluten-free diet in pregnancy.
spontaneous miscarriages and stillbirths recurrent ulcers should also take Iron and folate supplements are
compared to the normal population, as ranitidine. Endoscopy is the recommended. The prognosis for the
well as a risk of fetal neurological investigation of choice, if necessary. mother and fetus is good.
impairment. There is minimal fetal risk
if the mother is treated and euthyroid.
Thyroid function should be regularly
monitored, aiming to keep thyroid-
stimulating hormone within the normal Medical disorders in pregnancy
range and free thyroxine (T4) at the
« Structural heart disease in pregnancy has potentially serious implications for both mother and
upper end of the normal range. Fetal fetus.
hypothyroidism may occur when the
• Abnormal liver function tests may be related to the pregnancy, but are commonly coincidental.
mother carries antithyroid antibodies or
is receiving antithyroid drugs. » Asymptomatic UTIs should be treated.
• The fewer anticonvulsants, the less the risk of fetal abnormality.
Hyperthyroidism « Well-controlled thyroid disease poses little serious risk.
Thyrotoxicosis presents with weight
loss, exophthalmos, tachycardia and
28 OBSTETRICS
Diabetes in pregnancy I
Physiology In general the majority of diabetics all women who may develop gestational
The hormonal changes of pregnancy are non-insulin dependent (NIDDM), diabetes. Various risk factors may be
profoundly affect carbohydrate controlled by diet or oral hypoglycaemic assessed from the booking history
metabolism. The levels of oestrogen, agents. There is a hereditary element and (Table 2) and if a patient exhibits two or
progesterone, human placental lactogen an association with obesity. NIDDM is more of these, then a glucose tolerance
(HPL), prolactin and free cortisol rise less common in the childbearing years. test (GTT) can be organized for 24-28
progressively throughout pregnancy. Insulin-dependent diabetes (IDDM) weeks' gestation.
Cortisol and HPL, especially, are insulin occurs most often in young adults and Impaired glucose tolerance (IGT) is
antagonists, so women become relatively is due to cellular and humoral present if the fasting glucose is > 6 and
insulin resistant in pregnancy. To autoimmunity to pancreatic beta cells. < 7.8 but rises to 8.0-10.9 mmol/1 within
overcome this trend, normal women In pregnancy, diabetic control needs to 2 hours of the 75 g glucose load. These
compensate by producing increased be as careful for NIDDM as IDDM to women may develop gestational diabetes
amounts of insulin. avoid adverse perinatal outcome. White's as the pregnancy progresses or remain
classification (Table 1) is often used to with slightly impaired metabolism as
Definitions grade the severity of the disease. In pregnancy advances, reverting to normal
When the obstetrician is faced with general, the more severe the disease the afterwards. The significance of IGT is
diabetes in pregnancy it represents greater the perinatal mortality and controversial. There is no evidence that
either gestational diabetes or pre-existing incidence of congenital malformations. treatment is of benefit but commonly, if
disease. the preprandial sugar is > 6 or the
Potential diabetes postprandial value is > 8, treatment with
Gestational diabetes This term is often used to define a group dietary control and possibly insulin can
By definition, this is carbohydrate of women who are more likely to be introduced.
intolerance that develops during develop diabetes at some time in their Gestational diabetes is diagnosed if
pregnancy and disappears after delivery. lives than normal based on family, the fasting glucose is > 8 mmol/1 and the
Normally in the second half of medical or obstetric history. These risk 2-hour level is > 11 mmol/1.
pregnancy, and particularly in the third factors are still widely used in antenatal
trimester, there is a further increase in clinics today as part of screening for Alternative screening
insulin resistance and a slight gestational diabetes (Table 2). Although the above method is most
deterioration in glucose tolerance. widely used there are considerable
Women who develop gestational Diagnosis and screening limitations:
diabetes are unable to meet this with a Screening and diagnosis aims to identify
• 30% of gestational diabetics have none
compensatory rise in insulin production
of the recognized risk factors
and pregnancy-onset diabetes is
Table 1 White's classification of « glycosuria can be found in up to 50%
therefore most commonly detected at
established diabetes of all pregnant women at some stage
this time.
A Asymptomatic diabetes diagnosed by GTT
in their pregnancy
The situation is often not as clear-cut
B Diabetes onset after age 20 years
» not all women with gestational
as this. Some women have had pre-
Diabetes duration 0-9 years diabetes, or even IGT, have persistent
existing subclinical diabetes which was No vascular complications glycosuria and may be clear on
missed and therefore they appear to C Diabetes onset 10-19 years testing.
present as 'gestational' diabetes, since Diabetes duration 10-19years
the diabetes was first detected in No vascular disease Thus some gestational diabetics are
pregnancy. Some women with true D Diabetes onset before 10 years of age missed and a lot of normal women have
pregnancy-related diabetes will continue Diabetes duration > 20 years unnecessary GTTs. Routine screening
Vascular disease present
to be diabetic post-delivery (about 15%). for everyone has been suggested as a
F Diabetes with nephropathy
These are often missed, as postnatal more accurate approach, performing
R Diabetes with retinopathy
glucose tolerance tests (GTTs) are not random blood glucose tests at booking,
widely performed. Some will develop 28 weeks and 32 weeks (referring
diabetes in later life. Table 2 Antenatal screening risk factors equivocal cases for a GTT). Some
for gestational diabetes centres perform a modified GTT at
Pre-existing diabetes • Significant glycosuria on two occasions in antenatal booking.
clinic, or one occasion if a fasting urine sample is
The classical syndrome of diabetes is
tested, or one if less than 16 weeks' gestation
characterized by hyperglycaemia due to • Family history of diabetes, particularly parents or
Pre-conceptual counselling
a deficiency or diminished effectiveness siblings (IDDM in the father is of greater predictive For the patient with pre-existing diabetes
of insulin. This results in the well- value than in the mother; predictive value is greater if pre-conceptual counselling is vital (see
a sibling or both parents are diabetic; grandparents p. 6). There is an increased incidence of
known symptoms and signs of polyuria,
are less significant)
polydipsia, weight loss and glycosuria. congenital malformations amongst
• Previous big babies > 90th centile for gestational age
The effects, if untreated, are profound. and sex babies born to mothers whose diabetes
Eventually, cellular damage can occur, • Diabetes in a previous pregnancy is poorly controlled, with a 3-4 times
especially to vascular endothelial cells in • Previous unexplained intrauterine death or stillbirth higher rate of abnormality than in their
• Polyhydramnios
the eye, kidney and central nervous non-diabetic counterparts. The incidence
• Maternal obesity (> 20% above the ideal weight)
systems. of all malformations is increased,
Diabetes in pregnancy I 29
especially congenital heart disease and general advice regarding diet, smoking limits because maternal glucose
neural tube defects. and lifestyle homeostasis is well regulated. Protein
Multiple abnormalities are common. « establishment of tight diabetic control hormones such as insulin, glucagon,
Caudal regression syndrome (absence of with advice for its maintenance growth hormone and HPL do not cross
vertebrae anywhere below T10) is rare • examination of optic fundi the placenta. Ketoacids appear to diffuse
but peculiar to diabetics. The most • assessment of baseline renal function freely and serve as fetal fuel during
common form is sacral agenesis • plans made for early antenatal referral periods of maternal starvation. Periods
[Fig. 1). Tight diabetic control is and booking of maternal hyperglycaemia result in
therefore very important at the time of • commencement on folic acid. fetal hyperglycaemia.
organogenesis to reduce the incidence of Perinatal mortality rates (PNMRs)
congenital malformations. As Ongoing diabetic control (see p. 78) are closely linked to the
organogenesis occurs during the first Control of diabetes remains essential severity of the diabetes and the degree
7-9 weeks of fetal life, and patients throughout pregnancy for pre-existing of control achieved. Good control,
rarely book for antenatal care before and gestational disease. The movement however, does not completely preclude
10-12 weeks, pre-conceptual counselling of glucose across the placenta is by the development of macrosomia (large
is the only way to gain diabetic control carrier-mediated facilitated diffusion birthweight infants > 90th centile for
in time. At the pre-conception clinic the (Fig. 2). Fetal blood-glucose levels gestational age and sex, with
patient receives: usually remain 20-30 mg/dl lower than polycythaemia, adiposity and
those of the mother. There is close organomegaly) as up to 30% incidence
correlation between fetal glucose uptake has been reported in well-controlled
and blood levels. The fetal level is diabetics (Figs 3 and 4).
normally maintained within narrow
Diabetes in pregnancy I
« Pregnancy is a relatively insulin-resistant state.
« Gestational diabetes occurs if the increased insulin output fails to compensate.
• Antenatal screening methods are controversial; screening may be selective, based on risk factors,
or offered to all.
« The PNMR is closely linked to the severity of the disease and the degree of control.
Diabetes in pregnancy II
Antenatal care Table 1 Risks associated with diabetes in
Antenatal care for both existing and pregnancy
gestational diabetes should take place Maternal
jointly between physicians and Adverse effects on existing retinopathy, nephropathy
obstetricians, preferably at a specially and neuropathy
Increased incidence of infections - urinary, monilial and
run clinic which involves a dietician.
other
'Brittle' diabetics may need to be seen Obstetric complications - pre-eclampsia,
weekly. The support of a diabetic polyhydramnios, preterm labour
Management Sister is invaluable as she Trauma to the genital tract, e.g. haematomas and tears
can visit the patient at home, offering due to difficult delivery of large-birthweight baby
(macrosomia)
advice and supervision on
self-monitoring of blood sugars and Fetat
Fig. 2 Automated finger puncturer.
assessment of compliance to therapy. Congenital malformations
Prematurity associated with preterm labour
Intrauterinedeath
Therapy Fetal trauma (e.g. fractured clavicles, Erb's palsy), due to
In general, gestational diabetics are difficult deliveries
treated with diet alone - unless there Shoulder dystocia
is evidence that this is failing to Neonatal metabolic problems, e.g. hypoglycaemia
Increased incidence of respiratory distress syndrome
produce good control, when insulin is
substituted.
Established diabetics are changed to Table 2 Assessment of maternal and
insulin in early pregnancy if they were fetal well-being
previously managed by diet or oral Maternal
hypoglycaemics. As hypoglycaemic Blood sugar control
agents cross the placenta it is Weight
Blood pressure
preferable to change to insulin,
Optic fundi
although in developing countries they Renal function
may have an important role. Fetal
Good control can be achieved by a Fetal anomalies scan at 18 weeks
combination of a short-acting insulin Echocardiography at 20-24 weeks to detect congenital
cardiac anomalies
such as Soluble or Actrapid, with a
Serial scans to assess fetal growth
medium-acting insulin, such as Kick charts, biophysical profiles, Doppler studies and
Isophane or Monotard, given twice outpatient cardiotocographs in the third trimester to
daily. Human or highly purified assess well-being
porcine insulins reduce the risk of Amniotic phospholipid analysis to assess lung
maturation (if preterm delivery looks likely)
developing antibodies which can cross Fig. 3 'Glucolog' log book.
the placenta.
outpatient monitoring or admission Preterm labour prior to 34 weeks carbohydrate by 50 g per day is needed
may be indicated if: should generally be stopped if to cover the extra calories required for
possible. Betasympathomimetics (e.g. lactation. Insulin requirements of the
• good glucose control cannot be
salbutamol or ritodrine) should be established diabetic do not alter during
achieved as an outpatient
used with caution, especially if used in lactation.
• hypertension and/or proteinuria
conjunction with corticosteroids (see Family planning should be carefully
develop
p. 18) as they cause marked discussed. In the past, the combined
« weight gain is excessive
hyperglycaemia. Use of tocolytics can contraceptive pill has been avoided in
M renal function deteriorates
be covered by an insulin infusion and diabetics both because of the small but
« polyhydramnios develops
regular blood glucose monitoring, real risk of thromboembolism and
« fetal growth or well-being cause
along with potassium estimations. because of the effect on carbohydrate
concern.
metabolism. The newer low-dose pills
Route of delivery can now be used in all but the most
Delivery
If there are no obstetric or other brittle diabetics. Progestogen-only
Timing medical complications, the diabetes is contraception (Mirena coil, Implanon,
In the past, sudden intrauterine death well controlled and spontaneous onset Depo injection, progestogen-only pill)
near term led to a policy of induction of labour has been achieved, vaginal offers an alternative, especially if the
of labour between 36 and 38 weeks. delivery is both possible and desirable. woman is breast feeding, but may
This created a potential difficulty as Caesarean section is indicated if there produce some cycle irregularities. The
diabetic babies have less appropriate is evidence of fetal compromise or if other forms of contraception must be
surfactant levels for their gestational ultrasound and clinical assessment considered on merit.
age and are more prone to respiratory suggest a baby so large that a vaginal
distress syndrome (RDS) than delivery represents potential trauma to The neonate
neonates of non-diabetic mothers. mother and fetus. The management of all infants of
Improved diabetic control has diabetic mothers calls for expert
encouraged many centres to allow Intrapartum care neonatal care. The neonate is at risk of
their mothers to go into spontaneous During labour, close control of the a number of complications (Table 3).
labour if the pregnancy is blood sugar is required by a The perinatal mortality has dropped
uncomplicated. This has reduced the continuous infusion of soluble insulin dramatically over the past decade. In
incidence of both RDS and caesarean and an intravenous infusion of 10% the best centres it now approaches that
sections for failed induction. It has not dextrose. Blood sugars are checked for other pregnancies, after mortality
been accompanied by a rise in hourly and kept between 5 and for congenital malformations has been
unexplained intrauterine deaths but it 8 mmol/1. Urea and electrolytes are excluded.
remains common practice to induce at checked 4-hourly. Infants of diabetic mothers have a
40 weeks. Continuous fetal monitoring with greater than average chance of
If insulin requirements start to fall it cardiotocography is mandatory. An developing diabetes in later life (a risk
is prudent to deliver the infant as this experienced obstetrician should be in the order of 1% compared to 0.1%
may indicate placental failure. present at delivery because of the in infants of non-diabetic mothers).
increased risk of shoulder dystocia
Table 3 Neonatal complications of poorly
Premature labour (see p. 63). controlled diabetic pregnancy
If the pregnancy has reached 34 weeks,
Low APGAR scores - one-third of all cases require
no attempt should be made to stop Postnatal care intubation
labour. If there is genuine concern As insulin sensitivity increases • Respiratory distress syndrome (RDS) (see p. 83)
about the state of fetal lung maturity immediately after delivery of the • Hypoglycaemia, secondary to pancreatic cell
an amniocentesis can be performed or, placenta the insulin infusion is hyperplasia and hyperinsulinaemia
in the case of ruptured membranes, a stopped at this stage. The gestational - most commonly seen in macrosomic babies
sample of liquor can be collected, - usually asymptomatic, but can cause apnoea,
diabetic will return to normal within
hypertonia, excitability and fits
though this is more often considered 24 to 36 hours and insulin-dependent
• Hypocalcaemia
with induction, if required, preterm. diabetics will return to their
• Hypomagnesaemia
The presence of phosphatadyl glycerol prepregnancy dose requirements.
• Polycythaemia
(a lung surfactant] indicates lung Breast feeding is to be encouraged. H Jaundice
maturity and a low risk of RDS. If An increase in the dietary allowance of
levels are low or absent, dexametasone
should be given to accelerate lung
maturation.
Diabetes in pregnancy II
« Tight control of diabetes is necessary throughout pregnancy to minimize the risk of maternal and fetal complications.
m Management should be at a joint clinic run by physician and obstetrician.
• Emphasis is on home monitoring and outpatient management, minimizing hospitalization.
• Well-controlled uncomplicated pregnancies may be allowed to continue to 40 weeks to improve their chance of spontaneous labour.
• The perinatal mortality rate has been dramatically reduced and now approaches 9/100 000.
32 OBSTETRICS
in pregnancy
A useful guide to the acceptable lower Antenatal screening Routine supplements are associated
limit of haemoglobin (Hb) for each Haemoglobin is estimated at booking with a higher rise in red cell mass thus
trimester is 12.5 g/dl in the first and during the third trimester to reducing the physiological
trimester, 11.5 g/dl in the second and ensure anaemia is detected and haemodilution - which may have
10.5 g/dl in the third. The apparent fall treated. If the haemoglobin level is low, benefits in pregnancy. Conversely,
in level throughout pregnancy is due to then the MCV (mean cell volume) is maternal hypervolaemia may protect
the relatively greater rise in maternal probably the most sensitive indicator against supine hypotension and helps
plasma volume compared to the rise in of iron deficiency in pregnancy compensate for haemorrhage at delivery.
red cell mass. This physiological without measuring serum ferritin The question of whether to offer
dilution of the maternal blood ensures levels. Table 1 lists the indicators for routine iron supplementation in
normal circulation with less cardiac anaemia. A macrocytic anaemia may pregnancy remains controversial. Iron
work than might be expected allowing suggest folate deficiency. requirements during pregnancy are
for the increased amount of clotting increased three-fold to approximately
factors and fibrinogen. Iron metabolism 4 mg/day for the placenta, fetus,
Anaemia may affect 10% of There is increased iron absorption maternal red cells - as well as
pregnancies in developed countries during pregnancy but despite this the additional lactational needs. In
and is considerably commoner in most common reason for anaemia is developing countries all pregnant
developing countries, where it is a nutritional deficiency in both the women should receive daily iron
major source of maternal morbidity developed and developing world. Iron (60 mg) and folic acid (400 mg) and
and a contributor to mortality. Up to utilization is 700-1400 mg per should be considered for preventive
56% of all women living in developing pregnancy with a saving of ~ 500 mg measures against malaria and
countries are anaemic (Hb < 11 g/dl) due to no menstrual blood loss. hookworm.
due to infestations (particularly Dietary advice to eat plenty of green
malaria - Fig. 1), frequent pregnancies vegetables and high iron-containing Folate metabolism
or haemoglobinopathies (see p. 34). foods may need to be supplemented A normal diet supplies adequate
Maternal anaemia does not seem to with oral iron (Fig. 3). amounts of folate for pregnancy but, as
pose substantial problems for the fetus
but it is dangerous to both mother and
fetus if there is superimposed
haemorrhage (Fig. 2). It may also
predispose the mother to
thromboembolic problems and is
associated with puerpural infection.
The proportion of maternal deaths
due to anaemia has been reported as -
India 16%, Kenya 11%, Nigeria 9% and
Malawi 8%. Whether the anaemia is
directly responsible for death or acts as
an underlying factor in other causes is
not clear. Antimalarial prophylaxis in
endemic areas has been shown to
decrease moderate to severe anaemia
in pregnancy by over 50%. The
increased incidence of low birthweight
infants in affected women may be
more related to the malaria than to the
anaemia. Fig. 2 Postpartum haemorrhage is likely to be more hazardous with pre-existing
anaemia, particularly if transport to hospital is a problem.
500 ml, more loss than this being • Iron deficiency anaemia should be prevented with routine iron supplementation in developing
defined as a postpartum haemorrhage countries.
(see p. 60). Caesarean section or • Routine iron supplementation should not be necessary in patients with an adequate diet.
multiple delivery may be associated • Anaemia at the time of delivery may compromise both mother and baby in the face of a
with greater blood loss. The average postpartum haemorrhage.
blood loss which can be tolerated
34 OBSTETRICS
Haemoglobinopathies in pregnancy
The haemoglobinopathies are genetic Table l The haemoglobinopathies
disorders of haemoglobin structure Globin gene Bands on
and synthesis. They are important in Haemoglobinopathy composition Hb electrophoresis RBC features Clinical
pregnancy because of their effect on Alpha thalassaemia a-/aa A (i.e. normal) Normal Normal
maternal health and the possibility of a-/a- A Mild anaemia Normal
--/a- A, H Severe anaemia Splenomegaly
transmission to the offspring, thus
HbH cells
raising the question of prenatal __/__ H Hydrops fetalis
diagnosis (see p. 8). Table 1 lists the 'Non-deletional'
various types of haemoglobinopathy. A a-thal
basic resume of haemoglobin structure (abnormal a gene) a a/a a A, *, ± H Variable Variable
and formation may aid understanding.
Beta thalassaemia
B thal minor normal B/reduced p A, A2, F Mild anaemia Normal
Formation of haemoglobin
B thal intermedia normal p/absent p A, A2 F Moderate anaemia Hepato-
Haemoglobin consists of four haem reduced B/reduced p A,A2F splenomegaly
molecules attached to two pairs of B thal major absent B/reduced p (A) (A2) F Severe anaemia Hepato-
globin chains (Fig. 1). Each globin absent p/absent p F splenomegaly
chain has two genes which code for it, Bone
deformity
so faults in any of the genes may have
Delayed
effect on the structure or amount of puberty
globin produced. All types of Iron overload if
haemoglobin have a pair of alpha transfused
The thalassaemias
These disorders result from a reduced Table 2 Types of haemoglobin laboratory abnormalities rather than to
production of globin chains, limiting Type Globin % after clearly defined beta thalassaemia
the amount of normal haemoglobin in chains 6 months heterozygote or homozygote
the red cells available to transport old appearances.
oxygen. The clinical manifestation Adult haemoglobin HbA a2 B2 97% Severe disease with both beta chains
during pregnancy is anaemia. The beta Adult haemoglobin HbA2 a, 62 ~ 20/o affected means the disease was
thalassaemias have the greatest clinical Fetal haemoglobin HbF a2 72 < 1 o/o inherited from both parents (beta
impact and are found with an thalassaemia major with no beta chain
incidence varying from one in seven in production - see Table 1). Management
Cyprus to one in a thousand in the UK Beta thalassaemias is with regular transfusion but iron
[see Fig. 2 for affected areas). This condition only becomes apparent overload from the transfused red cells
Population movement has resulted in after birth when the fetus moves from may lead to hepatic and endocrine
some geographical overlap of the production of fetal haemoglobin with dysfunction and myocardial damage.
different haemoglobinopathies leading gamma chains to adult haemoglobin Cardiac failure is a major cause of death
to double heterozygote phenotypes, with beta chains. There are many if an iron chelation programme is not
e.g. HbS-beta thal. possible abnormalities of the beta gene used. Some patients can exist without
leading to a spectrum of clinical and regular blood transfusion but the
expanded bone marrow leads to severe
bone deformity. This group may
achieve pregnancy and would require
folate supplementation but iron in any
form is contraindicated.
Beta thalassaemia minor patients
may become iron deficient during
pregnancy with lowered MCV, MCH
and MCHC. They will need both folate
and iron supplements but should
never be given parenteral iron therapy.
Unresponsive anaemia may require
blood transfusion. Serum ferritin
should be monitored as this is the best
indicator of iron store status.
Fig. 1 The structure of haemoglobin.
Haemogiobinopathies in pregnancy 35
haemorrhage
Antepartum haemorrhage (APH) is defined as bleeding from Table 1 Gradings for placenta praevia
the genital tract after the gestation of potential viability Minor I Encroaches on lower segment
(approximately 24 weeks). Common causes of APH include: II Reaches internal os (marginal pp)
Major III Covers part of os (partial pp)
« placenta praevia
IV Covers os completely (complete pp)
« placental abruption (abruptio placentae)
* local causes.
The incidence of APH is far greater than the combined
incidence of placenta praevia and placental abruption and
many cases remain of unknown origin.
Placenta praevia
The incidence of placenta praevia is 0.4-0.8%. It is more
common in multiple pregnancy and conditions with large
placental surface area, increasing maternal age and in
patients with a previous caesarean section scar.
Grading [Table 1)
This grading is important as major degrees of placenta
praevia are likely to require operative delivery whereas the
minor grades may manage a successful vaginal delivery.
Clinical presentation
The lower uterine segment forms during the third trimester
and with differential growth of the uterus antepartum
haemorrhage is commoner at this stage. The classic
presentation is:
• recurrent pain-free antepartum haemorrhage
« abnormal fetal lie
» non-engagement of the fetal presenting part.
Abdominal palpation will usually reveal a soft uterus with
readily palpable fetal parts, an abnormal lie and a high
presenting part. The fetal heart is most commonly audible
except where there has been overwhelming haemorrhage.
The diagnosis may be confirmed using ultrasound scanning
to localize the placenta. This is still most commonly Fig. 1 Management plan for placenta praevia.
performed transabdominally where the maternal bladder
delineates the upper edge of the lower uterine segment
anteriorly. Without this landmark a posterior placenta
praevia is more difficult to diagnose. The presenting part also Abruptio placentae
obscures vision posteriorly. Abruptio placentae (also known as accidental haemorrhage)
Vaginal scanning enables more accurate measurement of results from retroplacental bleeding. Although it is not
the distance from the edge of the cervical os to the edge of possible to predict, there are
the placenta - placental location greater than 2 cm from the recognized associations:
cervical os would not be expected to cause any clinical « pregnancy-induced hypertension
problem. Transvaginal scanning is used with caution for fear • eclampsia
of precipitating catastrophic haemorrhage. More clear views • renal disease ± hypertension
of the pelvis, fetus and placenta can be obtained with • rapid changes in uterine size (e.g. release of
magnetic resonance imaging (MRI) scanning. However, this polyhydramnios or after delivery of first twin) - in reality
is not widely available and its fetal effects are less well very rare.
known than those of ultrasound.
The classic presentation is of abdominal pain associated with
Management (Fig. 1) an antepartum haemorrhage. There may be uterine activity.
The golden rule for APH is that no vaginal examination The condition is classified into whether the haemorrhage is
should be performed until placenta praevia has been revealed, concealed or a mixture of the two (Fig. 2).
excluded as this might precipitate torrential bleeding with
possible maternal and fetal demise. Blood should be cross- Examination
matched, haemoglobin checked and clotting screen The findings may be:
performed, with intravenous fluids and blood transfusion as • uterus - tense or irritable
necessary. « fetus - longitudinal, if cephalic presentation head engaged.
Antepartum haemorrhage 37
Differential diagnosis
This should include:
« placenta praevia
preterm labour
* other causes of acute abdomen.
Management
The management plan for abruptio placentae is shown in
Figure 3.
In the case where DIC develops, delivery is best vaginally
to avoid uncontrollable haemorrhage during surgery. A
logical treatment for severe haemorrhage may be heparin
therapy to break the clotting cascade and the consumption
that is occurring of all the patient's clotting factors. In these
cases the fetus is often dead, so management is not
complicated by the need for urgent delivery of the fetus.
Cervical lesions
Occasionally a cervical polyp or an infected cervix may bleed. Antepartum haemorrhage
Speculum examination of the cervix is therefore helpful in
• In APH, first exclude placenta praevia and abruptio placentae.
the differential diagnosis of antepartum haemorrhage.
• In a large number of cases the cause remains unknown.
Ruptured uterine scar « Postpartum haemorrhage is a recognized complication of APH.
A scar on the uterus may rupture during labour, and vaginal • Previous APH predisposes to APH in future pregnancies.
bleeding would be associated with signs of fetal distress.
38 OBSTETRICS
Multiple pregnancy
The UK incidence of twins is 12/1000
pregnancies (3/1000 of these are
monozygous). Worldwide this ranges
from 54/1000 in Nigeria to 4/1000 in
Japan with the differences being almost
entirely due to variations in dizygous
rates. The incidence is higher with
ovulation induction, e.g. clomifene (10%)
or gonadotrophins (30%). The perinatal
mortality in twin pregnancies is four or
five times higher than for singleton
pregnancies, largely related to preterm
delivery (40% deliver before 37 weeks
compared to 6% in singletons),
intrauterine growth restriction (IUGR),
feto-fetal transfusion sequence (FFTS),
malpresentation and an increased
incidence of congenital malformations.
Breech presentation
Breech presentations account for 2-3%
of all labours. The incidence falls with
gestational age, being 20% at 28 weeks,
16% at 32 weeks, falling to 3-4% at
term as most breeches will turn
spontaneously. Therefore there is only
a problem if premature labour ensues
or the presentation persists. Up to 30%
are undiagnosed by clinical
examination. Breeches may be frank,
complete or footling (Fig. 1).
Frank breech 65% Complete breech 10%
Causes Both legs extended Both legs flexed at knee
Excluding prematurity, in which the and hip
incidence is increased, there are several
possible reasons why breech Footling breech 25%
presentations persist to term: One foot up, one foot down
(more common in multiparae
• extended legs preventing spontaneous due to lax abdominal
muscles)
version, by 'splinting' the body
• uterine anomalies Fig. 1 Types of breech presentation.
• something preventing engagement,
placenta praevia, fibroid, head of twin is cephalic before labour begins. The term breech, ECV has also been
• fetal anomalies, especially procedure results in a lower incidence carried out after previous caesarean
hydro cephalus and anencephaly. of caesarean section. The success rate section and during early labour.
In the majority of cases no cause is is quoted to be 46-65% (UK and US Various interventions have been tried
found. studies), although it has been reported to further improve the success rate, e.g.
to be as high as 80% in Africa. vibroacoustic stimulation,
Antenatal management Cases must be carefully selected amnioinfusion and epidural analgesia,
(Fig. 2). A number of factors have been but these are still under evaluation.
External cephalic version (ECV) found to increase the likelihood of After the procedure mothers are
Spontaneous version becomes success, including multiparity, reviewed weekly to check that the
increasingly unlikely with advancing adequate liquor volume and the station cephalic presentation persists. Some
gestational age. ECV is usually of the breech above the pelvic brim. would advocate a second attempt at
attempted at around 36-37 weeks with Although intended for the ECV if the presentation reverts to
the intention of ensuring that the baby management of the uncomplicated breech.
Elkin's manoeuvre
Some National Childbirth Trust (NCT)
members may advocate attempting to
influence the fetal presentation by
natural means. The woman is
instructed to adopt the knee-chest
position for 15 minutes every 2 hours
during the day for 5 days. Studies have
failed to show significant benefits with
this approach.
Therefore, each case must be judged Table 1 Indications for caesarean partially dilated cervix and that the cervix
carefully by an experienced section for term breech even if vaginal may clamp down on the fetal head.
obstetrician before a decision is made delivery requested Immediate intravenous administration of
to allow a vaginal breech delivery. Elective caesareans tocolytics may be helpful. In extreme
Abdominal palpation may reveal a Pelvic cases the cervix can be incised or the
• small pelvis, flat sacrum, bony abnormalities, e.g.
baby that is obviously so large that baby pushed upwards from below and
rickets
elective caesarean section is required. Fetal delivered by caesarean section.
An ultrasound is performed at 37 • estimated birthweight 3.5 kg or over
Labour of the term breech
weeks to estimate the fetal birthweight • Large biparietal diameter, e.g. hydrocephalus
« Hyperextension of fetal head The management of a breech labour is
(EBW) and more importantly the
Pre-existing obstetric problems the same as for a cephalic
biparietal diameter (BPD) (Fig. 3). The • pre-eclampsia presentation. The rate of cervical
scan will also indicate the degree of • bad obstetric history
dilatation and descent of the
extension or flexion of the head and placental insufficiency
presenting part are plotted on a
legs. The baby may have adopted a Pre-existing maternal problems
» history of infertility partogram (see p. 50). Continuous fetal
complete or footling presentation.
• older prirnigravida monitoring is usual. An epidural may
Vaginal delivery is safest in the case • diabetes be desirable as it prevents the mother
of a frank breech as there is an
Emergency caesareans pushing involuntarily before full
increased risk of cord prolapse with an Failure to progress in first stage cervical dilatation (a more common
ill-fitting presenting part. An attempt Failure of descent of breech in second stage
problem with breech than vertex
must also be made to assess the size of
presentations) and provides pain relief
the pelvis. Clinically, this can be done
during the assisted delivery.
by a gentle vaginal examination to imaging (MRI) pelvimetry can be
Augmentation with Syntocinon
estimate: performed. It is essential to see the
should be used with caution. The
films as well as the measurements
• the width of the subpubic angle breech should descend easily into the
(ideally inlet: 13.5 x 11.5 cm, outlet
« the gap between the ischial spines pelvis. Fetal distress may intervene
12.5 x 10.5 cm). A well-curved sacrum
« the sacral curve. despite good progress in labour and
provides a large pelvic cavity; a flat
should be dealt with in the same way
An erect lateral pelvimetry X-ray may sacrum limits the space available to the
as a vertex presentation.
be helpful or magnetic resonance aftercoming head and may cause
Even at full dilatation the breech may
problems during a vaginal delivery,
not descend. The baby should be born
even if the inlet and outlet are adequate.
by the mother's own efforts with a little
If obstetric or medical problems co-
assistance from the obstetrician at key
exist, operative delivery is necessary
points, an assisted breech delivery. The
(Table 1).
overriding priority is control of the
aftercoming head. There is no time for
Management of labour
moulding, and if the head is allowed to
Preterm labour descend rapidly great pressure
Prospective data are still unavailable. differences occur that may cause
The poor outcome for very low tentorial tears and intracerebral bleeds.
birthweight infants is mainly related to Occasional difficulty is encountered with
prematurity and not the mode of extended arms but there are special
delivery. Some labours advance too manoeuvres available to overcome this.
rapidly to allow delivery by caesarean There is no merit in strong traction to
section. The baby may fare better if it bring down an undescended breech, a
is delivered within its intact breech extraction, because perinatal
membranes, a caul delivery. The main outcome is poor.
concern with vaginal delivery of very Most mothers will opt for external
small preterm infants is that the trunk cephalic version. If this fails, most
and limbs will slip through an only request caesarean delivery.
Breech presentation
• Most breeches spontaneously turn to the cephalic presentation by 36 weeks.
• Prematurity is associated with an increased incidence of breech presentation.
• ECV increases the chances of vaginal delivery.
« Careful selection must be made to decide which term breeches should be considered for an
attempt at vaginal delivery.
• Selection involves assessment of the biparietal diameter and estimated birthweight of the fetus
together with the size of the pelvis.
• Caesarean section may be best for some preterm babies.
Fig. 3 Assessment of mode of breech • The most important aspect of an assisted vaginal breech delivery is careful delivery of the
aftercoming head.
delivery. In this case the biparietal diameter is
close to size of outlet.
42 OBSTETRICS
DVT may be asymptomatic or, in • Activated protein C resistance (if present, test for the
factor V Leiden mutation)
addition to the traditional symptoms Antithrombin III
and signs, it may present with lower • Protein C deficiency
abdominal pain. It is essential to make • Protein S deficiency
a definitive diagnosis if possible, not • Lupus anticoagulant and antiphospholipid antibodies
• Prothrombin gene variant
just for management of the current
m Hyperhomocystinaemia
pregnancy but because there are major
implications for subsequent
pregnancies as well. Duplex Doppler results or is not available (Fig. 2). It is
ultrasound is particularly useful for also essential to fully investigate a
identifying femoral vein thromboses, suspected pulmonary embolism, and
although iliac veins are less easily seen pregnancy is not a contraindication to
(Fig. 1). It is safe and should be the a ventilation-perfusion (VQJ scan —
first-line investigation. Venography is any risks are far outweighed by the
better, but has the disadvantage of Fig. 2 Thrombus occluding the left benefits of accurate diagnosis (Fig. 3).
radiation exposure and should be common iliac vein, with patent left femoral A normal scan virtually excludes the
carried out if Doppler gives equivocal vein. diagnosis of pulmonary embolism.
Venous thromboembolic disease 43
Management of DVT or pulmonary perioperative hysterectomy deaths. As minimized by avoiding injection close
embolism in pregnancy is with prophylaxis is effective in reducing to the wound. Graduated compression
therapeutic subcutaneous heparin. thromboembolism, all gynaecological stockings would be an alternative,
Postnatally the patient may choose to patients should be assessed for risk although compliance with stockings
continue with subcutaneous heparin factors and prophylaxis prescribed may be reduced in those who find
or start warfarin, continuing accordingly (Table 3). The incidence is them uncomfortable. In addition, they
anticoagulation for 6-12 weeks as higher in those with malignancy have not been shown to reduce the risk
decided by timing of onset and clinical (35%), lower for 'routine' abdominal of fatal pulmonary thromboembolism.
severity. Once anticoagulants are hysterectomy (12%) and lowest for Dextran carries a significant risk of
stopped, the patient should be vaginal hysterectomy. anaphylaxis.
screened for thrombophilia. As some prophylactic methods may Any benefits to stopping the
Management of those with a be associated with side effects (e.g. combined oral contraceptive (COC)
previous thromboembolic history wound haematomas and 4-6 weeks prior to surgery must be
carries more uncertainties. Women hypersensitivity reactions with heparin), xveighed against the risk of unwanted
who have had a single episode of the methods chosen must be based on pregnancy. In the absence of other risk
DVT/PTE should be screened for some form of risk vs benefit assessment. factors there is insufficient evidence to
thrombophilia (Table 1). If the screen The benefits to the patient of heparin support a policy of routine COC
is negative, and the event occurred in moderate/high-risk groups are felt to discontinuation. It may be advisable to
outside pregnancy and was not severe, outweigh the approximately 2/100 risk stop hormone replacement therapy
thromboprophylaxis may not be of wound haematoma, which may be (HRT) before major surgery.
required. If positive, or there are other
risk factors, antenatal and postnatal
prophylaxis can be considered.
