Mims Jpog August 2015 Id

JPOG
INDONESIA – ISSN 2411-0183 • JUL/AUG 2015 VOL. 41 NO. 4
JOURNAL OF PAEDIATRICS, OBSTETRICS & GYNAECOLOGY Online Mobile Print Live
HOW TO CONDUCT
A ‘HEARTSINK’-FREE
MENOPAUSE CONSULTATION
OBSTETRICS
Mood Disorders in Pregnancy
How do They Affect Mother
and Baby?
PAEDIATRICS
Optimising Respiratory Health
in Children with Cystic Fibrosis
CME ARTICLE
Placenta Accreta – An updated
Approach to Diagnosis
and Management
FOCUS ON WORLD BREASTFEEDING WEEK, AUG 1-7
MIMS JPOG JUL/AUG 2015 i
JUL/AUG 2015 VOL. 41 NO. 4
Editorial Board
CONFERENCE
Board Director, Paediatrics
24th Asian and Oceanic Congress of Obstetrics
Professor Pik-To Cheung
Associate Professor Department of Paediatrics and Adolescent Medicine and Gynaecology 2015
The University of Hong Kong
Board Director, Obstetrics and Gynaecology

Professor Pak-Chung Ho 133
Head, Department of Obstetrics and Gynaecology
The University of Hong Kong • Dydrogesterone use early in pregnancy prevents
gestational hypertension
• Omega-3 fatty acids improve male fertility, antioxidants’
Professor Biran Affandi Associate Professor role still a grey area
University of Indonesia Raymond Hang Wun Li
Dr Karen Kar-Loen Chan
The University of Hong Kong Associate Professor Daisy Chan
Dato’ Dr Ravindran Jegasothy
Singapore General Hospital 134
Dean at the Medical Faculty, Adjunct Associate Professor • Cerebroplacental ratio can detect placental
MAHSA University, Malaysia Tan Ah Moy
KK Women’s and Children’s Hospital, insufficiency in AGA pregnancies
Professor Kenneth Kwek Singapore
KK Women’s and Children’s Hospital, • Physical activity after cancer diagnosis improves
Singapore Dr Rajeshwar Rao
KK Women’s and Children’s Hospital, overall patient well-being
Dr Kwok-Yin Leung Singapore
Adjunct Associate Professor
Dr Tak-Yeung Leung Ng Kee Chong
Chinese University of Hong Kong
Professor SC Ng
KK Women’s and Children’s Hospital,
Singapore JOURNAL WATCH
National University of Singapore Associate Professor Jeffrey Low
Professor Hextan National University Hospital, Singapore
Yuen-Sheung Ngan
Dr Catherine Lynn Silao
University of the Philippines Manila
135
Professor Carmencita D Padilla Dr MaryAnne Chiong • Locally produced ready-to-use
University of the Philippines Manila University of the Philippines Manila biscuits/spreads effective for
Professor Seng-Hock Quak Dr Ethiraj Balaji Prasath rehabilitating moderately to mildly
National University of Singapore Thomson Fertility Centre, Singapore
Professor Kok Hian Tan
wasted children
Associate Professor Dwiana
KK Women’s and Children’s Hospital, Ocviayanti • Targeted social marketing messages
Singapore University of Indonesia
can encourage immunization
Dr Wing-Cheong Leung
Kwong Wah Hospital, Hong Kong SAR of children
• Intermittent ulipristal acetate beneficial for long-term
management of symptomatic uterine fibroids
136
• Sexual intercourse decreases absorption of vaginal
progesterone gel, possibly reducing the effectiveness
of ART
JPOG_JulAug 2015_Final_TOC_ID.indd 1 9/7/15 2:54 pm

MIMS JPOG JUL/AUG 2015 iii
REVIEW ARTICLE
Publisher Ben Yeo OBSTETRICS
Managing Editor Elvira Manzano
Deputy Managing Editor Radha Chitale
Medical Editor Kavitha G. Shekar
Publication Manager Marisa Lam
137
Designers Agnes Chieng, Sam Shum
Production Edwin Yu, Ho Wai Hung, Steven Cheung Mood Disorders in Pregnancy: How do They
Circulation Christine Chok
Accounting Manager Minty Kwan
Affect Mother and Baby?
Advertising Coordinator Jasmine Chay Many postpartum mood disorders can
start during pregnancy and women
Published by:
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27th Floor, OTB Building, 160 Gloucester Road, Wan Chai, Hong Kong
Tel: (852) 2559 5888 | Email: enquiry@mimsjpog.com can relapse during pregnancy. The
risk–benefit ratio of treatment should
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fetus.
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145
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Menelik MH Lee

Underweight
INDONESIA
iv MIMS JPOG JUL/AUG 2015
REVIEW ARTICLE SPECIAL FEATURE

World Breastfeeding Week, 1-7 Aug
PAEDIATRICS
158 Journal Reports

Optimising Respiratory Health in Children
with Cystic Fibrosis
SF2
Cystic fibrosis is a multi-system genetic • Is breastfeeding really better than formula feeding?
disorder causing thick secretions, lung • Breast- and formula-fed infants have different lipid
infection and pancreatic insufficiency. profiles
Optimising respiratory health in children
with cystic fibrosis depends upon SF3
meticulous attention to maintaining • Maternal obesity linked to non-initiation of breastfeeding
general health, in addition to preserving
• Does breastfeeding reduce the risk of cardiovascular
lung health. Maximising nutrition and growth are essential as these
mortality?
are independent predictors of lung function and survival.
Matthew N Hurley, Alan R Smyth SF4
• Substantial improvement in breastfeeding rates in
Cambodia
CONTINUING
MEDICAL EDUCATION REVIEW ARTICLE
169 SF5
Placenta Accreta – An Updated 5 SKP
A Review of Evidence Around Postnatal
Approach to Diagnosis and Care and Breastfeeding
Management In the last 10 years, an evidence base
The incidence of placenta accreta has increased over the has been distilled around the key
years with the increase in caesarean section rate. Placenta components of optimum postnatal care
accreta is associated with substantial maternal risks and and breastfeeding support.
poses an obstetric challenge. The approach to diagnosing Denis Walsh
placenta accreta and its management will be discussed.
Charleen Sze-Yan Cheung, Ben Chong-Pun Chan
The Cover:
How to Conduct a ‘Heartsink’-Free Menopause Consultation
© 2015 MIMS Pte Ltd
Sam Shum, Designer