Table 2 Risk factors following caesarean section
Heparin treatment may induce
Low risk — early mobilization and hydration
thrombocytopenia and may also rarely Elective caesarean section - uncomplicated pregnancy and no other risk factors
lead to osteoporotic fractures.
Moderate risk - heparin [e.g. heparin 5000 U b.i.d. or enoxaparin 20 mg/day) and TED stockings
Age > 35 years
Postnatal risk assessment Obesity (> 80 kg)
The risks of thromboembolism should Para 4 or more
be assessed in all patients who have Gross varicose veins
undergone caesarean section (see Current infection
Pre-eclampsia
Table 2). It is also essential to consider
Immobility prior to surgery (> 4 days)
prophylaxis in those who have had Major current illness, e.g. heart or lung disease;cancer; inflammatory bowel disease; nephrotic syndrome
vaginal deliveries, whether Emergency caesarean section in labour
instrumental or not, who may be
High risk - heparin (e.g. heparin 5000 U t.i.d. or enoxaparin 40 mg/day) and TED stockings
considered to be at increased risk. A patient with three or more moderate risk factors from-above
Extended major pelvic or abdominal surgery, e.g. caesarean hysterectomy
Gynaecology Patients with a personal or family history of deep vein thrombosis; pulmonary embolism or thrombophilia; paralysis of
lower limbs
Venous thromboembolic disease
Patients with antiphospholipid antibody (cardiolipin antibody or lupus anticoagulant)
accounts for around 20% of
« Any symptoms should be investigated fully, even if this requires X-rays or isotope scanning.
Prophylaxis is important in both obstetrics and gynaecological practice.
44 OBSTETRICS
pregnancy. A full dietary and Racial aspects years. Anaesthetic is rarefy given and
substance-abuse history should be Every woman must be treated with asepsis is limited. The raw edges of the
taken. A more searching questionnaire respect and her religious and cultural labia are sutured together with catgut
for alcohol is the TACE questionnaire. views acknowledged wherever or more commonly thorns. The girl's
A total score of two points or more is possible. legs are bound together and a small
considered positive and correctly aperture is left to allow drainage of
identifies approximately 70% of heavy Female genital mutilation urine and menstrual fluids.
drinkers. Female genital mutilation (FGM) The practice is widespread in a band
Nutritional problems are common. affects more than 80 000 women and from the Horn of Africa through
Trace element deficiencies (e.g. zinc children worldwide. The type of Central Africa to parts of Nigeria, and
and copper) and vitamin deficiency mutilation performed varies from involves 90% of female children in
states (folate, thiamine and pyridoxine) Sunna (excision of the clitoral Somalia and Ethopia. Immediate
may exist. prepuce) to excision of the clitoris, complications include severe
Alcohol passes freely to the milk. labia minora and majora (in the most haemorrhage and infection and there
Regular heavy drinking by the mother severe form) (Fig. 1). The age at which is a significant mortality. Long-term
may impede psychomotor FGM is performed varies from birth to problems include recurrent urinary
development of the breast-fed infant, immediately prior to marriage, but tract infections, dysmenorrhoea, non-
although mental development is most commonly is between 6 and 7 consummation and lack of sexual
probably unaffected. Heavy binging enjoyment. Circumcision increases the
may lead to neonatal sedation. marriage prospects within that society.
Specific counselling, referral for Failure to undergo circumcision may
specialist treatment and a telephone lead to social rejection.
contact number provide support. Women who have been victims of
FGM and book for antenatal care
Domestic violence should, if possible, be treated in a
Most acts of domestic violence are specific African Well Woman Clinic
directed by men against women, and with access to a translator and
are unrelated to social class. An psychologist if required. They should
estimated 835 000 incidents were be encouraged to have the
reported in 1997. One woman in nine circumcision reversed in the second
is subjected to severe beatings by her trimester under spinal anaesthetic
partner each year. between 20-28 weeks. This allows
Violence against a partner is often adequate examination vaginally to
linked to wider family problems. In assess progress in labour. If a patient
three out of five cases where children declines, reversal should be performed
suffered abuse, their mother was in the first stage of labour, to allow
abused. Midwifery staff and health care catheterization, examination and
workers should be vigilant for any continuous fetal monitoring where
signs of domestic violence. Self-help required.
groups and one-parent hostel facilities It is illegal under the terms of the
may need to be considered. 1985 Prohibition of Circumcision Act
Fig. 1 Female circumcision. to resuture these women after delivery.
Psychological issues
Depression and psychosis
Patients who have been previously
treated with antidepressants or
antipsychotics will need to be
reassessed in the antenatal period. The
social, economic and domestic factors Psychosocial problems in antenatal care
that may have contributed to any
« The USA has the highest teenage pregnancy rate.
depression will need to be reassessed
and social service support provided • The UK has the worst record of teenage pregnancies in Europe.
early if deemed necessary. • There is increased morbidity and mortality in babies born to teenage mothers.
It is preferable to try to withdraw • Smoking is implicated in low birthweight babies.
any medication if possible, but if the
• Chronic heavy alcohol ingestion is associated with the fetal alcohol syndrome [FAS].
mental condition is brittle, the dose
should be reduced to the lowest • Domestic violence continues to be the most common violent crime against women in England
and Wales.
possible to maintain stability, or a
milder alternative substituted. It is • Although victims of female genital mutilation should be advised to undergo de-infibulation
between 20-28 weeks or certainly in the first stage of labour, this will depend on consent and
better to use behavioural and
consideration of cultural issues.
psychotherapeutic treatments during
pregnancy if possible.
46 OBSTETRICS
Fig. 1 The fetal skull. Fig. 3 Contractions start from the fundus.
Mechanisms of normal labour 47
Occurrence
Engagement of head
Descent to pelvic floor where
guttering encourages rotation
of head 90°
Further descent of head and
occiput under symphysis
Head extends and face passes
over perineum
Restitution - head realigns with
shoulders
The anterior shoulder is then delivered under the symphysis
with downward traction then an upward sweep to deliver
the posterior shoulder carefully over the perineum. Finally,
the infant is delivered onto the mother's abdomen.
Third stage • The shape of the maternal pelvis will affect the progress of labour.
• The second stage of labour may be managed passively, but active encouragement to push is
Signs of placental separation more usual.
These comprise:
« Episiotomy is used only if needed.
• lengthening of the umbilical cord
48 OBSTETRICS
• If abnormalities of the fetal heart rate are noted during auscultation or the liquor becomes
Descent of the presenting part meconium-stained then this low-risk labour becomes high risk and warrants continuous
When a primigravid patient enters electronic fetal monitoring.
labour the head is usually engaged but • Labour management requires use of the partogram.
in highly parous patients engagement
» Interpretation of cardiotocography is a skill that requires practice.
may not occur until the second stage of
labour. There should be no head • Fetal blood sampling gives additional information to the cardiotocography about fetal well-being.
Abnormal labour
Abnormal labour
Although normal labour can be
defined as that ending in a healthy
mother and baby, it is more
traditionally defined as beginning
between 37 and 42 weeks, progressing
at an acceptable rate and resulting in
the spontaneous vaginal delivery
(SVD) of a live non-distressed neonate
in the occipitoanterior position.
Deviation from this latter definition
may therefore occur if progress is too
fast (precipitate labour), or too slow
(often in association with malposition
or malpresentation).
Precipitate labour
This occurs especially with induction
of labour, augmentation and grand
multiparity. The risk is that excessively
frequent or prolonged contractions
reduce the blood supply to the baby
and may lead to hypoxia and
consequent damage. Such hypoxia may
occur over a short period of time to an
otherwise healthy fetus, so that the
prognosis is usually good.
If prolonged contractions occur,
Syntocinon should be stopped, and the
fetal condition assessed with the
cardiotocograph (CTG). If there is
evidence of'distress' a vaginal Fig. 1 Partogram. Progress was arrested at 8 cm and the baby was in right occipitoposterior
position (i.e. relative cephalopelvic disproportion). As the patient was a primigravida and the CTG was
examination (VE) should be performed
reassuring, Syntocinon was commenced, the head rotated and there was an SVD.
and consideration given to delivery. If not
fully dilated, caesarean section should be
considered. The uterine hypertonus skull are aligned, 2+ if overlapping and
may respond to a bolus of i.v. ritodrine 3+ if irreducible). If there is felt to be
or subcutaneous terbutaline. inadequate uterine activity,
consideration may be given to
Slow labour augmentation with Syntocinon, but
There may be an initial and sometimes caution is required in parous women,
prolonged (hours/days) latent phase particularly those with a previous
before true labour begins, but an caesarean section scar, owing to the
acceptable rate of dilatation after 3 cm risk of uterine or scar rupture.
is 1 cm per hour in a primigravida and
1-2 cm an hour in a multigravida. Cephalopelvic disproportion
Slow labour may be due to inadequate (CPD)
uterine activity or to cephalopelvic
The pelvis may be too small. This may
disproportion, i.e. too small a pelvis, or
occur following trauma to the pelvis,
too big a presenting part. A partogram
but is usually idiopathic Worldwide,
is very useful to assess progress
rickets and osteomalacia are the
(Fig. 1).
commoner causes (Fig. 2). The role of
computed tomography or radiographic Fig. 2 Pelvis in (a) rickets and
Inadequate uterine activity
pelvimetry to measure the size of the (b) osteomalacia. Pressure deforms the
In clinical practice, the strength of softened bones.
outlet is probably very limited.
contractions is difficult to measure,
and the diagnosis is usually made by The presenting part may be too big. The
excluding obstruction of whatever baby's head may be large, particularly
cause. Obstruction is suggested by in association with macrosomia (e.g. head is extended or rotated in some
malposition, caput (oedematous diabetes). Only rarely is there unfavourable way (malposition),
swelling on the fetal head) and hydrocephalus. More commonly, there presenting a larger diameter to the
moulding (1+ if the sutures of the fetal may be relative disproportion, i.e. the pelvis than is ideal.
Abnormal labour 53
Malpresentations and
malpositions
[see also Breech, p. 40)
It is possible to establish the position
of the fetal head at VE by palpation of
the scalp sutures (Fig. 3).
Occipitoposterior [Fig. 4). Although the
head usually rotates to occipitoanterior
(OA) in normal labour, some arrest in
the transverse position and a small
proportion (= 10%) rotate to
Occipitoposterior (OP). There are
usually longer first and second stages
of labour with an increased chance of
requiring a caesarean section, Fig. 4 Malpresentation and malposition.
rotational forceps or ventouse delivery.
If still OP and undelivered despite
second stage pushing, a low/mid-cavity
OP delivery, manual rotation,
rotational ventouse, or Kielland's
rotational forceps delivery will be
required.
Face presentation (Fig. 5). Caution is
required to avoid confusion with a
breech presentation. Most face
presentations engage in the transverse
position and 90% rotate to mento-
anterior so that the head is born with
flexion. If mento-posterior, a caesarean
section will be required unless very Fig. 5 Face presentation, (a) Mento-anterior - delivery possible. CD) Mento-posterior - delivery
preterm or there has been an impossible.
intrauterine death, as the extending
head presents an increasingly wide delivery is not possible and there is a
diameter to the pelvis and worsening risk of cord prolapse. Pre-labour external
relative CPD. cephalic version with or without
induction or elective caesarean section is
Brow presentation (Fig. 6). The
needed. Transverse lie
supraorbital ridges and the bridge of the
(± arm presentation) following
nose are palpable. The head may flex to
spontaneous rupture of the membranes
become a vertex presentation or extend
is an indication for urgent caesarean
to face presentation in early labour. If
section, which may require a vertical
the brow presentation persists or there
uterine incision to enable delivery of the
is no cervical dilatation, a caesarean
fetus.
section will be required.
Fig. 6 Brow presentation.
Transverse/oblique lie. This usually Abnormal labour
occurs in multiparous women and is Slow labour may be due to poor uterine activity or fetal obstruction.
associated with multiple pregnancy,
Obstruction may be due to true cephalopelvic disproportion (i.e. the baby is too big or the pelvis
preterm labour and polyhydramnios. It too small). It may also be due to relative cephalopelvic disproportion (i.e. with malposition or
may also occur with an abnormal malpresentation).
uterus or placenta praevia. Vaginal
54 OBSTETRICS
Operative delivery
Forceps and ventouse can be used to Table 1 Criteria for instrumental vaginal
deliver a baby in the second stage of delivery
labour. Caesarean section can be used The cervix fully dilated with the membranes ruptured
in both the first and second stages. • The head at spines or below with no head palpable
abdominally
Operative delivery may be indicated:
The position of the head known
Forceps delivery
There are three main types of forceps suture is in the anteroposterior
(Fig. 1): plane (usually occipitoanterior).
• Kielland's forceps for rotational
• Low-cavity outlet forceps (e.g.
delivery (the reduced pelvic curve
Wrigley's), which are short and light
allows rotation about the axis of the
• Mid-cavity forceps (e.g. Haig
handle).
Ferguson, Neville Barnes,
Simpson's) for when the sagittal The most common indications for use
of forceps are presumed fetal distress
or second stage delay. The criteria
listed in Table 1 should all be met
before forceps delivery is attempted.
The most difficult part is often
identifying the fetal position accurately.
If there is a suspicion from palpation of
the sutures that the baby is
occipitotransverse, it is often helpful to
try to feel for an ear anteriorly under
the symphysis pubis (this is painful).
and a transverse lower segment placing a finger behind each flexed made to ensure that the uterus is
incision made (Fig. 7a-c). hip (Fig. 7d) and, if transverse, a leg empty and that there are no ovarian
The baby's head is encouraged identified to deliver (i.e. internal cysts, and the incision closed with two
through the incision with firm fundal podalic version). After delivery, layers of dissolving suture to the
pressure from the assistant (Wrigley's Syntocinon is given i.v. stat. and the uterus (Fig. 7e,f)/ one layer to the
forceps are occasionally required). If placenta delivered after uterine sheath and one layer to the skin.
the baby is a breech presentation, contraction. Haemostasis is obtained
traction is applied to the pelvis by with straight artery forceps, a check
Operative delivery
• Forceps may be low-cavity (outlet), mid-cavity or rotational (Kielland's).
• The use of ventouse compared to forceps is associated with less maternal perineal trauma, more cephalhaematomata and more retinal haemorrhages.
• Maternal mortality is higher for emergency caesarean section than for elective section.
58 OBSTETRICS
The perineum
Perineal tears sphincter and those involving the anal Repair of episiotomy or first- or
Perineal trauma affects women's physical, mucosa. Anterior perineal trauma is second-degree tear (Fig. 1)
psychological and social well-being in defined as any injury to the labia, 1. Infiltrate with 1% lidocaine
both the immediate and long-term anterior vagina, urethra or clitoris and is (lignocaine) (unless an epidural is in
postnatal periods. It can also disrupt associated with less morbidity. situ or the perineum has been
breast feeding, family life and sexual Repair of perineal tears should be infiltrated prior to delivery) (Fig. la).
relations. In the UK, approximately a with an absorbable synthetic material 2. Find the apex of the vaginal incision
third of women will continue to have (Dexon or Vicryl), using a continuous or tear and place the first suture
pain and discomfort for 10-12 days subcuticular [possibly non-locking) above this level (but note that the
postpartum and 10% of women will technique to minimize short- and long- rectum is just posterior to the vaginal
continue to have long-term pain (3-18 term problems. Good perineal toilet wall) (Fig. Ib).
months following delivery). Faecal post-delivery is likely to aid healing, and 3. Use a continuous locking suture to
incontinence and urinary incontinence the use of ice packs and analgesia may appose the vaginal wall, continuing
can occur postpartum (see below). be useful to control symptoms. until the hymenal edges are apposed.
It was previously felt that the use of There is some evidence to support the The suture can then be tied, or more
episiotomy reduced the incidence of use of perineal massage in women simply locked, and the needle threaded
anal sphincter tears. There is, however, completing their first pregnancy as a between the apposed vaginal edges a
little good evidence to suggest that this preventive measure to reduce the few centimetres back ready to close the
is the case, and there is certainly no incidence of trauma. perineal body.
evidence to support routine episiotomy
in all deliveries to prevent third- or
fourth-degree tears. Midline episiotomy
in particular offers little protection and
right posterolateral episiotomy is
preferred (see p. 47).
The rate of episiotomy has wide
geographic variations from 8% in the
Netherlands, 20% in England and Wales,
50% in the USA to 99% in some Eastern
European countries. It is also high in
many developing countries. It is
therefore difficult to define what a 'good'
episiotomy rate should be. Restricting
the use of episiotomy to specific fetal
and maternal indications leads to lower
rates of posterior perineal trauma and
healing complications. A tear may be
less painful than an episiotomy and may
also heal better.
There is controversy about whether
the baby's head should be 'controlled'
during delivery (i.e. a hand used to slow
the head as it delivers). A controlled
head is likely to tear the perineum less,
but may increase the blood flow and
distract the mother in her pushing.
Spontaneous tears are defined as:
The perineum
« There is no evidence to support routine episiotomy - a tear may be less painful than an
episiotomy and may also heal better.
CLOT
Fig. 1 The usual mechanism for control of in cervix causes intense
uterine blood loss following delivery. The pain, cervical shock and
prevents retraction
mesh-like network of smooth muscle fibres, on
contraction and retraction, controls bleeding. Fig. 2 The main causes of uterine anatomy.
Postpartum haemorrhage and abnormalities of the third stage of labour 61
further occasion to check that all prevent the development of investigation to distinguish between the
products have been removed. This endometritis. Syntocinon or ergometrine pathologies.
procedure is usually done under are used to control blood loss. It is
regional blockade and only rarely under usually unnecessary to request uterine Sheehan's syndrome
general anaesthesia, unless in the ultrasound to make the diagnosis. This is an especial problem in obstetrics
presence of a PPH. if there is profound hypotension that
For practical management of primary Third stage problems remains uncorrected. During pregnancy
PPH: These may include: the pituitary gland increases in size
predisposing it to circulatory problems
• summon senior help • failure of placental separation
if there is blood loss. It has end arterial
• summon an anaesthetist • incomplete placental separation
blood supply which means no collateral
• keep ahead of the blood loss • postpartum haemorrhage - due to
supply, and hypotension may result in
• rub up a contraction and catheterize retained portion of placenta
an avascular pituitary gland. If this is not
to ensure bladder empty and allow « uterine atony - leading to excessive
corrected quickly enough the pituitary
monitoring of urinary output blood loss
gland will undergo avascular necrosis
• gain intravenous access with two large « tear of genital tract
(Sheehan's syndrome) (Fig. 3).
venflons; run in crystalloid or colloid • collapse (may be due to excessive
The consequences of this depend on
and cross-match 6 units of blood blood loss, eclamptic fit, amniotic
which area of the pituitary gland is
• give Syntocinon intravenously fluid embolus, cardiac failure,
inactivated. If the anterior lobe is lost
• remove placenta if possible; ensure no pulmonary embolus, cerebral
then no follicle-stimulating hormone
blood clot distending the cervix haemorrhage, diabetic coma)
(FSH), luteinizing hormone (LH),
• if apparent uterine atony, further • uterine inversion (p. 63).
thyroid-stimulating hormone (TSH),
intravenous Syntocinon and
Collapse in the third stage needs prompt growth hormone (GH), prolactin or
carboprost intramuscularly or
action to ensure maternal well-being. adrenocorticotropic hormone (ACTH)
intramyometrially
Epilepsy and diabetes would be known will be produced resulting in secondary
• if bleeding possibly due to trauma,
about from the history and there may amenorrhoea, atrophy of breasts and
general anaesthetic (not regional
be a relevant cardiac history. Blood loss genital organs, osteoporosis,
block) is required before repairing
would be obvious. Amniotic fluid hypothyroidism and Addisonian
lacerations
embolus, cerebral haemorrhage and symptoms.
• in the face of persistent bleeding
pulmonary embolus would all be The importance of adequate and urgent
consider internal iliac artery ligation,
associated with sudden collapse of the blood and fluid replacement in
hysterectomy or radiological
mother needing resuscitation and postpartum haemorrhage is thus obvious.
embolization
• intensive therapy unit support and
central monitoring; correct
coagulopathy as disseminated
intravascular coagulopathy (DIC) is
likely - fresh frozen plasma and
uncross-matched or group-specific
blood may be transfused; monitor for
development of acute renal failure and
adult respiratory distress syndrome.
Secondary postpartum
haemorrhage
Distinguishing between retained
products of conception and infection
allows effective management of
secondary PPH. Pyrexia, raised WBC,
offensive lochial discharge and a closed Fig. 3 Histology of pituitary gland in Sheehan's syndrome.
cervical os are found with endometritis
which will require antibiotics
particularly covering anaerobic Postpartum haemorrhage
organisms. Intravenous therapy for
• Postpartum haemorrhage can be life threatening.
24 hours and bed rest will usually see a
rapid improvement. • Uterine atony is the commonest cause of primary postpartum haemorrhage.
Bleeding, maybe with passage of • Emergency management includes ensuring contraction of the uterus and adequate fluid
tissue, an open cervical os and failure of replacement.
uterine involution leaving the uterus If the uterus is well contracted check for trauma to the genital tract and that blood is clotting.
larger than usual for the number of Active management of the third stage of labour reduces the incidence of primary postpartum
postpartum days are all features of haemorrhage.
secondary PPH due to retained products
• Retained products of conception are prevented by a thorough check of the completeness of the
of conception. The patient will be taken placenta and membranes at delivery.
to theatre for evacuation of the uterus
under anaesthesia. Antibiotic cover may
62 OBSTETRICS
Obstetric emergencies
Amniotic fluid embolism
This rare complication occurs when
amniotic fluid suddenly enters the
maternal circulation during labour or
delivery. It carries a high maternal
mortality (up to 80%) and is associated
with multiparity, precipitate labour,
uterine stimulation and caesarean
section. Clinically there is sudden
dyspnoea, fetal distress and
hypotension, followed within minutes Fig. 1 ARDS. There is bilateral alveolar
by cardiorespiratory arrest with or consolidation. Fig. 2 Cord prolapse.
without seizures. It is often followed
by haemorrhage from disseminated
Cord prolapse
intravascular coagulation (DIC) and patient should be instructed to adopt
This may occur especially when
uterine atony, and may lead to acute the knee-chest position (kneeling
membranes rupture (or are ruptured)
renal failure (ARF) and adult with head down) and transferred to
with a high or poorly fitting presenting
respiratory distress syndrome (ARDS; theatre for an immediate caesarean
part (Fig. 2). The risk is of cord
Fig. 1). It is often diagnosed by section under general anaesthesia or
occlusion with pressure from the
exclusion (Table 1), but is ideally rapid spinal anaesthesia.
presenting part, or of vessel spasm and
identified by the presence of fetal
constriction following exposure to the
squamous cells on a blood film from a Mendelson's syndrome
lower temperature of the air, leading
central line. This is due to pulmonary injury
to hypoxia and possibly death. It is
Management includes following inhalation of acid gastric
also more likely to occur with twins,
cardiopulmonary resuscitation (CPR) contents, and is more likely during
polyhydramnios, breech or transverse
with high-flow O2, with or without obstetric anaesthesia than routine
lie.
ventilation if required, and anaesthesia because of pressure from
consideration given to urgent delivery. • If the cord is palpated before the gravid uterus and reduced
Two large-bore i.v. lines are inserted artificial rupture of the membranes competence of the gastro-oesophageal
and the patient is rapidly infused with ('cord presentation') then caesarean sphincter. There is rapid onset of
a combination of crystalloid and colloid section is required. cyanosis, bronchospasm, tachycardia
until the blood pressure approaches • If cord prolapse occurs, the and pulmonary oedema. Cricoid
normal. This is then stopped to presenting part should be displaced pressure should be used with
minimize the risk of ARDS. As uterine upward with a hand and the hand induction of general anaesthesia to
atony is common, oxytocics are given kept there until delivery. If the cervix minimize the risk.
postnatally. Bloods are sent for clotting, is fully dilated and easy delivery is If inhalation occurs, the patient
screen and cross-match to anticipate anticipated, then an immediate should be given 100% O2, tilted head
DIC. Cardiogenic shock, ARDS and ARF forceps or ventouse delivery should down and turned onto her left side.
are managed as appropriate. be carried out. If not, then the The pharynx should be aspirated.
Antibiotics may prevent secondary
infection. Further management is with
Table 1 Causes of sudden collapse
ventilation if required, physiotherapy
and rarely bronchoscopic aspiration of
Problem Discussion
mucous plugs.
Amniotic fluid embolism Is associated with multiparity, precipitate labour, uterine stimulation and caesarean
section. There is sudden dyspnoea, fetal distress and hypotension, followed within
minutes by cardiorespiratory arrest ± seizures Shoulder dystocia
Anaphylaxis There may be cyanosis, hypotension, wheezing, pallor, prostration and tachycardia The shoulders are stuck in the
± urticaria anteroposterior (AP) plane with the
Cerebrovascular May be history of severe pregnancy-induced hypertension or past history of intracranial anterior shoulder behind the
accident problems (e.g. previous subarachnoid haemorrhage). Nausea and vomiting with symphysis pubis (Fig. 3). Prompt, calm
headache action is vital, as the baby will become
There is a tonic-clonic seizure (differentiate from epilepsy and amniotic fluid embolism rapidly asphyxiated and will die
on the basis of the history)
without appropriate action. The
Myocardial infarct May be past history of heart disease. Chest pain, sweating, pallor diagnosis is made after failure to
Tension pneumothorax There is sudden onset of pleuritic chest pain (differentiate from pulmonary embolus) deliver shoulders with the first
and diminished breath sounds
downward pull of the head.
There may be apprehension, pleuritic chest pain, sudden dyspnoea, cough,
haemoptysis and collapse (differentiate from pneumothorax) ± antecedent risk factors
Management
Uterine inversion Occurs in the third stage only. It may lead to profound hypotension (there may be only
The acronym 'PALE SISTER'
a partial inversion and therefore the diagnosis may not be obvious)
summarizes the management of
shoulder dystocia.
Obstetric emergencies 63
puerperium •
It is important to understand the controls milk ejection. Initially, milk familiar with nursing and bathing her
normal process of the puerperium in rich in colostrum is released. Milk infant with confidence, and the
order to be able to recognize production commences by day 3. method of feeding to be adopted.
complications when they occur, with Supervision of these processes may
the increasing trend towards early Routine care begin in hospital or be initiated in the
discharge from hospital, often before Routine observations carried out community.
lactation is established. postpartum include pulse rate, blood
pressure and temperature. If these are Breast feeding
normal, daily recordings of the pulse Most women have made the decision
Physiological changes
rate and temperature will suffice. If the to breast feed prior to delivery. Many
Physiological changes occur rapidly in
blood pressure has previously been units have a breast-feeding counsellor
the first week postpartum.
elevated, 4-hourly readings are to offer guidance. There are some
continued until it settles. The fundal obvious advantages to breast feeding
Structural height is checked daily to ensure that [Table 1). Consistent advice should be
Immediately postdelivery the fundus of involution is occurring normally. The given by health care professionals to
the uterus is just below the umbilicus. lochia is inspected and the volume, avoid confusion and demotivation.
It should be impalpable abdominally colour and odour noted. Very offensive The correct positioning of the baby
by the end of the first week and lochia will require further on the breast is vital to prevent
almost normal size on bimanual investigation. chewing of the nipples, causing sore or
assessment at 6 weeks. The lochia is It is important to check the urine cracked nipples which can predispose
the normal discharge from the genital output, as retention can occur to infection and discomfort [Fig. 1).
tract in the puerperium. It is red for postnatally secondary to a painful Milk production requires a good fluid
the first 3 days, then pink and becomes perineum, after an epidural, or intake. Many mothers feed their babies
yellow/brown by the end of week one, following surgery. A full bladder will 'on demand', others introduce a 3- to
diminishing in volume over 3-6 weeks. increase the apparent fundal height 4-hourly feeding regime.
and may retard uterine contraction. Supplementary and complementary
Perineal toilet after each bowel action feeds have not been shown in any
Endocrine
should prevent infection of the randomized controlled trials to be of
Serum progesterone and oestradiol fall
episiotomy and subsequent benefit to healthy term breast-fed
to non-pregnant levels by 72 hours.
breakdown. The perineum is often infants. Extra fluids are no longer
Human placental lactogen (HPL) levels
swollen and painful and many women recommended for jaundiced babies.
fall rapidly in the first 48 hours but are
develop haemorrhoids secondary to The best management is demand
still detectable at the end of the first
the expulsive efforts of labour. feeding. All babies will initially lose
week. Thyroxine and thyroid-binding
Adequate analgesia, laxatives and rectal weight until lactation is fully
globulin fall slowly to normal over
suppositories may be required. established.
6 weeks. Fasting plasma, insulin and
There must be adequate time for Human milk delivered at a rate of
the insulin response curve are normal
supervision and support of the mother 750-800 ml a day (in a healthy, well-
2 days postpartum.
following delivery. She must become nourished mother) contains calcium at
prolactin and oxytocin - the former • Babies with cleft palate can be fed with special
appliances.
stimulates lactogenesis, the latter
The normal puerperium 65
Postpartum contraception
The spacing of pregnancies is essential
for the health of the mother and child.
Severe anaemia may result if
pregnancies follow each other too
closely.
For breast feeding alone to be effective
contraception, lactation must be
complete (Table 3). Progestogen-based
contraception does not suppress
lactation and may be used by breast-
feeding women. For the bottle-feeding
mother, the combined oral contraceptive
pill is the most effective method of
contraception. Hypertension in
pregnancy is not a contraindication to
the combined oral contraceptive pill as
Fig. 1 Positioning of the baby on the breast. long as the blood pressure has returned
to normal. Women who intended to
Table 2 Situations requiring lactation suppression
breast feed but stopped will need to be
reminded to revise their contraception.
• Bereavement (if the mother wishes)
- mid-trimester miscarriage
The coil is traditionally fitted at the
- stillbirth 6-week postnatal visit Risk of uterine
- neonatal death perforation is slightly higher during
• The mother is adamant she wishes to bottle feed but has a history of mastitis or breast abscess lactation and following caesarean
• Breast feeding is contraindicated for whatever reason
section. Laparoscopic clip sterilization
• The child is to be given up for adoption
• The mother is HIV-positive carries a higher risk of failure in the
immediate postpartum period than
Bromocriptine is used, initially 2.5 mg daily increasing to 5 mg a day once it is seen to be tolerated or cabergoline 1 mg a
day stat. It must be initiated soon after delivery to be effective as milk production commences on day 3. Bromocriptine is
when it is performed as an interval
contraindicated in hypertensive women and those with coronary artery disease. The blood pressure should be monitored procedure. If the previously used
during treatment. contraception was the diaphragm, it will
need to be re-fitted 6 weeks postpartum.
Table 3 Contraceptive needs and breast-feeding status
The postnatal visit
Amenorrhoeic women who are fully breast feeding have a 98% protection for 6 months
2% of mothers who do not breast feed will ovulate before 28 days
Following uncomplicated normal
33% of mothers who do not breast feed will ovulate before their first period vaginal deliveries, the postnatal visit is
Ovulation does not occur provided full lactation is maintained, i.e. reduced intervals between feeds, preferably traditionally performed at 6 weeks at
2-hourly feeds, and 2- to 4-hourly feeds by night - and complete amenorrhoea the general practitioner's surgery.
• Once supplementary feeds are introduced 50% of women will ovulate within 3 months, even if lactation is maintained
Following difficult forceps deliveries
• All progestogen-based contraception can be used by breast-feeding mothers, e.g. progestogen-only pill, depot
injections, Implanon, Mirena
and caesarean sections the visit may be
)i The optimum time to start the contraceptive pill in non-breast-feeding mothers is 3 weeks postpartum; prior to this performed at the hospital. Certainly, if
there is a significant risk of thromboembolism there were complications at the time of
delivery it is important that the parents
have a chance to discuss the issues
a concentration of around 34 mg/dl. digestible. Milk feeds are fortified with with the consultant.
The loss of calcium from the mother is additional iron and vitamins. Clinicians should be alert to the
substantially more during lactation The volume of milk given possibility of postnatal depression.
than during pregnancy. Bone density commences at 20 ml/kg per day and It is now thought unnecessary' to
studies indicate a loss of bone mineral builds up to 150 ml/kg per day by the perform a routine vaginal examination,
density over 6 months, but this is seventh day. If babies exhibit an allergy which is reserved for symptomatic
recovered after feeding ceases. to cow's milk, soya milk can be women, or in cases where a smear is
substituted. It may sometimes be due or a coil is to be inserted. Most
Bottle feeding necessary to suppress milk lactation women will already have resumed
The mother should be taught how to (Table 2). coitus without difficulty
sterilize the bottle correctly, either by
boiling or immersing in a dilute
solution of hypochlorite (Milton) or The normal puerperium
using a steam sterilizer. Bottle-feeds « A hypercoagulable state exists until approx. 8 weeks postpartum, increasing the risk of venous
mimic breast milk as closely as thromboembolism.
possible. Cow's milk is used in Breastfeeding supplies passive immunity to the infant and reduces the risk of atopy and cot
artificial feeds and contains more death.
protein (casein) and less sugar Breast milk has a high carbohydrate, but low iron content - it is rich in calcium.
(lactose) than is found in human milk.
• Bottle milk has a higher protein content, but has less sugar - it is fortified with iron.
The fat content is similar. The higher
• Contraception is an important issue to allow spacing of pregnancies.
levels of casein make cow's milk less
66 OBSTETRICS
for evacuation of the uterus under poorly contracted with the lacerations, labial tears (Fig. 1)
fundus still above the umbilicus Coagulation disorders
antibiotic cover. Suction curettage is
the safest approach. Until full culture Secondary After 24 hours and May be fresh loss or old, altered Retained products of
haemorrhage up to 6 weeks blood, often malodorous. The conception
and sensitivity results are available
uterus may feel soft, poorly Endometritis
broad-spectrum antibiotics should be contracted and possibly tender, Dysfunctional bleeding
used that cover both aerobic and with the cervical os open
anaerobic organisms.
Infection
A puerperal pyrexia is defined as any Table 2 Causes of puerperal pyrexia
febrile illness where the temperature is Site Timescale Presentation Predisposing factors
38°C or higher during the first 14 days Breast
postpartum. This is no longer a Breast engorgement 2-3 days postnatal Can cause a transient pyrexia Physiological
Mastitis 2-3 weeks postnatal Spreading erythema (cellulitis) Milk stasis secondary to
notifiable illness but still needs to be
over the breast, lymphangitis, engorgement with
taken seriously. Examination should nipple discharge, malaise. bacteria entering the milk
include chest, breasts, abdomen, fatigue and swinging pyrexia ducts via cracked nipples
perineum and legs. Cervical swab, (usually Staphylococcus
Thromboembolism can present with Respiratory and urinary tract infections and thromboembolism may all produce pyrexias and would represent differential
pyrexia (see below). diagnoses (see p. 42).
The abnormal puerperium 67
approaches to delivery
Looking at the history of childbirth
through time the commonest position
adopted is the upright or ambulant
position. This prompted work in the
1980s to study the effect of change in
posture on uterine activity, blood loss
during labour and pregnancy outcomes.
There was much popular pressure for a
change in the routine practice found in
hospitals in the western world of
Fig. 1 Supine birthing position. Overall reduction in uterine activity, supine hypotension and
pregnant patients lying in bed during resultant fetal hypoxia.
labour and delivery.
Figures 1-4 show a variety of birthing
positions that may be adopted. There is
little good evidence that posture during
labour or delivery has a major effect on
the outcome for mother or baby.
Water birth
There have been many trends in
delivery type. The Leboyer delivery in a
darkened room is supposed to allow a
more calm experience for the mother
and to be less traumatic for the baby at
delivery. The French obstetrician
Michel Odent advocated delivery
upright and had many supporters. He
was the first person to present data on
delivery into water (Fig. 5).
The perceived advantages and Fig. 2 Side birthing position. Contractions of less frequency but greater intensity.
disadvantages (Table 1) to mother and
neonate have not been subjected to
rigorous study but are presumed from
physiological principles.
Maternal choice
Patients wish to be involved in decisions
regarding their treatment This extends
to pregnancy when some women wish
to choose an elective caesarean section
as their mode of delivery. The mode of
delivery may be determined by medical
events either which necessitate
caesarean section on a mechanical basis
or where a better fetal outcome is
associated with delivery by caesarean
section. If there is no medical indication
for caesarean section then the risks of
vaginal delivery and caesarean section
for both the mother and fetus need to
be assessed.
The risk of vaginal delivery for the
Fig. 5 Water bath. fetus is unpredictable but in those with
growth restriction the risk is likely to be
Table 1 Advantages and disadvantages of water birth
less with caesarean section. However,
Advantages Disadvantages
the fetus benefits from vaginal delivery
To the mother To the mother
Pain relief from the warm water Vasodilatation with circulatory redistribution, especially to the skin
by a lower incidence of respiratory
Relaxation with the water buoyancy Fatigue due to decreased muscle tone distress syndrome compared to infants
Fluid loss due to perspiration in the warm water of the same gestation delivered by
Increased hydrostatic pressure against which to deliver caesarean section.
Possible increase in blood loss due to hyperaemia with warmth
From the maternal side, elective
Difficult, physically, to get out if emergency arises (and disappointment)
caesarean section increases the mortality
To the neonate To the neonate risk for the mother by 50% compared
Gentle exit from the uterus Respiratory depression due to warmth and immersion in water - the exposure with a vaginal delivery in a healthy
to a cold stimulus before cessation of oxygen from the placenta is negated woman but numerically this is still a
Infection hazard - maternal organisms in the water from vagina and bowel
very small risk. There is an increased
may be aspirated
'Wet lungs' if the neonate aspirates and difficulty initiating breathing
need for blood transfusion after
Adequate fetal monitoring is difficult caesarean section and increased infection
risk, though this has been reduced with
the use of prophylactic antibiotics. If we
could predict the women most likely to
have a long and difficult labour, elective
caesarean section would probably be
safer and more acceptable for them
than the trial of labour.
Some women may prefer an elective
caesarean section with a small risk of
mortality and serious morbidity as a
way of avoiding the disabling
complication of incontinence and the
discomfort of labour. Many see the
element of predictability and control of
an elective procedure as important
advantages with about 50% saying they
would request another caesarean
section in a future pregnancy. Looking
at what is an ideal caesarean section
rate perhaps the correct answer is the
rate which gives maximum maternal
satisfaction for the least risk.
improve neonatal outcomes, but • Use of birthing chairs or cushions may be associated with greater perineal damage.
increases the chance of operative • Maternal choice regarding mode of delivery should be carefully discussed and all risks and
delivery. benefits considered.
70 OBSTETRICS
Analqesia in labour
The level of pain experienced by acupuncture point, may be easier to
women in labour varies considerably apply in labour and does not restrict
and is influenced by previous mobility.
experience, antenatal preparation,
length of labour and strength of Mobilization
contractions. The value of antenatal Labouring women, if left unrestricted,
preparation is largely unproven, but as adopt a wide variety of positions.
the experience of pain is related to the Sitting, standing and walking may all
mental state of the patient a lot of time be used during labour. Patients with
is invested in antenatal classes to low back pain often adopt a forward-
ensure adequate knowledge of the leaning position that may relieve
process of labour, thereby decreasing pressure on the sacroiliac joint.
the stress of the unknown. The various Control of breathing patterns is widely
methods of analgesia are shown in taught in antenatal classes - this may
Table 1. work by diverting the mind away from
the pain but is also a technique used to
Non-pharmacological relieve stress.
approaches
There are many accepted non- Hydrotherapy
pharmacological methods of relieving Many women already know the
labour pain, some deriving from long soothing effect of warm water on the
usage and others from more recent uterine cramping pain experienced Fig. 1 Uterine pain can be relieved by the
understanding of pain and its during menstruation. In the past, application of TENS to the lower back.
perception. obstetric care tended to confine
labouring women to bed but with innervation of the uterus) early in the
Massage - including greater freedom many select a warm first stage for optimum effect.
aromatherapy bath or shower during the first stage of Although concern has been expressed
Massage, especially to the lower back, labour. The mode of action of any about the use of TENS applied over
may work by the same principle as analgesic effect is unclear but over the the lower abdomen as the electrical
TENS (transcutaneous electrical nerve centuries hydrotherapy has been used activity may theoretically have an effect
stimulation - see below) with for many painful conditions so the on the fetal heart, no adverse effect has
incoming nerve impulses modifying expectation of a soothing effect may be been documented.
transmission along pain fibres. its main method of action. In the mid-
Massage may also relieve 'stress'. The 1950s abdominal decompression found 'Audioanalgesia'
'stress' hormones (adrenaline a role in labouring women and Music can reduce stress and enhance
(epinephrine) and noradrenaline immersion in water may be found to other pain-relieving measures. White
(norepinephrine)) are thought to act similarly by relieving external sound has been used during
interfere with the coordination of pressures on the uterus and allowing it contractions and may block external
uterine contractions and so relaxation to assume a more rounded position. stimuli. Studies of the use of so-called
techniques may enhance the progress 'audioanalgesia' have suggested a trend
of labour. Aromatherapy may work in Transcutaneous electrical nerve towards decreased use of analgesic
a similar way and the use of lavender stimulation medication.
oil has found favour with some TENS uses the gate theory of pain
mothers. control and, by application of an
electrical current to the nerves carrying Pharmacological approaches
Acupuncture and acupressure the painful stimuli, transmission of Inhalational analgesia
Acupuncture may also have a role, pain is partially blocked. Skin surface This has the benefits of long usage and
with use of specific points to provide electrodes (Fig. 1) are used to apply a thus familiarity whilst also being
pain relief and possible additional low voltage electrical current, which is controlled by the patient in both
electrical current to augment these modified by the patient. These are timing and dose. Entonox is most
analgesic effects. Acupressure, where usually applied across the lower back commonly used and contains a 50 : 50
the fingers are used to press over the covering the T10-L1 nerve roots (the mix of oxygen and nitrous oxide. This
would be expected to have a powerful
Table 1 Methods of analgesia in labour analgesic effect as a 20% mixture is
Non-pharmacological Pharmacological equipotent to 15 mg subcutaneous
Massage - including aromatherapy Inhalational analgesia morphine, but in reality it is a poor
Acupuncture and acupressure Opioid analgesia analgesic. Despite its widespread use -
Mobilization Regional analgesia, including epidural and spinal it is the most widely used agent in
'Audioanalgesia' Pudendal nerve block labouring mothers in the UK - no
Hydrotherapy major side effects have been noted. An
TENS
excess mav theoreticallv lead to
Analgesia in labour 71
demyelination and megaloblastic scar dehiscence but will give Methods of administration
anaemia but these effects have not adequate analgesia Intermittent doses. These are given as
been observed. Many women « preterm labour - there may be the mother requires, which may be at
experience light-headedness and positive advantages in these cases as an approximate hourly rate. This may
nausea, and hyperventilation may lead epidural analgesia has been shown mean that pain relief is not complete
to hypocapnia and eventually tetany. to be associated with a reduced and the midwife has to check with
neonatal mortality rate among low each dose whether the mother
Narcotic analgesia birthweight babies experiences any side effects. Patients
Pethidine was introduced in 1939 by • breech presentation - to ensure a are in bed and immobile.
the Germans who found it to be useful controlled delivery, by preventing
in treatment of war wounds. By 1950 it the urge to push prior to full Continuous infusion. This allows for
was generally accepted and in use by cervical dilatation - a problem in the more smooth pain relief and, if
midwives for pain relief in labour. preterm breech problems arise, a lower dose of the
Unfortunately it is a rather poor « multiple pregnancy - delivery may anaesthetic has been administered.
analgesic, being associated with a 20% be complicated and the presence of Better analgesia, however, may be at
reduction in pain score, but it has an epidural allows intervention as the expense of an increased
powerful sedative effects on the necessary instrumental delivery rate or caesarean
mother at the expense of nausea and » incoordinate uterine activity - pain section and immobilization.
vomiting. In as many as half of all relief in this situation is associated
mothers there is no analgesic effect with improved uterine action. Spinal opioids. By acting on the spinal
and, as it acts to delay gastric opioid receptors these enhance the
Correct placement of the catheter in the
emptying, it should probably be used analgesic effect of the epidural. They
epidural space is confirmed by loss of
in labour in conjunction with are short acting (2-4 hours) with a
resistance as the catheter finds the space
ranitidine. better analgesic effect in a more even
and the absence of cerebrospinal fluid
All opiates have a depressant effect distribution. They may be associated
running from the catheter end (Fig. 2).
on the neonate. This has led to with pruritus.
Confirmation of correct placement is
attempts to develop other opioid vital before giving the full dose of local
analgesics with better pain-relieving Mobile epidural. These developed from
anaesthetic down the catheter or a 'total
properties and less respiratory the wish to overcome the immobility
spinal' (i.e. a high block) may result,
depression in the neonate. Though associated with standard epidural
with rapidly rising numbness and
neonatal respiratory depression is techniques. The pain-carrying nerve
dyspnoea which may require ventilation
noted it need not limit the use of fibres are smaller than the motor nerve
until the effect wears off
pethidine, as naloxone will rapidly fibres and by giving appropriate
Alternatively, the catheter may be
reverse the respiratory effects, after anaesthetic mixes it may be possible to
located intravascularly and during the
delivery. achieve blockage of only the smaller
test dose the patient will note light-
Diamorphine is used for its fibres.
headedness and tingling in the lips and
enhanced pain-relieving effect though fingers. If further anaesthetic is given,
some mothers experience considerable Pudendal nerve block
convulsions and cardiac dysrhythmias
nausea and vomiting with it. This technique is used in the second
may ensue, necessitating resuscitation.
stage of labour to obtain analgesia for
an instrumental delivery. It blocks the
Epidural analgesia
pudendal nerve (S2,3,4) and is usually
This developed from the need for
combined with perineal infiltration to
analgesia without neonatal respiratory
allow episiotomy. The pudendal needle
depression and acts by affecting the
is guarded so that it can be advanced
spinal opioid receptors directly. Epidural
into the vagina in the region of the
analgesia has indications besides simple
ischial spine. The needle is then
pain relief during labour:
advanced in turn and lidocaine
• pregnancy-induced hypertension - (lignocaine) is introduced around the
to control hypertension which may nerve. Once both sides are blocked the
worsen during labour (exclude analgesia achieved should allow outlet
coagulopathy) forceps but would not give complete
» trial of scar - the epidural has not Fig. 2 Equipment used for correct pain relief for a mid-cavity
been found to mask the pain of a positioning of the epidural. instrumental delivery.
I Analgesia in labour |
• Pain is an integral part of the process of labour.
• Adequate pain relief is associated with lower levels of maternal catecholamines ('stress' hormones which inhibit co-ordinated uterine activity).
« Non-pharmacological methods are widely used - both before the patient presents to hospital and in hospital.
« Entonox and opioids have a role but up to 30% may select an epidural.
• Excessive volumes of local anaesthetic can cause convulsions, hypertension and bradycardia.
72 OBSTETRICS
Maternity care
Severely high maternal mortality rates in underdeveloped countries have prompted the WHO Safe Motherhood initiative.
• The introduction of birth attendants trained in basic hygiene must be complemented by efficient access to obstetric units.
• In the U K the Cumberlege Report stressed the need for women-centred care.
The woman should have a choice of carer and place of delivery and be offered continuity of care.
• The Domino scheme offers continuity of midwife and 6-hour discharge from hospital.
• The low-risk midwifery-run delivery unit offers an alternative venue for delivery.
74 OBSTETRICS
Vaginal discharge
Normal physiological vaginal discharge
increases during pregnancy. If the
discharge is clear and non-offensive the
woman can be reassured. Fungal
infections (particularly candidiasis),
Trichomonas vaginalis and bacterial
vaginosis are more common in
pregnancy. The treatment can be
difficult as clinical response tends to be
slower and recurrences are common.
Topical antifungal treatment with
imidazoles or nystatin can be given as
either a vaginal pessary or a cream.
Bacterial vaginosis carries a five- to
seven-fold increased risk for late
miscarriage and preterm labour.
Treatment is with metronidazole or,
preferable in pregnancy, topical
clindamycin.
usually all that are needed. In more • A number of minor ailments do occur, for which symptomatic relief may be possible.
severe cases the woman is advised to • Women should be encouraged to discuss minor symptoms with their health care professionals as
sleep with her hand slightly elevated they might indicate a more serious condition.
and may be fitted with night splints to
78 OBSTETRICS
Vital statistics
Maternal mortality estimated maternal mortality in each haemorrhage and obstructed labour do
Audit of clinical practice is important continent (Fig. 2) shows wide variation: not feature as major causes of death in
in the identification of areas for the UK. Looking back to the figures
• Africa 640/100 000
improvement The maternal mortality from the 1950s (Fig. 4), it is obvious
Asia 420/100 000
report run in the UK is a good that deaths from haemorrhage have
« Latin America 270/100 000
example of clinical audit. Data have reduced considerably due to the use of
« all developed countries 30/100 000
been collected since 1952 and reports oxytocic drugs and blood transfusion
• Northern and Middle Europe
are produced every 3 years. The last and an awareness of this as a major
-10/100000.
four reports cover the UK as a whole. problem. Tackling the issues posed by
The maternal mortality rate has Figure 3 shows the main causes of maternal mortality globally will
officially been approximately 10 per maternal mortality worldwide. An require health care provision and effort
100 000 maternities for the past decade assessment of the causes of maternal directed specifically at the areas of
but may have been ~ 12/100 000 due to mortality makes it clear what steps are major concern. The loss of a mother in
missed cases. The major causes of needed to reduce the mortality: childbirth leaves the child orphaned
death are thromboembolism, and the other children of the family
oxytocic drugs and blood
pregnancy-induced hypertension, needing care. Money directed at the
transfusion
amniotic fluid embolism, early problem of maternal mortality would
• antibiotics
pregnancy complications and sepsis. In thus be well spent and might reduce
• anticonvulsants
the 1994-1996 report these accounted money needed in other areas.
partograms
for 85% of direct maternal deaths In 1987 the 'Safe Motherhood'
contraception.
(Fig. 1). initiative called for a halving of
The problem globally is much Comparison of the causes of maternal maternal deaths within a decade.
bigger with the annual pregnancy- death between the worldwide list and Fifteen actions were suggested, mostly
related death rate at 585 000. The that in the the UK report reveals that multifaceted approaches to problems
identified as contributing to the high
maternal mortality in developing
countries. Ten years later the reduction
had not been achieved, with obstetric
disorders still a leading cause of death.
The relationship between
discrimination against women and
maternal morbidity and mortality has
been questioned, since countries that
do discriminate do not have the
highest mortality rates.
Promotion of family planning to
reduce maternal mortality is
questionable when most maternal
deaths occur after wanted pregnancies.
Antenatal care is also unlikely to offer a
major reduction in deaths when most
Fig. 1 Causes of maternal deaths in the UK 1997-1999.
complications of childbirth arise in low-
risk pregnancies. Training of traditional
birth attendants has not shown any
effect on the mortality rate. Further
advances will necessitate the provision
of accessible care for obstetric
emergencies by trained staff with
appropriate facilities - a costly necessity.
Perinatal mortality
This is another indicator of the level of
health care provision and annual
figures are available for many
countries (Fig. 5). In the UK the
perinatal mortality rate (PMR) is
defined as the number of stillbirths
plus the deaths in the first week of life
per thousand births (live and still), but
variations in other countries include
Fig. 2 Worldwide maternal mortality rates in 1990. stillbirths from 20 weeks and loss for
Vital statistics 79
newborn
Separation of the placenta means the Table 1 Assessing the Apgar score Table 2 Advantages and disadvantages
infant must adapt to extrauterine life. Score of nasopharyngeal suction
The physiological changes are many 0 1 2 Advantages Disadvantages
and need to be immediate as the infant Colour Pale Blue Pink Improved air exchange Bradycardia
takes over oxygen exchange for itself Respiration Nil Gasps Regular Decreased likelihood of Laryngospasm and pulmonary
Heart rate Absent <100 >100 aspiration of secretions artery vasospasm
Acidosis in the baby and a fall in paO2
Tone Flaccid Present Good Less acquisition of
will result in failure to breathe - if of Response to stimulation Nil Present Brisk pathogens from amniotic
short duration there is usually a rapid fluid or birth canal
response to resuscitation; a slower
response suggests anoxia of longer requiring resuscitation the need for
duration. The newborn has large resuscitation is not recognized prior to reduce the postnatal fall in
glycogen stores in the brain, liver and delivery. It thus is necessary for those temperature include:
heart which enable survival up to involved in delivery to be able to initiate
and continue infant resuscitation. • skin-to-skin contact with the mother
20 minutes with no oxygen. Thus
Assessment of the infant • drying the neonate
resuscitation is always worthwhile.
immediately after delivery is usually by • radiant heater
Adequate equipment (Fig. 1) in the
means of the Apgar score (Table 1). • covering the head + body with
delivery room to deal with infant
resuscitation includes: insulated material.
Resuscitation The indications for resuscitation are:
• radiant warmer
Most infants require only removal of
• resuscitation bags and masks • heart rate < 100 bpm after birth -
mucus from the oropharynx, drying
• endotracheal tubes needs oxygen administration
and handing to the mother or,
• laryngoscope • generalized cyanosis - needs oxygen
preferably, delivery straight onto the
stethoscope administration
mother's abdomen. The ambient
oxygen source and suction • inadequate chest excursion and poor
temperature in a delivery room is high
• naloxone. breath sounds - bag and mask
to ensure that there is minimal cooling
• poor response to bag and mask
All high-risk deliveries should be of the infant Neonates maintain their
attended by someone skilled in infant body temperature in a cool ventilation - needs endotracheal
intubation.
resuscitation but it is recognized that environment at the metabolic cost of
in approximately half of all cases increased energy expenditure. Ways to Proper ventilation of the infant is the
single most important aspect of
neonatal resuscitation. Observation of
the chest distending with squeezing the
bag indicates a proper head position
and a clear airway. A rise in the heart
rate is an indicator of the success of the
resuscitation. Enough pressure on the
bag to produce chest excursion is
needed as well as an adequate inspired
oxygen concentration.
Nasopharyngeal suction has benefits
and risks (Table 2) but in a delivery
complicated by passage of meconium,
nasopharyngeal suction before delivery
of the chest may be useful. The use of
routine intubation in these cases is
accompanied by the risks of hypoxia,
bradycardia and increase in
intracranial pressure.
Medication
Routine administration of certain
medications to the neonate is standard
practice. Vitamin K is offered routinely
for all newborns to prevent
development of haemorrhagic disease
of the newborn (HDN) which has an
incidence of 0.25-0.5%. The vitamin K
level in breast milk is considerably
lower than in infant formula feeds and
Fig. 1 Resuscitation equipment. puts the infant at risk of serious
The newborn 81
the group who had had i.m. Neck Sternomastoid 'tumour1 Head movement may be restricted
administration of the vitamin. This has Pulses Brachials and femorals Absent femorals represent possibility of coarctation
subsequently been disproved but some Hands Shape, creases, nails, accessory digits
parents may refuse i.m. vitamin K and Chest Shape, resp. rate, recession, auscultation Heart murmurs
Abdomen Palpable masses Liver is always palpable and kidneys usually
thus oral doses should be administered.
Umbilicus Discharge, flare around Suspect cord sepsis
skin is more translucent. Peripheral • Adequate ventilation should move the infant's chest.
cyanosis is common at delivery. Tone • The first routine examination of the newborn is to exclude identifiable abnormality.
can readily be assessed by ventral
82 OBSTETRICS
Trauma
Caput succedaneum (oedema caused
by pressure over the presenting part) is
common and resolves within a few Fig. 3 Respiratory distress syndrome
following emergency caesarean section.
days. Cephalhaematoma (a Fig. 4 Meconium aspiration syndrome.
The mother had diabetes which predisposes to
subperiosteal haematoma) is much respiratory distress syndrome. Note the ground Note the widespread patchy shadowing in both
rarer, but is significantly commoner glass appearance of the lungs. lungs.
following vacuum extraction compared
to forceps delivery. Subgaleal
(subaponeurotic) haemorrhage occurs Scalp damage may occur from a after 40 weeks, it also has an
when there is bleeding into the scalp ECG clip. Rarely, this can be association with fetal hypoxic stress.
potential space beneath the aponeurosis severe and associated with secondary Meconium is irritant to the neonatal
of the scalp - this is a large space and infection and long-term scarring. lungs and may lead to a pneumonitis,
can accommodate a large volume of the meconium aspiration syndrome
blood. Although rare, it can be life- Respiratory distress syndrome (Fig. 4). Clinical features range from
threatening (Fig. 2). Forceps are more (RDS) mild neonatal tachypnoea to severe
likely to cause craniofacial injuries, This is caused by a deficiency of respiratory compromise. Treatment is
including bruising, linear skull fractures surfactant and is commoner in with oxygen, mechanical ventilation
and facial nerve palsies. preterm infants (0.1% at term vs 30% and, if very severe, extracorporeal
Fractured clavicle and brachial at 28 weeks). Surfactant, a complex membrane oxygenation.
plexus injuries are more common lipoprotein consisting largely of
following shoulder dystocia. Erb's palsy phosphatidyl choline, is synthesized by Seizures
is a C5-6 lesion in which the arm is type II pneumocytes within the alveoli The immature central nervous system
held loosely at the baby's side with and is important in allowing the is particularly prone to seizure activity,
internal rotation of the shoulder and alveolus to expand. Hypoxia, acidosis which is the brain's common response
extension of the elbow (waiter's tip). In and hypothermia reduce surfactant to differing pathologies. They may be a
Klumpke's palsy there is impairment production; antenatal steroids increase feature of neonatal encephalopathy
of C8-T1. There is often very good, if production and thereby reduce the (see above) but can also occur with
not necessarily complete, recovery of incidence of RDS. Clinically, there is focal cerebral infarction, cerebral
palsies within the first few months, tachypnoea, grunting and intercostal malformation, meningitis (e.g. with
and physiotherapy may be offered to recession commencing within the first group B B-haemolytic streptococci),
prevent contractures. A fractured 4 hours of life, and the chest X-ray hypoglycaemia, hypocalcaemia,
clavicle will heal spontaneously. Other demonstrates a generalized maternal drug misuse and inborn
orthopaedic injuries, including spinal reticulogranular appearance referred to errors of metabolism.
injury, are rare. as like 'ground glass' (Fig. 3). The commonest timing of onset is
Treatment is with oxygen ± supportive between 12 and 48 hours. The
ventilation and often includes giving resulting membrane damage of seizure
artificial surfactant through an activity releases excitotoxic substances
endotracheal tube. such as glutamate, which can trigger
further seizure activity, and
Meconium aspiration syndrome investigation and treatment are
In utero, meconium is usually retained therefore of great importance. In
within the colon. Although it may be particular, prolonged fits can cause
passed through the sphincter under cerebral hypoxia and cerebral oedema.
physiological conditions, particularly
Fig. 2 Cephalhaematoma (a) and Probably less than 10°/o of cerebral palsy is related to intrapartum problems.
subgaleal (subaponeurotic) haematoma Neonatal encephalopathy is a better guide to long-term prognosis than Apgar scores.
(b). Note that the potential subgaleal space can
Respiratory distress syndrome responds well to surfactant administration.
hold a much greater volume of blood than the
smaller potential space under the periosteum.
84 OBSTETRICS
should be admitted and treated Father given the opportunity to stay in hospital overnight
Postmortem discussed and requested, consent obtained or refused
promptly, as long waits may enhance
Clinical information and postmortem form completed
anxiety. Certificate of Non-Viability [< 24 weeks) or stillbirth certificate completed
Parents should be given the Consultant obstetrician informed
opportunity to discuss the miscarriage Consultant paediatrician informed, if neonatal death
General practitioner informed
with a counsellor and a suitable clinic
Patients Officer informed regarding funeral/disposal arrangements and birth registration
appointment should be made. Parents given appropriate booklets/access to videos
Information leaflets and contact Any special clothing or items to be placed on baby
numbers should be available. They Discussion on suppression of lactation
may well wish to involve a religious Family planning advice offered
Community midwife informed
adviser even at this early gestation. A
Health visitor informed
Certificate of Non-Viability will need to Medical social worker informed if necessary
be completed together with a Appointment made for appropriate consultant's clinic
Notification of Miscarriage Form in Parent education classes cancelled
England. This is sent to the antenatal Antenatal appointments cancelled
Counselling offered
clinic to avoid the distress of an
Bereavement in obstetrics and gynaecology 85
Table 2 Investigations for late fetal loss Parents must never be left to feel agencies (Table 3) and there are
(intrauterine deaths and stillbirths) that they alone made the decision to excellent information leaflets, books
Maternal withdraw intensive care support. and videos available (Fig. 2).
TORCH screen (check if done antenatally) Adequate provision of privacy for the
Kleihauertest
parents to be with their child to allow
Lupus anticoagulant test Table 3 Chromosome analysis
Anticardiolipin antibodies
them to say goodbye is very important.
Indications
Syphilis serology screening (check if done • Malformed or dysmorphic baby
antenatally] Arrangements for cremation and K Any baby significantly small for dates
m Random blood glucose burial m Significanlly macerated stillbirths (although may be
• Thyroid function tests
There is no legal requirement to bury difficult to oblain karyolype)
• Rhesus antibody litre (if mother is Rhesus negative)
• High vaginal swab and endocervical swab
or cremate a baby lost before 24
Specimens required
• Parvovirus titre (if ultrasound evidence of hydrops) weeks' gestation, as it was non-viable, • Blood sample by cardiac punclure (2-3 ml of blood
• Genetic sludies (if indicated) and no legal requirement for the in lithium heparin suitable from fresh stillbirth and
Placental parents to be involved. However, staff early neonatal deaths)
m Histology should be aware that parents could, if • Skin biopsy (a full thickness 0.5 cm ellipse from the
lateral border of the thigh if blood sample difficult)
m Swab - or cullure they so wish, take the body away for
H Placental tissue (sample of membranes and placenlal
Fetal burial. Usually, they prefer the hospital disc senl dry in a universal conlainer if maceration is
• Photograph ± X-ray to make appropriate arrangements. A significant)
• Postmortem book of remembrance is often kept in
• Chromosomal analysis
the hospital chapel and parents can
enter their baby's name and an
inscription of their choice regardless of
bereavement. A checklist (Table 1) is the gestation. Often chapels will hold
usually helpful for the midwifery and an annual service of remembrance for
medical staff involved, who are often all bereaved parents.
distressed themselves. Some mothers In the case of stillbirths and
regard lactation as a tangible link with neonatal deaths, there is a legal
the child they have lost, others are requirement for the baby to have a
horrified by the prospect and proper burial or cremation. Parents
bromocriptine should be prescribed may make their own private
Fig. 2 'When our Baby Died' video and
immediately to prevent lactation arrangements or the hospital can 'Grieving after the Death of your Baby'
occurring. Advice regarding family arrange for a funeral. It is vitally accompanying booklet.
planning should be offered as soon as important that carers are sensitive to the
is practicable. religious and cultural needs of the
Table 4 Useful support agencies
Often no satisfactory cause is found bereaved relatives. For members of the
• The Miscarriage Association
but every attempt should be made to Jewish and Muslim faiths it is important
• Stillbirth and Neonatal Death Society (SANDS)
do so (Table 2) and consent to a that burial takes place, if possible, within (Jewish Baby Bereavement Support affiliated to
postmortem may be useful. If this is 24 hours of the baby's death. SANDS)
refused, clinical photographs and • ARC (Antenatal Results and Choices)
Continued support (formerly Support Around Termination for
X-rays of the baby can be substituted.
Abnormality, SATFA)
Genetic counselling may be indicated Most units now have a special The Compassionate Friends
when fetal malformation is detected. bereavement suite where the couple The Asian Bereavement Counselling Service
Chromosomal analysis on fetal can stay overnight. Usually the mother Bereaved Parents Mutual Support Group
material is required. Most areas run a is inclined to go home as quickly as The Twins and Multiple Births Association (TAMBA)
The Bereavement Clinic, The Lone Twin Network
regional congenital malformation possible after delivery. Counselling
from the Multiple Birth Foundation
register and a Notice of Malformation should be continued and often a m Foundalion for Study of Infant Dealhs (FSID)
should be completed and sent counsellor will offer to call on the (Cot Death Helpline 24-h service - run by FSID)
appropriately. For gestations less than mother at home. She will not have • Child Death Helpline
24 weeks a stillbirth certificate will worked through all the bereavement (run by Great Ormond Street & Alderhey Children's
Hospitals)
need to be completed. issues prior to leaving hospital. There
9 The Child Bereavement Trust
are a number of useful support
Neonatal deaths
It is important to recognize the family
as a unit and to involve the parents as
much as possible in the care of the Bereavement
terminal baby. They should be « Couples often feel the loss of a miscarriage as greatly as the loss of a baby.
encouraged to handle their child and A longstanding intrauterine death may result in clotting abnormalities and a clotting screen
to have photographs of the baby whilst should be taken on admission.
alive. In the case of twins, photographs • Even if a postmortem is refused, clinical photographs and X-rays of the baby can be useful to
of the two babies together should be identify the cause of death.
encouraged. Children need to grieve • The parents should be encouraged to be involved in nursing a terminal baby.
for their lost brother or sister and this
» It is unwise to rush into another pregnancy to compensate for a lost child due to the greater risk
process is facilitated if the sibling is
of depression.
actively involved from the beginning.
86 GYNAECOLOGY
character of a mass, the timing of bleeding history, or length Menorrhagia Regular heavy menses
of infertility suffered. Thus many aspects of the Intermenstrual bleeding (lMB) Bleeding between menses
gynaecological history may be covered under presenting Postcoital bleeding (PCB) Bleeding after intercouse
Dysmenorrhoea Pain associated with menstruation
complaint and further history discussed later.
Patient history
Menstrual history
Table 1 outlines the history to be elicited. The volume of
blood lost during menstruation is usually gauged from the
amount and type of sanitary protection, passage of clots and
flooding bedding and outer clothes.
Vaginal discharge
Physiological discharge is usually off-white and varies in
amount. This increases in mid-cycle when the nature also
changes to that of a stringy mucous discharge at the time of
ovulation. Questions concerning the volume of the
discharge, the timing of it in relation to the menstrual cycle,
the association with pruritus, and the odour of the discharge
all need to be determined.
Non-physiological discharge may be associated with intense
itching as caused by candidiasis, where the discharge would be
thick and curdy. A frothy yellow/ green offensive discharge
Fig. 1 Abdominal palpation of the nine areas of the abdomen.
might be caused by Trichomonas [see also p. 104).
Gynaecological assessment
• The patient history starts with the presenting complaint.
This is followed by menstrual history, any pains, urinary symptoms
and details of past history.
• Physical examination begins with general systems, followed by
breasts, abdomen then pelvis.
88 GYNAECOLOGY
Intersex disorders and ambiguous genitalia Exogenous administration of androgens (e.g. danazol). This
Early multidisciplinary sub-specialist involvement is essential, may lead to virilization of a female fetus.
particularly surrounding the issues of genital surgery and
gender assignment. There will be initial parental shock at the Other rare abnormalities
diagnosis, with possible subsequent depression, doubts of These may occur with XO, XX or XY chimerism. True
gender, concerns over fertility, issues of sexuality, cultural hermaphroditism (i.e. the presence of male and female
problems and a sense of worthlessness. Peer support from gonadal tissue) is also rare.
those with similar problems is essential.
Abnormal genital tract development
XY but look female (male pseudohermaphroditism)
Vagina (Fig. 2)
Testicular feminization syndrome (androgen insensitivity).
There may be horizontal septae, vertical septae or the vagina
This is an X-linked recessive disorder caused by an absence
may be absent.
of androgen receptors. Although testosterone is present, it
has no effect on the external genitalia and these individuals Horizontal septae. There may be cryptomenorrhoea with
appear female. Mullerian inhibitory factor is also still present cyclical pain and a haematocolpos. If obstruction is caused
and therefore no internal genitalia form. Presentation is simply by the hymen (blood looks blue behind it) then a
usually after puberty with amenorrhoea in the presence of cruciate incision, usually under anaesthesia, is all that is
normal breast development, scanty pubic and axillary hair, a required. If the septum looks pink rather than blue the
blind-ending vagina, absent uterus and female habitus and situation is potentially more serious and should be referred
psychosexual orientation. Gonadectomy is essential because to a specialist surgeon. If the septum is in the low or
of the risk of malignant change. midportion of the vagina, total excision and resuturing is
There is a small phallus, some degree of hypospadias, a necessary. If the septum is high, a combined abdominal and
bifid scrotum and a blind vaginal pouch. vaginal approach may be required. Pregnancy rates are
excellent with low septae, but only around 25% for those
5a-reductase deficiency. There is an autosomal recessive target higher in the vagina.
enzyme defect of 5a-reductase. This converts testosterone to
dihydrotestosterone in the target organs, and is therefore Vertical septae. These may be associated with abnormal
important for male development At puberty considerable, but uterine development. Although presentation may be with
still incomplete, virilization occurs with male body habitus, dyspareunia or infertility, they may occasionally present in
psychosexual orientation and gender conversion. advanced labour. They can be surgically removed.
XX but look male (female pseudohermaphroditism) Vaginal atresia. This is associated with an absent, or only a
Congenital adrenal hyperplasia (accounts for 70% of rudimentary, uterus and is known as the Rokitansky
ambiguous genitalia). There is an autosomal recessive syndrome. Presentation is at puberty with amenorrhoea (or
Fig. 3 Hymens, (a) Acute tearing, (b) Partial thickness tear at the posterior margin, (c) Concavities in the hymen.
cryptomenorrhoea) in the presence of Bicornuate uterus. This may often carry essential in this highly emotive area
normal secondary sexual a pregnancy to an adequately advanced where incorrect interpretation of the
characteristics. It is possible to create a gestation, and the chance of this signs may have major consequences. A
vagina with regular use of vaginal probably increases with subsequent colposcopic examination is helpful and
dilators, or by one of a variety of pregnancies. A 'Strassman' procedure photographic records are extremely
surgical techniques. Surrogacy is an will correct the defect, but the benefits useful.
option for childbearing. for pregnancy are unproven. A The history should be carefully
bicornuate uterus may be asymmetrical taken and documented, and the social
Uterus (Fig. 2) with one side hypoplastic Pregnancy in work team involved if appropriate.
Abnormal uterine shapes are usually the hypoplastic horn carries a risk of Swabs (which may include swabs for
asymptomatic but may present with rupture. DNA analysis) should be taken with a
primary infertility, recurrent pregnancy 'secure chain of evidence' in case they
loss or menstrual dysfunction Septate uterus. If appropriate to are required for a later legal action.
(oligomenorrhoea, dysmenorrhoea or remove the septum, a hysteroscopic Particular attention should be paid to
menorrhagia). In pregnancy, there may approach is probably the most bleeding, bruising or any other area of
be miscarriage (p. 92), preterm labour appropriate. injury, particularly lacerations at the
or an abnormal fetal lie. posterior fourchette and perineal
Prepubertal problems abrasions.
Unicornuate uterus. With this there is A normal hymen has a number of
Sexual abuse
a higher miscarriage rate and risk of different shapes (annular, crescentic,
This is the involvement of dependent
preterm labour. fimbriated, septate, sleeve- or funnel-
sexually immature children and
adolescents in sexual activity they do shaped). Notches and clefts can be
not truly comprehend, and to which highly suggestive of penetrating injury,
they are unable to give informed but may be normal if associated with
consent, and which violates social an intravaginal ridge above them; they
taboos or family roles. The abuser is are very rare in the posterior segment
usually male and well known to the in non-abused girls (Fig. 3). Straddle
child and family. It may present injuries very rarely affect the hymen,
acutely, following injury or allegation, and there is much more likely to be
or may be suggested by bruising anterior to the vagina or
precociousness and other behavioural laterally (e.g. labia majora). It is also
disorders. rare for tampon use to cause hymenal
There are numerous pitfalls to the injury (although it may increase the
clinical examination, and a depth of diameter slightly), and there are no
experience is required for an reported cases of congenital absence of
examination to stand up in court. Early the hymen. A normal pre-pubertal
senior multidisciplinary help is hymen does not exclude abuse.
Abnormalities of puberty
Precocious puberty
Signs of pubertal development before
the age of 8 are accepted as precocious
puberty which in three-quarters of
females has an idiopathic aetiology.
However, before allocating a child to
this category, it is important to rule
out treatable causes (Table 1).
The idiopathic group includes girls
with constitutional sexual precocity due
to premature maturation of the
hypothalamic-pituitary-ovarian axis.