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CONFERENCE COVERAGE MIMS JPOG JUL/AUG 2015 133
24th Asian & Oceanic Congress of Obstetrics & Gynaecology, June 3-6, Kuching, Malaysia –
Kavitha G. Shekar reports
Dydrogesterone use early vent or reduce its incidence should be p=0.001) and sperm cell concentration
in pregnancy prevents during the first trimester,” said lead re- (from 15.6 ± 4.1 106 per ml to 28.7 ±
gestational hypertension searcher Professor Zainul Rashid from 4.4 106 per ml, p=0.001) was seen in
the Department of Obstetrics and Gy- the group receiving omega-3. [Androlo-
Current guidelines for the management naecology, National University of Ma- gia 2011;43:38-44]
of gestational hypertension (GH) need laysia, Medical Centre, Kuala Lumpur, Another study comparing 82 in-
to be revised, say researchers. This is Malaysia. fertile men with iOAT to 87 fertile men
based on the results of a cross-section- Current guidelines do not recom- found serum omega-6/omega-3 FA
al comparative study which showed mend the use of dydrogesterone early ratio to be significantly higher in infer-
that dydrogesterone supplementation in pregnancy. tile men (14.8+/-4.3) compared to the
during the first trimester of pregnancy “We used dydrogesterone in this fertile controls (6.3+/-2.2) (p=0.001).
significantly reduced the incidence of study because of its pure progesteron- [Clin Nutr 2010;29:100-105]
GH in primigravidae. ic effect. The chemical shape of dydro- “Omega-3 is supposed to be the
Researchers analysed data on gesterone is almost similar to naturally most important group of FAs, but now
progesterone supplementation, inci- derived progesterone, with the excep- there are some studies telling us that
dence of foetal distress, neonatal intention of an extra chain,” noted Zainul. perhaps it’s not so much the absolute
sive care unit admission (NICU), mode level of omega-3 but the ratio between
Professor Zainul Rashid. Proceedings of the 24th Asian & Oce-
of delivery, and babies’ birth weight. anic Congress of Obstetrics & Gynaecology, June 3-6, Kuch- omega-3 and omega-6 [that play an im-
ing, Malaysia [Oral Presentation].
The study group consisted of 113 portant part in fertility],” Sinthamoney
primigravidae who conceived follow- said. “Infertile men have lower concen-
ing assisted reproductive technology trations of omega-3 FAs in spermato-
(ART) and received dydrogesterone 10 Omega-3 fatty acids improve zoa than fertile men.”
mg thrice daily for 16 weeks. The con- male fertility, antioxidants' While doctors commonly prescribe
trol group consisted of 113 age- and role still a grey area antioxidants such as vitamin C, vitamin
race-matched primigravidae who con- B, zinc, selenium and carnitines dur-
ceived naturally and did not receive Omega-3 fatty acid (FA) consumption ing male fertility treatment, studies on
any dydrogesterone supplementation. during assisted reproductive technolo- its effectiveness in improving semen
[Gynecol Endocrinol 2014;30;217- gy (ART) improves fertility outcome in parameters and pregnancy rates vary
220] men, however evidence on the role of A Cochrane review of 48 randomized
The results were significant for antioxidants in fertility remains meagre. controlled trials involving 4,179 subfer-
dydrogesterone use with only two Dr. Eeson Sinthamoney, consultant, tile men who consumed antioxidants
women in the study group develop- Sunfert International Fertility Clinic, during ART found low quality evidence
ing GH versus 15 in the control group Kuala Lumpur, Malaysia, presented suggesting an improvement in live birth
(p=0.002). The incidence of foetal dis- data linking these nutrients to fertility rates (odds ratio [OR], 4.21, 95% CI,
tress was also significantly lower in the in men. 2.08 to 8.51, p< 0.0001). [Cochrane
study group compared with the control Researchers randomised 238 Database Syst Rev 2014;12;CD007411]
group (5 vs 21; p=0.001). However, no infertile men with idiopathic oligoas- “The Cochrane Database sug-
difference between the two groups was thenoteratospermia (iOAT) to receive gests a role, although not that great, for
observed for the mode of delivery, ad- 1.84 g per day of eicosapentaenoic the use of antioxidants in male subfertil-
mission to NICU and birth weight of the and docosahexaenoic acids, (common ity,” said Sinthamoney.
baby. omega-3 FAs used in fertility treatment)
Dr. Eeson Sinthamoney. Proceedings of the 24th Asian & Oce-
“GH develops early in pregnancy or a placebo for 32 weeks. A signifi- anic Congress of Obstetrics & Gynaecology, June 3-6, Kuch-
ing, Malaysia [Oral Presentation].
and is only reflected in the second half. cant improvement in sperm cell count
Hence, the best time to intervene, pre- (from 38.7 ± 8.7 106 to 61.7 ± 11.2 106,
JPOG_JulAug 2015_Final_Combine.indd 133 9/7/15 2:22 pm

134 MIMS JPOG JUL/AUG 2015 CONFERENCE COVERAGE
24th Asian & Oceanic Congress of Obstetrics & Gynaecology, June 3-6, Kuching, Malaysia –
Kavitha G. Shekar reports
Cerebroplacental small-for-gestational-age (SGA) foe- exercise, including home-based activ-

ratio can tuses are at risk of placental insuffi- ities like gardening or walking around
detect placental ciency and FRGP. the house after a meal. Walking up
insufficiency in AGA “Across the various centiles there stairs is preferable to taking elevators
pregnancies are a proportion of AGA babies with or escalators. The ACS also cautions
decreasing proportion of CPR, and we against sedentary activities like watch-
Doppler measurement of cerebropla- are not diagnosing these babies,” said ing television or other screen-based
cental ratio (CPR) can detect chronic Dr Tan. Explaining why CPR cannot be entertainment.
placental insufficiency and failure to used to time delivery in monochorionic Exercise will help improve the pa-
reach growth potential (FRGP) in ap- pregnancies, he said: “Monochorionic tient’s quality of life, promote under-
propriate-for-gestational age (AGA) pregnancies often have an artery-to-ar- standing of the condition, and reduce
pregnancies. This allows to time de- tery anastomosis that cause intermittent fatigue during and post-treatment, Karu-
livery of pregnancies, except mono- reversal of end-diastolic flow in the um- naratne said. However, cancer patients
chorionic pregnancy, says Dr Tony Tan bilical artery. Since the umbilical artery should take precautions against anae-
from the Department of Obstetrics and does not reflect the impedance accu- mia, low blood count, frequent vomiting,
Gynaecology, Raffles Hospital, Singa- rately, CPR cannot be used in these diarrhoea and electrolyte imbalance be-
pore. cases.” fore undertaking physical activity.
Tan’s statement corroborated re- Psychosocial care forms an inte-
Dr Tony Tan. Proceedings of the 24th Asian & Oceanic Con-
sults from a retrospective cohort study gress of Obstetrics & Gynaecology, June 3-6, Kuching, Malay- gral part of cancer treatment. Cancer
sia [Oral Presentation].
which showed that CPR was able to centres should house a counselling
identify most AGA pregnancies at risk unit comprising of nurses and doctors
of foetal complications. [Ultrasound trained to provide psychosocial care,
Obstet Gynecol 2014;43:303-310] Physical activity Karunaratne said. These care givers
The study, conducted over a 10- after cancer diagnosis should be able to provide detailed
year period from 2002 to 2012, includ- improves overall information on various treatment op-
ed data from 11,576 term foetuses patient well-being tions available, including alternative
obtained from a single tertiary referral and complementary therapy.
centre. CPR between 37+0 and 41+6 Staying physically active after being “Discussing treatment options
weeks within 14 days before birth was diagnosed with cancer can help pa- and providing detailed information pro-
recorded. In AGA pregnancies, the tients cope with the mental and physi- motes psychosocial well-being,” said
percentage of foetuses with FRGP was cal demands of the disease and treat- Kanishka, since it enhances patient un-
found to be 1 percent in the 75 to 90th ment. derstanding and reduces psychologi-
birth weight centile group, 1.7 percent “Many studies have shown that cal morbidity. “Cancer treatment is not
in the 50 to 75th centile group, 2.9 per- [physical activity] aids in early recov- restricted to surgery, chemotherapy
cent in the 25 to 50th centile group and ery, delays recurrence and boosts the or radiation therapy. There are many
6.7 percent in the 10 to 25th centile patient’s immune system,” said Dr Ka- social and psychological activities a
group. nishka Karunaratne, a consultant at doctor needs to provide a patient for
This implies that CPR has the the National Cancer Institute in Mahar- recovery.”
potential to identify placental insuf- agam, Sri Lanka.
Dr Kanishka Karunaratne. Proceedings of the 24th Asian &
ficiency complications in AGA preg- The American Cancer Society Oceanic Congress of Obstetrics & Gynaecology, June 3-6,
Kuching, Malaysia [Oral Presentation].
nancies, said Tan. It also challeng- (ACS) recommends 150 minutes per
es conventional thinking that only week of regular physical activity and

JOURNAL WATCH PEER REVIEWED MIMS JPOG JUL/AUG 2015 135
ume-based biscuits (n=44), or the same surveys. The campaign used billboards
P biscuits supported by intensive nutrition and billboard-enhanced social market-
education (n=38). The children were in- ing techniques such as the distribution
Paediatrics dividually discharged after they reached a of backpacks, pens, pencils, and fliers
WHZ ≥-1.5SD. that contained the social marketing mes-
Despite children in the cere- sage.
Locally produced ready-to-use
al-based biscuit groups being younger The ‘Take Control! Immunize’ mes-
biscuits/spreads effective for
and more likely to be moderately wast- sage was recalled by approximately 85%
rehabilitating moderately to
mildly wasted children ed at admission, their recovery rates of the survey respondents, 46% of whom
were higher than those of children in indicated that they were motivated to
the peanut-based group (cereal-based immunize their child or to contact their
biscuit 84%, cereal-based biscuit plus physician regarding their child’s immuni-
intensive education 79% versus pea- zation status. Ninety-six percent report-
nut-based spread 62%, p=0.086). Com- ed that they believed immunization was
pliance was also greater in these groups important and that they were ‘very likely’
(86% and 84% vs 45%, respectively, to immunize their child. No significant
p<0.001). High compliance, weight differences were observed between the
gain, and a lower degree of wasting at effects of the billboard and billboard-en-
admission were independent and signif- hanced social marketing techniques.
icant predictors of reaching the target The researchers concluded that
WHZ. Cultural factors may have impact- using a community-based participatory
ed compliance as the taste of the pea- research approach when designing the
nut/milk powder spread was novel and immunization message and then en-
disliked by many caregivers. suring strategically targeted community
placement of billboards can be an effec-
Scherbaum V et al. Locally produced cereal/nut/legume-based
biscuits versus peanut/milk-based spread for treatment of tive approach for increasing awareness
moderately to mildly wasted children in daily programmes on
Nias Island, Indonesia: an issue of acceptance and compli- and intent to immunize in low-income
ance? Asia Pac J Clin Nutr 2015;24(1):152–161.
minority neighbourhoods.
Ngui EM et al. Evaluation of a social marketing campaign to