Idiopathic 74%
Ovarian hormone production 11%
Intracrania! pathology 7%
McCune-Albright syndrome 5%
Adrenal problem 2%
Fig. 1 The timing of pubertal changes. Ectopic gonadotrophin production Less than 1 %
Puberty and its abnormalities 91
This tends to run in families and tends Table 2 Causes of delayed puberty
to occur around the cut-off age of 8 Cause Percentage Underlying cause
years. Intracranial pathology includes Hypergonadotropic hypogonadism 43% Gonadal dysgenesis, e.g. Turner's syndrome
cranial trauma, encephalitis, cysts or Hypogonadotropic hypogonadism 31% Constitutional, chronic medical illness, anorexia
tumours - the mechanism by which Eugonadism 26% Abnormal genitalia, e.g. absent uterus, vaginal septum
they produce precocious puberty being
uncertain. Ovarian hormone production
Ask about chronic illnesses, progesterone challenge test will
is usually associated with an ovarian cyst
anorexia, excessive physical exercise or identify constitutional menstrual delay,
which should be diagnosable by
family history of delayed puberty. i.e. will result in bleeding only with an
ultrasound scanning, but is often
Heart problems may be found with adequate estradiol level and normal
present as a palpable mass in the
chromosomal disorders, urinary or genital tract. Give 5 days of oral
abdomen. The McCune- Albright
bowel disorders with anatomical progesterone and there should be a
syndrome (polyostotic fibrous dysplasia)
disorders of the genital tract, hernia withdrawal bleed within 10-14 days of
presents with cystic bone lesions which
repairs may suggest gonadal disorder stopping.
easily fracture, cafe-au-lait patches and
and slow general development is Poor or absent secondary sexual
sexual precocity. The cause is uncertain.
associated with hypothyroidism. characteristics. These comprise:
Referral to a paediatric endocrinologist
Examination should include
ensures everything is addressed. 1. Constitutional delay. The
measurement of height, weight and
diagnosis is likely in a healthy
visual fields; check for secondaiy
Delayed puberty adolescent who is short for the family
sexual characteristics, virilization and
Delayed puberty (Table 2) is rare with but appropriate for the stage of
hirsutism. Vaginal examination is
only 1% of females not having had puberty and bone age. There is often a
inappropriate unless the girl is sexually
menarche by the age of 18. If there are family history and it may be associated
active. Check for stigmata of Turner's
no secondaiy sexual characteristics by with chronic systemic disease (rare,
syndrome (short stature, webbed neck,
the age of 14 delay is diagnosed and but consider hypothyroidism and
and wide carrying angle).
investigation is appropriate. The largest malabsorption). If the bone age on
Investigations include sending
group are those with ovarian failure, X-ray is less than the chronological age
serum for LH and FSH (low with
more than half of whom have than it is reasonable to adopt a
constitutional delay), testosterone
chromosomal anomalies. conservative approach. Anorexia
(increased in polycystic ovarian
In girls with hypergonadotropic nervosa should also be considered.
syndrome), free T4, TSH (increased in
hypogonadism the ovarian failure may 2. Ovarian dysfunction. This may
primary hypothyroidism) and
be associated with an abnormal be due to gonadal agenesis with
prolactin (ideally measured under non-
karyotype, particularly Turner's Turner's syndrome or Turner's mosaic.
stressed conditions). Karyotype is
syndrome. In those with a normal Treatment is specialized as oestrogen
needed if a chromosomal problem is
karyotype it may be that there is treatment may predispose to short
suspected; if an XY chromosomal
gonadal dysgenesis (the external stature by premature epiphyseal
pattern is found, it is usual to suggest
genitalia are usually of infantile female closure. Therapy is with low-dose
gonadectomy due to the 25% risk of
type) or the resistant ovary syndrome ethinylestradiol initially, increasing
tumour in the gonad. X-ray for bone
with normal appearance of external over the next 18 months. A
age would confirm constitutional delay.
genitalia (where the ovary fails to progestogen is then added for 5 days
Assessment of 17-hydroxyprogesterone
respond to the increased levels of LH every 4 weeks. The dose of oestrogen
when congenital adrenal hyperplasia is
and FSH) but where there can be is increased if response is adequate
suspected, pelvic ultrasound to assess
spontaneous ovulation and obviously and the contraceptive pill substituted.
pelvic anatomy and skull X-ray if
pregnancy can thus occur, though 3. Hypothalamopituitai-y disorders.
prolactin is raised are appropriate.
prognosis with respect to future Hypogonadotropic hypogonadism is
pregnancy in these cases should be usually associated with pituitary
Causes and further management
guarded. tumours and other pituitary
Normal secondary sexual characteristics
With hypogonadotropic deficiencies. In Kallmann syndrome
but with primary amenorrhoea. This
hypogonadism (low levels of LH and there is a congenital deficiency of
is most commonly caused by an
FSH) the delay may be constitutional - luteinizing hormone-releasing
imperforate hymen and is
particularly when short compared to her hormone (LHRH) and absent olfactory
characterized by cyclical pain and a
family but appropriate for the stage of sensation. Hypothyroidism is likely to
haematocolpos (see p. 88). A
puberty and bone age - or due to a cause pubertal delay.
chronic medical condition or anorexia
nervosa.
In the eugonadotropic group (normal
LH and FSH) congenital absence of the
uterus (Rokitansky syndrome) or vaginal Puberty and its abnormalities
developmental obstruction should be * For puberty to occur there must be oestrogen production from the ovaries.
considered.
Thelarche and sexual hair growth follow the somatic growth spurt. Menarche is the final stage of
puberty.
Treatment of delayed puberty
Precocious puberty is associated with failure to achieve full adult height so must be treated.
Initial management Delayed puberty is only found in 1%.
First exclude pregnancy.
92 GYNAECOLOGY
Miscarriage
Spontaneous miscarriage
• Spontaneous miscarriage is the loss of a pregnancy before
24 weeks' gestation. It is most common in the first
trimester and is said to occur in = 25% of all pregnancies.
• The word 'abortion' has connotations of induced abortion
and should not be used for miscarriage. The term 'blighted
ovum' used to describe an anembryonic pregnancy should
be discarded.
« Extreme care must be taken not to advise uterine
evacuation if there is any possibility of viability.
« It should not be assumed that the pregnancy is non-viable
simply because the gestation does not agree with the
expected dates.
« There should also be a low threshold of suspicion for
ectopic pregnancy.
• Approximately 50% of miscarriages occurring early in the
first trimester are associated with chromosomal
abnormality (trisomy, monosomy, polyploidy), although
this becomes less with increasing gestation.
Presentation
There is usually a history of bleeding per vagina and lower
abdominal pain, although an empty gestational sac [or fetal
pole with absent fetal heartbeat) may be an asymptomatic
finding at booking scan ['missed'). Miscarriage is 'inevitable'
if some products of conception (not dots) are passed. Rarely, Fig. 1 Different types of miscarriage.
products of one twin may be passed, with the other twin
being viable, justifying an ultrasound scan in every case. The
miscarriage is said to be 'threatened' if the pregnancy is still Pseudosac. See Ectopic pregnancy, page 98, and Figure 3.
viable, and 'incomplete' if there is residual tissue within the
cavity (Fig. 1). Fetal pole with no fetal heartbeat (FH). An FH is usually seen
on transvaginal (TV) scan if the fetal pole is > 2-3 mm in
Management diameter, but will always be seen by 6 mm diameter (Fig. 4).
This is based on USS findings. A similar cut-off of 15 mm diameter is appropriate for a
transabdominal (TA) scan. If in doubt, rescanning should be
Viable intrauterine pregnancy. The prognosis is good and the arranged in 7-10 days.
parents can be offered reasonable reassurance.
Empty uterus. Either there has been a complete miscarriage
Empty gestational sac. A true gestational sac usually has a (tissue may have been passed), or the pregnancy is very early
double decidual ring, unlike a pseudosac which is suggestive (e.g. < 5 weeks), or there is an ectopic pregnancy. Ectopic
of ectopic pregnancy. If there is an empty gestational sac pregnancy must be excluded. An intrauterine sac will usually
greater than 25 mm maximum diameter, the pregnancy is be seen on TV scan if the human chorionic gonadotrophin
very likely to be non-viable (Fig. 2). (hCG) is > 1000 IU O 6500 IU for a TA scan) and its absence
Septic abortion « A positive pregnancy test and an empty uterus should be considered as an ectopic pregnancy
until proven otherwise. The absence of adnexal findings does not exclude an ectopic pregnancy.
This is rare unless after illegal
terminations with inadequate asepsis, • Those with recurrent spontaneous miscarriage associated with lupus anticoagulant or raised
anticardiolipin antibodies should be given aspirin and heparin in the next pregnancy.
and therefore more common in
countries with anti-abortion policies.
94 GYNAECOLOGY
It is important to confirm that the woman is pregnant and per cent will pass products of conception in the following
to establish the gestation either clinically or by USS. Blood 4 hours and this should be confirmed by clinical inspection
should be sent for grouping and testing for antibodies, and and speculum examination before discharge. Ninety-four per
anti-D should be given post-termination to Rhesus-negative cent will abort spontaneously and most will bleed for a total
women. Options (if available) should be explained and the of 10 days. Follow-up should be arranged for 2 weeks to
woman given the choice as outlined below: ensure that bleeding has settled and to confirm complete
• less than 9 weeks: suction evacuation or medical abortion by bimanual examination. If in doubt, an ultrasound
termination scan is useful. Retained products can almost always be
« 9-12 weeks: suction termination only managed conservatively unless bleeding is particularly heavy.
• more than 12 weeks: medical termination only. Less than 5% require uterine evacuation.
Induced abortion
• Unsafe abortion is a major worldwide public health issue.
Trophoblastic disorders
Trophoblast is naturally invasive, but the initially be a fetus, but it often dies early filled with relatively homogeneous solid
invasion normally ceases after in the first trimester. Although 1% invade tissue with a vesicular appearance (Fig.
placentation has occurred. Gestational ('invasive mole') and a few of these can 2). There may also be multiple luteal
trophoblastic disorders represent an develop metastases, they virtually never cysts on the ovaries from stimulation by
abnormal proliferation of trophoblastic become choriocarcinoma. Only 0.5% the very high hCG levels. Ten per cent
tissue, leading to often massive placental require treatment following uterine invade through the uterus ('invasive
overgrowth, occasional invasion and evacuation. mole' - Fig. 3) and can metastasize to
rarely even metastases. Malignant change
can also occur with transformation to Complete hydatidiform mole
choriocarcinoma. Trophoblastic disorders This is the 'classical' molar pregnancy. It
occur in approximately 1 : 1000 UK is androgenetically diploid; in other
pregnancies. Large differences in words, although there are the normal
incidence between different racial groups number of chromosomes, all are
have been reported (e.g. 1 : 85 in paternally derived and the female
Indonesia, 1 : 1700 in USA) but are not nuclear DNA is inactivated (Fig. 1). In
confirmed by all authors. All secrete 90% there is duplication of one haploid
human chorionic gonadotrophin (hCG), sperm (XX) and the rest are from two
making it a very useful tool to monitor spermatozoa, i.e. dispermic (and usually
treatment and screen for recurrence. In XY). There is never an embryo and the
the UK, management of post-uterine patient usually presents at 8-24 weeks'
evacuation is confined to one of the gestation with vaginal bleeding (± the
three centres: Charing Cross, London; passing of grape-like tissue). The uterus Fig. 2 Ultrasound scan of hydatidiform
Ninewells, Dundee; Weston Park, may be soft, doughy and large for dates. mole.
Sheffield. There may also be pre-eclampsia,
hyperemesis, cardiac failure and
Hydatidiform mole thyrotoxicosis, probably related to the
This is the commonest type of very high levels of hCG (hCG and
gestational trophoblastic disease. thyroid-stimulating hormone share a
common structure and a subunit).
Partial hydatidiform mole Ultrasound is said to show a 'snowstorm
This is triploid with one set of maternal appearance' but this describes the older
and two sets of paternal chromosomes, B-scan pictures. On a real-time scan it
usually 69 XXY (Fig. 1). There may more correctly looks as if the cavity is
lung, vagina, liver, brain and the Table 1 Prognostic factors in gestational trophoblastic disease. Differing forms of
gastrointestinal tract [Figs 4 and 5). chemotherapy are used for differing risk groups: low risk is < 4, medium 4-8 and high > 8
These may occasionally regress Score 0 1 2 4
spontaneously. Approximately 15% of Age <39 >39
complete moles require chemotherapy Previous pregnancy Mole Miscarriage Term pregnancy
after uterine evacuation. The incidence Interval from previous pregnancy (months) 4 4-6 7-12 >12
of choriocarcinoma is 3%. hCG <1000 1000-10000 10000-100000 > 100 000
Parental blood group OorA B or AB
Gestational choriocarcinoma Size of tumour 3-5 cm > 5 cm
Gestational choriocarcinoma contains Metastasis site Spleen, kidney Gl tract, liver Brain
• the lung, causing haemoptysis It is important to track urinary hCG after uterine evacuation to ensure that there is no residual
tissue and that there is no invasion.
« the brain, leading to neurological
abnormalities There is an increased recurrence risk in subsequent pregnancies.
98 GYNAECOLOGY
Ectopic pregnancy
An ectopic pregnancy is one which implants outside the
uterine cavity. It occurs in about 1 in 200 pregnancies in the
United Kingdom, 1 in 30 in the West Indies arid in the
United States is found twice as commonly in the non-white
as in the white population. The incidence has been rising
slightly, but the death rate of about 1 per 1000 ectopic
pregnancies has been falling due to earlier diagnosis and
treatment in western societies.
Aetiology
The mechanism by which the fertilized ovum reaches the Fig. 1 A cornual ectopic (rare). This is
uterine cavity is dependent upon motility of the tube, the dangerous as it ruptures early and bleeds heavily.
movement of the cilia of the fallopian tubes, and currents set up
within the tubes. These all contribute to the sperm making
passage upward to meet the egg which is coming down the
fallopian tube. Three or four days after fertilization the fertilized
ovum implants within the uterine cavity. This implantation will
occur at the appropriate time wherever the zygote happens to
be at that stage. The associations and possible causes of ectopic
pregnancy are thus thought to operate by changing the motility
of the tube or damaging the cilia and disturbing the normal
progression of the fertilized ovum.
Any past history of pelvic infection or ruptured appendix
which will cause peritubular adhesions or pelvic
inflammatory disease causing damage to the internal
structure of the tube may predispose to ectopic implantation.
Tubal surgery, even using micro surgical techniques, is
Fig. 2 Sites of ectopic pregnancies.
unlikely to reconstruct the tube to its native form and thus
predisposition to ectopic pregnancy remains. Reversal of
sterilization is the tubal surgery with the lowest incidence of
ectopic pregnancy. With other indications for tubal surgery
the incidence of ectopic pregnancy is dependent upon the
original damage to the tube. Where there has been
conservative surgery for an ectopic pregnancy the chance for
a future ectopic pregnancy is dependent upon the pre-
existing tubal disease.
The presence of an intrauterine contraceptive device is
associated with a higher rate of ectopic pregnancy, thought
to be due to the ability of the device to prevent intrauterine
but not ectopic gestation. The presence of the device may
also alter tubal motility which is the mechanism that has
been proposed for ectopic pregnancy seen in association
with progestogen-only oral contraception (see p. 108). About
half of all ectopic pregnancies are idiopathic.
Radical
• Salpingectomy with or without oophorectomy
Fig. 4 Investigations in cases of suspected subacute ectopic quicker recovery associated with an improved rate of
pregnancy. subsequent intrauterine pregnancy compared to treatment
by laparotomy. There is also a lesser risk of recurrent ectopic
Clinical examination may reveal peritonism with guarding but a higher rate of persisting trophoblastic tissue during
and rebound on abdominal palpation, but often the findings laparoscopic management.
are more vague with only tenderness in the lower abdomen. The surgery may be laparoscopic or may require
Prior to pelvic examination, if ectopic pregnancy is expected laparotomy. Laparotomy would be indicated where access to
it is wise to site an intravenous line as rupture of the ectopic the tube was limited by adhesions or in a patient with
may occur during the examination. Gentle pelvic haemorrhagic shock, but ectopic pregnancies are commonly
examination may reveal cervical excitation pain, because the managed laparoscopically. The tube may be removed
tube is distorted by the enlarging ectopic pregnancy. It may (salpingectomy) or conserved (salpingostomy).
be possible to feel a mass in the adnexal region in about Salpingectomy is associated with a lower rate of persisting
20%. The uterus would be bulky due to the normal early trophoblast and subsequent repeat ectopic, whilst having a
pregnancy changes. similar intrauterine pregnancy rate to salpingostomy. The
Since assays have been available for the detection of the advent of laparoscopy has reduced laparotomy rates during
sub-unit of human chorionic gonadotrophin (hCG) it has ectopic pregnancy by at least 40% and as conservative
been possible to detect this in the serum of a pregnant management down the laparoscope proceeds many fewer
patient between 7 and 10 days after ovulation has occurred. laparotomies need be performed.
Thus diagnosis of pregnancy can occur before the patient The ultimate conservative management would be to cause
has missed her period. In a normally-sited pregnancy the tubal abortion by ensuring death of the ectopic tissue -
doubling time for hCG levels is approximately 48 hours, so attempts have been made to inject the ectopic with
serial measurements of hCG may help in the diagnosis of an methotrexate or with high-dose potassium, a risky procedure
ectopic pregnancy (Fig. 4). The detection of urinary hCG is due to the possibility of intravascular injection and harm to the
the standard pregnancy test and with a positive pregnancy mother. Follow-up with hCG levels to ensure non-continuation
test an intrauterine gestation sac would be seen from 5 of the trophoblastic tissue is essential.
weeks onwards.
Ultrasound examination earlier than this may reveal an The future
empty uterus with a positive pregnancy test. Failure to detect Most patients will wish to discuss the recurrence risk for
a sac should raise the possibility of ectopic gestation. The ectopic pregnancy - this being highly dependent upon the
thickening of the endometrium for the implantation of the reason for the current ectopic pregnancy. The usually quoted
fertilized ovum may lead to an ultrasound picture known as risk of ectopic pregnancy after surgery is approximately
a 'pseudo-sac', which should be distinguishable from a 5-15%, depending on whether management is laparoscopic
normal gestation sac. An hCG discriminatory zone is or open. Some patients will not wish further conception after
described whereby a titre of 1000-1500 lU/ml is associated an ectopic pregnancy but of those who do, approximately
with the presence of an intrauterine sac on transvaginal 50% achieve a live birth.
ultrasound (6000-6500 IU/1 for transabdominal scan). This
may help to increase the accuracy of the diagnosis.
Ectopic pregnancy
Management (Table 1)
Ectopic pregnancy is a diagnosis easily missed unless a high index of
The initial management of the acute patient involves
suspicion is maintained.
correction of shock with rapid fluid replacement, cross-
The fallopian tube is the commonest site for ectopic implantation.
matching of blood, check on the haemoglobin and
immediate recourse to laparotomy to stem the source of the Slow rise in hCG levels may indicate an ectopic pregnancy.
haemorrhage. In the more usual subacute presentation a • On ultrasound examination beware the pseudo-sac and look for free
laparoscopy is performed to make the definitive diagnosis peritonal fluid or an adnexal mass.
and to plan the type of treatment that would be appropriate. There is decreased fertility after ectopic pregnancy
The laparoscopic treatment of ectopic pregnancy offers a
100 GYNAECOLOGY
Related factors
Sexual history. An increased risk of PID
has been noted in association with a
young age at first sexual intercourse, a
high frequency of sexual intercourse and
multiple sexual partners.
Genital infections
Introduction be examined for skin lesions, particularly genital warts, genital
The World Health Organization (WHO) estimated that, in herpes and ulceration. The commonest cause of genital
1995, there were over 333 million cases of curable sexually ulceration in the UK is herpes; syphilis is rare. The urethra
transmitted infections (STIs) in adults aged 15 to 49 should be inspected for inflammation urethritis. Where
throughout the world. Many of the STIs can cause long-term appropriate, the anal area needs to be inspected.
morbidity, particularly in females. Untreated, some infections On speculum examination, the posterior fornix should be
can lead to infertility or cause miscarriage, premature birth, or inspected for discharge, and the cervix examined for discharge,
infection of the newborn. Prompt diagnosis and appropriate ulceration, bleeding, polyps, tumours or the threads of an
management are crucial in reducing these complications. This intrauterine contraceptive device. A bimanual pelvic
may be difficult as some infections, for example, for example examination should also be performed to detect tenderness of
Chlamydia trachomatis, are often asymptomatic until the cervix or adenexa.
complications arise. Swabs should be taken from the urethra, vagina and
Certain demographic features increase the likelihood of endocervix. Although chlamydia is readily identified from
someone having an STL There are: appropriate endocervical swabs, the ligand chain reaction
(LCR) or the polymerase chain reaction (PCR) testing of urine
• age under 25 years
is also an extremely sensitive test. Immediate microscopy of
« lack of barrier contraception use
vaginal swabs can detect yeasts, Trichomonas vaginalis and
• being single, separated or divorced
'clue cells' - vaginal epithelial cells covered with large numbers
• having an occupation involving staying away from home.
of Gram-positive and Gram-variable bacilli, characteristic of
Women undergoing termination of pregnancy and those with Gardnerella vaginalis. Measurement of vaginal pH may be
an infection such as genital warts are at increased risk of STIs. useful. It is normally < 4.5 but will be > 4.5 in bacterial
In reality, these factors are surrogate markers of sexual activity vaginosis and trichomonal infection.
and rates of partner change, as it is these factors mainly that (See also HIV infection, p. 16.)
determine the risk of transmission and acquisition of an STL With the possible exception of PID, genital infections are
To be able accurately to assess someone's risk of having an best managed in an STD clinic with facilities for counselling,
STI, therefore, it is necessary to take a good sexual history. contact tracing and on-site Gram staining and microscopy.
History Actinomycosis
A good history should be taken in a relaxed, communicative Actinomyces are Gram-positive bacteria which only rarely
and non-judgmental way with reassurances about cause salpingitis (often unilateral, more often on the right),
confidentiality. Choice of words, appropriate facial expressions chronic tubo-ovarian abscesses and fistulae. Actinomycosis
and appropriate body language by the questioner are may occur secondary to appendicitis or with use of an
extremely important. There is never a 'routine' way to take a intrauterine contraceptive device (IUCD). It is not sexually
history, but the questions will need to cover: transmitted and is treated with long-term high-dose oral or
• Symptoms parenteral penicillin.
- vaginal discharge - is it offensive (vaginosis) or does it
cause irritation (Candida)? Bacterial vaginosis
- dysuria - suggestive of gonorrhoea or chlamydial infection This is very common and occurs when lactobacilli are replaced
— genital ulcers - timing, prodromal symptoms (e.g. before by anaerobes, particularly Bacteroides species (Fig. 1). It is not
herpes), painful (also genital herpes) sexually transmitted and many women are asymptomatic, but
- abdominal pain or dyspareunia - suggestive of pelvic it can cause an offensive green or grey discharge (the pH is
inflammatory disease (PID) (see p. 100) raised to ~ 5.5 and bacterial metabolites produce volatile
« The place and time of recent sexual contacts amines with a 'fishy' odour), particularly after intercourse. On
• Whether the contact was penile-vaginal, or anal, or oral
• Sexual orientation and whether the contacts were with a
man or a woman
• Foreign travel and sexual contact
• Contraceptive precautions, and the requirement for
postcoital contraception
• Risk factors for HIV, especially:
- unprotected sexual activity with others at high risk for
HIV, or in areas of the world where HIV is endemic
— injected drug misuse by the patient or partner
• A gynaecological history to exclude the possibility of
pregnancy and to check cervical smear test results.
Physical examination
The skin and mouth should be examined and the abdomen
palpated looking especially for tenderness (PID) or for
evidence of lymphadenopathy. The external genitalia should Fig. 1 Gram-stained smear of bacterial vaginosis.
Genital infections 103
wet microscopy, there are 'clue' cells (see Prophylactic treatment, however, may be symptoms) is very rare in women. In the
above). If symptomatic, it is treated with of benefit, e.g. if the patient's symptoms male, C. trachomatis infection may cause
oral or vaginal metronidazole or with are particularly troublesome urethral discharge, dysuria, epididymo-
vaginal clindamycin cream (if the premenstrually, a single pessary may be orchitis and Reiter's syndrome.
woman is pregnant, ampicillin may be inserted midcycle. Alternatively, a Diagnosis in the female is by
more appropriate). There is no benefit weekly pessary may be used. Natural endocervical swabs, urethral swabs or
in treating the partner or in using yoghurt on a tampon for 3 nights, acetic first-void urine sent in a specific
condoms. acid jelly/ wiping the anus front to back, transport medium for investigation via
and cotton underwear may also be of the LCR or the PCR. Uncomplicated
Bacteroides spp. help. infection may be treated with an
These are commensals but may cause a immediate oral dose of azithromycin or
vaginal discharge (see 'Bacterial Chlamydia with doxycycline for 7-10 days or
vaginosis', above) or complicate pre- This is the commonest bacterial sexually erythromycin for 7-10 days. Increased
existing PID (leading to chronic transmitted infection in the UK doses plus the addition of metronidazole
infection). They are not sexually (0.5-15% depending on the sample are employed for complicated infection.
transmitted. Treatment is with selected), and is a much commoner Contact tracing is important and
metronidazole or with clindamycin cream. cause of infection than the gonococcus individuals should avoid unprotected
(Neisseria gonorrhoeae). In the female it intercourse for 2 weeks.
Candida or thrush (Candida is often asymptomatic, but may cause The main concern with chlamydial
albicans) PID, bartholinitis, spontaneous abortion, PID is its association with tubal damage
This presents with a whitish discharge premature labour, neonatal and infertility. As infections may be
and pruritus and is not sexually conjunctivitis (5-14 days postnatally, subclinical, it has been suggested that at-
transmitted (Fig. 2). The vulva and Fig. 3) and neonatal pneumonia. PID risk groups should be screened -
vagina may be fissured and painful. It with associated perihepatitis is known as particularly as this can now be achieved
occurs more commonly in the sexually the Fitz-Hugh-Curtis syndrome simply through LCR/PCR testing of
active, the pregnant, the (Fig. 4). Reiter's syndrome (arthritis, urine. Those at greatest risk are those
immunocompromised, the diabetic and mucosal ulceration and conjunctival aged < 25 years, particularly those with
after antibiotic treatment. The combined
oral contraceptive (COC) probably
makes no difference. Microscopy reveals
yeasts and pseudohyphae, and a high
vaginal swab may be cultured on
Sabouraud's medium. Treatment is with
clotrimazole (e.g. Canesten) pessaries
and cream. Oral fluconazole (Diflucan)
given immediately is also effective, but
may have systemic side effects, and
should not be used in pregnancy. If
proven infection is recurrent, there is no
benefit from treating the partner.
two or more sexual partners in the urethritis, polyarthralgia, miscarriage, painful to apply and may lead to
preceding year or who are presenting premature labour and neonatal hypersensitivity reactions). Aciclovir
with a request for termination of a ophthalmia (2-7 days postnatally). Most orally shortens the duration of
pregnancy. It has also been argued that men have symptoms of urethritis and symptoms and lessens infectivity
all women under 25 years old should be penile discharge (Fig. 6). Swabs should (famciclovir and valiciclovir are
regularly screened. be taken from the urethra and cervix alternatives). Recurrent infections are
and placed in Amies transport medium. shorter (lasting 5-10 days) and usually
Genital warts (Fig. 5) A Gram stain of an endocervical swab less severe. Ninety-five per cent of Type
These are usually caused by human shows Gram-negative intracellular II and 5% of Type I infections recur in
papilloma virus (HPV) types 6 and 11, diplococci in only 50% so that definitive the first year. Aciclovir cream should be
though types 16 and 18 are occasionally diagnosis is by culture on NYC (New used at the start of subsequent
implicated. Most patients with genital York City) medium. Treatment is with infections. Prophylactic oral aciclovir
HPV have no visible warts but the virus ampicillin orally stat. together with should be reserved for those with
can be transmitted to sexual partners probenecid. Ciprofioxacin orally stat. is frequent incapacitating infections (e.g.
who may then develop visible lesions. used in penicillin allergy and for > 10/year) and should be continued for
Twenty-five per cent of those with warts infections acquired in regions where at least 12 months. There is no necessity
have other demonstrable STIs. resistance is common. for annual cervical cytology. (See p. 15
Podophyllin paint can be applied weekly for 'infections in pregnancy'.)
to the non-pregnant patient by medical Herpes Cherpes simplex virus,
staff, with advice to wash the solution HSV) Syphilis (Treponema pallidum)
off 6 hours later. Self-treatment is also This infection classically occurs (Table 1)
available with podophyllotoxin solution secondary to the sexually transmitted A primary chancre (raised, round,
- this is applied twice a day for 3 days, Type II virus, but infection with Type I indurated usually painless ulcer; Fig. 8)
and the treatment repeated on a weekly from cold sores is increasingly common. resolves in 3-8 weeks and may be
cycle for four cycles. For patients with The incubation is 2-14 days with itch followed by secondary fever, headaches,
multiple or large warts, treatment with and dysuria prominent early symptoms. bone and joint pain, generalized rash,
cryotherapy using liquid nitrogen, or The vulva becomes ulcerated (Fig. 7) and flat papules known as condylomata lata
laser treatment, or diathermy under exquisitely painful and, in the first attack and generalized painless
general anaesthetic is appropriate. (which may last 3-4 weeks), there may lymphadenopathy. Following the latent
Annual cervical screening is not be systemic flu-like symptoms with or phase, there may be tertiary gummas
required but those with visible cervical without secondary bacterial infection. (Fig. 9) or quaternary neurological and
warts or abnormal cytology should be Autoinoculation to fingers and eyes can cardiovascular disease. Congenital
colposcoped. occur and there may be a sacral syphilis may lead to intrauterine death
radiculopathy giving a self-limiting or midtrimester loss. Survivors may be
Gonorrhoea (/Ve/sser/a paraesthesia to the buttocks and thighs. premature, have intrauterine growth
gonorrhoeae] Only very rarely is there an associated restriction, and failure to thrive as well
The incubation period is 2-5 days for meningitis or encephalitis. Strong oral as bone, joint, liver and kidney disease.
men. The vast majority of women are or intramuscular analgesia and advice to The diagnosis is made serologically,
asymptomatic but infection may cause micturate while in the bath may be of with most laboratories using the
PID (often at the time of menstruation), help (lidocaine (lignocaine) gel is Venereal Disease Research Laboratory
Table 1 Syphilis
Stage Timing Features
Primary Usually 14-28 days Chancre
from contact
Secondary Approx. 6 weeks after Rash, condylomata lata, lymphadenopathy
chancre
Tertiary More than 10 years after Gumma in skin, mucous membranes,
infection long bones
Quatenary Late Cardiovascular and neurosyphilis
Table 3 Advice to be given to women who miss the combined contraceptive pill feeding as it inhibits breast milk
Omission Advice production. Women who plan to bottle
For single pill omissions of less than 12 hours Take the pill immediately and further pills as usual feed their baby may start the pill 3
For one, or more, pill omissions, more than 12 hours late: weeks after delivery. The relative
-in week 1 of pill packet • Take the pill immediately thromboembolic risk is high in the
• Continue the packet as usual immediate postparmm period. Most
If intercourse has not occurred for 7 days - use
postpartum regimens would advise
sheath in addition for 6 days
If intercourse has occurred - see a doctor [consider
waiting until the sixth postnatal week
emergency contraception] (see p. 65).
- in week 2 of pill packet « Take the last pill immediately
« Continue with the packet as usual Emergency contraception
1 If four, or more, pills are missed - use sheath for There is still a problem with the
7 days as well under-utilization of emergency
- in week 3 of pill packet Take the pill immediately contraception due to a lack of
Continue with the packet as usual awareness. The much used misnomer
At the end of the packet continue with the next
'the morning after pill' is confusing:
packet without a break, (breakthrough bleeding
may occur) progestogen-only emergency
contraception (Levonelle-2) - can be
used for up to 72 hours post
unprotected intercourse
Table 4 Drug interactions with the combined contraceptive pill
» the intrauterine device (a copper
Drug category Example Drug effect Notes
coil) - may be fitted up to 5 days
Drug interactions that may lead to contraceptive failure
after unprotected intercourse.
Broad-spectrum Ampicillin, tetracycline, Disturb bowel flora and
antibiotics cephalosporins affect absorption The Levonelle-2 pill is very effective,
(? erythromycins)
preventing four out of five potential
Rifampicin - Potent enzyme inducer Used to treat tuberculosis,
(even brief exposure can but more commonly pregnancies with few side effects.
interfere with contraceptive encountered as prophylaxis
cover for 1 month) following meningococcus Adolescent contraception
exposure Many adolescents are mentally and
Antifungal agents Griseofulvin (? oral Anecdotal reports of pill emotionally unprepared for early
imidazoles, failure with oral imidazoles
sexual experience. There is a risk of
fluconazole,
ketoconazole, unwanted pregnancy, sexually
itraconazole) transmitted diseases, pelvic
• Anticonvulsants Barbiturates, phenytoin, Enzyme-inducing agents The neu/eranticonvulsants inflammatory disease, and cervical
primidone, are safe to use with the pill - dyskaryosis.
carbamazepine sodium valproate,
cionazepam, vigabatrin
It is important that any service for
young people is user-friendly,
The contraceptive pill may interfere with drug action:
confidential, approachable and offers a
• Antihypertensives Ace-inhibitors, beta blockers Oestrogen antagonizes
hypotensive effect
full range of options. The pill is the
Anticoagulants Effects antagonized most popular choice, but other
Antidepressants Effects antagonized methods including the sheath are
Oral hypoglycaemics Effects antagonized frequently used - the latter because it
Diuretics Effects antagonized
is easy to obtain.
Controversy surrounds treating
with a steady hormonal environment. weeks before major surgery, and before under 16-year-olds. Since 1985 in the
Monophasics are recommended in minor surgery where immobilization UK there are strict guidelines covering
epileptics. A stronger pill is normally follows. For emergency (i.e. unplanned) these circumstances, including that the
prescribed, often tricycling three surgery the pill should be stopped and girl fully understands the doctor's
packets (to minimize risks from the heparin prophylaxis provided. The pill advice and that the doctor tries to
pill-free week). The pill itself may should be recommenced 2 weeks after persuade her to inform her parents or
interact with pre-existing medication. full mobilization. guardian - but obviously will respect
her confidentiality if she decides she
Surgery and the pill Breast feeding does not wish to do so.
The pill should be stopped at least 4 The pill is contraindicated in breast
Progestogen-dependent hormonal
contraception
It is in this area that contraception has Table 2 Disadvantages of the depot progestogen injections
made the most advances in recent Menstrual cycle disturbance Initial irregular bleeding
years. Oral, depot and intrauterine Eventual amenorrhoea
treatment modalities are now available Weight gain Often 4-5 Ibs
with the length of activity ranging Commoner in slimmer women
from 24 hours to 5 years, allowing the Fertility Slower return to fertility than with oral methods
Usually returns by 5 months after last injection
clinician to pick the contraception that
This may be a deciding factor in some women
is most suitable to the individual
Osteoporosis Conflicting evidence, certainly no noticeable increase in osteoporotic fractures in
woman's needs. long-term users
However, generally, not recommended for women > 45 years
Progestogen-only pill (POP)
Amenorrhoea induced by depot could mask the onset of the menopause
The progestogen-only pill contains
General symptoms Tiredness
norethisterone, levonorgestrel or Low mood
norgestrel. There are three possible Low libido
modes of action: Mastalgia
Chemical methods
Spermicidal agents
Spermicides are generally advised for
use as supplements to other methods.
They have a mild bactericidal action.
The active agent for most products is
nonoxynol-9. Spermicides can be
manufactured as foam, pessary, cream
or gel. Use of spermicides as a sole
method of contraception is advisable
only in couples with very low fertility,
i.e. perimenopausal or oligospermia.
Intrauterine contraceptive
methods
All coils are copper bearing except the
Mirena IUS. The Nova T and the Nova
Gard contain both silver and copper.