Two nutritionally comparable forms of increase awareness of immunizations for urban low-income
children. WMJ 2015;114:10–15.
locally produced ready-to-use foods for Targeted social marketing
daily use were found to be effective in messages can encourage
rehabilitating moderately to mildly wast- immunization of children
ed children in a study on Nias island in
Indonesia, which suffered a devastating Parental awareness and intention to im- G
tsunami in 2005. munize can be encouraged by targeted
Between October 2007 and June
2008, 111 children aged ≥6 to <60
social marketing messages, say US-
based researchers.
Gynaecology
months with a weight-for height z-score They assessed the effects of a so-
(WHZ) of ≥-3 to <-1.5 SD were recruit- cial marketing campaign developed Intermittent ulipristal
ed through community-based monthly using community-based participatory acetate beneficial for long-term
growth monitoring activities and admi research on parental awareness and management of symptomatic
tted to the intervention programme with intention to immunize in targeted, pre- uterine fibroids
their parents’ consent. They received dominantly African American, low-in-
either locally produced peanut/milk- come, urban neighbourhoods using Women who suffer from symptomatic
based spreads (n=29), cereal/nut/leg- two interviewer-assisted street-intercept uterine fibroids may benefit from inter-

136 MIMS JPOG JUL/AUG
MIMSJPOG JUL/AUG 2015
2015 JOURNAL WATCH PEER REVIEWED
mittent treatment with ulipristal acetate, endpoint of amenorrhoea at the end of men and women were measured 10
according to a recent study. both treatment courses (p=0.03). hours after intercourse during the first
In most patients, menstruation re- two weeks as well as once in the morn-
sumed after each treatment course, but ing during the week of abstinence.
was diminished relative to baseline. The Serum levels of progesterone were
median fibroid volume was reduced by significantly reduced when women
54% and 58% after the second course who used the vaginal progesterone gel
of treatment with ulipristal acetate 5 and had sexual intercourse compared with
10mg/day, respectively. Pain and qual- when they abstained from such activity
ity of life scores were also significantly (2.9mg/mL versus 6.9 mg/mL). Moreo-
improved from baseline, and ulipristal ver, their male partners absorbed signif-
acetate was well tolerated. icant amounts of progesterone during
intercourse, which is of concern as this
Donnez J et al. Efficacy and safety of repeated use of ulipristal
acetate in uterine fibroids. Fertil Steril;2015;103:519-527. may result in adverse effects such as
decreased libido.
The researchers comment that
their findings are troubling as only two
progesterone formulations have been
O approved by the FDA, and both require
vaginal administration.
Obstetrics
Merriam KS et al. Sexual absorption of vaginal progesterone: a
randomized control trial. Int Jnl Endocrinol 2015; http://dx.doi.
Sexual intercourse decreases org/10.1155/2015/685281
absorption of vaginal
progesterone gel,
possibly reducing the
The phase III, double-blind, paral-
effectiveness of ART
lel group study evaluated the efficacy
and safety of ulipristal acetate for the The effectiveness of assisted re-
treatment of uterine fibroids in 451 pre- productive technology (ART) may be re-
menopausal women with symptomatic duced when a vaginal progesterone gel
fibroids and heavy bleeding at 46 study is used, as sexual intercourse reduces
sites in 11 countries. All women had at progesterone absorption by the female,
least one fibroid ≥3 cm and none >12 and increases absorption by the male.
cm in diameter. They were randomized In a recent prospective, crossover
in a 1:1 ratio to oral ulipristal acetate 5 study, researchers compared serum
or 10mg/day and matching placebos progesterone levels among 20 wom-
for two 12-week courses separated by a en of reproductive age and their male
drug-free interval. Ulipristal acetate was sexual partners. The women were ran-
started during the first 4 days of men- domized to a vaginal progesterone gel
struation, and the second course com- or placebo cream for one week and re-
menced after the second off-treatment ceived the opposite formulation the fol-
menstruation. lowing week. In the third week, the pro-
A total of 62% of patients in the 5mg gesterone gel was applied at night and
group and 73% of patients in the 10mg the women abstained from intercourse.
group achieved the primary efficacy Serum progesterone levels in both the

11
th
Asia Pacific Congress in
Maternal Fetal Medicine
27 – 29 November 2015
Sheraton Grande Taipei Hotel Taiwan
RADIOLOGY MEETS OBSTETRICS

Invited Speakers
BALAKRISHNAN Bijoy K. (India) LAO TH Terence (Hong Kong)
BUI The-Hung (Sweden) LAW Lai Wa (Hong Kong)
CHAN Kok Yen Jerry (Singapore) LAU Wai Lam (Hong Kong)
CHAN Te Fu (Taiwan) LEUNG Tak Yeung (Hong Kong)
CHAN YM Olivia (Hong Kong) LEUNG Wing Cheong (Hong Kong)
CHANG Sheng Hsiung (Taiwan) LIN Gi Gin (Taiwan)
CHANG Yao Lung (Taiwan) POOH Ritsuko (Japan)
Rabih CHAOUI (Germany) POON CY Liona (UK)
CHEN Ming (Taiwan) Daniela PRAYER (Austria)
CHENG KY Yvonne (Hong Kong) Prathima RADHAKRISHNAN (India)
CHENG Po Jen (Taiwan) Uma RAM (India)
CHIM SC Stephen (Hong Kong) Michael ROBSON (Ireland)
CHO Fu Nan (Taiwan) SAGO Haruhiko (Japan)
CHOOLANI Mahesh (Singapore) SAHOTA Daljit Singh (Hong Kong)
CHOR CM Michael (Hong Kong) SEOW Kok Min (Taiwan)
CHOU Min Min (Taiwan) SHAW Sen Wen Steven (Taiwan)
CHOY KW Richard (Hong Kong) SHIH Jin Chung (Taiwan)
Gustaaf DEKKER (Australia) Seshadri SURESH (India)
Gian Carlo DI RENZO (Italy) TAN Lay Kok (Singapore)
ENDOH Masayuki (Japan) Tony TAN (Singapore)
Dan FARINE (Canada) Gerard VISSER (The Netherlands)
HSIAO Ching Hua (Taiwan) Tuangsit WATAGANARA (Thailand)
HUANG Tai Ho (Taiwan) WON Hye Sung (Korea)
HUANG Yu Ting (Taiwan) George YEO (Singapore)
Jonathan HYETT (Australia)
Deadlines Secretariat
Abstract Submission : 31 July 2015 Department of Obstetrics and Gynaecology
Early Bird Registration : 31 August 2015 The Chinese University of Hong Kong
Tel: (852) 2632 1534 | Fax: (852) 2636 0008
Email: apcmfm@med.cuhk.edu.hk
Website: www.apcmfm.hk
Organisers:
OBSTETRICS PEER REVIEWED MIMS JPOG JUL/AUG 2015 137
Mood Disorders in
Pregnancy: How do They
Affect Mother and Baby?
Anne Buist, MBBS MMED MD FRANZCP
Many postpartum mood disorders can start during pregnancy and women with
pre-existing psychiatric conditions can relapse during pregnancy. The risk–
benefit ratio of treatment should be assessed to protect the mother and fetus.
INTRODUCTION unwanted. The whole concept of moth-

The experience of pregnancy and motherhood is influenced by the woman’s
erhood is not the same for everyone and age, social background, culture and ear-
is rarely as it is portrayed by the media ly childhood experiences, and the pres-
and on television – either as a blissful ence of stress and mental illness have
new life where women can have it all or been associated with poorer obstetric
a stressful time driving mothers to aban- outcomes.1
don their babies. The physical changes The woman’s current circumstanc-
of pregnancy can be onerous and un- es should be assessed by the GP as
expected, and the financial and social part of the management of pregnancy,
implications can be difficult, particularly as they are critical to determining her
if the pregnancy was unplanned and/or risk for developing mental health issues