These coils are licensed for 5 years'
contraceptive use and have a failure rate
of 1-2 per 100 woman-years. A Multiload
Cu 250 is licensed for 3 years. There are
two third generation copper devices, the
Multiload Cu 375 and the Gynae T 380 Fig. 2 Female sterilization, (a) Operation to apply clips to tubes, (b) Clip on tube.
slimline. The former is licensed for 5
years and the latter for 8 years; both have Sterilization epididymitis may occur. Sexual activity
a failure rate as low as 0.5 per 100 Sterilization offers a permanent method may be resumed as soon as there is no
woman-years. Should pregnancy occur, of contraception once the decision has further discomfort.
the miscarriage rate is increased. been made that the couple's family is
Problems can be encountered when complete. Appropriate counselling is Female sterilization
the coil is fitted (Table 1) which should needed, and if there is any ambivalence This is a more invasive technique and
only be done by a certified practitioner. alternatives should be considered. carries the risks of any laparoscopic
Fitting in women with a regular cycle can procedure. Originally the tubes were
be done from the end of the period up Male sterilization diathermied but this increased the risk
until day 19 of the cycle. Removal should Vasectomy offers several advantages: of postoperative pelvic pain and
be preceded by either 7 days' abstinence sometimes caused ovarian dysfunction.
or the use of other contraceptive « It can be performed under local
Currently, the application of tubal clips
precautions. Ideally, devices should not anaesthetic.
is the most common technique (Fig. 2).
be removed after day 19 of a 2 8-day cycle. • Significant operative morbidity and
The current failure rate stands at 1.5
mortality are virtually non-existent.
per 1000. There may be certain
Areas of concern • It is an easy procedure to perform.
situations where a mini laparotomy will
The copper-bearing coils often produce • It is certainly cheaper than female
be required, e.g. if there are multiple
menorrhagia and dysmenorrhoea. The sterilization as it does not require such
adhesions that block access to the tubes
coil is relatively contraindicated in a sophisticated operative equipment
or if the tubes are too thick for the
history of previous ectopic pregnancy, « It usually involves less disruption to
application of the clips with guaranteed
subfertility, immunosuppression and family life than female sterilization.
occlusion.
where infection would be of grave No inpatient stay is needed.
Women can be advised that they
concern, e.g. previous tubal surgery, The man can return to work after 1-3 may return to work within 5-7 days,
bacterial endocarditis and the presence days depending on whether he is an that tubal ligation is effective at once
of prosthetic heart valves. Fibroids are office or manual worker. and that there is no need to continue
not a contraindication unless the uterine Seminal analysis should be performed contraception following the procedure
cavity is distorted. at 12 and 16 weeks. Two negative semen if it is performed immediately
Previous cervical surgery resulting in analyses are required to confirm that the postmenstrually. Sterilization does not
stenosis may make insertion difficult procedure has been effective. affect menstruation, but does increase
and the coil should not be fitted during Complications are rare, but scrotal the incidence of tubal pregnancy.
active pelvic infection. haematomas, wound infection or
Actinomyces israelii is more common
in women with an IUD.
Non-hormonal methods of contraception
Table 1 Risks associated with the fitment
« There are many approaches to the natural method of family planning. It has a high failure rate and
of an IUD
requires considerable commitment
Expulsion Most often occurs in the first
• The sheath is easy to obtain but is often not used correctly by young people. It does have the
few weeks after fitting
advantage of reducing sexually transmitted disease.
Perforation Most commonly occurs with
inexperienced fitters and The 'double Dutch' technique utilizes the contraceptive pill for safe contraception and the sheath
when the uterus is retroverted to prevent STDs.
Pain Lidocaine (lignocaine) gel The diaphragm is easy to use and does not need to be inserted immediately prior to intercourse.
may be inserted It is not particularly effective in preventing STDs.
intracervically
Paracervical block The cap is occlusive and is therefore a good barrier method to infection; it can be left in place for
Oral analgesia (NSAIDs) or several days.
Voltarol suppositories, given Spermicidal agents and the contraceptive sponge have higher failure rates and should not be
prior to fitting used alone except in perimenopausal women with reduced fertility.
Prolonged vasovagal Have atropine available
• There are several different types of copper-bearing IU D. They carry a slight risk of infection. The
bradycardia
coil should be fitted by a trained certified practitioner and there should always be equipment on
Bronchospasm Have intubation equipment,
hand for the emergency situation.
oxygen and adrenaline
[epinephrine) available • Sterilization should be considered as final. Female sterilization carries the risks of any
Small risk of infection laparoscopy. Male sterilization is under-utilized, and is cheap and safe.
112 GYNAECOLOGY
Amenorrhoea
Amenorrhoea can be considered under age of 16 years. This requires systematic Prolactin - raised implies a pituitary
two categories - physiological investigation if the correct diagnosis is to adenoma; arrange a CT scan.
[including prepuberty, pregnancy- be reached and to ensure appropriate Testosterone - levels at upper end of
related and postmenopausal) and management If secondary sexual female range found in PCOS, levels in
pathological (primary and secondary). characteristics fail to develop it is male range suggest ectopic production.
Disorders which can lead to appropriate to investigate earlier (age 14). Estradiol - low levels need to be
amenorrhoea are shown in Table 1. Secondary amenorrhoea is arbitrarily interpreted with LH/FSH values as
defined as a 6-month absence of menses they can be due to no stimulation
Physiological without any physiological reason. from the hypothalamus or pituitary, or
Puberty occurs between the age of 10 may suggest ovarian failure.
and 16 years, so amenorrhoea before Investigation of amenorrhoea
this is normal and only requires Normal secondary sexual development Progestogen challenge test
investigation if at age 16 no menstrual should not preclude chromosomal Administer a progestogen for 5 days
loss has been noted. Puberty is analysis as Turner's mosaic and and within 3 days of stopping there
associated with a somatic growth spurt, testicular feminization are associated will be a withdrawal bleed. This
breast budding and pubic hair growth. with normal secondary sexual implies that the endometrium has
Menarche [the first period) is within characteristics. Measurement of follicle been primed with oestrogen, that the
2 years of breast development Any stimulating hormone (FSH), uterus is present and that there is no
obvious causes for not reaching puberty luteinizing hormone (LH), thyroid outflow tract obstruction.
have often been sorted out in childhood stimulating hormone (TSH), prolactin,
so with otherwise normal development estradiol and testosterone will clarify Ultrasound
it may be expected that menses will most other problems. A progestogen Ultrasound scanning shows the pelvic
arrive. Menarche often follows a familial challenge test determines whether the organs. Absent uterus may be due to
pattern - if the girl's mother had a late endometrium has been exposed to Mullerian failure or testicular
menarche it may be anticipated that oestrogen and is a more physiological feminization (see p. 88). A fluid-filled
this will occur in the patient method than measuring estradiol uterus and vagina implies
Pregnancy should always be levels. Raised prolactin levels indicate cryptomenorrhoea (see p. 89). Ovaries
excluded before any investigation for the possibility of a pituitary adenoma, showing a dense stroma and more
amenorrhoea commences. The which should be further investigated than 10 follicles per field are classical
postpartum period will be associated with appropriate imaging. of PCOS (see p. 114).
with absence of menstrual loss for a
variable phase, particularly in CT scan of pituitary
Investigations and their
association with breast feeding. Prolactinomas are classified as
interpretation
The menopause is the last microadenomas (< 1 cm in diameter)
menstrual period and can only be Blood tests or macroadenomas (Fig. 1).
recognized in retrospect, being LH - low level implies no stimulation
diagnosed after amenorrhoea for a from the hypothalamus; higher than Management of amenorrhoea
year. This signifies the end of the usual levels may be found in polycystic Abnormalities causing amenorrhoea
reproductive phase of a woman's life ovarian syndrome (PCOS), or very are usually divided into anatomical
and bleeding after this is abnormal, high levels suggest ovarian failure. areas to facilitate both the investigation
unless she is taking cyclical hormone FSH - low if no stimulation from of the problem and management,
replacement therapy. the hypothalamus; high levels found which follows logically from the
with ovarian failure. diagnosis.
Pathological TSH - raised with hypothyroidism, Asherman's syndrome is caused by
Primary amenorrhoea is defined as the an easily treatable cause of scarring of the endometrial cavity and
failure of any menstrual loss by the amenorrhoea. synechiae are seen at hysteroscopy. It
may follow over-vigorous surgical
Table 1 Disorders leading to amenorrhoea curettage or endometrial infection
Site of disorder Diagnosis Investigations including tuberculosis. After breaking
Hypothalamus Hypothalamic hypogonadism (rare) FSH, LH and estradiol - all low down these adhesions, a coil may be
Weight-related amenorrhoea FSH, LH and estradiol - low inserted to allow endometrial
(common] regrowth.
Pituitary Pituitary adenoma (common) Prolactin - raised, FSH. LH and estradiol - low
'Imperforate hymen' represents one
Sheehan's syndrome (rare] LH, FSH and estradiol-low
form of failure of complete
Endocrine - thyroid Hypothyroidism (rare) TSH - raised, T4 - low or normal
canalization of the vagina (see p. 88).
Ovary Gonadal dysgenesis (rare) FSH, LH - high, estradiol - low
Polycystic ovarian syndrome (common) LH - high, FSH - normal, androgens - high normal Gonadal dysgenesis occurs with
Premature ovarian failure (rare) FSH, LH - high, estradiol - low streak gonads and is characterized by
Mullerian tract Absence of uterus (rare) Ultrasound and progesterone challenge an infantile female phenotype from
Genital tract Imperforate hymen (common) Ultrasound and examination low levels of oestrogen. A karyotype is
Asherman's syndrome or HSG and AAFB testing required to exclude any Y
endometrial fibrosis (rare)
chromosome material necessitating
Amenorrhoea
Amenorrhoea
« Exclude pregnancy before any investigation of amenorrhoea.
Only use investigations that will confirm or refute a suspected
diagnosis; it is inappropriate to do all tests on all patients.
• Follow a logical plan of investigation and the diagnosis will become
clear.
Fig. 2 Turner's syndrome.
114 GYNAECOLOGY
Treatment
As PCOS is found in a large proportion of the female
population, treatment is only required for the patient's
symptoms.
Fig. 4 Reducing levels of androgen will reduce hirsutism.
Amenorrhoea
Either induce ovulation which will result in regular
menstruation (see below), or protect the endometrium
against the effects of unopposed oestrogen stimulation by:
• using the oral contraceptive pill which will result in
regular menses
• giving progestogens three or four times per year to induce
Benefits of exercise:
endometrial shedding.
tBMR (basal metabolic rate)
The setting
The ideal day surgery unit [Fig. 1) should be completely self-
contained with its own operating theatre, ward and staff, a
consultant director and an experienced nurse manager.
Purpose-built units are often built onto the back of existing
hospitals to facilitate intercommunication with the main
theatre suite and intensive care facilities should
complications occur. In other situations they are built as
freestanding units, containing several operating theatres,
consulting rooms and a medical day unit.
Ambulatory care and diagnostic CACAD) centre (Figs 2
and 3) developments are substantially larger and include
radiology suites, endoscopy units, lecture theatres and
outpatient consulting rooms allowing for diagnostic imaging
and interventional radiology (e.g. arterial embolectomies) on
site. All units should be light, bright and welcoming with Fig. 2 Ambulatory care and diagnostic centre.
good access for the staff and patients. Some hospitals still
nurse day surgery patients on general gynaecology wards,
converting a 4-6-bedded bay for this purpose. The patients
are then cycled through the main theatre suite. Children are
usually admitted via the paediatric wards.
Preoperative evaluation
For day surgery to be successful and safe there must be
adequate preoperative assessment and strict patient selection Fig. 3 Entrance foyer, ambulatory care and diagnostic centre
Day care surgery 117
Table 1 Advantages of day care surgery Table 2 Preoperative selection guidelines for day care surgical admissions
• Minimal disruption to patient's personal life Surgical
• Earlier return to work or school • Operations lasting less then 1 hour
• Patients prefer day surgery • Minor and intermediate procedures
• Psychological benefits, especially for children • Exclude procedures where severe postoperative pain is likely
• Shorter waiting lists for admission Si Exclude procedures where significant postoperative bleeding is likely
• Reduced incidence of hospital-acquired infection Exclude procedures where significant disability is likely, e.g. bilateral varicose veins, bilateral herniae, bilateral Keller's
• Reduced incidence of respiratory complications Social
• Reduced frequency of medical errors • Must live within 15 miles or ] hour's drive of the hospital
• Large numbers of patients may be treated Must not go home by public transport
• Cost effective Must have responsible fit adult escort home.
Must be supervised by responsible fit adult for at least 24 hours
Medical
junior medical staffer trained day care • Patient's age > 6 months and < 70 years
nurse practitioners. Many units have • Obesity - BMI > 30 not accepted to day unit
designed specific history proformas to a ASA class 1 and 2 only
aid clerking and have devised - ASA 1: a normal healthy individual
- ASA 2: a patient with mild systemic disease which does not interfere with normal life including mild medical
protocols for the assessment and pre-
conditions which are well controlled on treatment, e.g. mild hypertension, asthma, osteoarthritis or epilepsy, and
clerking process (Fig. 4). also non-insulin-dependent diabetes.
Investigations are kept to a Antiepileptics and antihypertensives should be taken on the day of surgery
minimum and are performed at the Oral hypoglycaemic agents should not be taken on the day of surgery
outpatient appointment with results
The Amer ica n Sccie ty or Ane st ne siolo gist s [ASA ] class ifi catio n ranks pati ents in classes 1 to 5. Class 1 s essenti ally a fit
available on the day of surgery. All
nor mal in dividual with only leca lzec path ology re quiri ng treat ment . Class 5 s mon bun d with poor cha nce f sur vial .
patients for therapeutic termination of
pregnancy will have their Rhesus
status and blood group checked.
Patients of West Indian, African and
Mediterranean origin will have their
sickle cell status tested. In some
centres the preoperative anaesthetic
assessment is performed in specific
outpatient assessment clinics. More
usually patients are seen in the day
unit on the day of surgery.
counselling regarding contraceptive • Preoperative assessment is often performed by specialist day unit nurse practitioners.
118 GYNAECOLOGY
Uterine fibroids
Correctly known as leiomyomas, Pathology
fibroids are benign tumours of uterine Fibroids may be found singly within
smooth muscle interlaced with the uterus, but are more commonly
connective tissue which develop within multiple and may vary in size from
the wall of the uterus causing seedling fibroids to enormous tumours
distortion, and disturbance of filling the whole pelvic cavity and
menstrual and reproductive function. extending into the abdominal cavity.
Approximately 20°/o of women of They often start intramurally (Fig. 1)
reproductive age have fibroids, but as they grow become more
commonly presenting later in predominantly submucosal or
reproductive years with menstrual subserosal (Table 1). The cut surface
problems. Presentation may be earlier has a characteristic whorled
following infertility investigations. In appearance where the interlacing of
Afro-Caribbeans up to 50% of women the muscle and fibrous tissue can be
may have fibroids. clearly seen (Fig. 2). After the
menopause fibroids are noted to
Aetiology shrink and regress, presumably due to
The actual cause of fibroids is unknown the withdrawal of oestrogen support.
although it is appreciated that raised Fibroids can go through a variety of Fig. 2 Cut surface of a fibroid showing
degenerative processes (Table 2). fibrous tissue and whorled appearance.
oestrogen levels are associated with
increased growth of fibroids. This might
explain the association between obesity Presentation
fibroids decreases successful
and the presence of fibroids, as there is Menorrhagia implantation resulting in subfertility,
peripheral conversion of androgens to Menorrhagia is the common or whether it is the lack of pregnancy
oestrogens in adipose tissue. Hormone presenting symptom of fibroids and is that predisposes to fibroid growth in
replacement therapy (HRT) can be thought to arise due to the increased later reproductive years is uncertain. In
given to women with fibroids without surface area of the endometrium patients with recurrent abortion,
adverse effect as the hormone levels which bleeds at the time of fibroids may be responsible due to the
achieved from standard HRT are much menstruation. It may also be due to mechanical distortion of the
lower than in pregnancy when fibroids pressure from the fibroid on venous endometrial cavity disturbing
do grow. drainage increasing blood flow. A implantation. Pedunculated fibroids
disturbance of the balance of E and F within the uterus may block the
prostaglandins noted within the cornual region, decreasing fertility.
menstrual effluent raises the question
of whether a disturbance in the Investigations
metabolism of prostaglandins is a Pelvic examination usually reveals an
contributory factor or possibly even an irregularly enlarged uterus of firm
aetiological factor. Another theory is consistency and the presence of fibroids
that ulceration of endometrium may be confirmed by ultrasound (Fig. 3).
overlying a submucous fibroid may Ultrasound will clearly show intramural
cause haemorrhage. Large fibroids can and submucous fibroids but
present with pressure symptoms on distinguishing subserous fibroids from
adjacent organs (Table 3). the ovary may not be easy.
Submucous and intramural fibroids
Subfertility will show as a filling defect on a
This is a well recognized association, hysterosalpingogram. A
Fig. 1 Types of fibroids. although whether the presence of the hysterosalpingogram should be
considered for those with infertility to
assess tubal function and cavity structure.
Table 1 Fibroids are predominantly submucosal or subserosal
The presence of fibroids does not
Site Findings necessarily imply a causal relationship to
Submucosal These lie under the endometrial lining of the uterus and may cause distortion of the uterine cavity
subfertility - they may be coincidental.
leading to menorrhagia, subfertility and late miscarriage
If polypoid they may grow from the endometrial lining and appear to develop a stalk. They may
then be extruded by the uterus through the cervix causing cramping uterine pain and often heavy Management
bleeding
Medical
Subserosal Predominantly under the outer peritoneal coat of the uterus and may cause distortion of the pelvic
anatomy. They grow between the leaves of the broad ligament, down towards the cervix and can
Medical management is appropriate
make surgery complicated for patients with menorrhagia and
Fibroids under the serosal surface of the uterus may grow out on a stalk-like projection - parasitic small fibroids or for those with
fibroid, which takes blood supply from elsewhere [commonly the omentum) and becomes subfertility where fibroid size requires
detached from the uterus
some shrinkage. Anti-prostaglandins
Uterine fibroids 119
Cystic degeneration The centre of the fibroid becomes ischaemic and degenerates, becoming cystic Bladder Frequency, urgency and nocturia
Calcification Degeneration may proceed to calcification at a later stage, and therefore tends to be found in Rectum Diarrhoea or constipation
older patients. In an extreme form it may be found as 'womb stones', the uterus containing a Uterus Cramping abdominal pain due to
collection of stony masses attempts at extrusion of fibroid
Torsion Pedunculated fibroids may undergo torsion with pain and haemorrhage into themselves. polyp
Rarely this subsequently becomes infected but more commonly would go on to cystic Acute abdominal Torsion or degeneration of fibroid
degeneration and possibly calcification pain
Red degeneration This is the classic degeneration of a fibroid during pregnancy associated with rapid uterine
growth. The cut surface would appear red but the fibroid should not be surgically removed
during pregnancy due to a very high risk of haemorrhage. Can be extremely painful requiring incision. Any incision should be placed
analgesia and bed rest
on the anterior surface of the uterus if
Sarcomatous change Very rare (<0.1%) but should be considered if the fibroid is growing rapidly (see p. 139)
possible to avoid adhesions involving
the fallopian tubes. It is usual to avoid
entering the uterine cavity at operation
to avoid intrauterine adhesions which
may compromise future fertility or
necessitate caesarean section in a
future pregnancy due to the presence
of a full thickness scar.
Endoscopic removal of fibroids is a
possibility but is more commonly used
in the treatment of menorrhagia than
of subfertility because of the resultant
scarring within the uterine cavity.
Submucous fibroids may be resected
hysteroscopically (Fig. 4) and
subserous fibroids approached
laparoscopically with removal by
morcellation.
Embolization of the blood supply to
the fibroid will result in shrinkage but
this can be associated with
Fig. 3 Appearance of fibroid uterus on an ultrasound scan.
considerable pain.
« Medical management for menorrhagia may tide a woman over to menopause when natural
shrinkage occurs.
Physiology of menstruation
The physiology of menstruation is pulse secretion. The positive feedback
closely linked to factors controlling of oestrogen and progesterone on
ovulation. If ovulation is regular, so is gonadotrophin secretion may involve
the menstrual cycle. alteration of the sensitivity of the
pituitary to LHRH action.
The ovulation process
Follicles of all stages of development The normal menstrual cycle
are found within ovarian stroma. Most cycles are between 24 and
Folliculogenesis takes place in several 32 days in length and the standard
steps - recruitment and intermediate normal cycle is considered to be
follicular development. Most follicles 28 days. Some irregularity occurs at
are primordial and only a few are both ends of the reproductive
recruited into the 'growing' pool, the spectrum, i.e. at puberty and at the
group designated to develop. This menopause. Once cycles are
cohort of growing follicles undergoes a established, they are most regular
process of development and between the ages of 20 and 40 years.
differentiation spanning 85 days, i.e. The mean menstrual blood loss in a
three ovarian cycles. The recruitment healthy western woman is
process is probably independent of approximately 40 ml, 70% of which is
pituitary control and may depend on lost within the first 48 hours. Within
paracrine factors. Growing follicles Fig. 1 Action of gonadotrophins on the
each individual the loss varies very
induce changes in surrounding cells, theca and granulosa cells of the ovary and little from one period to the next.
which differentiate into granulosa and the ripening follicle. There is a considerable variation,
theca cells. Only a fraction of these however, comparing one woman to
follicles reach a stage of maturation another. The upper limit of normal
where ovulation is possible, the rest menstruation is taken as 80 ml per
become atretic. menses. Reported menstrual loss can
Follicle stimulating hormone (FSH) vary between a few ml to several
pushes responsive follicles into the hundred. Menstrual fluid loss contains
final stages of the growth phase. mucus and endometrial tissue, as well
Luteinizing hormone (LH) binds to the as blood. Uterine contractility is usually
theca cells, stimulating androgen greatest in the first 24 to 48 hours of the
production. FSH binds to granulosa period. This possibly aids expulsion of
cells activating the aromatase enzyme degenerating endometrium. Contractility
system, enabling the conversion of is variable and can produce only a mild
androgens to oestrogen (Fig. 1). One discomfort or severe cramping pain (see
dominant follicle responds to the high p. 123).
oestrogen milieu and ripens.
The rising oestrogen level produces Mechanisms of blood loss
a negative feedback on the anterior The uterine wall consists of three
pituitary to inhibit FSH secretion. FSH layers: the serous coat, which is firmly
levels fall, preventing further follicles adherent to the myometrium; the
ripening, but the dominant follicle myometrium, which contains smooth
continues to grow. Once it reaches muscle fibres and branches of blood
maturity, oestrogen levels are sufficient vessels and nerves; and finally the
to induce a positive feedback, and a endometrium, which consists
massive discharge of LH occurs. The principally of glandular and stromal
LH surge, acting through cells. The blood supply is via the
prostaglandins, produces follicular arcuate and radial arteries (Fig. 3). The
rupture. LH then binds to granulosa radial arteries develop a corkscrew-like
cell receptors to stimulate Fig. 2 Feedback control mechanism in the appearance as they approach the
progesterone secretion. The main hypothalamic-pituitary-ovarian axis. endometrial surface, at this point
product of the corpus luteum is called spiral arterioles. These arterioles
progesterone. The lifespan of the are sensitive to changing levels of sex
corpus luteum is 12 to 14 days. As it control of LHRH secretion is highly hormones. A fall in progesterone
degenerates, progesterone levels fall complex, depending on a number of results in constriction of the arterioles
and menstruation occurs. inhibitory (dopamine) and excitatory with ischaemia and shedding of the
The secretion of FSH and LH is (noradrenaline, prostaglandin) upper two-thirds of the endometrium.
controlled by luteinizing hormone neurotransmitters, modulated by The end arterioles are lost with the
releasing hormone (LHRH), released ovarian hormones. Ovarian steroids glands and the stroma during
by the hypothalamus (Fig- 2). The modulate the pattern of gonadotrophin menstrual shedding.
Physiology of menstruation 121
Control of menstrual blood flow prostaglandin synthesis will therefore alpha is a potent oxytoxic and
The factors controlling blood loss include: decrease blood flow to some extent vasoconstrictor and administration to
(also dysmenorrhoea secondary to the uterus leads to dysmenorrhoea-like
myometrial contractility
myometrial contractility; see p. 123). pain. The role of prostaglandin E2 is
haemostatic plug formation
Excessive bleeding may be related to less clear, but it may work by
vaso constriction.
an alteration in the ratio between the increasing the sensitivity of nerve
Myometrial activity is probably one of vasoconstrictor prostaglandin F2 alpha endings. An increase in uterine
the lesser mechanisms since drugs and the vasodilator prostaglandin E2. contractility can be demonstrated in
which inhibit contractions, such as There may also be enhanced synthesis women with dysmenorrhoea
prostaglandin synthetase inhibitors, do of prostacyclin from the myometrium compared to controls by measuring
not increase menstrual blood loss. in women with heavier periods, which, the intrauterine pressure. This
Menstrual fluid and endometrium by inhibiting platelet aggregation, contractility may be associated with a
have marked fibrinolytic activity (hence reduces haemostatic plug formation. decrease in endometrial blood flow.
antifibrinolytics can be useful in As yet we do not understand the cause Leukotrienes are also produced by
treatment) (see p. 124). of the increased synthesis of these the endometrium and increase
Vasoconstriction is probably the vasodilator substances. myometrial contractility. Receptor sites
most important mechanism in are present in the myometrium.
controlling blood loss. Here the role of Period pains (dysmenorrhoea) Vasopressin is also a stimulant of the
prostaglandins is central. Prostaglandin There are several possible aetiological non-pregnant uterus, and it is active at
F2 alpha is a potent vasoconstrictor, mechanisms causing period pains. the onset of menstruation. The plasma
whereas prostaglandin E2 and Both prostaglandin F2 alpha and E2 concentration of vasopressin, which is
prostacyclin lead to vasodilatation. are found in higher concentrations in known to stimulate prostaglandin
Prostacyclin is a potent inhibitor of the menstrual fluid of those with release, is higher in those suffering
platelet aggregation. Inhibitors of dysmenorrhoea. Prostaglandin F2 with dysmenorrhoea.
Physiology of menstruation
• LHRH controls the secretion of both FSH and LH from the anterior pituitary.
• Ovarian hormones modulate the proportions of gonadotrophic secretion.
• The control of LHRH secretion is highly complex and depends upon inhibitory and excitatory neurotransmitters, again modulated by ovarian hormones.
• The recruitment process promotes some ovarian follicles into the growing pool; this is probably independent of pituitary control.
» FSH controls maturation of the growing follicle, the LH surge produces follicular rupture to allow ovulation.
« Following ovulation a corpus luteal cyst is formed producing progesterone; with falling progesterone levels menstruation occurs.
« The interaction between vasodilator and vasoconstrictor prostaglandins controls menstrual flow; an alteration in the ratio of these prostaglandins can
produce excessive bleeding and/or pain.
122 GYNAECOLOGY
Disorders of menstruation I
This chapter considers menstrual
abnormalities - regular and irregular
heavy bleeding and painful periods.
Disorders of menstruation are
common, comprising 21% of
gynaecological referrals.
Menorrhagia
This is heavy, regular bleeding defined
as a menstrual blood loss greater than
Fig. 2 Multiple submucous fibroids.
80 ml. Women differ in their subjective
reporting - some will describe loss as
Fig. 3 Hysteroscopic view of uterine
heavy when it is within normal limits, cavity and endometrial polyps.
« intrauterine contraceptive devices
others cope stoically with excessive flow.
(except the Mirena)
A careful assessment should be made Table 1 Types of dysfunctional uterine
« pelvic infection (often heavy and
enquiring as to the type of protection bleeding
painful menses).
(pads or tampons) used, the number of Anovulatory
changes needed per day, the amount of Impaired positive feedback, e.g. adolescents
Intermenstrual bleeding
clots and frequency of accidents (e.g. Inadequate signal, e.g. polycystic ovaries and
This is bleeding occurring between premenopause
soiling of clothes or bed linen). A
menses. It may be physiological in Ovulatory
menstrual chart can be helpful (Fig. 1).
origin, related to the sudden rise (and Inadequate luteal phase
Menorrhagia can be caused by: Idiopathic
then fall) of oestrogen at ovulation.
• idiopathic More often it is associated with
« fibroids (Fig. 2) cervical or endometrial polyps (Fig. 3), cervical carcinoma or stress. Postcoital
• bleeding disorders cervical erosions or, occasionally, bleeding may have similar causes.
painless bleeding. An extreme form of Table 2 Causes of dysmenorrhoea make the pill unpopular amongst
this (metropathia haemorrhagica), Primary Secondary adolescents.
results in excessive bleeding after long dysmenorrhoea dysmenorrhoea Reassurance is essential and it may
intervals. The endometrium has a • Prostaglandin production Idiopathic be appropriate to substitute a
classic cystic appearance, often termed • Increased myometrial Endometriosis transabdominal ultrasound for a
contractility Adenomyosis
a 'Swiss cheese' pattern (Fig. 4). vaginal examination in a young girl
• Decreased endometrial Pelvic inflammatory
Impaired positive feedback will blood flow disease
who is a virgin. Symptoms not
cause anovulatory cycles by failing to • Leukotrienes • Pelvic venous uncommonly settle with time, and
produce the mid-cycle surge of « Vasopressin congestion there is no association with later
luteinizing hormone that triggers Cervical stenosis problems, particularly infertility.
Intrauterine device
ovulation. Failure of follicular
OUDJ
development will occur in the Secondary dysmenorrhoea
perimenopausal age group, and in This develops after menarche and
Table 3 Treatment of primary
polycystic ovarian syndrome. If there may be identifiable underlying
dysmenorrhoea
follicular development is insufficient pathology (see Table 2). Treatment is
• Analgesics
there will be an inadequate oestrogen dependent on the cause. Investigation
- e.g. paracetamol
signal. Therefore a luteinizing Non-steroidal anti-inflammatory drugs (NSAIDs)
may include thorough examination,
hormone surge is not induced and - mefenamic acid (PonstanJ ultrasound scan and laparoscopy.
ovulation does not occur. - ibuprofen Although psychological factors are
- naproxen quoted as being involved in both
- diclofenac
Ovulatory dysfunctional bleeding primary and secondary
(NSAIDs work by direct inhibition of the cyclo-
A shortened luteal phase arises from oxygenase system reducing prostaglandin dysmenorrhoea, the evidence for
inadequate follicular development. production) physical factors is strong. Recurring,
Deficient luteal phase will cause
• Combined oral contraceptive pill (COC) debilitating pain may well cause
(suppresses ovulation)
irregular bleeding and may be depression and anxiety, rather than
Transdermal GTN
associated with subfertility The depression initiating the pain.
idiopathic category of ovulatory
dysfunctional bleeding is probably Treatment of primary Toxic shock syndrome
related to intrinsic prostaglandin dysmenorrhoea Toxic shock syndrome (TSS) is a rare
imbalance. Simple analgesia is often sufficient. condition occurring in women who
Further treatment is based either on forget to remove or regularly change
blocking prostaglandin formation with tampons. It is caused by a
Dysmenorrhoea non-steroidal anti-inflammatory drugs Staphylococcus aureus exotoxin (toxic
Dysmenorrhoea can be either primary, (NSAIDs) or by suppressing ovulation shock syndrome toxin-1). Influenza-
with the onset of menarche, or (combined oral contraceptive pill) like symptoms occur with high fever
secondary, developing later (Table 2). (Table 3). NSAIDs are best started just (39°C), diarrhoea, vomiting, rash,
There may be cramping lower prior to the onset of menstruation, muscle aches and offensive vaginal
abdominal pains, which often radiate although timing this is only possible discharge. Complications can be severe,
to the back, or down the inner aspect with regular predictable cycles. If including disseminated intravascular
of the thigh. These may be symptoms remain debilitating, despite coagulation (DIC), renal, tubal or
accompanied by faintness or NSAIDs, the pill may be appropriate. cortical necrosis, micromrombi, adult
gastrointestinal symptoms, including This has the additional advantage of respiratory distress syndrome (ARDS)
loose stools or nausea. providing contraception. A 20 ug and tissue hypoxia. Mortality is in the
preparation may suffice, and recent order of 30 to 50%. Women should be
Primary dysmenorrhoea concerns about the increased risk of advised to use the lowest absorbency
Menstrual symptoms vary widely venous thromboembolism in third tampon suitable for the flow, change
amongst individuals, but some suffer generation progestogen pills seem 4- to 8-hourly and to wash their hands
more severely than others. Primary unfounded. Third generation before and after insertion. Toxic shock
dysmenorrhoea occurs almost progestogen pills reduce side effects syndrome can also be associated with
exclusively in ovulatory cycles. such as acne and weight gain which cases of septic abortion.
Disorders of menstruation I
m Disorders of menstruation are common; at some stage over 20% of women will complain of heavy periods.
• Dysfunctional uterine bleeding is a diagnosis made by exclusion and can be either ovulatory or anovulatory.
« Toxic shock syndrome (TSS) is caused by Staphylococcus aureus exotoxin - mortality is 30 to 50%, related to lost tampons and septic abortions.
124 GYNAECOLOGY
Disorders of menstruation 11
Management of dysfunctional achieve amenorrhoea after 8 to 9
uterine bleeding months of use. Initially, there is a 30%
Management should include an chance of irregular bleeding. It is not
assessment of the situation, the pattern only effective, but also provides
of bleeding and the degree of loss. contraception. Cyclical progestogens
Menorrhagia with a regular cycle is and danazol have also been used.
probably ovulatory and does not require
endocrine investigation. Endometrial Endoscopic
biopsy is not considered necessary in
Hysteroscopy
women under the age of 40 years.
This is the transvaginal approach to
Irregular periods warrant tests for
looking directly into the endocervical
follicle stimulating hormone,
canal and the uterine cavity (Figs 1 and
luteinizing hormone, prolactin, thyroid
2), with an endoscope introduced into
function and testosterone. A
the endocervical canal and advanced
characteristic profile is found in cases
under direct vision until the uterine
of polycystic ovarian syndrome [see p. Fig. 1 Hysteroscopy technique.
cavity is reached. Fibre-optically
115). Anovulatory menorrhagia is
transmitted light provides illumination.
common in the older perimenopausal
The endocervical canal and uterine
woman. Endometrial carcinoma can
cavity are slightly distended with an
present as irregular bleeding in the
appropriate medium to obtain a
mid to late 40s - if there is any
panoramic view of the uterine cavity.
suspicion, endometrial assessment is
Saline or Hyskon (32% dextran-70 in
warranted (see p. 138).
10% dextrose) are used as uterine
distension media. Visualization can
Treatment for heavy bleeding
also be obtained with carbon dioxide,
Medical but vision is often obscured by gas
Treatment is initially by inhibition of bubbles. Complications related to
prostaglandin synthesis (e.g. dextran usage are very rare, but
mefenamic acid) or an anti-fibrinolytic include anaphylaxis, pulmonary
agent (e.g. tranexamic acid) (Table 1). oedema, electrolyte imbalance (e.g.
The pill can also be used - it promotes hyponatraemia and hypocalcaemia)
anovulation by ovarian suppression, and coagulation disorders. The
but provides short, regular controlled incidence of complications is related to
cycles. The levonorgestrel-impregnated the volumes of Hyskon used, high
intrauterine contraceptive device distending pressures and long surgical
(Mirena) has changed the approach to procedures. Hysteroscopy itself has
the management of dysfunctional practically no complications. However,
bleeding. It reduces blood loss in 70% some blind manipulation may be
of cases, and 20% of women will required in sounding the uterine cavity Fig. 2 Performing hysteroscopy.
Disorders of menstruation II
Prostaglandin synthetase inhibitors decrease menstrual blood loss and myometrial contractility.
Anti-fibrinolytics are useful as first-line management of dysfunctional bleeding.
The Mirena progestogen-secreting coil plays a useful role in dysfunctional uterine bleeding, also providing contraceptive cover.
Acute pain
Pain may be due to ectopic pregnancy
(see p. 98), miscarriage (see p. 92),
ovarian cyst accident (see p. 140), pelvic
infection (see p. 100), ureteric calculus,
painful bladder conditions,
appendicitis, diverticular disease or
irritable bowel syndrome.
Investigations of the cause of acute
pelvic pain are listed in Table 1 and the
management of acute pain is outlined
in Figure 1.
menstruation, bowel or bladder Irritable bowel syndrome (IBS) Alternating loose bowels and constipation, abdominal bloating,
pain often in left iliac fossa
fullness and sexual intercourse.
Nerve entrapment Previous pelvic surgery, pain easy to pinpoint
Pelvic pain syndrome (PPS) is a
Residual ovary syndrome Previous hysterectomy, deep dyspareunia
disorder of the premenopausal
Uterogenital prolapse Dragging sensation, dull pelvic ache, vaginal bulge
woman. In PPS there would be
Urethral syndrome Urinary frequency and urgency, voiding difficulty
tenderness on palpation over the ovary.
Interstitial cystitis Urinary frequency and urgency, pain relief with voiding, haematuria
The pain responds to postural change, Idiopathic Many other symptoms but other diagnoses excluded
in that lying flat eases the pain
Acute and chronic pelvic pain 127
Endometriosis
Endometriosis is a common benign Table 2 Possible aetiologies of endometriotic tissue has been found
condition estimated to affect between 10 endometriosis within lymph channels, lymph nodes
and 25% of women. It is commonest Retrograde menstruation and implantation and pelvic veins.
among European and nulliparous Lymphatic and haematogenous spread There are racial differences and a
women and has its peak incidence Transformation of coelomic epithelium higher incidence of endometriosis is
Genetic and familial aspects
between 30 and 45 years of age. encountered in the first-degree
Implantation at operation
relatives of patients.