138 MIMS JPOG JUL/AUG 2015 OBSTETRICS PEER REVIEWED
Box 1. Risk Factors for Antenatal and Postpartum Mood Disorders intervention for psychiatric problems by clinicians
was during the first postpartum month, the time
• Family history of affective disorder, suicide attempts or alcohol when postpartum psychosis occurred in one in
abuse 600 deliveries. However, since that article was
published research and reviews have highlighted
• Past personal history of depression, anxiety, self-harm
that women are at least as likely to be depressed
• History of drug abuse during pregnancy as they are afterwards, with a
• History of domestic violence personal or family history of affective disorders
being key risk factors.4,5
• Poor support network
Women with pre-existing psychiatric condi-
• Childhood abuse history
tions may cease their psychotropic medications
• Unwanted or unexpected pregnancy when they discover they are pregnant, and this
may in part lead to an increase in their symptoms
antenatally.6,7 This appears to be especially true
in women with bipolar disorder and more severe
Box 2. Useful Phrases and Questions to Use With Patients
illness who have not been euthymic for at least
six months before becoming pregnant. Recur-
• It’s common for women to be anxious in pregnancy. Are there rence of bipolar disorder has been shown to be
things you are really worrying about? twice as common in women with the condition
• Stress is sometimes tough to deal with when you’re pregnant. who ceased mood stabilisers (86% vs 37%) com-
How are you going? pared with those who continued their medication;
• I can see you really want to be a good mum. Asking for help can the average time to relapse was found to be two
be one way of doing that (e.g. even though I know you like to be weeks in women who ceased treatment suddenly
independent). versus 22 weeks in those who ceased it gradu-
• I can understand you want to do the right thing by your baby, so ally.8
let’s think carefully about what’s the biggest risk– the medication Psychosocial factors need to be considered
or you being unwell. when assessing a woman’s risks of antenatal de-
pression and postpartum mood disorders (Box
1). The circumstances of the pregnancy will inev-
during the perinatal period; if she has a partner, itably affect the woman’s initial response to being
he or she should be involved in this assessment. pregnant: Was the pregnancy planned and is the
About 10% of women are likely to have significant baby wanted? What are her attitudes to the preg-
depression and anxiety during this time (8.9% in nancy and motherhood? What are her financial
the beyondblue study). 2
circumstances? What is the state of her relation-
ship with the child’s father?9 Does she have other
Risk Factors for Antenatal Mood supports? Useful questions to ask patients are
Disorders listed in Box 2.
Kendall’s seminal paper in 1987 showed a 30- A poor relationship with her own mother
fold increase in psychiatric admission in the post- and a history of abuse may underpin a woman’s
partum period compared with any other time in fear about her own ability to rear a child, as well
a women’s life, with a decrease antenatally pos- as causing focused anxiety about childbirth. En-
sibly because treating professionals mistook hancing a woman’s support network is likely to be
psychological symptoms as being secondary to a critical part of her management. Domestic vio-
the pregnancy rather than being a mental health lence and alcohol abuse patterns may worsen in
problem. At that time the focus of diagnosis and
3
pregnancy and may be orientated towards the ab-

domen. Women may feel even more trapped and

unable to leave the relationship because of the tie
through the child and the financial burden.10 Drug
abuse, a risk factor for depression and parenting
problems, will increase risks to both mother and
child; if drug use occurs when the woman is re-
sponsible for the child, a risk assessment is re-
quired with possible mandatory reporting.
DIAGNOSIS
There are three main mood disorders that require
consideration during pregnancy, with anxiety dis-
orders being the main differential diagnosis. Of-
ten anxiety and depression are interwoven and
the main symptoms causing concern need to be
established. Midwives and obstetric services may
screen for these disorders and then request an
evaluation by the GP. However, GPs who are man-
aging or co-managing perinatal women should
consider screening (e.g. with the Edinburgh Post-
natal Depression Scale, which can be used ante-
natally, or the K10) and/or routinely asking how
the woman is managing emotionally. Depending
on the answer and the presence of risk factors, a
further psychiatric history may be required. An en- Pregnancy is a time of substantial physical change and mental preparation for
quiry should be made at each visit; screening ear- the birth and caring of a dependent child.
ly in the pregnancy and then again later is ideal.

ful monitoring during the postpartum period for
Adjustment Disorder the development of a more serious illness. In par-
Pregnancy is a time of substantial physical change ticular, women with a history of sexual abuse may
and mental preparation for the birth and caring of need help addressing the anxiety around child-
a dependent child. Many women who have un- birth itself.
planned pregnancies or fragile relationships with
little support will struggle with aspects of these Major Depression
changes, if not during pregnancy then in the post- As in the postpartum period, major depression
partum period. Women with a history of childhood during pregnancy may present as anxiety. ‘Why
abuse or a vulnerable personality are particular- would I be depressed, I want this baby’ is a fa-
ly at risk of developing an adjustment disorder, miliar misinterpretation of how women are feeling
which may be associated with mood or anxiety. leading to a delay in seeking help and therefore
If the woman has an adjustment disorder a delay in diagnosis.11 Often the woman’s anxiety
rather than major depression, her symptoms will is focused on the pregnancy or the developing
fluctuate and she will still be able to function and fetus. If her fears do not settle with reassurance
enjoy aspects of her life. However, if the woman and, where appropriate, negative test results,
is struggling to talk and work through her issues then the presence of depression should be con-
surrounding the pregnancy, she will require care- sidered. Psychosis should also be considered

Table. Comparison of the DSM-V Diagnostic Criteria for Major Sleep disturbance may be dismissed as be-
Depression and Adjustment Disorder in Pregnant Women12 ing due to the pressure of the uterus on the blad-
der, reflux or the general discomfort of pregnancy
Major Depression Adjustment Disorder but may be a symptom of major depression. A
in Perinatal Context (Anxious/Depressed Subtype) careful history of sleep separate from these is-
Five or more of the following Symptoms that cause distress sues should be taken. Fatigue can also be con-
symptoms lasting more than and difficulties in functioning, sidered a ‘normal’ part of pregnancy but women
two weeks, which must occurring within three months of
include at least one of the first stressor and lasting less than six should be asked if they are still getting enjoyment
two symptoms: months and fulfilling the criteria from their lives. A change in appetite can also be
for major depression (or anxiety diagnostic – is the woman enjoying her food or
disorder):
just eating ‘for the baby’ or for comfort? Is she
Depressed mood Sadness
paying attention to her self-care? Any associated
Loss of interest (usually in Loss of interest (but is interested psychotic symptoms need to be regarded seri-
everything, may be a little sometimes in some things)
better with baby) ously and the woman should be referred for ur-
Significant weight changes No significant independent weight gent assessment by a psychiatrist or crisis team if
(not explained by pregnancy change indicated by her level of risk.
and delivery)
Women with personality disorders and those
Sleep changes (not explained Sleep disturbance who are drug abusing are particularly at risk of
by discomfort of pregnancy or
need to feed/settle an infant) developing depression. This may be the one time
that women will try hard to limit or cease their illicit
Psychomotor agitation or Minimal psychomotor signs
retardation drug and alcohol use, but as these substances
Decreased energy out of Decreased energy often mask underlying problems, ceasing them
proportion to other women at may result in depression emerging.
the same stage of pregnancy/
level of sleep disturbance Once the baby is born the woman may be
assessed using the Edinburgh Postnatal Depres-
Feelings of worthlessness/ Decreased concentration
guilt sion scale. If she has a score of 10 or more, a
Diminished concentration - more detailed psychiatric history is warranted.13

out of proportion to other
women at the same stage Bipolar Disorder
of pregnancy/level of sleep
disturbance Women with known bipolar disorder are strong-
Thoughts of death/suicide – Feeling overwhelmed, thoughts of ly advised to plan pregnancies and discuss their
often persistent suicide – usually fleeting management with their psychiatrist. They should
be closely monitored throughout pregnancy and
the postpartum period. Women with these disor-
during pregnancy; however, if there is no previous ders require management by a psychiatrist.
history of psychosis, this diagnosis is more often
seen postnatally. ASSESSING RISK–BENEFIT RATIO
Physical symptoms and the severity and Pregnancy is not a risk-free venture for anyone.
persistence of psychiatric symptoms are the keys Although worldwide maternal and child mortali-
to differentiating major depression from an ad- ty rates have decreased dramatically in the past
justment disorder. An adjustment disorder must century, fertility, a normal delivery and a healthy
occur within three months of delivery or other baby cannot be guaranteed and suicide remains
postpartum stressor and may have anxious and/ a leading cause of maternal mortality.14 Several
or depressed mood but not fit the criteria of a ma- risks exist that affect mother and fetus, including
jor depression (Table).12
those listed below.