Pathology
Endometriosis may be defined as the mechanism may account for why Presentation
presence of tissue outside the uterus certain susceptible individuals go on to The most common site for
that is histologically similar to that of develop the disease. Antigens, endometriosis is the ovary, followed by
the endometrium. This can be found produced by degrading endometrial the pelvic peritoneal surface, the
within the pelvis or at more distant proteins, have been identified which uterosacral ligaments and the posterior
sites. The site will in turn determine stimulate an immune response aspect of the uterus.
the presenting symptoms and signs as characterized by peritoneal irritation The classic symptom of
the ectopic endometrial tissue will and fibrosis. There appears to be endometriosis is pain - deep
continue to bleed (Table 1) on a evidence of decreased cellular dyspareunia, secondary
cyclical basis under hormonal control. immunity to endometrial tissue in dysmenorrhoea or pelvic pain.
Endometriosis can be diagnosed sufferers. 'Crescendo' dysmenorrhoea is typical,
accurately by visualization and Another theory is that of where the pain precedes the onset of
inspection. Histological confirmation is transformation of coelomic epithelium menstruation by several days, reaches a
not usually required. Endometriosis which proposes that adult cells climax, and is relieved when bleeding
involving the ovaries may lead to undergo de-differentiation by commences. There is a wide variation
endometriomas ('chocolate cysts'; metaplasia back to their primitive - some women are asymptomatic yet
Figs 1 and 2). origin and then transform to have a severe degree of endometriosis
endometrial cells, influenced by on laparoscopy, others have only one
Aetiology prolonged oestrogen stimulation. or two localized deposits and
There is uncertainty surrounding the Vascular and lymphatic experience considerable pain.
aetiology of this common condition embolization to distant sites outside Endometriosis is associated with
(Table 2). An immunological the peritoneum are probable and infertility. Luteal phase defiency and
luteinized unruptured follicles (LUf)
Table 1 Documented sites of endometriotic implants with associated symptoms syndrome occur with increased
Site Symptoms frequency. Dyspareunia may reduce
Intrapelvic Ovarian, uterosacral ligaments, pelvic Dysmenorrhoea, lower abdominal pain, pelvic pain
the frequency of intercourse and
(common) peritoneal surfaces, e.g. broad ligament. dyspareunia, low back pain, ovarian accident - torsion inhibit penetration.
tubes or rupture of endometrioma, infertility
Extrapelvic Small bowel Obstruction Diagnosis
(rare) Appendix Pseudoappendicitis
There may be cervical excitation on
Rectum Cyclical rectal bleed, tenesmus, cyclical pain with
defecation/altered bowel habits
bimanual assessment. The uterosacral
Ureters Ureteric obstruction ligaments may feel scarred, nodular
Bladder Cyclical haematuria/dysuria and irregular, and there may be
Lungs Cyclical haemoptysis exquisite tenderness in the pouch of
Surgical scars, e.g. caesarean or Cyclical pain and bleeding Douglas. Adnexal endometriomas may
hysterectomy scar, vaginal vault
be palpable. Chronic pelvic infection
Umbilicus Cyclical pain and bleeding
Limbs/joints/skin Cyclical pain and swelling
(see p. 100) should be excluded as this
can also present with dysmenorrhoea,
pelvic pain, deep dyspareunia and
infertility. Corroboration is by
diagnostic laparoscopy - the
appearance of endometrial peritoneal
deposits varies (Fig. 2).
The typical lesion is the slate-grey
powder burn. Other appearances
include white opacification of the
peritoneum, red flame-like lesions
(Fig. 2a), glandular excrescences,
subovarian adhesions in the fossa
ovarica (Fig. 2d), yellow-brown
peritoneal patches, and cafe-au-lait
Fig. 1 Ovarian endometriosis. A pseudo ('chocolate'] cyst has been created (containing altered spots (Fig. 2c). Accumulation of scar
blood and breakdown products) surrounded by dense fibrosis. tissue may deform the surrounding
Endometriosis 129
Fig. 2 Laparoscopic appearance of endometriosis. (a) Endometriotic deposits - red 'flares', (b) Intact endometrioma. (c) Uterovesical fold - cafe-au-
lait spots, (d) Filmy adhesions over ovarian cyst.
Endometriosis can be reactivated in Fig. 3 Adenomyosis. The cut surface of the • Treatment can be difficult, relapses can
postmenopausal women by hormone occur, support groups are helpful.
uterus showing the typical interdigitating whirled
replacement therapy. appearance.
130 GYNAECOLOGY
Investigation of infertility
Infertility exists when a couple trying menstrual cycle results in 13 secondary to pelvic inflammatory
for pregnancy have not achieved this ovulations per year. Couples should be disease) are high in the Caribbean and
after 12 months. Eight in 10 healthy encouraged to have regular intercourse West Indies. The tendency for women
couples will become pregnant in the throughout the menstrual cycle. in 'advanced' countries to delay
first 12 months of trying, so it is The early conceptus produces childbearing whilst establishing a
reasonable to commence investigations human chorionic gonadotrophin career may result in more cases of
if pregnancy has not been achieved in (hCG) which is necessary for the infertility as fecundity decreases with
this time. continuation of the pregnancy and is increasing maternal age. There are
the basis of urine and blood tests to increasing numbers of anovulatory
Physiology confirm pregnancy. The production of cycles and the oocytes are ageing
The sperm meets the egg in the tubal progesterone by the corpus luteum is whilst there is a lower frequency of
ampulla and an understanding of the also essential for at least the first sexual activity with increasing age.
complexity of the process leading to 9 weeks of pregnancy, until placental
Investigations
that moment and the subsequent production takes over this role.
Investigation of an infertile couple
fertilization (Fig. 1) and implantation is Infertility affects 1 in 10 couples
(Fig. 2) needs to rapidly assess
important to the understanding of with varying causes predominating in
ovulation, patency of tubes and
infertility. The human female starts life different countries. The common
presence of sperm. A diagnosis allows
with many eggs and 'wastes' most: causes of infertility in the UK (usually
formulation of a management plan to
a combination of causes) are:
Fetus 2 000 000 ova at about help allay anxiety and ensure that
« unexplained 28%
20 weeks older couples do not miss the chance
sperm problem 21%
Birth 750 000 ova of assisted conception (see p. 132).
ovulatory failure 18%
Puberty 250000 Check the rubella status and offer
tubal damage 14%
Reproductive 200-300 ovulations vaccination if negative - remember to
endometriosis 6%
life advise avoiding pregnancy within
coital problems 5%
Menopause a few residual ova but 1 month of vaccination. Advice to take
cervical mucus hostility 3%
unresponsive to follicle folic acid whilst trying to conceive is
other male problems 2%
stimulating hormone. appropriate, along with advice to stop
In the USA the male factors can smoking and reduce alcohol intake to a
Eggs are held in prophase of first
account for 40% of cases of infertility. minimum. A body mass index (BMI) over
meiosis. Meiotic division resumes as
Female factors (e.g. tubal blockage 30 necessitates a supervised weight loss
the follicle matures and is complete by
the time of ovulation. A regular 28-day
programme. The male partner should Antibodies may be found on the head A sensible investigation plan allows
also be advised to stop smoking and limit [affecting ability to fertilize the egg] or speedy diagnosis of the problem and
alcohol to optimize his reproductive tail (affecting sperm motility). the most appropriate management.
performance. Intercourse two to three
times per week throughout the cycle Tests of ovulation
should optimize the chance of conception. Measurement of serum progesterone in
the mid-luteal phase confirms ovulation if
Semen analysis
> 30 nmol/1. Ultrasound 'tracking' of the
The World Health Organization normal
ovaries can follow developing follicles
values are:
during ovulation induction cycles (Fig. 3).
volume 2-5 ml
sperm count > 20 million sperm Tubal function
per ml Hysterosalpingography (HSG) and
motility > 50% progressive diagnostic laparoscopy are
motility complementary methods for assessment
morphology > 30% normal of tubal patency. Before instrumentation
forms of the uterus, screen for Chlamydia
white blood < 1 million/ml trachomatis or give appropriate
cells antibiotic prophylaxis. At HSG, radio-
liquefaction within 30 mins opaque dye is introduced through the
time cervix and outlines the uterine shape Fig. 3 Ultrasound scan showing a follicle
Counts below 20 million sperm per ml being measured.
and fallopian tubes, determining their
are associated with lower pregnancy patency (Table 1).
rates. Over recent years decreased sperm Laparoscopy allows assessment of the
counts have been noted - possibly due pelvis for endometriosis (see Table 1 Assessing the results of
to environmental pollutants such as p. 128) and peritubal adhesions due to hysterosalpingography
agricultural chemicals, stress, infection (see p. 100). There may be an Findings at HSG Presumptive diagnosis
intercurrent illness and jet lag. With obvious corpus luteum (evidence of Uterine synechiae Asherman's syndrome
azoospermia, luteinizing hormone (LH) ovulation) and free fluid from the pouch Irregular uterine cavity Uterine fibroids
and follicle stimulating hormone (FSH) of Douglas can be assessed Septum in cavity Congenital abnormality
of uterus
should be checked - high FSH suggests bacteriologically to rule out pelvic
Cornual blockage Spasm of tubes
failure of sperm production and needs infection. Dye injected through the
Tubal distension Blocked tubes
further investigation with chromosome cervix can be observed flowing from the
Peritoneal spread of dye Normal tubal patency
study. Normal FSH may imply a fimbriae of the tubes in healthy cases.
blockage to the outflow of sperm.
A sperm migration test will assess the ( Investigation of infertility I
number of viable sperm with good
Infertility investigations can commence after 12 months of intercourse not resulting in pregnancy.
forward motility [normal value
An investigation plan should enable couples to learn rapidly the cause of their infertility.
> 5 million/ml). Antibodies can be
detected in semen (IgA and IgG) using Investigation should always be in parallel for male and female partners.
immunofluorescent techniques.
132 GYNAECOLOGY
Management of infertility
Management of anovulation (GnRH) from the hypothalamus and harvesting the eggs using suction. This
manipulation of their levels is used to allows the eggs to be fertilized in vitro
Clomifene citrate
affect egg production. FSH is used to and replacement of up to three
Clomifene citrate is used in cases of
achieve ovulation in women with embryos per cycle into the uterine
anovulation or infrequent ovulation
clomifene-resistant PCOS. GnRH cavity. The legal limit of three embryos
found in the presence of normal
analogues can be used to suppress per cycle (UK) maximizes the chance
seminal analysis before any further
endogenous activity in the of a successful pregnancy whilst
investigation is needed. The oestrogen-
pituitary-ovarian axis but there is no minimizing the risk of a high-order
like structure of clomifene confers
increase in pregnancy rate in women multiple pregnancy, though many
anti-oestrogenic properties and induces
with clomifene-resistant PCOS and units replace two routinely.
a rise in follicle stimulating hormone
there may be an increased risk of
(FSH) and luteinizing hormone (LH)
ovarian hyperstimulation (see below). Gamete intrafallopian transfer
output possibly by affecting
Down-regulation with a GnRH (GIFT)
gonadotrophin releasing hormone
analogue allows exact timing of This procedure was introduced for the
(GnRH) release. Treatment is given on
ovulation so that it coincides with management of unexplained infertility
days 2-6 of the menstrual cycle in the
theatre time if a gamete intrafallopian and is now used also with mild
UK [to avoid the anti-oestrogenic effect
transfer (GIFT - see below) cycle is in oligospermia or mild endometriosis. As
on the cervical mucus), though in the
progress or the presence of an ovulation timing is difficult to predict in
USA, where treatment is given on days
embryologist if an in vitro fertilization a natural cycle, and usually produces
5-9, similar results are obtained. The
(IVF) cycle is planned. The analogue is only one or two eggs, gonadotrophins
starting dose is 50 mg daily with step-
commenced during the middle of the are used (see above). Egg collection is
wise increase until ovulation is
cycle prior to the procedure (long cycle) carried out at laparoscopy, allowing
achieved - as evidenced by appropriate
or on day 1 of the treatment cycle replacement of eggs and 'washed' sperm
rise in the mid-luteal progesterone.
(short cycle). Once low FSH, LH and into the fallopian tube at the same time.
Seventy-five percent of pregnancies
estradiol are achieved, FSH is Two or three oocytes per tube are
occur in the first three ovulatory
commenced at 150 IU per day until placed just proximal to the tubal
treatment cycles.
three or four 18-22 mm follicles are ampulla. There has been an increased
Conception rates, if no other causes
produced (follicle maturation) as incidence of corpus luteal dysfunction in
of infertility are present, approach
followed by ultrasound tracking. these cycles so progesterone 400 mg is
normal (80-90%). There is a
During IVF and GIFT procedures given twice daily for 2 weeks after the
cumulative rise in pregnancy rate up to
the gonadotrophins are used to GIFT procedure.
9 months of treatment so alternative
produce more than one egg per cycle
therapies should be considered at this
(superovulation). Purified FSH is given In vitro fertilization and embryo
stage. If used in conjunction with
starting with a low dose and transfer (IVF and ET)
intrauterine insemination (see below)
monitoring the response with serum The classic indication for this is in the
timing of ovulation is important. Once
estradiol and ultrasound scanning of patient with tubal disease which is not
ultrasound shows a follicular diameter
the ovaries. When three or four appropriate for surgery. The tube is by-
of 18-20 mm or appropriate serum
follicles 18-22 mm diameter are noted, passed, and multiple oocytes are
estradiol levels, a human chorionic
hCG is given to mature the eggs prior collected and made available - allowing
gonadotrophin (hCG) injection can be
to harvesting. Spare eggs may be in vitro fertilization with sperm (Figs 2,
given - usually around day 11.
frozen for use in subsequent cycles. 3, 4). If more than three embryos
Ovulation occurs 36-40 hours later and
develop, the extra ones can be
sperm can be introduced at this stage.
Egg collection cryopreserved, allowing two or three IVF
Side effects of clomifene include a
The technique is by transvaginal scan cycles to be achieved from one ovulation
15% incidence of poor cervical mucus,
using a needle guide to ensure correct induction cycle. There is at least a 25%
which may hamper sperm transport. A
placement of the needle (Fig. 1) and loss of embryos at defrosting. The
multiple pregnancy rate of 5% is
reported. There may be a slight
increase in risk of ovarian carcinoma
with clomifene, but not if used for
fewer than 12 cycles. Ovarian
hyperstimulation (see below) is rare
but can occur particularly in
association with polycystic ovarian
syndrome (PCOS). Headaches,
dizziness and abdominal discomfort
are also reported.
Gonadotrophins
The gonadotrophins are controlled by Fig. 2 The zona pellucida is chemically
gonadotrophin releasing hormone Fig. 1 Ultrasound scan of egg collection. eroded to assist access to the eggs.
Management of infertility 133
Aetiology
The causes of CIN are the same as
those of cervical carcinoma, since one is
a precursor of the other (Table 1).
At puberty, the squamo-columnar
High oestrogen levels
junction corresponds to the anatomical Squamous epithelium make ectropions common
(pale pink) on cervix when pregnant, or when
external os. Hormonal changes cause
taking the combined
cervical oedema with exposure of the contraceptive pill
columnar epithelium - an ectropion;
common misnomer, 'an erosion'. The
exposure of the fragile columnar cells to
vaginal acidity stimulates squamous Squamous metaplasia Process completed - new
metaplasia. Tongues of squamous cells growing inwards transformation zone
grow inwards to cover the exposed
columnar epithelium. It takes
approximately 3 months for this Fig. 1 Ectropion and transformation of the transformation zone.
metaplasia to mature into stable
squamous epithelium. Early sexual Diagnosis the amount of cytoplasm (Fig. 3).
intercourse will expose immature stable To obtain a complete diagnosis the triage Indirectly, it is commenting on the
metaplasia to several potentially degree of cellular maturation, since
of cytology, colposcopy and histological
oncogenic agents. The area of previously biopsy are needed, as smears are often parabasal cells should not be present at
exposed columnar epithelium that under reported (Fig. 2). the surface of the epidermis and
undergoes squamous metaplasia is accessible to cellular sampling. Cytology
known as the transformation zone (TZ)
Cytology reports always highlight the most
(Fig. 1). Dyskaryosis is a cytological term. It immature cells present.
describes features of individual cells
Screening such as size and staining of nuclei and Histology
Screening for CIN is based on a cervical Dysplasia is a histological term. It
smear - sampling surface cells from the requires a full-thickness biopsy for
cervix with a spatula. The success of any diagnosis (Fig. 4). Carcinoma-in-situ and
screening programme depends on the CIN 3 are more or less synonymous.
age screening commences and finishes, The basement membrane remains
how frequently it is performed (1- to intact. Precancerous lesions have also
3-yearly) and the reliability of the been identified for adenocarcinoma,
cytology laboratory (the number of false termed mild or severe glandular atypia.
positive and false negative results).
Fig. 2 Diagnosis of CIN. Colposcopy
The colposcope is a low-power
binocular microscope which allows the
Table 1 The risk factors for CIN and cervical carcinoma
cervix to be viewed stereoscopically (Fig.
Young age at first intercourse Exposure to tumour promoters has a greater influence on immature cells
5), at magnifications of x6 to x40. In
Number of sexual partners
dysplastic tissue the normal pattern of
Smoking Increases the risk of cervical cancer four-fold; the risk remains elevated in
ex-smokers
blood vessels becomes distorted and
Poor uptake of screening programme punctation (Fig. 6) and mosaicism (Fig.
Long-term use of the contraceptive pill Pill takers do not necessarily use barrier methods - increasing exposure to 7) are seen. Abnormal tissue stains
seminal fluids white with acetic acid but will not take
Male-related risk factors The number of the partner's previous sexual relationships is relevant up the brown iodine stain. Studying the
Cervical cancer risk increased if partner has penile cancer vessel patterns and staining reactions, a
Cervical cancer risk increased if partner's previous sexual contact had cervical
colposcopist gauges the degree of CIN
cancer
present. Colposcopically directed
Immunosuppression Risk increased with immunosuppressed renal transplant patients, and
in HIV-positive women biopsies are taken from suspicious areas
HPV infection Mainly subtype 16 to exclude the presence of invasive
disease. The extent of the lesion must
Cervical intraepithelial neoplasia (CIN) 135
CIN 3
Severe dyskaryosis
• Maturation confined to
• Parabasal cell
superficial 1/3 (or absent)
• Nucleus > 50% of cell
• Nuclear abnormalities marked
• Cell border rounded
and throughout full thickness
• Nucleus darker
• Mitotic figures numerous,
(hyperpicnotic)
bizarre and at all levels
• Nucleus irregular
Cone biopsy
Cone biopsy is reserved for when the
upper limit of the lesion cannot be seen,
when there is a suspicion of invasive
disease and if cytology is persistently
positive with negative colposcopy. Most
Fig. 5 Colposcope. Fig. 7 Mosaicism. cone biopsies are now performed by
loop diathermy. Some situations require
knife cones. Complications include
haemorrhage (10%), cervical stenosis or
incomplete excision. Stenosis is related
to the depth of the cone excised.
Hysterectomy should be considered for
a patient with recurrent abnormal
smears suffering from menorrhagia and,
in the case of an incomplete cone
biopsy, when the family is complete. In
a woman with a uterine prolapse, a
Fig. 6 Punctation seen with carcinoma-in- Fig. 8 Loop diathermy apparatus. vaginal hysterectomy would be ideal.
situ and microinvasion.
If a hysterectomy is performed
also be defined. If the lesion enters the laser ablation or loop wedge excision. because of abnormal smears, annual
endocervical canal the colposcopist must Laser treatment destroys the tissue by vault smears should be performed.
be sure that the upper limit is clearly evaporation and coagulation. It has been There is growing evidence to suggest
visualized. This will determine whether superseded by loop diathermy which a psychosexual morbidity following
the lesion is suitable for local destructive involves running an electric current investigation. Patients need to be
techniques or if a cone biopsy is through a thin loop of varying size and approached with confidence and
required. Destruction is carried out by shape (Fig. 8). The tissue is excised rather sensitivitv.
an expert. There must be adequate
cytology and colposcopy follow-up.
Cervical intraepithelial neoplasia
Local treatment
CIN is a premalignant condition of the cervix characterized by specific cytology (dyskaryosis)
There are several different treatment
and histological (dysplasia) features.
modalities including cryocautery, cold
Aetiological factors are similar to those of cervical carcinoma.
coagulation, electrodiathermy, carbon
dioxide laser, loop diathermy. Small It is usually asymptomatic; diagnosis requires cytology, colposcopy and histology.
localized lesions of CIN 1 and possibly Cone biopsies are taken if the upper limit of the lesion is not clearly visualized.
of CIN 2 may be treated by cryocautery. Loop excision is currently the most common treatment modality; laser is useful if dysplastic areas
Lesions entering the canal and those extend into the vaginal fornices.
that look more severe require either
136 GYNAECOLOGY
Cervical carcinoma
Epidemiology papilloma virus (HPV). Several risk
Worldwide, cancer of the cervix is the factors have also been identified
second most common malignancy in (see p. 134).
women after breast cancer - 77% of HPV infection is far more common
cases occur in developing countries. than the development of cancerous
Finland, which has an advanced change, so other factors must influence
population-based screening programme, the malignant potential between one
has one of the lowest rates in the world. individual and another (Fig- 1).
Israel has a low incidence as a result of HPV subtype 16 appears to be the
conservative sexual practice. main oncological agent. It is present in:
Approximately 2000 deaths occur
• only 5% of cytologically normal
annually in the UK. A bimodal
women
distribution with an initial peak of
• up to 50% of smears containing
incidence for women in their 30s, and
CIN 1
a larger peak for women in their 50s
• over 90% of invasive cervical cancer.
has emerged. The incidence of cervical Fig. 2 Cervical carcinoma. Exophytic lesion.
cancer is higher in lower socio- HPV subtypes 18, 31 and 33 may also
economic groups. be implicated.
(10%) in type. Microinvasion (stage la)
Risk factors Pathology is defined as invasion that is less than
The main aetiological agent is infection Malignant tumours of the cervix may 5 mm from the basement membrane.
with certain subtypes of human be squamous (85-90%) or glandular Most squamous cell carcinomas
involve the external os and are visible
on speculum examination. The lesion
may be either exophytic, growing
outwards in a papillary or polypoidal
excrescence, (Fig. 2), or endophytic,
infiltrating the surrounding structures.
Ulceration and excavation frequently
occur. Invasive squamous cell
carcinomas vary in their degree of
cellular differentiation, but often
attempt to form a keratin pearl.
Assessment
Presentation
Many women are asymptomatic. More
advanced disease will present with
symptoms (Table 1). Screening for
cervical cancer has resulted in an
increase in the number of women found
to have asymptomatic disease (Table 1).
Staging
Fig. 1 Possible aetiological pathway for CIN and carcinoma.
Accurate staging of the disease
determines the treatment and
Table 1 Symptoms and signs of cervical carcinoma prognosis (Table 2). Early detection is
Symptoms Signs associated with significantly better
Confined to cervix At routine examination survival rates. Clinical staging is based
Postcoital bleeding Cervix looks suspicious at time of smear on an examination under anaesthesia
Postmenopausal bleeding Abnormal cells, indicative of invasive carcinoma on (EUA). This should include:
is Intermenstrual bleeding cytology
• Offensive, blood-stained vaginal discharge
At colposcopy
cervical biopsy
Spread to adjacent structures M Heavy, contact bleeding cystoscopy
Fistulae - passage of urine, faeces or flatus vaginally Irregular surface contour a rectal examination including
(if bowel/ bladder involved) Atypical vessels - capillaries of irregular calibre and sigmoidoscopy
Renal failure - bilateral ureteric obstruction branching pattern
• dilatation and curettage.
Deep visceral or nerve root pain (if sacral nerve root
involved) The patient should undergo an
Lower limb oedema - extensive pelvic side wall
intravenous pyelogram (IVP) and a
infiltration
chest X-ray. Magnetic resonance
imaging (MRI) is useful in assessing
Cervical carcinoma 137
Table 2 Staging and survival rates of cervical carcinoma m in women who are not medically fit
5-year survival rate for surgery.
Stage 1: Tumour confined to the cervix
Obesity makes surgery more difficult,
a Microinvasive carcinoma
but may also compromise the delivery
a1 Stromal invasion < 3 mm depth and < 7 mm horizontal spread 95.1%
a2 Lesions with a depth > 3 mm, but < 5 mm, and a horizontal spread < 7 mm 94.90/0 of radiotherapy.
b Clinical lesions confined to the cervix Some centres now perform
bl Tumour diameter < 4 cm 80.1% laparoscopic lymphadenectomy, in
b2 Tumour diameter > 4 cm conjunction with the radical vaginal
Stage 2: Spread beyond the cervix, but not to the pelvic side wall, with involvement of upper hysterectomy - this may represent less
two-thirds of the vagina
morbidity than a radical abdominal
a Vaginal spread, but no obvious parametrial spread 66.3%
b Parametrial spread, but not as far as pelvic side wall 63.5%
operation. These new combinations
Stage 3: Spread in the pelvis await full evaluation.
a Involvement of lower one-third of the vagina 33.3%
b Extension to the pelvic side wall or hydronephrosis 38.7% Advanced disease (stage 4)
Stage 4: Distant spread
Combinations of chemo- and
a Spread to involve adjacent organs [bladder, rectum] 17.1%
b Distant spread 9.4%
radiotherapy are used but the overall
survival rate is very poor.
FIGO classification, Montreal 1994. FIGO Data for survival 1990-1992 (n= 11 945].
Follow-up
early-stage disease and tumour « there is better chance of preserving Follow-up is for 5 years with more
extension into the bladder, rectum, sexual function [vaginal stenosis frequent clinic visits initially as 90% of
vagina and pelvic floor. Computed occurs in up to 85% of irradiated relapses present within the first
tomography (CT) scanning or MRI patients, although use of topical 3 years. Recurrent disease may present
can be used in later-stage disease. CT oestrogens vaginally has reduced this) with weight loss, leg oedema, pelvic, leg
scanning is now routinely used for • a more accurate prognosis can be or back pain, supraclavicular
radiotherapy treatment planning. MRI obtained as surgery allows nodal lymphadenopathy, vaginal discharge,
is the imaging modality of choice sampling. [Total staging is not renal failure, bone pain or haemoptysis.
when salvage surgery is indicated for possible from an EUA.) The most frequent sites of recurrence
an isolated central pelvic recurrence. are in the pelvis, lung, para-aortic nodes,
The classical surgical procedure is the
Wertheim's radical hysterectomy liver, bone, vulva, inguinal nodes and
Treatment options supraclavicular nodes. There are four
including pelvic lymphadenectomy and
Microinvasive disease 3 cm vaginal cuff The original operation possible therapeutic options for
In the woman who has not yet conserved the ovaries, since squamous recurrent disease:
completed her family, it is possible to carcinoma does not spread directly to • radiotherapy
adopt a conservative approach. A knife these tissues. Oophorectomy should be chemotherapy, e.g. platinum,
cone biopsy will provide both performed in cases of adenocarcinoma bleomycin or ifosfamide
diagnosis and treatment and preserve of the cervix as there is a 5-10% surgery, generally exenterative
the uterus. Ablative techniques are incidence of ovarian metastases. Some palliation.
inappropriate. surgeons remove the ovaries if the
Stage la superficial invasion only lesion is large [stage Ib2) or if there is a The role of surgery for recurrent
occurs with squamous cancers of the poorly differentiated tumour on biopsy. disease is confined to specific
cervix because the lesion spreads Postoperative radiotherapy is given subgroups of patients, where there is
evidence of central pelvic recurrence
contiguously. Adenocarcinomas are in all cases where there is proven
known to have skip lesions in separate without metastatic disease and where
lymph node involvement.
crypts and cannot be treated in a the patient accepts such radical
Radiotherapy is recommended as
similar conservative fashion. first-line treatment in the following intervention. As 40% of patients with
Follow-up is indicated with cytology cervical carcinoma will eventually die,
circumstances:
and colposcopy. Once the family is palliative care for the terminally ill is
when surgical expertise is not very important. The objective is to
complete a hysterectomy may be
available relieve or control any symptoms
appropriate. The vaginal approach is
in women with a tumour greater affecting the patients' quality of life
preferred as it is easy to remove a
than 4 cm in diameter whilst maintaining dignity.
small cuff of vagina with the specimen.
some rare variations, e.g. Endometrial biopsy Pipelle, 'Z' sampler, Vabra aspirator
adenoacanthoma. Sarcomas which are Hysteroscopy Under general anaesthetic or as outpatient procedure
derived from stromal cells may be Dilatation and curettage Endometrial sampling under general anaesthesia
Sonohysterography The instillation of fluid into the uterine cavity during scanning
endometrial or myometrial in origin.
3-D scanning (still in Facilitates accurate volume measurements
Prognosis and treatment are different
semi-experimental stage)
for these two categories of uterine
Doppler and colour flow Used to detect changes in uterine and endometrial blood flow with malignancy
cancer. imaging [still in
semi-experimental stage]
Endometrial carcinoma
This is a disease which predominantly carcinomas, endometrioid carcinomas Ultrasonography provides a useful
presents in the postmenopausal years and Krukenberg tumours (squamous screening tool. Atrophic endometrium
(over 75% of cases). Around 3-5% of ovarian tumours) have also been has a thickness of 3 mm or less -
cases will present under the age of associated with an increase in thickened endometrium in a
40 years. Over one-third of the oestrogen secretion. postmenopausal woman is therefore
premenopausal patients present with Care must be taken when prescribing suspicious. Some centres use 5 mm as
heavy, but regular periods. The hormone replacement therapy (see p. a cut-off point but 6% of cancers will
incidence of endometrial cancer is 150). The administration of unopposed be missed. With a cut-off point of
highest in white North Americans, oestrogens leads to a risk of developing 4 mm most cancers are detected.
who have a rate approximately seven endometrial carcinoma 7-10 times Demonstration of fluid in the
times higher than the Chinese. higher than that of the general endometrial cavity is associated with
population. Tamoxifen used in the uterine and extrauterine malignancy in
Risk factors for endometrial treatment of breast cancer has also been 25% of cases and warrants a careful
carcinoma associated with endometrial hyperplasia inspection of the adnexa.
Most of the known risk factors for and cancer as it has both oestrogenic Outpatient endometrial sampling
carcinoma of the corpus uteri share a and anti-oestrogenic properties. techniques have been introduced
common basis - that of excessive, Smoking appears to be protective. together with visualization of
unopposed oestrogen stimulation of endometrial tissue via the 3-mm
the endometrium (Table 1). A Presentation and investigation hysterosope (Table 3 and p. 124).
doubling in body weight results in a The commonest presentation of There is always a small risk of uterine
doubling of peripheral conversion of endometrial carcinoma is perforation in the presence of friable
androgens to oestrone in the fat cells. postmenopausal bleeding. Pain may cancerous tissue.
In polycystic ovarian syndrome there is indicate metastatic disease. Discharge Introduction of the
an increase in the free, unbound is often associated with the presence of sonohysterogram (SHG), seems to
oestrogen fraction available to a pyometra. Although postmenopausal improve the detection of endometrial
stimulate the endometrium (see bleeding is the commonest polyps, submucous fibroids and focal
p. 114). presentation for endometrial cancer, thickening of the endometrium.
There appears to be an association and occurs in 80% of cases, Further techniques under evaluation
between endometrial cancer and non- endometrial cancer is not the include 3-D scanning and colour
insulin-dependent diabetes mellitus commonest cause of postmenopausal Doppler blood-flow imaging.
(NIDDM). Although rare, the bleeding (Table 2).
granulosa-theca cell ovarian tumours All cases of abnormal bleeding must Pathology
secrete excess oestrogen - 10% of cases be thoroughly investigated including Endometrial carcinoma appears as a
are associated with endometrial cancer irregular and/or heavy regular bleeding raised, rough or even papillary area
and 50% are associated with in the premenopausal group. and often arises in the fundus. The
endometrial hyperplasia. Mucinous internal os is rarely involved early in
the disease (Fig. 1). Endometrial
carcinoma has several distinct sub-
Table 1 Risk factors for carcinoma of the Table 2 Causes of postmenopausal
bleeding
types; the commonest is the
uterus
endometrioid adeno carcinoma, when
Obesity Benign causes - Malignant causes -
88% of cases 12% of cases the glandular pattern generally
Impaired glucose tolerance
Nulliparity Atrophic vaginitis Endometrial carcinoma [8°/o]
resembles a normal proliferative phase
Late menopause Endometrial polyps Cervical carcinoma endometrium (Fig. 1).
Unopposed oestrogen therapy Endometrial hyperplasia Ovarian tumours
Functioning ovarian tumours [granulosa-theca cell Rare uterine tumours Prognosis
tumour] Extragenital tumours, bladder,
A number of prognostic factors have
• Family history of carcinoma of breast, ovary or colon colonic and rectal cancers
been identified. Clearly, the stage and
Carcinoma of the uterus 139
Treatment
Treatment will depend on both the
stage of the disease and the fitness of
the patient The patient must be As per FIGO classification, 1988. FIGO Data for Survival 1990-1992.
accurately assessed preoperatively to
exclude suspicious lymphadenopathy, they indicate an aggresive tumour. the most common pure sarcoma of
ascites or organomegaly. Renal and Radiotherapy is of great value for the uterus. The gross appearance is
hepatic function tests, tumour similar to that of a leiomyoma,
palliation. Medroxyprogesterone acetate
markers, chest X-ray and possibly an has been widely used for distant although the cut surface may be paler
intravenous urogram will need to be recurrence - the response rate is 15-20%. and more yellow, with areas of
undertaken. The CA125 level increases Tamoxifen and aminoglutethimide haemorrhage and necrosis.
with increasing spread of the disease. (an aromatase inhibitor) have also The majority present with irregular
The operation of choice is a total been assessed for stage 4 disease, i.e. to or postmenopausal bleeding, vaginal
abdominal hysterectomy and bilateral shrink distant spread. discharge, pelvic pain or pressure
salpingo-oophorectomy. Removal of a symptoms. In some situations the
vaginal cuff does not reduce the Uterine sarcoma sarcoma is detected when fibroids
recurrence rate or improve survival. The enlarge rapidly. Only 5-10% of
pelvic and the para-aortic nodes should Endometrial stromal sarcomas and
leiomyosarcomata arise from pre-
be removed if the cervix or adnexa are mixed Miillerian tumours rarely occur.
existing fibroids and these have a
involved, or if the myometrium is better prognosis. Surgery is the
obviously deeply infiltrated. Myometrial tumours
treatment of choice.
Radiotherapy is indicated if the Leiomyosarcoma
histology shows a poorly differentiated This is the malignant counterpart of
or high-grade tumour, if the nodes are the benign leiomyoma (fibroids) and is
involved, or if staging at the time of
surgery scores more than a Ib.
The stage 3 patient should have
Carcinoma of the uterus
further imaging to determine whether
the disease is confined to the pelvis. If • Endometrial carcinoma commonly presents with postmenopausal bleeding, butendometrial
possible, radical surgery with carcinoma is not the commonest cause of postmenopausal bleeding.
radiotherapy should be offered. Stage 4 • Most of the known risk factors for endometrial cancer involve excessive unopposed oestrogen
disease most commonly spreads to the stimulation of the endometrium.
lungs followed by peripheral lymph • The differentiation (grading] and staging of the disease are the most important factors
nodes and the bladder. influencing survival.
Approximately 70% of recurrences • Total abdominal hysterectomy and bilateral salpingo-oophorectomy is the treatment of choice
following primary treatment occur (for stage 1 disease).
within the first 2-3 years. Early • Sarcomas carry a much worse prognosis than endometrial cancer, but are a much rarer tumour.
recurrences carry a grave prognosis as
140 GYNAECOLOGY
(a) (b)
Fig. 6 Ultrasound examination of ovarian cyst, (a) Smooth outline in a non-malignant cyst.
Fig. 4 Opened dermoid cyst. Showing hair, (b) Projections into a malignant cyst.
fat tissue and peripheral infarction due to ovarian
torsion.
Hormone assays. If the main symptoms minimal chance for adhesion
Symptoms found with ovarian cysts suggest hormone-producing cysts (such formation is the aim. This ensures that
include: as menstrual upset, hirsutism or future fertility is not compromised. A
virilization) check oestrogen and fine, inert suture is used on the ovary
« pain - due to torsion or
androgen levels. to excite less tissue reaction and
haemorrhage
peritoneal lavage used to remove all
« asymptomatic - especially
CA125. This tumour marker will be blood, which would promote
physiological cysts
modestly raised in the face of development of adhesions. The need to
« abdominal swelling - large cyst or
endometriosis but a high value is limit adhesion formation has
associated ascites (fibroma)
suggestive of malignancy. Unfortunately encouraged the development of
« pressure symptoms - affecting laparoscopic techniques to allow
a low value does not completely exclude
bladder and bowel function
malignancy. removal of the cyst with minimal
• menstrual upset due to hormone
tissue handling. The contents of a
secretion.
Diagnostic laparoscopy. This allows dermoid cyst, if spilled into the
visualization of the cyst, peritoneal peritoneal cavity, may cause a chemical
Investigations washings for cytology if concerned peritonitis so this may be best
Bimanual examination (Fig. 5). This may about possible malignancy and managed through a mini-laparotomy
allow distinction between an enlarged treatment by laparoscopic removal if incision.
fibroid uterus and an ovarian cyst but appropriate (see below). Laparoscopic management of simple
ultrasound may also be necessary. cysts can be performed by drainage of
Treatment the cyst contents then peeling off the
Ultrasound scan. The cyst fluid will Asymptomatic cysts less than 5 cm in cyst capsule, which is sent for
show as dark on the picture (see diameter in a young woman require histological examination. In the case
follicular cyst) with a white-flecked no action as these will usually undergo where the cyst may be malignant it is
appearance if blood is present Dermoid spontaneous resolution. sometimes appropriate to offer
cysts appear more complex. It is Asymptomatic cysts greater than 5 cm laparoscopic oophorectomy. This will
important to look for features which in diameter in a young woman should be considerably less invasive for the
may suggest malignancy (Fig. 6) be rescanned in 6 weeks. The cyst will patient than the previous practice of
(protrusions inside the cyst, be either smaller (or the same size) and total abdominal hysterectomy with
multilocular, neovascularization, ascitic need no action, or enlarged in size, bilateral salpingo-oophorectomy and
fluid in pouch of Douglas). possibly with blood in the fluid, and omentectomy in any woman over
would be best removed to avoid the 45 years old found to have an ovarian
risk of torsion and loss of the ovary. cyst The ovary is captured in a bag
A cyst that is symptomatic or rapidly and removed intact from the abdomen
enlarging requires removal. The so there is no risk of peritoneal
traditional approach is by laparotomy. seeding if any tumour exists. The
An ovarian cystectomy conserving all patient may not require to proceed
normal ovarian tissue and restoring with more major surgery if histology
the ovarian surface to normal with confirms benign disease.
Ovarian carcinoma
The peak incidence is between 50 and may demonstrate malignant cells.
70 years and carcinoma is more likely Pleural fluid, if present, may also
with nulliparity and in those with a demonstrate malignant cells and this
positive family history. The use of the should be aspirated prior to surgery.
combined oral contraceptive protects, CA125 is not a specific marker and
probably because it reduces the may be elevated with many intra-
number of ovulations, which is abdominal problems including pelvic
thought to be an aetiological factor. inflammatory disease, endometriosis
Presentation is usually with abdominal and after surgery itself Preoperative
pain and swelling, but may be with bowel preparation should be given if
urinary frequency, weight loss, bowel surgery is anticipated. On
dyspeptic symptoms or abnormal opening the peritoneum, peritoneal
Fig. 1 Omental 'cake' in a stage 3c
menses. Three-quarters of cases have fluid should be aspirated or washings
ovarian adenocarcinoma.
spread outside the pelvis at taken with saline. Conservative surgery
presentation (to the peritoneum, (with removal of one ovary) may be
diaphragm, para-aortic lymph nodes, warranted if the patient is young, plans of these are cured even if metastatic
liver and lung); hence the overall further family, has unilateral disease disease is present. Sex-cord/stromal
5-year survival of only 29%. Epithelial and has no ascites. A peroperative tumours may occur at either end of
tumours account for 80% of all ovarian frozen section may be used, but is the age spectrum. Most are stage 1 at
neoplasms and 90% of all primary often difficult to interpret. Otherwise, presentation and can be effectively
malignant ovarian tumours. total abdominal hysterectomy, bilateral treated with conservative surgery if the
salpingo-oophorectomy and infracolic patient is young.
Management omentectomy should be performed.
Malignancy in an ovarian cyst is more Peroperative rupture of intact cysts Recurrent disease
likely in those > 45 years, or in whom probably has no adverse prognostic Most women with advanced epithelial
cysts are bilateral, or where there is effect providing careful peritoneal ovarian cancer relapse after primary
ascites, or solid areas within the cyst, toilet is performed. If there is extensive management. There is considerable
or an irregular growth on the capsule disease, cytoreductive surgery potential for palliative therapy in such
or where the cyst is fixed. (debulking) is appropriate to improve instances. New chemotherapaeutic
quality of life, improve response to agents have traditionally been first
Staging (see Table 1) chemotherapy, prolong remission and evaluated in such patients, but if a
increase median survival. Some patient is offered palliative
Investigations and treatment surgeons would consider pelvic and experimental chemotherapy in this
Initial investigations should be with para-aortic node sampling to ensure way, it is vitally important to consider
ultrasound scanning (USS) accurate staging in apparent la and Ib the side effects, as these can
(± computed tomography (CT) or cases. considerably impair a patient's quality
magnetic resonance imaging (MRI)), Postoperative chemotherapy is of life. If relapse occurs more than a
measurement of urea and electrolytes usually given for epithelial tumours if year after platinum-based
(U & Es), liver function tests (LFTs), a the staging is > la (or for la if poorly chemotheraphy, the disease will often
cancer antigen 125 test (CA125) and differentiated), ideally with a platinum- respond again and patiens may gain
chest X-ray a-fetoprotein (AFP), human based agent in combination with Taxol. useful palliation in this way.
chorionic gonadotrophin (hCG) and Germ cell tumours are very sensitive
estradiol should also be measured if a to chemotherapy, so fertility- Screening for ovarian cancer
sex-cord/stromal or germ cell tumour conserving surgery in the young The poor survival rates associated with
is suspected). Peritoneal fluid cytology patient is appropriate and the majority advanced ovarian cancer have
contributed to the concern that
effective screening tests be developed.
Table 1 FIGO staging of ovarian cancer
Presently there is no evidence that
Stage Definition 5-year survival
screening the general population is
la One ovary 60-70% but can be 95% for 1 a
1b Both ovaries
useful or cost effective. Women with a
Ic la or Ibwith ruptured capsule, tumour on the surface of the capsule, positive family history who are deemed to be
peritoneal washings or malignant ascites at high risk should be considered for
2a Extension to uterus and tubes 30% the national familial ovarian cancer
2b Extension to other pelvic tissue, e.g. pelvic nodes, pouch of Douglas screening study run through clinical
2c 2a or 2b with ruptured capsule, positive peritoneal washings or malignant
genetics centres.
ascites
3a Pelvic tumour with microscopic peritoneal spread 10%
3b Pelvic tumour with peritoneal spread < 2 cm Familial ovarian cancer
3c Abdominal implants > 2 cm ± positive retroperitoneal or inguinal Although overall there is an increased
nodes (Fig. 1) risk of ovarian cancer in those with a
4 Liver parenchymal disease. Distant metastases. If pleural effusion, must family history (relative risk 1.1 for
have malignant cells
mother, 3.8 for sister and 6.0 for
144 GYNAECOLOGY
Benign vulval diseases « Psoriasis. The vulva is an unusual invading vulval cancer. Treatment of
These are classified as: site for this, but if present, VIN may be indicated in those > 45,
moderately potent steroids are better those who are immunosuppressed and
Lichen sclerosus. This can present at than coal tar. those with multifocal lower genital
any age, but is more common in the Intertrigo with Candida. This tract neoplasia. The main treatment is
older patient and usually presents with responds to antifungal preparations. wide local excision (the exception is
pruritus, and less commonly with Lichen planus. This appears as VIN 3 on the clitoris in young women
dyspareunia or pain. The skin appears purple-white papules with a shiny - use an Nd-YAG laser). A colposcope
white, thin and crinkly but may be surface and keratinized area and should be used to inspect the vulva
thickened and keratotic if there is may respond to strong steroids ± (keratinization may make visualization
coexistent squamous cell hyperplasia. azathioprine or PUVA. It is usually of abnormal cells difficult) and then
There may also be clitoral or labial idiopathic, but can be drug related, take a biopsy with a 4-mm trephine
adhesions. Diagnosis is by biopsy and and tends to resolve within 2 years. under local or general anaesthesia
there is an association with Surgery should be avoided. (Fig. 3). It is also necessary to check the
autoimmune disorders in < 10% perianal area as there may also be anal
(pernicious anaemia, thyroid disease, Varieties of intraepithelial intraepithelial neoplasia.
diabetes mellitus, systemic lupus neoplasia (i.e. the presence of
erythematosus, primary biliary neoplastic cells within the confines of Melanoma in situ. This is uncommon.
cirrhosis or bullous pemphygoid). It is the epithelium).
non-neoplastic but may coexist with Non-squamous VIN (Paget's disease).
VIN and there is an association with Squamous VIN. This is classified as 1, This is also uncommon. There is a
subsequent development of squamous 2 or 3 depending on the severity poorly demarcated often multifocal
cell carcinoma of the vulva [probably ('Bowen's disease' and 'Bowenoid eczematoid lesion associated in 25%
between 2-9%) (Fig. 2). Long-term papulosis' have been used to describe with adenocarcinoma either in the
follow-up is probably warranted. atypical squamous lesions, but are part pelvis or at a distant site. Treatment is
Treatment is required only if of the same process of VIN). It is by wide local excision.
symptomatic, e.g. Dermovate twice considered that human papilloma
daily initially, reducing gradually to virus (HPV) may be important in
hydrocortisone twice daily, once daily, aetiology. Many are asymptomatic
or less as symptoms require. Eosin although pruritus is present in
paint may also be of help. Vulvectomy between one-third and two-thirds, and
has no role, the recurrence being = 50%. pain is an occasional feature. Lesions
may be papular and rough surfaced
Squamous cell hyperplasia. This resembling warts, or macular with
frequently presents in premenopausal indistinct borders. White lesions
women with severe pruritus. Diagnosis represent hyperkeratosis, and
is again by biopsy and treatment is pigmentation is common. The lesions
with hydrocortisone as for 'lichen tend to be multifocal in women under
sclerosus'. 40 and unifocal in the postmenopausal
age group. Diagnosis is by biopsy,
Other dermatoses. These include: which may be taken at vulvoscopy,
using 5% acetic acid as at colposcopy,
Allergic/irritant dermatosis. This
under either local or general
may be caused by detergents,
anaesthesia. The opportunity should
perfume, condom lubricants,
be taken to look at the cervix as well,
chlorine in swimming pools or
as there is an association between
podophyllin paint. There may be
cervical intraepithelial neoplasia (CIN)
secondary infection. Irritants should
and VIN. As the natural history is so
be removed and the area treated
uncertain, treatment is controversial. Fig. 3 Squamous VIN. (a) There is a
with emollients + topical superficial hyperkeratosis. Hyperchromatic nuclei
Regression has been observed
corticosteroids. are seen within all cells from the basement
(particularly in low-grade VIN) but
membrane to the epithelial surface, (b) There is a
progression of high-grade VIN to
raised wart-like area of leukoplakia on the medial
invasion may occur in approximately aspect of the left labia majora. A biopsy is required
6% of cases and up to 15% of those to differentiate this from other conditions with a
with VIN 3 may have superficial similar appearance.
Vulval carcinoma
Vulval cancer is not a common disease
• approximately 800 new cases are
registered annually in the UK. It is an
unpleasant but potentially curable
disease - even in elderly, unfit ladies if
they are diagnosed and referred early.
Vulval cancer should be referred to
specialist centres where adequate
numbers are seen to maintain a level
of expertise.
Treatment requires a
Fig. 1 Vulval carcinoma, (a) Polypoidal lesion. Cb) Ulcer.
multidisciplinary approach with
adequate supportive care and
symptoms or appearance of the lesion. completely at the first sitting, so that
counselling facilities. The patients are
Multifocal or multicentric disease can excision both provides a biopsy
usually elderly and often have
be very difficult to manage. specimen and achieves symptomatic
coexisting disease.
relief in the very frail. Small lesions
Diagnosis (less than 2 cm in diameter) may be
Aetiology
Most patients with invasive disease removed by a wide local excision as
The majority of vulval carcinomas are
complain of irritation or pruritus both biopsy and curative procedure.
squamous in origin with a number of
(71%) and 57% notice a vulval lesion, Once a diagnosis has been
much rarer cancers contributing to the
which may be a polypoidal mass or an confirmed the patient requires a full
remaining 10%. Basal cell carcinoma
ulcer (Fig. 1). The presentation of explanation of the situation.
and verrucous carcinoma represent
symptoms and the appearance of the Preoperative assessment must be
uncommon squamous subtypes.
epithelium may be quite varied. Vulval thorough as the majority of patients
Malignant melanomas and Bartholin
symptoms in a postmenopausal affected are elderly and may have
gland tumours can occur. Several risk
woman should be promptly examined other medical conditions. In a younger
factors have been identified for vulval
and atypical areas biopsied. One of the patient who remains sexually active
carcinoma:
most worrying features of this disease there are both psychological and
« other genital cancers is the delay between the onset of the psychosexual connotations involved.
• smoking first symptoms and the diagnosis of Female lower genital tract cancer is
• prior history of genital warts the condition - delays of over often multicentric and the
• vulval carcinomas in situ (VIN) 12 months have been reported. investigation of a patient with vulval
• chronic vulval inflammatory Warts are not common in cancer must include inspection of the
disorders. postmenopausal women and should cervix and up-to-date cervical cytology.
be treated with suspicion. Nodal involvement, if present, must be
Several conditions are thought to have
Lesions that fail to respond to simple identified before surgery. Full blood
malignant potential (Table 1) although
first-line treatment in premenopausal count, biochemical profile and chest
progression to carcinoma has not yet
women should be investigated. X-ray are necessary. An
been proven. Vulval intraepithelial
electrocardiogram (in the elderly
neoplasia is graded in order of severity
patient), intravenous urogram or
in a similar fashion to cervical Assessment
lymphangiogram may be required. A
intraepithelial neoplasia (CIN) (see Diagnosis should be confirmed by
magnetic resonance imaging (MRI)
p. 135). Patients with precursor lesions appropriate biopsy so that definitive
scan may be helpful if there is nodal
should undergo continued management can be planned. It may
involvement in defining the extent of
surveillance. Early biopsy is be appropriate to remove a large
the spread.
recommended if there is any change in ulcerated or fungating mass
Management
Table 1 Precursor lesions The management of vulval carcinoma
Lesion Lifetime risk of vulval carcinoma depends entirely on the stage of the
Vulval intraepithelial neoplasia (VIN) disease at presentation. Early invasion
Histologically recognizable atypia present of the vulva is termed 'superficially
VIN 1 - mild invasive vulval cancer' and is analogous
VIN 2 -moderate 5-10% (range quoted at 2-80%)
to stage la cervical cancer. This is rarely
VIN 3 -severe
(Full thickness abnormalities, disordered maturation,
associated with lymph node metastasis.
excess mitotic figures) The risk of metastasis increases with
Paget's disease Rare. In 20% of cases, there is evidence of malignancy the depth of invasion of the tumour -
A disorder of skin adnexal structures (apocrine sweat elsewhere tumours showing less than 1 mm
glands) depth of invasion appear to have a
Lichen sclerosus 3-E negligible risk of lymph node spread
Cause unknown, associated with autoimmune disorders
(Table 2).
Vulval carcinoma 147
Table 2 Staging of vuival carcinoma Spread can either be direct (to healing associated with the classical
Stage adjacent organs), lymphatic, or, in very butterfly incision of radical vulvectomy.
0 Carcinoma-in-situ, intraepithelial late cases, haematogenous. The femoral
neoplasia grade 3 and inguinal nodes are the sites of Advanced vuival disease
1a Lesion confined to the vulva, diameter regional spread. Involvement of pelvic The management of stage 3 disease
< 2 cm with < 1 mm invasion,
lymph nodes, (external iliac, hypogastric, will require radical dissection. There
superficially invasive vuival carcinoma
1b Lesion confined to the vulva, diameter
obturator and common iliac nodes) is are no data available to support the
< 2 cm, depth > 1 mm no nodal considered distant spread. Lymphatic use of the triple incision technique for
metastasis drainage from the vulva and perineum stage 3 tumours when the nodes are
2 Lesion confined to the vulva, and/or is complex. Tumours that are close to obviously involved. In these situations
perineum, diameter > 2 cm - no nodal
midline structures, e.g. the clitoris, can radical vulvectomy via the butterfly
metastasis
3 Lesion of any size extending beyond the
spread quickly bilaterally. incision with complete node dissection
vulva with adjacent spread to lower en bloc is the standard technique.
urethra and/or vagina, or anus, without Management of early stage Healing is by granulation (Fig. 3),
grossly positive groin nodes disease unless skin flaps or skin grafting is
Lesion of any size confined to the vulva
The high morbidity associated with employed. Wound breakdown still
and having nodal metastasis (unilateral or
regional)
radical surgical treatment of vuival affects 30 to 50% of cases (Table 3).
4a Tumour invades any of the following: upper cancer has prompted the development Consider reconstructive surgery at the
urethra, bladder mucosa, rectal mucosa, of more conservative, but effective, time of radical excision.
pelvic bone and/or bilateral nodes Preoperative radiotherapy with or
alternatives. Early stage disease is best
4b Any distant metastasis, including pelvic
treated by wide radical local excision, without concurrent chemotherapy can
lymph nodes
which should remove all areas of cause tumour shrinkage - this may
As per FIGO classification, including 1994 modifications. atypical epithelium - although this allow for urinary and anal sphincter
*The depth of the invasion is defined as the measurement may be difficult to achieve in conservation.
of the tumour from the epithelial stromal junction of the
multifocal disease. In these situations, Postoperative radiotherapy is
adjacent most superficial dermal papilla, to the deepest
point of invasion. multiple diagnostic biopsies must be considered valuable if two or more
considered as it is important to try to nodes are found positive, and if the
Table 3 Complications of radical surgery exclude areas of occult invasion. The primary tumour has not been
Short-term
decision to perform groin node adequately excised.
• Wound infection and breakdown dissection would depend on the depth
• Deep vein thrombosis, pulmonary embolism of the lesion (if > 1 mm). Recurrent disease
• Pressure sores The site of the lesion will determine Local recurrence is associated with
Long-term whether unilateral or bilateral groin inadequate excision margins and is
• Introital stenosis, dyspareunia
dissection is required. For stage Ib and more likely with verrucous and basal
• Urinary and faecal incontinence
Rectocele stage 2 tumours the triple incision cell carcinomas. Radiation may be
Lymphoedema/lymphocyst technique is employed - excision of useful and further excision may be
Hernias the vuival tumour and then excision of possible in previously irradiated cases.
Psychological and psychosexual problems
the groin nodes via separate incisions Erosion into the femoral artery is the
Recurrence
(Fig. 2). This avoids the prolonged usual long-term outcome.
Fig. 2 Surgery for early stage vuival carcinoma, (a and b] Triple incision technique, (c) Butterfly incision.
Vuival carcinoma
Vulval carcinoma is an uncommon gynaecological cancer affecting mainly the elderly age group.
Lesions less than 1 mm in depth have a negligible risk of lymph node metastasis.
Early stage disease can be treated with wide radical local excision.
Advanced disease is still treated by radical vulvectomy with en bloc node dissection.
Fig. 3 Healing by secondary intention
148 GYNAECOLOGY
10 minutes and can occur from once to 20 times a day. Night women until women reach the menopause - subsequently
sweats may lead to chronic sleep depletion. Seventy percent of catching up rapidly. Comparing age-matched groups of
women exhibit vasomotor symptoms for 1 year, 30% for premenopausal and postmenopausal women, the incidence of
5 years and 10% for 10 years. There appears to be a temporal IHD is found to rise with increasing age, but is consistently
relationship between flushes and pulsatile release of LH. less in the premenopausal groups at all ages. This would
suggest that oestrogen has a protective effect
Osteoporosis
Total cholesterol is made up of low density lipoprotein (LDL)
Osteoporosis represents reduction in bone mass and micro-
and high density lipoprotein (HDL) fractions. The former is
architectural disruption leading to enhanced bone fragility and
easily deposited on damaged endothelium and predisposes to
increased fracture risk. The World Health Organization
atherogenic change. At the menopause, total cholesterol, LDL-
(WHO) definitions are as follows:
cholesterol and triglyceride levels rise. HDL-cholesterol and in
• osteopenia (1-2.5 SDs below adult reference peak bone mass) particular the HDL 2 subfraction falls. Oestrogen reverses these
osteoporosis (> 2.5 SDs below adult reference peak bone trends and appears also to act at the cellular level.
mass).
The bone remodelling process involves four processes (Fig. 1).
Formation takes longer than resorption - the two are linked,
or coupled. At the menopause the remodelling cycle becomes
imbalanced, or uncoupled. The osteoclasts produce larger
cavities which the osteoblasts do not completely fill with
osteoid, resulting in a net decrease of bone mass. Oestrogen
has an anti-resorptive effect.
In women, peak bone mass is achieved in the early 30s. It is Fig. 2 (a) Normal and (b) osteoporotic bone.
influenced by diet (including calcium intake), exercise, genetics
and environment. Subsequently bone mass is lost gradually
until the menopause, when falling oestrogen levels accelerate
the process. When bone density falls below a critical level (the
fracture threshold) the risk of fracture is increased. There is a
50% loss of trebecular bone and a 5% loss of cortical bone
(Fig. 2). The commonest fracture sites are vertebral body,
upper femur, distal forearm, humerus, ribs. The incidence of
these fractures varies with age (Fig. 3). One in four women in
the 60s suffer vertebral crush fractures, causing pain,
shortened stature and spinal curvature - the classical
'dowager's hump' (Fig. 4).
Fig. 3 Incidence of different types of fractures with age.
Cardiovascular changes
Ischaemic heart disease (IHD) represents the biggest cause of
death in women. Men suffer from IHD more commonly than
Menopause: management
Hormone replacement therapy (HRT) is widely accepted as a
treatment for symptoms of the menopause and osteoporosis.
Epidemiological data suggest a role against ischaemic heart
disease (IHD) and, from more recent evidence, Alzheimer's
disease.
14 years. The added progestogen effects protection by - transdermal (as sequential combined and
continuous combined preparations)
secretory transformation.
Gonadomimetics
Several routes of administration are available (Table 2). No Oral
one preparation is better than another, but there is a wide SERMs
variation in patients' needs, requiring a flexible approach to • Oral
treatment. Oral HRT enters the enterohepatic circulation,
activating hepatic enzymes that accelerate metabolism.
and can be given in conjunction with testosterone. Careful
Systemic HRT achieves 'liver bypass' entering the circulation
monitoring of the serum estradiol level is required to prevent
directly. Patches or gels may therefore be better for epileptics,
tachyphylaxis. The body adapts to supraphysiological levels of
tablets for those with hypercholesterolaemia or skin
oestrogen resulting in severe symptoms, even though levels
conditions. Estradiol implants are useful for long-term therapy
are well above the accepted therapeutic range.
Tablets, gels and nasal spray are administered daily, patches
Table 1 Components of hormone replacement therapy and either once or twice a week and implants 6-monthly. Vaginal
related preparations preparations may be useful for relief of vaginal dryness.
Oestrogens
• Conjugated equine oestrogens (CEEs) Approach to treatment
17 beta estradiol (plant extract oestrogens)
Many women show great interest in HRT, but some express
Estradiol valorate Cplant extract oestrogens)
Estrone
reservations. Main concerns focus on side effects, weight gain,
Progestogens
risk of cancer and withdrawal bleeds. A structured approach to
Progesterone (the natural hormone) treatment includes information, counselling and HRT.
Progesterone analogues, C21 derivatives
- didrogesterone
Every woman should be fully counselled as to the risks and
- medroxyprogesterone acetate benefits of treatment (Table 3) and should be included in the
19-nortestosterone derivatives decision-making process. Information should include what
- norethisterone/norethisterone acetate routes of administration and types of HRT are available, how
- levonorgestrel
long therapy should continue (for adequate bone protection a
Gonadomimetics
Tibolone (containing oestrogenic, progestogenic and androgenic components)
minimum of 5 years' therapy is advised), and what side effects
Selective oestrogen receptor modulators
may be encountered. Bleeding usually lessens over four to six
(SERMs) successive cycles to a light, regular 3- to 5-day loss. Minor
Raloxifene (modified oestrogen molecule stimulating bone receptors, but not transient side effects may occur and the patient should be
endometrial and breast receptors; also reduces cholesterol levels) encouraged to persevere. Changing brands every 1-2 months
Phyto-oestrogens promotes problems.
m Natural dietary fibre oestrogens, obtained from a health food shop
Menopause: management 151
Fig. 2 Bone densitometry equipment. Fig. 3 Bone densitometry plot for hip.
Uterovaginal prolapse
Uterovaginal prolapse is rare in connective tissue supporting structures
quadripeds, but evolution to an under additional strain. The type of
upright posture has added additional connective tissue found in those with
strain to the biped pelvic floor. prolapse may predispose them to
tissue failure contributing to the
Aetiology genesis of prolapse.
The pathogenesis of prolapse is thought
to be multifactorial, with congenital Presentation (Table l, Fig. 1)
weakness of supporting structures,
History
damage to pelvic floor musculature
Commonly the patient complains of a
during childbirth, menopausal atrophy
lump or fullness within the vagina
of the tissues and raised intra-abdominal
which may have been first noticed
pressure. Potential aetiological factors
during a lifting episode or be of
include the following.
gradual occurrence. It is commonly
worse in the evening, after standing.
Congenital weakness
There is often associated back pain
A deficiency of the supporting tissues
[possibly due to tension on the utero-
may be important. There are families
sacral ligaments), and bleeding and
where prolapse is noted through the
discharge may be present if the prolapse
generations. Nulliparae may also
has ulcerated. Care should be taken not
develop prolapse. This may be a less
to miss a coincidental endometrial
extreme form of cases where herniae
carcinoma. Associated symptoms may
formation are well recognized.
be urinary incontinence and frequency
(see p. 154) or problems with
Childbirth
defecation - or, less commonly, faecal
It is well recognized that childbirth
incontinence. Patients may mention the
damages the pelvic floor innervation and
need to reduce a posterior prolapse in
the secondary muscle atrophy
order to complete defecation or a
predisposes to Uterovaginal prolapse.
cystocele to aid voiding.
Caesarean section appears to afford some
degree of protection over vaginal delivery.
Examination
It has been assumed that the length of
On examination there may be signs of
the second stage of labour and heavy Fig. 1 Types of Uterovaginal prolapse.
vaginal wall laxity at rest - asking the
birth weight would be factors associated
patient to bear down or cough should
with prolapse, but surprisingly studies (see p. 86), examining first the anterior
demonstrate the problem. Urinary
have not confirmed this. Tearing of tissue, vaginal wall with cough to
incontinence may also be
as might occur with a precipitous labour, demonstrate urinary incontinence and
demonstrable. The patient is then
may be a factor. then the posterior vaginal wall by
placed in the Sims' position and
examined using the Sims' speculum reversing the speculum. The patient is
Menopause then returned to the dorsal position
After the menopause there is marked and a bimanual examination
atrophy of the vaginal tissues. While Table 1 Types of prolapse performed to assess the size of the
this may be associated with stenosis of Name Condition pelvic organs. Neurological
the vagina, it is more common to find Cystocele Prolapse of the anterior vaginal examination as in cases of urinary
some form of prolapse. wall and bladder
incontinence (see p. 154) may be
Urethrocele Prolapse of the anterior vaginal
appropriate. Urinary symptomatology
wall and urethra - often found with
Raised intra-abdominal pressure cystocele
may necessitate urodynamic
Chronic cough or the presence of an Rectocele Prolapse of the posterior vaginal investigation (see p. 154).
intra-abdominal mass is associated wall and rectum
with raised intra-abdominal pressure Enterocele Prolapse of the upper posterior Management
and may be a factor in the vaginal wall (posterior fornix) and The management may be conservative
development of prolapse. Work has pouch of Douglas
or surgical, the conservative approach
shown that obesity is not a factor in Uterine prolapse The cervix uteri descends within
being appropriate in patients who
1 st degree the vagina but does not pass
transmission of raised pressures to the outside the introitus during
prefer this, who wish to avoid surgery
urinary tract, thus it is of questionable straining or who may be unfit for surgery.
importance in the genesis of prolapse. Uterine prolapse The cervix uteri protrudes beyond Surgical treatment includes anterior
2nd degree the introitus during straining colporrhaphy, Manchester repair
Other factors Uterine prolapse Total prolapse of the uterus and (anterior repair and cervical
Chronic straining at stool with 3rd degree cervix outside the vaginal introitus, amputation - rarely performed),
perineal descent may damage pelvic (procidentia) dragging the vaginal walls and
vaginal hysterectomy, posterior repair,
associated structures with it
floor innervation, thus putting the repair of enterocele and vault fixation.
Uterovaginal prolapse 153
Conservative (Fig. 2)
A ring pessary made of a circle of
pliable plastic is inserted by
compressing it into an oval shape.
When it regains its circular shape in
the vaginal fomices it is then larger Fig. 3 Anterior repair.
than the vaginal outlet and keeps the
vaginal walls elevated. Patients should
be unaware of it once it is correctly Posterior colporrhaphy or
positioned and should be able to lead colpoperineorrhaphy (or posterior
a normal life including sexual repair). The posterior vaginal wall is
intercourse. It is changed every opened in the midline and tissues
6-12 months and oestrogen cream dissected free from the vagina until the
may improve tissue quality, preventing fascial plane is clear. An overlapping
ulceration of the ring site. A shelf fascial repair is performed above the
pessary may be used in very unfit rectum. The tissue has already failed,
patients not suitable for surgical so its strength is questionable. If there
correction where the ring pessary will is also an enterocele, the hernial sac
not stay in place. Vaginal cones may be should be located, a purse-string
used to strengthen the pelvic floor in suture applied round this and the
more mild degrees of Uterovaginal uterosacral ligaments brought together
prolapse (see p. 155). in the midline to supply support
underneath this. There is usually an
Surgical associated deficiency of the perineum,
Numerous operations exist for corrected by sutures to the superficial
correction of prolapse. The principle perineal muscles.
behind them all remains the same -
that of correction of the protrusion Vaginal hysterectomy. This procedure
with placement of supporting sutures is seldom carried out alone for
and tissues to prevent recurrence. The prolapse but often in combination Fig. 4 A procidentia (whole uterus outside
problem with this approach is that the with anterior and/or posterior repair as the body) may be best treated with a
tissues have failed in their supporting the descent of the uterus usually drags vaginal hysterectomy.
role already and thus may fail again, so other structures with it (Fig. 4).
the patient should be warned of this Operating from the vagina, the uterus Clinical note
before surgery is undertaken. is removed and the uterosacral Bleeding from an ulcerated prolapse
ligaments used to provide support to may mask endometrial carcinoma -
Anterior colporrhaphy (or anterior the vaginal vault. assessment with ultrasound and
repair). The anterior vaginal wall is
endometrial sampling is important to
opened, the bladder and urethra
exclude this.
dissected free, and sutures placed from Uterovaginal prolapse
the pubocervical fascia under the
« Prolapse is caused by childbirth, menopause and/or congenital weakness.
bladder neck to the pubocervical fascia
on the other side, giving support and • It is important to establish any history of associated urinary and bowel problems.
continent function. The operation is • Examination should include use of Sims' speculum and neurological examination.
completed with supporting sutures to • Conservative management with pelvic floor exercises may supplement surgery to correct the
the bladder base, if possible, repairing prolapse.
the fascia under the bladder [Fig. 3).
154 GYNAECOLOGY
Urinary incontinence
The main conditions affecting women pressure, and general neurological
are urodynamic stress incontinence examination - especially testing S2,3,4
(USI] and detrusor overactivity (DO). perianal sensation, informing on the
Between them these comprise over innervation of the bladder. Abdominal
90% of female incontinence with palpation should rule out the presence
45-50% being USI. The remaining of a full bladder or pelvic mass (see
5-10% are a mixture of congenital p. 86).
Fig. 1 Uroflowmetry. A normal female flow.
abnormality, neurological problems Pelvic examination is performed first
resulting in overflow incontinence, and in the dorsal position. The health of
postsurgical or postdelivery problems. the vaginal tissues is determined and which is a provocative manoeuvre for
Urinary symptomatology may trouble whether there is any redness due to detrusor contraction whilst the patient
a woman at any stage in her life but incontinence. Parting the labia to reveal attempts to inhibit this. The usual
onset is particularly prevalent any time the external urethral meatus allows bladder capacity is ~ 500 ml and during
after childbirth and through into the demonstration of stress incontinence filling there should be no appreciable
postmenopausal phase. with coughing. If the jet of urine is not rise in detrusor pressure. Other
Genitourinary fistulae have an simultaneous with the cough it may provocations used during filling include
unknown incidence as many affected point to cough-induced detrusor coughing, listening to the sound of
women throughout the world do not overactivity. running water, and change of position.
seek medical help. In developing An assessment of the degree of The patient coughs when standing.
countries, fistulae are mainly of prolapse is performed in Sims' Should coughing produce incontinence
obstetric origin due to obstructed position. Examination is completed by with a flat detrusor pressure the
labour leading to pressure necrosis or a bimanual examination, during which diagnosis is USI. Various patterns of
due to a traumatic delivery with injury assessment is made of the strength of raised detrusor pressure are noted
to the urinary tract In developed pelvic floor muscle contraction. which make the diagnosis of DO (Fig. 2b).
countries, most genitourinary fistulae The patient then voids on a
are due to pelvic surgery, malignancy Investigations commode while the pressures are still
or radiation therapy and if of obstetric Mid-stream urine examination for being measured, allowing an
origin are likely to be the result of infection is always the first assessment of whether voiding is by
forceps delivery, caesarean section or investigation as many of the patient's abdominal straining, detrusor
peripartum hysterectomy. symptoms may be caused by urinary contraction, or purely by pelvic floor
tract infection. Uroflowmetry will relaxation. These basic investigations
Symptoms allow assessment of the voiding time may not result in a diagnosis in all
The symptoms show wide variation and also the peak flow rate achieved. patients and improved sensitivity may
and include stress incontinence, In females this is commonly 50 ml/sec be obtained by using ambulatory
urgency, urge incontinence, frequency as the short, wide urethra allows rapid cystometry or filling using contrast
and nocturia (Table 1). Enquiry for voiding (Fig. 1). The lower normal medium to allow visualization of the
voiding disorder includes completeness limit is 15 ml/sec, although voiding urinary tract (videocystometry). Pelvic
of bladder emptying, straining to disorder is quite uncommon in the ultrasound can assess whether the
initiate micturition, and whether the female patient patient voids to completion and
urinary stream has a good volume and Subtracted cystometry is performed investigation of the kidneys with
is constant. However, the history is a to assess the detrusor pressure during intravenous urography may be
surprisingly poor discriminator of the filling of the bladder and voiding. appropriate if haematuria is noted.
different diagnostic groups. This Intravesical pressure is a mix of Cystoscopy may also be indicated.
makes investigation important. intra-abdominal pressure and
intravesical pressure. By measuring Management
Examination intrarectal pressure and subtracting Once the diagnosis is made a decision
Examination of the patient should this from intravesical pressure, about the type of management is
include general examination, including detrusor pressure or pure bladder necessary. For both USI and DO there
the chest for signs of chronic pressure is measured (Fig. 2a). are conservative and surgical options.
obstructive airways disease resulting in The standard approach is to use fast-
chronically raised intra-abdominal fill cystometry (50-100 ml per minute), Conservative management of USI
Conservative management of USI
Table 1 Symptoms of urinary incontinence centres around controlling and
Symptom Meaning improving pelvic floor function. There
Stress incontinence Leakage of urine during raised intra-abdominal pressure, e.g. coughing, laughing are many ways to do this. The
Urgency Uncontrollable desire to micturate, necessitating rushing to toilet physiotherapist teaches pelvic floor
Urge incontinence Urinary leakage associated with uncontrollable need to micturate exercises, either using digital
Frequency Voiding more than seven times during day examination and teaching the patient
Nocturia Woken to void twice or more at night to do this herself whilst contracting the
Continuous leakage Possible genitourinary fistula
pelvic floor, or aided by the use of a
Enuresis - childhood or Bed-wetting - not woken with the desire to void
perineometer which grades the
adult onset
strength of contraction achieved.
Urinary incontinence 155
Urinary incontinence
Urodynamic stress incontinence [USI] and detrusor overactivity (DO) are the two main causes of
female incontinence.
The incidence of genitourinary fistulae is unclear due to the large numbers of women who do not
seek medical help.