Women with known bipolar disorder are strongly advised to plan pregnancies and discuss their management with their psychiatrist.
• Genetics may put the mother and/or fetus at Although there are large databases of in-
risk of a mood disorder. formation about the use of antidepressants in
• A current mood disorder in the mother is asso- pregnant women and the outcomes, numerous
ciated with less favourable obstetric outcomes confounding variables are present and no ran-
independent of medication use. domised controlled trials have been conducted in
• Being off medication might pose a risk of re- women who are pregnant. However, it is known
lapse to the mother, but being on it may pose that there is about double the rate of complica-
a risk to the developing child. tions (i.e. fetal death, miscarriage and teratogenic
In an ideal world, pregnant women would effects) in pregnant women taking antidepres-
be well and not taking any medications or other sants compared with those who are not.15 Also,
drugs, with a good support system and access to women taking antidepressants are more likely to
psychological therapies if needed for prevention be using multiple drugs or illicit drugs, drink al-
and treatment of mental illness. However, in the cohol (women taking antidepressants have been
real world women have unplanned pregnancies shown to have 10 times the rate of babies with fe-
or are in their late thirties or forties when they are tal alcohol syndrome compared with women not
planning pregnancies and do not have the luxury taking them),16 smoke, be overweight and have
of time to become well and medication free. Psy- diabetes – all of which impact negatively on the
chotherapy is not suitable for everyone, even if infant.
they can afford and access it, and in those wom- Studies have shown that pregnant women
en with severe illnesses, medication and elec- taking paroxetine have a higher rate of babies with
troconvulsive therapy can be important forms of heart defects, and babies of mothers taking fluox-
treatment. etine while pregnant have higher rates of a range

If the woman’s mood disorder is left untreated, there may be a risk to the fetus through the mother’s decreased care of herself.
of problems such as respiratory distress at deliv- There may be a higher risk of developmental
ery. 15,17,18
When considering which antidepressant delays, but genetics and current mood disorder
to start in pregnancy, if needed, sertraline is more play a part here too, and a current disorder is
appropriate if the women wishes to breastfeed. likely to have an influence through attachment
The serotonin–noradrenaline reuptake inhibitors and parenting styles, and there may be com-
are secreted at slightly higher levels in breast milk pensation over time.17 A full review of these
than other antidepressants and may not be first risks are available elsewhere17-19 and basic up-
choice unless indicated due to previous tolerance to-date patient information is available at www.
and efficacy issues. ppmis.org.au.
Both depression and the use of antidepressants are linked

to preterm birth
Both depression and the use of antidepres- If the woman’s mood disorder is left untreat-
sants are linked to preterm birth.16,17 Discontin- ed, there may be a risk to the fetus through the
uation syndrome is common but short-lived.19 mother’s decreased care of herself. In addition,

infants of anxious mothers have high cortisol lev-

els and maintain these throughout their life, which
may represent an already altered and vulnerable
stress response.20,21
The best evidence to date suggests preg-
nant women with a mood disorder need to stay
well, and if psychological therapies they are
using do not work or are not suitable then they
should be taking the minimum dose possible
of as few as possible psychiatric medications.
Overall, the average antidepressant doses used
appear to be relatively safe to the fetus. Ceasing
an antidepressant abruptly increases the risk of
relapse, and for many women continuing to take
medication may be the best option in the risk–
benefit balance.
A MULTIDISCIPLINARY
MANAGEMENT PLAN FOR WOMEN
WITH PRE-EXISTING MOOD DISORDERS
Pregnancy in women with mental illness is a time
for co-operation with the supporting family and
between medical professionals across several
specialties. GPs are at the forefront of day-to-day
management, with the back up of the obstetric, Pregnancy in women with mental illness is a time for cooperation with the
supporting family and between medical professionals.
paediatric and psychiatric teams.
Management of pregnant women with mood
disorders is a three-stage process. ing,24 and websites and brochures provided by the
Planning the pregnancy. In an ideal world,
• Black Dog Institute (www.blackdoginstitute.org.
the woman will be euthymic for at least a year au) and beyondblue (www.beyondblue.org.au).
with, in certain cases, medication withdrawn •
Implementation of an (ideally) predis-
or reduced before becoming pregnant. cussed management plan if the woman
Cognitive behavioural therapy (CBT) can becomes psychologically unwell through
be introduced at this time, either for the first time pregnancy. This needs to be individually tai-
or as a refresher in women with depressive and lored. Because of the risks of exposure to the
anxiety disorders. Supportive and couple therapy fetus from medication, psychotherapeutic in-
focusing on adjusting and planning for the post- terventions are often preferred by the women,
partum period is recommended. A meta-analysis although there has been limited evaluation
of preventive strategies suggests a small but sig- of their effectiveness in pregnancy. In cas-
nificant effect of several different therapies such es of bipolar disorder or severe depression,
as CBT, interpersonal therapy and medication. 22
medication and hospitalisation is likely to be
Recommended reading for the pregnant woman required. GPs should consider referring the
and her family include books such as Overcom- woman to a psychiatrist if her symptoms do
ing the Baby Blues23 and, for those who cannot or not settle quickly or are severe and/or there
do not wish to breastfeed, Guilt-Free Bottle Feed- are risk issues.

Key Points atrician. The role of the GP throughout this pe-

riod is to identify women with these disorders.
• Mood disorders often begin in pregnancy, particularly during the GPs should have a high index of suspicion
third trimester. that women will mask symptoms, not associ-
• Women with mood disorders often present with anxiety symptoms ate the pregnancy with the mood changes or
focused on the pregnancy and unborn child. think their symptoms will improve afterwards.
• Women may mask their symptoms, afraid of the stigma of being In addition, co-ordinating and ensuring ready
seen as a bad mother. and timely access to specialists is critical; GPs
• Stopping psychiatric medication, particularly abruptly, may not be can often organise urgent appointments with
in the best interest of the mother or fetus. specialists when their patients cannot.
• The risk–benefit ratio of treatment must be considered for the
mother and her unborn child, ensuring both parents are well- CONCLUSION
informed in order to make the best decision. Mood disorders are more common in pregnancy
•
Women with bipolar disorder or psychotic depression need than previously thought. Early intervention can
referral to a psychiatrist. prevent a more serious postpartum illness and
help smooth the transition to parenthood, improv-
ing outcomes for all family members.
Planning the delivery and postpartum
•
© 2015 Medicine Today Pty Ltd. Initially published in Medicine Today April
period. Women on high doses of antidepres- 2015;16(4):42–46. Reprinted with permission.
sant medication ideally should delivery at a

hospital with a neonatal intensive care unit, About the Author
Professor Buist is Professor/Director of Women’s Mental Health at Austin
and the baby will need assessment by a paedi- Health and the University of Melbourne, Melbourne, Vic.
REFERENCES
1. Wakeel F, Wisk LE, Gee R, Chao SM, Witt 2006;295:499–507. Diagnostic and statistical manual of mental 19. G albally M, Lewis AJ, Lum J, Buist A.
WP. The balance between stress and per- 7. Y onkers KA, Gottman N, Smith MV, et al. disorders. 5th ed. Arlington: APA;2014. Serotonin discontinuation syndrome
sonal capital during pregnancy and the re- Does antidepressant use attenuate the risk 13. Cox JL, Holden JM, Sagovsky R. Detec- following in utero exposure to antidepres-
lationship with adverse obstetric outcomes: of a major depressive episode in pregnan- tion of postnatal depression. Development of sant medication: prospective
findings from the 2007 Los Angeles Mom- cy? Epidemiology 2011;22:848–854. the 10 item Edinburgh Postnatal Depression controlled study. Aust N Z J Psychiatry
my and Baby (LAMB) study. Arch Womens 8. Viguera AC, Whitfield T, Baldessarini RJ, Scale. Br J Psychiatry 1987;150:782–786. 2009;43:846–854.
Ment Health 2013;16:435–451. et al. Risk of recurrence in women with bi- 14. King JF, Slaytor EK, Sullivan EA. Mater- 20. O’Connor TG, Heron J, Golding J, Bev-
2. Milgrom J, Gemmill AW, Bilszta JL, et al. polar disorder during pregnancy: prospec- nal deaths in Australia, 1997-1999. Med J eridge M, Glover V. Maternal antenatal anx-
Antenatal risk factors for postnatal depres- tive study of mood stabilizer discontinua- Aust 2004;181:413–414. iety and children’s behavioural/emotional
sion: a large prospective study. J Affect Dis- tion. Am J Psychiatry 2007;164:1817–1824. 15. Udechuku A, Nguyen T, Hill R, Sze- problems at 4 years. Report from the Avon
ord 2008;108:147–157. 9. Sockol LE, Epperson CN, Barber JP. The go K. Antidepressants in pregnancy: a Longitudinal Study of Parents and Children.
3. Kendell RE, Chalmers JC, Platz C. Ep- relationship between maternal attitudes systematic review. Aust N Z J Psychiatry Br J Psychiatry 2002;180:502–508.
idemiology of puerperal psychosis. Br J and symptoms of depression and anxiety 2010;44:978–996. 21. Ashman SB, Dawson G, Panagiotides
Psychiatry 1987;150:662–673. among pregnant and postpartum first- 16. Wisner KL, Sit DK, Hanusa BH, et al. H, Yamada E, Wilkinson CW. Stress hor-
4. G avin NI, Gaynes BN, Lohr KN, Melt- time mothers. Arch Womens Ment Health Major depression and antidepressant treat- mone levels of children of depressed moth-
zer-Brody S, Gartlehner G, Swinson T. Per- 2014;17:199–212. ment: impact on pregnancy and neonatal ers. Dev Psychopathol 2002;14:333–349.
inatal depression: a systematic review of 10. Hellmuth JC, Gordon KC, Stuart GL, outcomes. Am J Psychiatry 2009;166:557– 22. Sockol LE, Epperson CN, Barber JP.
prevalence and incidence. Obstet Gynecol Moore TM. Women’s intimate partner vi- 566. Preventing postpartum depression: a
2005;106(5 Pt 1):1071–1083. olence perpetration during pregnancy 17. Y onkers KA, Blackwell KA, Glover J, meta-analytic review. Clin Psychol Rev
5. O’Hara MW, Swain AM. Rates and risks and postpartum. Matern Child Health J Forray A. Antidepressant use in pregnant 2013;33:1205–1217.
of postpartum depression – a meta-analy- 2013;17:1405–1413. and postpartum women. Annu Rev Clin 23. Parker G, Eyers K, Boyce P. Overcom-
sis. Int Rev Psychiatry 1996;8:37–54. 11. Bilszta J, Ericksen J, Buist A, Milgrom J. Psychol 2014;10:369–392. ing the baby blues: a complete guide to
6. Cohen LS, Altshuler LL, Harlow BL, et Women’s experience of postnatal depres- 18. Ornoy A, Koren G. Selective serotonin perinatal depression. Sydney: Allen & Un-
al. Relapse of major depression during sion – beliefs and attitudes as barriers to reuptake inhibitors in human pregnancy: on win;2014.
pregnancy in women who maintain or dis- care. Aust J Adv Nurs 2010;27:44–54. the way to resolving the controversy. Semin 24. Morris M, Howard S. Guilt-free bottle
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GYNAECOLOGY PEER REVIEWED MIMS JPOG JUL/AUG 2015 145
How to Conduct
a ‘Heartsink’-Free
Menopause Consultation
Jane Elliott, MBBS
After more than a decade of confusion, HRT can be confidently prescribed again to
healthy women who have significant symptoms at menopause. Structuring consulta-
tions enables GPs to identify the women’s concerns and individualise their treatment
(if it is needed), and helps women to understand the fluctuations in symptoms they
are experiencing and the treatment they would like to receive.
INTRODUCTION managing the menopause, both from the

Caring for women at menopause is just International Menopause Society, have
one of many topics a busy GP needs to made assessing and managing women
be knowledgeable about. However, for the at this time of life clearer and less compli-
past decade managing menopause has cated and every GP can now be confident
been in the ‘too hard’ basket for many GPs again in caring for these women.1,2
because of the conflicting and confusing It can be helpful to have a structure
information presented both in the medi- in mind for consultations at which meno-
cal literature and to patients in the media. pause is discussed. This article provides
Recently published guidelines on meno- guidance about conducting menopause
pausal hormone therapy and a toolkit for consultations.

146 MIMS JPOG JUL/AUG 2015 GYNAECOLOGY PEER REVIEWED
Box 1. Menopause Websites for Health Professionals and Patients menopause comes as a big surprise that can be
quite distressing, patients often saying they ‘didn’t
• Australasian Menopause Society: www.menopause.org.au think it would happen to them.’ Despite several
• Jean Hailes: www.jeanhailes.org.au excellent sources of information available now
(see the Australasian Menopause Society [AMS]
• International Menopause Society: www.imsociety.org
website, www.menopause.org. au, and the Jean
Hailes website, www.jeanhailes.org.au), women
often say that they cannot find good information –
Box 2. Menopause Information Sheets perhaps partly because there is, disappointingly,
a lot of misinformation out there. Reliable sources
The Australasian Menopause Society (AMS) has information sheets of information on menopause are listed in Boxes
available for downloading from its website (www. menopause.org.au/ 1 and 2.
for-women/ information-sheets). These include: A GP should be able to give women evi-
• AMS guide to equivalent HRT doses dence-based information about menopause that
is individualised to each woman’s personal and
• Bioidentical hormones for menopausal symptoms
family history. Treatments offered also need to
• Complementary and herbal therapies for hot flushes
be individually tailored. It is important for all fe-
• What is menopause? male patients at this normal stage of life that their
• Diagnosing menopause GPs are comfortable and knowledgeable about
• Menopause and body changes how to care for them, regardless of whether they
have symptoms. Women are very grateful when
• Menopause – combined hormone replacement therapy
their own GP is willing to discuss this stage with
• Menopause – oestrogen only therapy them and offer options for treatment if needed.
• Mood problems at menopause The 45 to 49 year-old health check can be
• Nonhormonal treatments for menopausal symptoms used as an opportunity to proactively educate

women about menopause and prepare them for
it as well as managing any presenting issues they
may have.
HOW AND WHY DOES THE PATIENT
PRESENT WITH MENOPAUSE DIAGNOSING MENOPAUSE
PROBLEMS? Explain to a patient presenting with symptoms of
There are many reasons why women present to menopause about this time of her life. Points to cov-
their GP at the time of menopause. It is not un- er include the following:
usual for a woman to come to the consultation • The term menopause means a woman’s final
with a long list of symptoms and questions and menstrual period
the request that her GP ‘fix my life!’ This can be • It is a clinical diagnosis made only retrospec-
daunting if you have only a 15-minute consulta- tively after there has been no menstrual period
tion in which to manage her problems, and can for 12 months
lead to the feeling that menopause is all too dif- •
This final period (‘last menstrual period’ or
ficult. Often the women will have preconceived LMP) comes as the ovaries stop producing
ideas about what she is hoping to get out of the oestrogen
consultation, but she will not necessarily volun- • Only about 20% of women are asymptomatic,
teer this information unless directly asked. but these women are still at risk of longer term
There is still silence and ignorance in the chronic diseases such as osteoporosis due to
community about menopause. For many women the loss of oestrogen

• A proportion of the 80% of women who experi-

ence symptoms will find them debilitating and
that they impair quality of life – various treat-
ments can reduce these symptoms.
Women can present at any stage of the
perimenopause (less than 12 months since
LMP) or after menopause with a range of symp-
toms. Cycle irregularity is often one of the first
signals of the beginning of menopause. Other
symptoms may be present at this stage but it
is unnecessary and unhelpful to perform hor-
mone blood tests if a woman is in her 40s or
50s because hormone levels, symptoms and
bleeding patterns fluctuate widely throughout
the perimenopause.
Should a Menopause Symptom Score

be Used?
The list of symptoms attributable to decreasing and
fluctuating levels of oestrogen is long (see the AMS
information sheet Diagnosing menopause; this and
other sheets are available at www.menopause. org.
au/for-women/informationsheets) but the classic
common symptoms are:
• Vasomotor symptoms Cycle irregularity is often one of the first signals of the beginning of menopause.
• Joint aches and muscle pains
• Mood irritability
• Dry vagina. What Investigations and Tests
Women can present with many constellations are Required?
of these symptoms, and using a menopause rating Before considering options for treatment, check
scale can clarify whether the majority of a wom- that the woman is up to date with routine screens
an’s symptoms fit within the menopause cluster. A such as Pap smear and mammogram. Blood tests
symptom score is included in the previously men- are not essential and hormone blood tests can be
tioned AMS information sheet Diagnosing meno- positively unhelpful; exceptions are younger women
pause, and a version is reproduced in Box 3. with amenorrhoea or oligomenorrhoea in whom you
After it is established that menopause is suspect premature menopause and women who
the presenting issue, determine which three have had a hysterectomy or have a hormone (lev-
symptoms really matter to the woman and tell onorgestrel)-releasing intrauterine device fitted, as
her that you will initially focus on those. Women these women do not have the signal of menopause
may present with classic symptoms but other of changes in the menstrual cycle.
symptoms may be of more concern to them – Although not mandatory, it can be useful to
for example, they may be having hot flushes but update routine lipid and blood glucose measure-
their mood irritability or concern about a fami- ments and to consider other tests (e.g. thyroid
ly history of osteoporosis is more important to function tests and full blood evaluation), depend-
them. ing on history.