Fig. 4 Vaginal cone. Tampon pictured for size
• Investigation of urinary symptoms is needed as there is large overlap in symptoms between DO
comparison.
and USI.
• Surgery or conservative therapies are appropriate for USI and DO but the balance favours
surgery for US I and conservative treatment for DO.
156 GYNAECOLOGY
Diagnosis
This is based on the history and
supported by cycle charting [Fig. 2).
Symptom charting is required to obtain
a sound diagnosis and to monitor
therapeutic interventions. Cycle charting
increases patient insight into the
condition and empowers her to take
control of her own experiences. Charting
will clearly differentiate cyclical symptoms
with a symptom-free week from those
where the symptoms are continuous, e.g.
endogenous depression, hypothyroidism,
lethargy due to anaemia.
It is important to differentiate
cyclical from non-cyclical breast pain
which may require mammography or
ultrasonography. Breast cancer must
be excluded.
Few women exhibit significant fluid
retention with PMS - daily weighing Fig. 3 Management of PMS.
may differentiate.
In ambiguous cases a therapeutic If non-medical treatments are suppositories have been used
3-month trial of a gonadotrophin unsuccessful, a combination of oil of extensively, but no study has
releasing hormone (GnRH) analogue to evening primrose, vitamin B6 or demonstrated a benefit superior to that
suppress ovarian function is very calcium and magnesium supplements of placebo.
helpful. If symptoms persist, despite may be considered. Some also make Diuretics, e.g. aldosterone
amenorrhoea, the diagnosis cannot be claims for zinc and copper antagonists, should be reserved for
PMS. supplements. Oil of primrose contains those who demonstrate true fluid
the polyunsaturated essential fatty retention.
Management acids linoleic and gamma linolenic Antidepressants have been used
The list of therapies employed in PMS acids, which are the dietary precursors with some benefit. The selective
is extensive, partly because the theories of several prostaglandins, mainly El serotonin re-uptake inhibitors appear
of aetiology are numerous. It is and E2. Efficacy and treatment has to be especially beneficial, e.g.
reasonable to start with simple, non- probably been over-stated, but some fluoxetine (Prozac). Oestrogens in the
hormonal approaches (Fig. 3) and ask studies do demonstrate benefits over form of implants or transdermally as
the woman to complete a stress placebo. Many patients will have self- patches have produced measurable
management diary. There may be prescribed before seeking medical benefits. For the intractable, severe
certain situations which trigger stress treatment; one problem with this cases of PMS it may be necessary to
or inability to cope. These are best approach is cost. refer to a clinical psychologist to offer
avoided in the premenstrual phase. Ovulation suppression with the pill group and individual therapy. No
Exercise may reduce stress by or depot progestogens is successful. woman should be subjected to
enhancing endorphin metabolism in Danazol is helpful, but because of its bilateral oophorectomy as a treatment
the luteal phase. side-effect potential is not first-line until a proven benefit from ovarian
Some women report benefit from therapy. Natural progesterone suppression has been confirmed.
caffeine withdrawal. An evening meal
which is carbohydrate-rich and
protein-poor has been recommended - Emotional disturbances
this could have an effect via serotonin • In the perimenopausal age group, severe premenstrual tension, endogenous or reactive
metabolism. depression may present with emotional lability.
Circadian modification has been The patient must be treated with care and sensitivity, or background social and emotional
shown to reduce the severity of PMS problems may be missed.
symptoms. The manoeuvre involves The diagnosis of PMS depends on proven, cyclical variation with 1 week clear of symptoms, or at
sleep deprivation for 1 night early in least a reduction in severity of symptoms.
the luteal phase. Postulated
« Ovulation suppression will eradicate symptoms; failure to do so puts the diagnosis in question.
mechanisms involve melatonin
• Treatment options are varied, but should involve the woman and ideally start with non-hormonal
secretion. PMS appears to be a
therapies.
seasonal variation disorder, as it is less
troublesome in the summer.
158 GYNAECOLOGY
Psychosexual disorders
Psychosexual disorders are very
prevalent. They may be secondary to a
physical problem or the primary
aetiology may be psychogenic or
psychosocial. Often women are
reluctant to admit to problems and
find it easier to consult their doctor
about 'discharge' or 'general malaise',
hoping their real concern will
eventually be addressed. Sometimes
the problem is more obvious, e.g. non-
consummation, and the partner or the
family, concerned about lack of
offspring, may demand referral.
Courtesy of Dr Lynne Webster, Consultant Psychiatrist with a special interest in Psychosexual Medicine, Manchester Royal
or sexual drive. A woman who and to offer the patient hope that Table 2 Causes of painful penetration
presents with loss of urge to have sex therapy or treatment is possible, Anatomical Intact hymen/hymenal
with her partner, but who masturbates referring her to someone who can remnants
regularly and who can generate sexual provide it. Vaginal stenosis
history requires a great degree of trust • Vaginismus is a common cause of painful penetration.
and openness in the consultation - » Sexual difficulties following delivery are not uncommon.
particularly if both partners are
« Loss of libido at the time of the menopause may be primary, requiring testosterone, or secondary,
present. Any doctor should be able to responding to hormone replacement therapy.
at least identify that there is a problem
160 GYNAECOLOGY
Postoperative care
Postoperative gynaecological care has electrolyte derangement is likely, It is usual to leave a drain for
been radically changed, aiming to serum urea and electrolyte estimation difficult surgery, e.g. major oncological
manage most patients as day cases should be performed daily until the procedures, and where oozing is likely
[approximately 70%). Outpatient patient is stable as the clinical to occur, e.g. myomectomy or
procedures frequently replace the need consequences can be profound. colposuspension. A closed-system
for admission (see p. 116). Surgical drain allows blood loss to be assessed
procedures that require hospital The use of catheters and drains accurately and is left until the loss is
admission are discharged earlier. The Prophylactic catheterization of patients less than 30-40 ml in a 24-hour period
aim is to increase patient throughput aseptically in theatre for the first 24 or (Fig. 2). Surgery on a patient with
and reduce bed occupancy. An 48 hours reduces the incidence of established disseminated intravascular
abdominal hysterectomy may stay for postoperative urinary tract infection. coagulation (DIC) will require a wide-
2-4 days (previously 7) and vaginal Uncatheterized patients who do not bore rather than suction drainage, and
hysterectomies may be discharged void spontaneously require clotting factors must be corrected.
within 1-3 days. Endometrial ablative catheterization on the ward where the
techniques and laparoscopically- environment is less aseptic. Perioperative prophylactic
assisted vaginal hysterectomy (LAVH) Spontaneous retention is more management
are being performed in some centres - likely after large pelvic masses and Prophylactic antibiotic cover is
the former as day cases, the latter with posterior vaginal repairs where widespread for vaginal surgery where
overnight stay. neurogenic retention can occur. For vaginal flora may precipitate
Work has been done with routine vaginal and abdominal surgery opportunistic infection if the patient's
community teams of multi-skilled nurse a urethral catheter is adequate. For resistance is reduced. The antibiotic
practitioners who will visit the patients surgery on the bladder neck a should be effective against anaerobes.
at home once they have fulfilled suprapubic catheter is usually inserted The final decision as to which broad-
guideline criteria to be discharged from (see p. 155) and, after allowing spectrum antibiotics are used will
hospital. Others have looked at the periurethral oedema to settle, is depend on local bacterial factors and
American model of discharging the clamped (Fig. 1). If the patient is the patient's history of drug sensitivity.
low-risk patient from the hospital ward unable to void, the clamp is released The prophylactic use of anti-
to a hotel-style setting where the and the catheter left on free drainage thrombogenic agents is now well
patients are more ambulant and for a longer period. Further recognized. Many will use them
nursing care is less labour intensive. instrumentation of the patient is thus routinely for all gynaecological
The postoperative patient is entitled avoided. procedures, but specifically targeted
to high-quality care and the traditional
approach to postoperative management
continues - common to all surgical
specialties. The management of fluid
balance, drains and catheters, and the
ability to detect the signs of
postoperative complications and act
upon them remain essential. Within
each specialty however, particular skills
and specialized requirements may be
necessary.
Postoperative complicatons The multidisciplinary approach the continence advisors. Both these
Postoperative complications can be to care specialized nurse practitioners will
divided into immediate, intermediate The standard of care for patients is assess the patient on the ward and
and late. Some are common to all greatly enhanced if all health-care liaise with the medical team. Extensive
surgical procedures, e.g. wound professionals can work together in a ovarian cancer debulking requiring
infection or thrornboembolism, some constructive and integrated fashion. covering colostomy may need the
are confined to specific operations. The The physiotherapist has an important involvement of stoma care sisters.
latter are dealt with in the relavant role teaching pelvic floor exercises, Throughout all of this it is
chapters. Prophylaxis has greatly particularly relevant to vaginal and important to remember the patient.
reduced the incidence of bladder neck surgery - in addition to Staff must be perceived to be friendly
complications, but an understanding of the routine chest expansion, breathing and approachable. Great emphasis
when they are likely to occur and the and calf exercises that should be must be placed on communication
presenting symptoms is essential taught to all postoperative patients. skills. Many units now run
[Table 1). The early detection of Nursing staff mobilize patients early hysterectomy support groups allowing
complications is the main reason for postoperatively to limit the risk of discussion of indications for surgery
daily postoperative ward rounds. It is thrornboembolism. and giving the patient the chance to air
also important that the patient feels The nurse practitioner is emerging her views and concerns. Leaflets are
that she has regular access to the as a professional with added essential to reinforce any message.
medical team conducting her care, responsibilities and roles in the Research has shown that probably
who should work in conjunction with discharge process. Integrated care only 30% of verbally-given information
the nurse practitioners. pathways (ICPs) set objectives and is retained.
goals for routine postoperative Ongoing postoperative management
Medicolegal aspects of care management. It may be necessary to will vary and include hormone
The concept of risk management is involve community nurses, carers or replacement therapy following
now widespread and is based on the the local surgery practice nurse in oophorectomy, ongoing contraceptive
theory that if problems arise they postoperative management if the issues following miscarriage or ectopic
should be recognized promptly, dealt patient is unlikely to cope unaided and pregnancy and possibly suppression
with efficiently, and the patient kept has little family support. Advanced therapy following surgery for
fully informed at all times. Notes oncology patients will require the endometriosis. All of this must be
should contain a full and involvement of the Macmillan nurses; explained with care to enhance
comprehensive account of all urogynaecological patients may need subsequent compliance.
investigations, actions and discussions
with the patient - particularly if the
latter have been contentious. It is often Postoperative care
advisable to conduct discussions with a
third party present. It is always Patients are now discharged much earlier following gynaecological major surgery.
important to obtain senior help early if Integrated care pathways establish goals and objectives for patient discharge.
complications arise. Problems should The routine use of prophylactic antibiotics and antithrombogenic agents has reduced
be relayed to the consultant in charge postoperative complications.
of the case. Some hospitals have a Routine catheterization for 24 to 48 hours reduces the risk of postoperative infection.
specific risk management officer who
Detailed notes and adequate communication with the patient reduce litigation.
acts as the liaison between clinical staff
and the hospital's solicitors.
162
Index
diabetes, 30 antenatal management Cocaine, 74
palpation of abdomen, 4, 5 Elkin's manoeuvre, 40 Coeliac disease, 77
pattern of, 4 external cephalic version, 40 Colposcopy, 134-5
Abdominal palpation, 4, 5, 86-7
presentation of findings, 4 causes, 40 Combined oral contraceptive pill,
Abortion
psychosocial problems, 44—5 complete breech, 40 106-7
induced, 94—5
urine tests, 5 footling breech, 40 adolescent contraception, 107
counselling, 94
venous thromboembolic disease, frank breech, 40 breast disease, 106
ethics, 94
42 labour, 41 breast feeding, 107
HIV infection, 17
see also Pre-conceptual persistent, 41-2 contraindications, 106
medical termination, 95
counselling preterm, 41 drug interactions, 106-7
method, 94-5
Antepartum haemorrhage, 36—7 Brenner cell tumour, 140 emergency contraception, 107
psychological problems after, 95
abruptio placentae, 36—7 Bronchodilators, 74 in endometriosis, 129
risks of, 95
cervical carcinoma, 37 Brow presentation, 53 practical prescribing, 106
surgical termination, 95
cervical lesions, 37 side effects, 106
septic, 93
concealed, 37 and surgery, 107
see also miscarriage
mixed, 37 Condoms, 110
Abruptio placentae, 36—7
placenta praevia, 36 Caesarean section, 56-7 Cone biopsy, 135
Actinomycosis, 102
revealed, 37 elective, 59 Congenital adrenal hyperplasia, 88
Acupressure, 70
ruptured uterine scar, 37 Candida albicans, 102-3 Congenital anomalies, 82—3
Acupuncture, 70
vasa praevia, 37 Cannabis, 74 Congenital heart disease, 10-11
Acute fatty liver of pregnancy, 25
Antibiotics, 74 Caput succedaneum, 83 Connective tissue disease in
Adenomyosis, 129
Anticonvulsants, 74 Cardiac disease in pregnancy, 24 pregnancy, 24
Adnexal mass, 93
fetal anomalies, 6, 25 Cardiotocography, 50 Constipation, 76
Adolescent contraception, 107
Antidepressants, 74 Cardiovascular system, 2 Contraception, 86, 110—11
Alcohol abuse, 74
Antihistamines, 74 Carpal tunnel syndrome, 77 adolescents, 107
Alpha thalassaemias, 35
Antihypertensives, 74 Caudal regression syndrome, 29 barrier methods
Ambiguous genitalia, 88
Antimalarials, 74 Cephalohaematoma, 83 caps, 110
Amenorrhoea, 112—13
Antiphospholipid syndrome, 93 Cephalopelvic disproportion, 52 diaphragm, 110
disorders leading to, 112
Antiprogesterones, induction of Cerebral damage in neonates, 82 female condom, 110
investigation of, 112
labour, 49 Cervical carcinoma, 136—7 male condom, 110
management, 112—13
Antipsychotic drugs, 74 advanced disease, 137 chemical methods, 110-11
pathological, 112
Apgar score, 80, 82 and antepartum haemorrhage, 37 contraceptive sponge, 110
physiological, 112
Aromatherapy, 70 epidemiology, 136 intrauterine contraceptives, 111
Amniocentesis, 9
Artificial rupture of membranes, pathology, 136 spermicides, 110
Amniotic fluid embolism, 62
48-9 presentation, 136 emergency, 107
Amfetamines, 74
Asherman's syndrome, 112 risk factors, 136 hormonal
Anaemia, 32—3
Audioanalgesia, 70 staging, 136-7 progestogen-dependent,
antenatal screening, 32
Audit, 79 staging and survival rates, 137 108-9
diagnosis, 32
treatment, 137 oestrogen-dependent, 106-7
folate metabolism, 32-3
see also Cervical intraepithelial natural methods, 110
iron metabolism, 32
neoplasia and pelvic inflammatory disease,
response to blood loss, 33
treatment, 33 Backache, 76, 77 Cervical cerclage, 18—19 100-1
Bacterial vaginosis, 102 Cervical incompetence, 93 postpartum, 65
Anal incontinence, 59
Bacteroides spp., 102 Cervical intraepithelial neoplasia sterilization, 111
Analgesia, 70-1
Bartholin's cyst, 144 (CIN), 134-5 Contraceptive caps, 110
non-pharmacological
Benzodiazepines, 74 aetiology, 134 Contraceptive sponge, 110
acupuncture and acupressure,
Bereavement, 84-5 colposcopy, 134-5 Cord prolapse, 62
70
continued support, 85 cone biopsy, 135 Cordocentesis, 9
audioanalgesia, 70
cremation and burial, 85 cytology, 134 Counselling
hydrotherapy, 70
intrauterine death and stillbirth, definition, 134 induced abortion, 94
massage, 70
84-5 diagnosis, 134 pre-conceptual, 6-7
mobilization, 70
miscarriage, 84 histology, 134 Couvelaire uterus, 37
transcutaneous electrical nerve
neonatal death, 85 hysterectomy, 135 Cumberlege Report, 72
stimulation, 70
pharmacological, 70—1 Beta thalassaemias, 34 risk factors, 134 Cyproterone acetate, 115
Bimanual examination, 87 screening, 134 Cystic fibrosis, 12
epidural analgesia, 71
Birthing chair, 68-9 treatment, 135 Cystic hygroma, 12—13
inhalational analgesia, 70—1
Birthing cushion, 68-9 Cervical smear test, 134 Cystometry, 155
narcotic analgesia, 71
Birthing positions, 68 Chickenpox, 15 Cytomegalovirus, 14
pudendal nerve block, 71
Analgesics, 74 Birthing stool, 68-9 Chlamydia trachomatis, 100, 103
Androgens, and fetal virilization, 88 Bishop's score, 48 Chorioamnionitis, 19
Anencephaly, 11 Blood tests, 5 Choriocarcinoma, 97
Aneuploidy, 10 Bottle feeding, 65 Chorionic villus sampling, 8-9 Danazol, 129
Anovulatory dysfunctional bleeding, Bowel problems, postnatal, 59, 67 Chorionicity, 38 Day care surgery, 116-17
122-3 Breast development (thelarche), 90 Chromosome abnormalities, 8—9, advantages of, 116
Antenatal care, 4—5 Breast disease, and oral 93 changing surgical practice, 116
aims of, 4 contraceptives, 106 Chronic active hepatitis in preoperative evaluation, 116—17
anaemia, 32 Breast examination, 86 pregnancy, 25—6 role of nurse practitioner, 117
antenatal visit, 4—5 Breast feeding, 64-5 Cirrhosis in pregnancy, 25 setting, 116
blood tests, 5 and oral contraceptives, 107 Clomifene citrate, 132 Delayed puberty, 91
clinical examination, 4 Breech presentation, 40—1 Coagulation changes in pregnancy, 3 Depression, 45
Index 163
Huntington's chorea, 8, 13 Intermenstrual bleeding, 122 second stage, 47 signs and symptoms
Hydatidiform mole, 96—7 Intersex disorders, 88 third stage, 47 external changes, 148
Hydrosalpinx, 101 Interstitial cystitis, 126 problems of, 61 psychological and emotional
Hydrotherapy, 70 Intertrigo, 145 Leiomyosarcoma, 139 changes, 148-9
Hymen, 89 Intracytoplasmic sperm injection Leukotrienes, 121 reproductive tract, 148
Hyperemesis gravidarum, 25 (ICSI), 133 Lichen planus, 145 urinary tract, 148
Hypertension, 20-1 Intrahepatic cholestasis of Lichen sclerosus, 145 vasomotor symptoms, 149
essential hypertension, 20 pregnancy, 25 Liquor amnii, 51 uterovaginal prolapse, 152
gestational hypertension and pre- Intrapartum fetal monitoring, 50—1 Listeria monocytogenes, 15 Menorrhagia, 118, 122
eclampsia, 20—1 accelerations, 50 Liver disorders in pregnancy, 25—6 Menstrual disorders, 122—5
HELLP syndrome, 21 active phase, 51 Loss of libido, 123 anovulatory dysfunctional
Hyperthyroidism in pregnancy, 27 baseline heart rate, 50 Low birth weight, 22 bleeding, 122-3
Hypothalamic amenorrhoea, 113 baseline variability, 50 LSD, 74 dysfunctional uterine bleeding,
Hypothyroidism in pregnancy, 27 cardiotocography, 50 122
Hysterectomy contractions, 51 treatment of, 124
cervical intraepithelial neoplasia, decelerations, 50-1 dysmenorrhoea, 121, 123
135 descent of presenting part, 51 Macrosomia, 29 primary, 123
dysfunctional uterine bleeding, latent phase, 51 Malaria, 32 secondary, 124
125 liquor amnii, 51 Male pseudohermaphroditism, 88 treatment, 124
management of fibroids, 119 partogram, 51 Male sterilization, 111 intermenstrual bleeding, 122
Hysterosalpingography, 131 Intrauterine contraceptive device, Malpresentation, 53 menopause, 123
Hysteroscopy, 124—5 111 breech see Breech presentation menorrhagia, 118, 122
Intrauterine death, 84-5 brow presentation, 53 ovulatory dysfunctional bleeding,
Intrauterine growth restriction, face presentation, 53 123
6, 22 occipitoposterior presentation, 53 toxic shock syndrome, 123
Imperforate hymen, 113 Intrauterine insemination, 133 transverse/oblique lie, 53 treatment, 124-5
In vitro fertilization (IVF), 132-3 Iron Massage, 70 hysterectomy, 125
Induction of labour, 48—9 in foods, 33 Maternal mortality, 78 hysteroscopy, 124-5
antiprogesterones, 49 metabolism, 32 Maternity care, 72—3 Menstrual history, 86
artificial rupture of membranes, serum levels in pregnancy, 3 developing countries, 73 Menstruation, 120-1
48-9 Irritable bowel syndrome, 126 Domino scheme, 73 control of menstrual blood flow,
extra-amniotic saline, 49 Europe and USA, 73 121
failure of, 49 midwifery-run delivery units, 73 mechanisms of blood loss, 120
fetal indications, 48 needs-based community service, normal cycle, 120
maternal indications, 48 73 ovulation process, 120
Kallmann syndrome, 91
prostaglandins, 48 rural setting, 73 period pains [dysmenorrhoea),
Karyotyping, 9
syntocinon, 49 United Kingdom, 72-3 121
Infections in pregnancy, 14-15 Meat, infection risks, 15 Microcephaly, 15
chickenpox, 15 Meconium aspiration syndrome, 83 Midwifery-run delivery units, 73
cytomegalovirus, 14 Medical disorders in pregnancy, 24— Mifepristone, 95
(B-haemolytic streptococci group Labour and delivery, 46-7 7 Milk, 64
B, 15 abnormal, 52—3 acute fatty liver of pregnancy, 25 Mirena coil, 109
hepatitis, 15 abnormal labour, 52 cardiac disease, 24 Miscarriage, 84, 92-3
herpes simplex virus, 15 breech presentation, 40—1 chronic active hepatitis, 25-6 incomplete, 92
Listeria monocytogenes, 15 malpresentations and cirrhosis, 25 inevitable, 92
parvovirus, 14 malpositions, 53 connective tissue disease, 24 missed, 92
risks precipitate labour, 52 epilepsy, 25 recurrent spontaneous, 93
food, 14 slow labour, 52 gallstones, 25 septic abortion, 93
nurses, 14 alternative approaches, 68-9 hepatic disorders, 25 spontaneous, 92—3
occupation, 14 birthing cushion, chair and hyperemesis gravidarum, 25 threatened, 92
rubella, 14, 15 stool, 68-9 intrahepatic cholestasis of see also abortion
toxoplasmosis, 14 maternal choice, 69 pregnancy, 25 Mortality
Infertility, 130-1 water birth, 68 primary biliary cirrhosis, 26 maternal, 78
investigations, 130—1 analgesia, 70-1 renal disorders, 26 perinatal, 78-9
management, 132—3 acupuncture and acupressure, respiratory disorders, 26 Mucinous cystadenoma, 140
clomifene citrate, 132 70 systemic lupus erythematosus, Multiple pregnancy, 38—9
egg collection, 132 audionalgesia, 70 24-5 chorionicity, 38
gamete intrafallopian transfer, epidural analgesia, 71 thrombocytopenia chromosomal abnormalities, 39
132 hydrotherapy, 70 fetal, 27 fetal abnormality, 38
gonadotrophins, 132 inhalational analgesia, 70—1 maternal, 26—7 labour, 39
intracytoplasmic sperm massage, 70 thyroid disorders, 27 management of, 39
injection, 133 mobilization, 70 urinary tract infection, 26 structural defects, 38—9
intrauterine insemination, 133 narcotic analgesia, 71 viral hepatitis, 25 triplets and higher multiples, 39
ovarian hyperstimulation, 133 pudendal block, 71 Medroxyprogesterone acetate, 129 twins see Twin pregnancy
tubal surgery, 133 transcutaneous electrical nerve Menarche, 90 Mvometrial tumours, 139
in vitro fertilization and embryo stimulation, 70 Mendelson's syndrome, 56, 62
transfer, 132-3 diabetic pregnancy, 30-1 Menopause, 123, 148-9
ovulation tests, 131 episiotomy, 47 cardiovascular changes, 149
physiology, 130 first stage, 46-7 definitions, 148 Naloxone, 81
semen analysis, 131 induction see Induction of labour hormonal changes, 148 Narcotic analgesia, 71
tubal function, 131 initiation of labour, 46 hormone replacement therapy, Natural family planning, 110
unexplained, 133 mechanism of labour, 46 150-1 Nausea and vomiting, 76
Inflammatory bowel disease, 77 multiple pregnancy, 39 osteoporosis, 149 Needs-based community services,
Inhalational analgesia, 70-1 preterm, 18-19 pathogenesis, 148 73
Index 165
Neisseria gonorrhoeae, 100, 103—4 Partogram, 50—1, 52 obstetric, 6—7 Prolonged pregnancy, 49
Neonatal death, 85 Parvovirus, 14 risk of fetal anomaly, 7 Prostaglandins
Neonate, 80-1 Pelvic arthropathy, 67, 77 Pre-eclampsia, 20—1 cervical ripening, 48
diabetic pregnancy, 31 Pelvic examination, 87 Precipitate labour, 52 induced abortion, 95
examination, 81 Pelvic inflammatory disease, 100-1 Precocious puberty, 90—1 Pruritus vulvae, 144
medication, 80-1 acute, 100-1 Pregnancy, 2—3 Pseudomyxoma peritonei, 140
naloxone administration, 81 changes to fallopian tubes, 100 body water, 3 Pseudosac, 92
postpartum problems, 82-3 chronic, 101 cardiovascular changes, 2 Psoriasis, 145
cerebral damage, 82 diagnosis, 100 coagulation changes, 3 Psychosexual disorders, 158—9
congenital anomalies, 82-3 incidence, 100 drug treatment in, 7 counselling skills, 159
maternal drug abuse, 75 treatment, 101 energy balance, 3 painful penetration, 159
meconium aspiration Pelvic mass, 87 gastrointestinal tract, 2 physiology of sexual arousal, 158
syndrome, 83 Pelvic pain, 126-7 glucose, 3 sexual history, 158—9
prematurity-related, 82 acute, 126 iron, 3 specific situations, 159
respiratory distress syndrome, 83 chronic, 126-7 medical disorders in, 24—7 Psychosis, 45
seizures, 83 diagnosis, 126 prolonged, 49 puerperal, 67
trauma, 83 management, 126—7 respiratory system changes, 3 Psychosocial problems, 44-5
resuscitation, 80 see also Pelvic inflammatory thyroid, 3 alcohol, 44-5
surfactant, 81 disease urinary tract, 2 depression and psychosis, 45
Neural tube defects, 11 Peptic ulcers, 77 Pregnancy-related problems, 76—7 domestic violence, 45
Nicotine, 74 Perinatal mortality, 29, 78-9 backache, 77 female genital mutilation, 45
Norethisterone, 129 Perineal tears, 58 carpal tunnel syndrome, 77 racial aspects, 45
Nuchal translucency, 8 repair of, 58, 59 coeliac disease, 77 smoking, 44
Nurse practitioners, 117 Perineum, 58—9 constipation, 76 teenage pregnancy, 44
anal incontinence, 59 dyspepsia, 76 Puberty, 90-1
bowel problems, 59 inflammatory bowel disease, 77 abnormal
elective caesarean section, 59 nausea and vomiting, 76 delayed puberty, 91
Obesity, in polycystic ovarian episiotomy repair, 58 peptic ulceration, 77 precocious puberty, 90—1
syndrome, 115 perineal tears, 58 pregnant pelvic arthropathy, 77 normal
Oblique lie, 53 postnatal urinary tract problems, urinaiy symptoms, 76 breast development, 90
Occipitoposterior presentation, 53 58-9 vaginal discharge, 77 growth spurt, 90
Oedema, 3 repair of tears, 58 varicosities, 76 hair growth, 90
Oestrogen-dependent hormonal Period pains, 121 Premature infants menarche, 90
contraception see Combined Physical abuse, 75 breech presentation, 41 Pudendal nerve block, 71
oral contraceptive pill Pituitary adenoma, 113 labour and delivery, 18—19 Puerperal cardiomyopathy, 24
Oligohydramnios, 12 Placenta problems of Puerperal psychosis, 67
Operative delivery, 54—7 chorionicity, 38 central nervous system, 82 Puerperal pyrexia, 66
caesarean section, 56—7 retention of, 60-1 gastrointestinal system, 82 Puerperium, 64—5
forceps delivery, 54-6 twin pregnancies, 38 heat loss, 82 abnormal, 66—7
low/mid-cavity non-rotational Placenta praevia, 36 respiratory support, 82 bladder and bowel problems, 67
forceps, 54, 55 Placental separation, 47 retinopathy of prematurity, 82 haemorrhage, 60—1, 66
rotational forceps, 54, 55 Placental site trophoblastic tumour, sepsis, 82 infection, 66
ventouse, 56—7 97 see also Preterm labour musculoskeletal problems, 67
Opiates, 74 Pneumocystis carinii, 16 Premenstrual syndrome, 156—7 puerperial affective disorders,
Osteoporosis, 149 Polycystic kidney disease, 12 diagnosis, 156-7 67
Ovarian carcinoma, 142—3 Polycystic ovarian syndrome, 114—15 management, 157 venous thromboembolism, 66—7
familial, 142-3 amenorrhoea in, 113 symptoms, 156 bottle feeding, 65
investigations and treatment, 142 hirsutism in, 114 Prenatal diagnosis, 8—9 breast feeding, 64—5
management, 142 investigations, 114-15 Preterm labour, 18-19 physiological changes, 64
pathology, 143 symptoms, 114 benefits/risks of in utero postnatal visit, 65
recurrent, 142 treatment, 115 existence, 19 postpartum contraception, 65
screening for, 142 Polyhydramnios, 13 breech presentation, 41 routine care, 64
staging, 142 Posterior urethral valves, 12 cervical cerclage, 18—19 Pulmonary hypoplasia, 12
Ovarian cysts, 140-1 Postnatal depression, 67 delivery, 19 Pyelectasis, 12
Brenner cell tumour, 140 Postnatal visit, 65 diabetic pregnancy, 31 Pyosalpinx, 101
dermoid cyst, 140 Postoperative care, 160-1 diagnosis, 18
endometrioid cystadenoma, 140 catheters and drains, 160 management, 18
granulosa cell tumour, 140—1 complications, 161 uterine suppression (tocolysis), 18
investigations, 141 fluid balance, 160 see also Premature infants Raw eggs, infection risks, 15
mutinous cystadenoma, 140 medicolegal aspects, 161 Preterm premature rupture of 5a-Reductase deficiency, 88
pathological, 140-1 multidisciplinary approach, 161 membranes, 19 Renal disorders in pregnancy, 26
physiological, 140 perioperative prophylactic chorioamnionitis, 19 Renal dysplasia, 12
serous cvstadenoma, 140 management, 160-1 see also Preterm labour Residual ovary syndrome, 126
solid teratoma, 140 Postpartum haemorrhage, 60—1, 66 Primary biliary cirrhosis in Respiratory distress syndrome, 83
treatment, 141 causes of, 60 pregnancy, 26 Respiratory tract, 3
Ovarian hyperstimulation, 133 primary, 60-1 Progestogen challenge test, 112 disorders in pregnancy, 26
Ovtilation, 120 secondary, 61 Progestogen-dependent hormonal Resuscitation, 80
Ovulation tests, 131 Postpartum thyroiditis, 27 contraception, 108-9 Retained placenta, 60-1
Ovulatory dysfunctional bleeding, 123 Potter's syndrome, 7, 12 depot progestogen injections, 108 Retained products of conception, 93
Pre-conceptual counselling, 6—7 Fem-ring, 108-9 Retinoids, 74
diabetes, 28-9 levonorgestrel intrauterine Retinopathy of prematurity, 82
general, 6 system, 109 Rhesus negative patients, 6
lifestyle education, 7 progestogen implants, 109 Rokitansky syndrome, 89
Painful penetration, 159
medical, 6 progestogen-only pill, 108 Rubella, 14, 15
Palpation, 4, 5, 86-7
166 Index
Ruptured uterine scar, 37 Testicular feminization, 113 management, 154-5 Vaginal septae, 88-9
Rural maternity care, 73 Thalassaemias, 34—5 symptoms, 154 Varicose veins, 76
alpha thalassaemias, 35 Urinary tract, 2 Vasa praevia, 37
antenatal diagnosis, 35 history of problems, 86 Vasectomy, 111
beta thalassaemias, 34-5 infection in pregnancy, 26 Velamentous cord insertion, 37
Sacral agenesis, 29 Thrombocytopenia menopausal changes, 148 Venous thromboembolic disease,
Seizures in neonates, 83 fetal (alloimmune), 27 postnatal problems, 58—9, 67 42-3
Semen analysis, 130-1 maternal, 26-7 symptoms in pregnancy, 76 antenatal care, 42
Septic abortion, 93 Thyroid, 3 Urine tests, 5 gynaecology, 43
Sexual abuse, 89 disorders in pregnancy, 27 Uroflowmetry, 154 postnatal risk assessment, 42—3
Sexually transmitted disease see Tocolysis, 18 USA, maternity care, 73 postpartum, 66—7
Genital infections Total body water, 3 Uterine carcinoma, 138—9 Ventouse, 56—7
Sheehan's syndrome, 61, 113 Toxic shock syndrome, 123 endometrial carcinoma, 138—9 Viral hepatitis in pregnancy, 25
Shoulder dystocia, 62—3 Toxoplasmosis, 14, 15 myometrial tumours, 139 Vulva, benign conditions, 144—5
Sickle cell syndromes, 35 Transcutaneous electrical nerve uterine sarcoma, 139 anatomy, 144
management of sickle cell crises, 35 stimulation (TENS), 70 Uterine fibroids see Fibroids Bartholin's cyst, 144
Slow labour, 52 Transverse lie, 53 Uterine sarcoma, 139 herpetic ulceration, 104
Small for dates fetus, 22—3 Trauma in neonates, 83 Uterogenital prolapse, 126 intraepithelial neoplasia, 145
born too soon, 22 Treponema pallidum, 104, 105 Uterovaginal prolapse, 152—3 lichen sclerosus, 145
fetal assessment Trichomonas vaginalis, 104, 105 aetiology pruritus vulvae, 144
biophysical profile, 23 Triplet pregnancy see Multiple childbirth, 152 simple atrophy, 144
fetal movement charts, 22 pregnancy congenital weakness, 152 squamous cell hyperplasia, 145
monitoring, 23 Trophoblastic disorders, 96-7 menopause, 152 ulcers, 144
symphysis-fundal height, 22 gestational choriocarcinoma, 97 examination, 152 urethral caruncle, 144
ultrasound, 22—3 hydatidiform mole, 96—7 history, 152 vulvodynia, 144
intrauterine growth restriction, placental site trophoblastic management, 152—3 Vulval carcinoma, 146—7
6, 22 tumour, 97 conservative, 152—3 aetiology, 146
low birth weight, 22 Turner's syndrome, 113 surgical, 153 assessment, 146
management, 23 karyotyping, 9 presentation, 152 diagnosis, 146
Smoking, 7 Twin pregnancy Uterus management, 146—7
Soft cheeses, infection risks, 15 chorionicity, 38 abnormal development, 89 advanced disease, 147
Speculum examination, 87 dichorionic, 38 anatomical abnormality, 93 early stage disease, 147
Spermicides, 110 management of delivery, 39 bicornuate, 89 precursor lesions, 146
Spina bifida, 6, 11 monochorionic, 38 couvelaire, 37 recurrent, 147
Sterilization, 111 with one fetal death, 39 inadequate activity, 52 Vulval warts, 103
Steroids, 74 placentation, 38 inversion, 63 Vulvodynia, 144
Stillbirth, 84-5 see also Multiple pregnancy rupture, 63
Sudden infant death syndrome, 75 Twin reversed arterial perfusion septate, 89
Surfactant, 81 sequence (acardia), 39 unicornuate, 89
Sweeping the membranes, 49 Twin-twin transfusion syndrome, 39 Water birth, 68
Symphysis-fundal height, 4, 22
Syntocinon, induction of labour, 49
Syphilis, 104-5 Vaccines, 74
Systemic lupus erythematosus, 24-5 Ultrasound, fetal, 22-3 Vagina, abnormal development, i 88 Zavanelli manoeuvre, 63
Urethral caruncle, 144 9
Urethral syndrome, 126 Vaginal atresia, 89
Urethritis, gonococcal, 104 Vaginal cones, 155
Tay-Sachs syndrome, 7, 8, 13 Urinary incontinence, 154—5 Vaginal discharge, 77, 86, 104-5
Teenage pregnancy, psychosocial examination, 154 history, 104-5
problems, 44 investigations, 154 management, 105