Box 3. Menopause Symptom Score Sheet*
AMS Diagnosing Menopause: Symptom Score Sheet
This valuable diagnostic tool can be completed together with the woman, or she can do it herself in the waiting room. The woman judges
the severity of her own symptoms and records the score - 1= for mild, 2 for moderate, 3 for severe and of course 0 if she does not have
that particular symptom. A score of 15 or over usually indicates oestrogen deficiency that is intrusive enough to require treatment, but
this is only a guideline. Women are very variable in their tolerance of discomfort, often tolerating quite severe symptoms before they will
even consider taking HRT. Scores of 20-50 are common in symptomatic women, and with adequate treatment tailored to the individual, the
score will reduce to 10 or under in 3-6 months.
Using the symptom score sheet at subsequent follow-up visits is a useful method of judging whether adequate oestrogen is being taken to
alleviate symptoms. Generally there is a halving of thesymptom score after 2-3 months on HRT and if the woman is still experiencing a lot of
symptoms, she may require a dose increase. If symptoms still persist, changing from the oral route to transdermal may help if the problem
is oestrogen malabsorption. Women with irritable bowel syndrome, or taking H2 antagonists commonly absorb oral oestrogen poorly.
SYMPTOM SCORE
Score Before 3 Months After
6 Months
HRT Starting HRT
Hot flushes
Light headed feelings
Headaches
Irritability
Depression
Unloved feelings
Anxiety
Mood changes
Sleeplessness
Unsual tiredness
Backache
Joint pains
Muscle pains
New facial hair
Dry skin
Crawling feelings under the skin
Less sexual feelings
Dry vagina
Uncomfortable intercourse
Urinary frequency
TOTAL
SEVERITY OF PROBLEM IS SCORED AS FOLLOWS

SCORE: None =0; Mild =1; Moderate =2; Severe =3
NB: The symptoms are grouped into 4 categories, vasomotor, psychological, locomotor and urogenital. If one
group does not respond to HRT, look for other causes and specific treatments for that group.
Not all of the symptoms listed are necessarily oestrogen deficiency symptoms.
© Australasian Menopause Society 2015 www.menopause.org.au
Abbreviation: HRT = hormone replacement therapy.
* Reproduced with the permission of the Australasian Menopause Society. Adapted by the AMS from the AMS
information sheet Diagnosing menopause (www.menopause.org.au/for-women/informationsheets).

As you send the patient away to have these symptoms benefit from being given information
checks, you can also give her information sheets about menopause.
on menopause or recommend reputable web- Start with information about basic physiolo-
sites (such as AMS or Jean Hailes) so she can gy at menopause, explaining the erratic fluctua-
become better informed. tions in hormone levels, symptoms and bleeding
in the perimenopause. This will help women un-
Does the Patient Require Further derstand that at a time they are ‘running out of
Consultations or Referral? oestrogen’, they may experience both symptoms
It is not usually necessary to refer a woman to a of low or high oestrogen levels and more ‘stable’
specialist for treatment of her menopause symp- or normal times. This is a ‘lightbulb’ moment for
toms. It is, however, necessary to give yourself many women who have been confused by the
time to manage the list of concerns. At the initial fluctuations they feel.
consultation, set the expectation with the patient
that you will need a further one or two long con- Lifestyle Treatments
sultations to do this properly, with regular follow All women at menopause can benefit from a review
up after that. of lifestyle factors for chronic disease prevention.
All women at menopause can benefit from a review of lifestyle

factors for chronic disease prevention
Also set expectations that any treatment of- Take the opportunity to discuss diet and weight
fered will not be a ‘quick fix’ but a plan for a reduc- management, exercise participation, alcohol
tion in symptoms. This sets the scene for patients intake and smoking cessation. These interven-
being patient and allowing any treatment several tions do not necessarily directly impact or reduce
months to become effective before being evaluat- symptoms, but if a woman is exercising, eating a
ed. Explain that it may be necessary to try several healthy diet and not smoking she may well feel
formulations/ options/medications to get the ‘right better and manage menopause better.
fit’. Similar to your explanation of why blood tests
to diagnose menopause are usually unhelpful, Addressing Psychosocial Issues
you can explain that you will be using symptoms, Menopause is not necessarily associated with de-
not blood tests, to monitor treatment success. pression but women who have a past history of
hormone-related mood issues (such as premen-
TREATMENT OPTIONS TO CONSIDER strual dysphoric disorder or postnatal depression)
AT MENOPAUSE can be more vulnerable at menopause to mood
Using lifestyle interventions and pharmacological issues or exacerbation of pre-existing depression.
options, it is possible in general practice to offer Be aware of the different presentation of depres-
most women wishing treatment at menopause an sion that can occur at menopause, which can in-
evidence-based range of options that are medically clude feelings of irritability, anger and hostility.
appropriate and also take into account the woman’s
beliefs and preferences. Pharmacological Treatments
It is appropriate to use medications to reduce the
Information Giving symptoms of menopause when:
Even women who do not require treatment for • Symptoms are moderate or severe and im-

HRT can be confidently prescribed by GPs to healthy women with significant symptoms around the time of menopause.
pact on function and/or quality of life • HRT consists of oestrogen to treat symptoms
• Benefits outweigh the known risks in the indi- and, for those with an intact uterus, proges-
vidual patient. terone/progestogen to prevent the oestrogen
Hormone replacement therapy (HRT) is the causing endometrial hyperplasia or cancer
‘gold standard’ treatment but there are nonhormo- • All HRT preparations have oestrogen every day
nal options that can be offered to women who have •
For women who have had a hysterectomy,
contraindications to HRT or prefer not to take it. oestrogen is all they need – ‘oestrogen-only
HRT’
Hormone Replacement Therapy • For women with a uterus, it is essential to pair
For over a decade inappropriate and conflicting the oestrogen with a progestogen
advice about HRT from various research and gov- •
Women who are still perimenopausal (i.e.
ernment bodies has made it difficult to counsel less than 12 months since LMP) should take
women who are considering using this treatment. the progestogen in a cyclical manner, giving
The Women’s Health Initiative trial in particular a monthly withdrawal bleed – ‘cyclical com-
caused confusion when research based on pre- bined HRT’
vention of chronic disease in older women was • Women who are postmenopausal should take
extrapolated to symptomatic younger women at the progestogen in a smaller dose daily, which
the time of menopause.3 The confusion has now does not give a bleed – ‘continuous combined
been clarified, and HRT can again be confidently HRT’.
prescribed by GPs to healthy women with signif- The AMS information sheet AMS guide to
icant symptoms around the time of menopause. HRT equivalents provides a guide to the different
Basic principles regarding prescribing HRT HRT preparations available in Australia in April
include the following: 2015.

Nonhormonal Pharmacological Options Key Points

Nonhormonal options for treating symptoms of
menopause include selective serotonin reuptake • Plan to manage the woman’s concerns about menopause over
inhibitors (SSRIs; off-label use for menopause two or three long consultations.
symptoms other than anxiety and depression), • Take time to listen to the patient’s individual list of menopause
serotonin and noradrenaline reuptake inhibitors symptoms and concerns so you can personalise advice. Initially
(SNRIs; off-label use for menopause symptoms focus on the woman’s top three symptoms of concern.
other than anxiety and depression), gabapentin • Use a menopause rating scale to evaluate symptoms.
(off-label use) and clonidine (TGA indicated for
• Update routine checks and perform any required tests based on
the treatment of menopausal flushing). Details symptoms. Hormone blood tests are unnecessary.
are available in the AMS information sheet Non-
•
Include information and lifestyle advice for all women and
hormonal treatments for menopausal symptoms. hormone replacement therapy (HRT) or nonhormonal options for
symptomatic women.
IMPORTANT ASPECTS OF THE
• Review all women taking HRT or any other therapy at menopause
MENOPAUSE CONSULTATION at least yearly.
Important aspects of the menopause consultation
• Use the 45 to 49 year-old health check to proactively educate
not to be missed are listed below.
women about menopause.
•
Not all cycle irregularity at menopause is
•
Remember about the increased risk of osteoporosis after
normal. It is important not to automatically at-
menopause.
tribute all irregular bleeding to perimenopause
(new menorrhagia, intermenstrual bleeding and
postcoital bleeding should be investigated).4
Contraception may still be required for pa-
• SPECIALIST REFERRAL
tients who are sexually active. Contracep- Ideally a woman’s own GP, who has knowl-
tion should be offered to all women under 50 edge of her past history and a good aware-
years of age until two years post-LMP and for ness of her family and social situation, is
women over 50 years for one year post-LMP. 5
the best person to offer assistance at men-
• What about symptoms that persist despite opause. Also, the general medicine back-
adequate treatment? If a woman presents ground of GPs enables them to manage the
with a long list of symptoms at the usual age multiple systems of the body that are affected
of menopause then it is sometimes difficult to at menopause.
work out what is related to decreasing levels Some menopause patients have more
of oestrogen and what potentially could be complex problems, and it is reasonable to
due to other causes. As long as you have refer them to a menopause specialist. Meno-
done basic investigations for any symptoms, pause is an area of special interest for some
it is reasonable to treat the menopause and GPs, some gynaecologists and some endo-
see what is left. If vasomotor symptoms for crinologists.
instance persist despite adequate HRT then To tell a woman that this is a natural stage
there is a long list of rare causes and drugs and she should just put up with it, which has
that can cause hot flushes. It is not necessary been some women’s experience, is unreason-
to investigate for all of these in an otherwise able and poor patient care, given that symp-
healthy woman at menopause before initiating toms can last for many years. Often an initial
HRT. If symptoms persist despite adequate consultation with a menopause specialist can
treatment, it may be time to investigate or refer put a woman on the right track, and GP follow
to a menopause specialist. up is then appropriate.

FACILITATING INFORMED There is no set minimum or maximum duration

DECISION-MAKING for using HRT. Every few years consider either re-
I am often asked whether I ‘believe in’ HRT, as ducing the dose of HRT to see whether a lower
though treatment for menopause is a belief sys- dose would still cover symptoms or ceasing the
tem rather than an evidence-based area of medi- therapy if several years have passed since start-
cine. No one has ever asked me as a GP whether ing it. If symptoms return, discuss with the patient
I ‘believe in’ treatment for diabetes or asthma! the HRT risks and benefits individualised for her
The GP’s task, once the patient’s agenda (her top updated personal and family history.
three issues initially), check-ups and any possible
contraindications have been reviewed, is to give CONCLUSION
the patient verbal and written information about Menopause is a common presentation in gener-
options for treatment and allow her to make up al practice and can be challenging for both the
her own mind. Checking what she was hoping to GP and the woman experiencing the symptoms.
get out of her consultations with you and what her Patients appreciate their GP taking time to lis-
particular concerns are will help inform the discus- ten to their particular experience of menopause
sion. This personalising of your advice creates a and individually tailoring information and evi-
much more meaningful decision-making process. dence-based options for treatment. GPs should
Many women will have tried or want to try plan menopause management over several con-
complementary and alternative medicines. As sultations to give themselves time to manage the
with any other area of medicine, it is important list of concerns and update routine check-ups
to stick to the evidence and steer people away and to give patients the time to digest information
from sometimes costly, often ineffective and about options for treatment.
sometimes risky therapies. The AMS information After a decade of confusion, new guidelines
sheets Complementary and herbal therapies for are available to assist in safely prescribing HRT
hot flushes and Bioidentical hormones for meno- again to healthy women at the time of meno-
pausal symptoms can be of help in explaining to pause. Several nonhormonal prescribed medi-
patients why you would not advise these forms cations are also effective at reducing symptoms.
of therapy. Patient expectations should include gradual re-
duction in symptoms and the need to tailor treat-
FOLLOW UP – YEARLY REVIEW ments over time.
All women taking HRT or any other therapy at
© 2015 Medicine Today Pty Ltd. Initially published in Medicine Today May
menopause should have at least an annual follow 2015;16(5):27–33. Reprinted with permission.
up consultation to update their medical history,

determine any need for further investigations and About the Author
Dr Elliott is a General Practitioner in Adelaide, SA, with a special interest
generally review the treatment they are taking, in menopause; a Clinical Lecturer in Obstetrics and Gynaecology at the
University of Adelaide; and the Past President of the Australasian Meno-
taking into account the latest available evidence. pause Society.
REFERENCES
1. de Villiers TJ, Gass MLS, Haines CJ, Hall 3. Langer RD, Manson JE, Allison MA. Have Gynaecologists, Cancer Australia National cc/5ex3ux (accessed May 2015).
JE, Lobo RA, Pierroz DD. Global consensus we come full circle – or moved forward? Centre for Gynaecological Cancers. Ab- 5. Bateson D, Harvey C, McNamee K.
statement on menopausal hormone thera- The Women’s Health Initiative 10 years on. normal vaginal bleeding in pre-, peri- and Contraception: an Australian clinical prac-
py. Climacteric 2013;6:203–204. Climacteric 2012;15:206–212. post-menopausal women. A diagnostic tice handbook. 3rd ed. Brisbane: Family
2. Jane FM, Davis SR. A practitioner’s 4. Royal Australian and New Zealand Col- guide for general practitioners and gynae- Planning New South Wales, Family Plan-
toolkit for managing the menopause. Cli- lege of Radiologists, Royal Australian and cologists. Canberra: Commonwealth of ning Queensland, Family Planning Victo-
macteric 2014;17:564–579. New Zealand College of Obstetricians and Australia; 2011. Available from: http://tiny. ria;2012.

SPECIAL FEATURE WORLD BREASTFEEDING WEEK MIMS JPOG JUL/AUG 2015 SF1
• WHO recommends exclusive

breastfeeding for the first six
months of life
• Breastfeeding reduces the risk

of breast and ovarian cancer
in women
• At six months of age, mashed

solid foods should be introduced
as a complement to breastfeeding
World Breastfeeding Week

August 1-7

SF2 MIMS JPOG JUL/AUG 2015 SPECIAL FEATURE WORLD BREASTFEEDING WEEK
JOURNAL REPORTS
Is breastfeeding really better than formula feeding?

Despite extensive public health campaigns emphasizing the
long-term importance of breastfeeding for a number of in-
fant outcomes, researchers are now questioning whether the
evidence underpinning these campaigns may be biased by
disparities in feeding practices based on race and socioeco-
nomic status.
In a recent modelling study, US-based researchers an-
alysed data derived from 11,504 children of 4,932 female
respondents from the National Longitudinal Study of Youth,
1979 Cohort (NLSY79) study. They based their analysis on 25
years of data (1986 through 2010) and assessed eleven out-
come measures, including three pertaining to physical health
(body mass index, obesity, asthma), three behavioural indi-
cators (hyperactivity, parental attachment, behavioural compli-
ance), and five predictors of academic achievement (reading
comprehension, vocabulary recognition, math ability, memory
based intelligence, and scholastic competence).
Standard regression models revealed significantly better They concluded that disparities in infant feeding practic-
outcomes for ten of the eleven measures among breastfed, as es based on demographic characteristics may be driving the
opposed to bottle fed, infants. However, when the researchers observed differences and noted that much of the empirical ev-
limited their analysis to data from siblings (7,319 respondents idence regarding the benefits of breastfeeding does not ade-
from 3,153 families, including 1,773 siblings from 665 fami- quately address the high degree of selection into breastfeeding.
lies with discordant feeding practices) and incorporated with-
in-family fixed effects, none of the differences in these meas- Golen CG and Ramey DM. Is breast truly best? Estimating the effect of breastfeeding on
long-term child wellbeing in the United States using sibling comparisons. Soc Sci Med. 2014
ures remained statistically significant. May;109:55–65.
Breast-and formula-fed infants have different lipid profiles
The lipid profiles of breast- and formula-fed infants are sig-

nificantly different at age 3 months but these differences are
attenuated over time.
In a recent analysis, researchers used high-resolution
mass spectrometry to evaluate dried blood spot samples col-
lected from infant participants in the Cambridge Baby Growth
study at ages 3 (n=241) and 12 (n=144) months. They com-
pared the lipid profiles of infants who were exclusively breast-
fed, infants who were exclusively formula fed, and infants who
were fed a mixture of breast milk and formula, and related the
lipid profiles to weight at age 12 months.
Breast-fed infants were found to have lower levels of short

JOURNAL REPORTS
chain unsaturated phosphatidylcholines (PCs) and higher lev- and female infants at 3 or 12 months of age. However, levels of
els of long chain polyunsaturated PCs than formula-fed infants PC (34:1) and PC-O (34:1) at age 3 months were positively as-
at age 3 months; they also had higher levels of cholesterol sociated with infant weight at both 3 and 12 months and were
esters. The mixed-feed infants had intermediate lipid profiles. lower in exclusively breast-fed infants.
These differences were no longer evident at age 12 months,
Prentice P et al. Lipidomic analyses, breast- and formula-feeding, and growth in infants. J Pediatr
and no significant differences were observed between male 2015;166:276-281.
Maternal obesity linked to non-initiation of breastfeeding
New targeted interventions are needed during the pre- and

postnatal period to support pregnant women who are classi-
fied as obese as the rate of non-initiation of breastfeeding is
two-fold higher in these women, say researchers in Canada.
In their study, they evaluated the incidence of breast-
feeding initiation in the post-partum period according to ma-
ternal pre-pregnancy body mass index (BMI) in a birth cohort
of 7,866 women aged 18 or older who delivered a singleton
infant in Quebec City between March 2005 and April 2010.
Data from 6,592 women were included in the final analyses.
In addition, data on prenatal non-intention to breastfeed were
collected from patients who gave birth between 2009 and
2010.
A total of 4,105 (62.3%) women included in the study were
classified as normal weight according to their pre-pregnancy
BMI and 833 (12.6%) as obese. Non-initiation of breastfeed-
ing during the postnatal hospitalisation period was observed
in 20% of obese mothers compared with 12% of normal weight
mothers. The relative risk (RR) of not initiating breast feeding graphic factors (RR 1.22, 95% CI 1.04–1.42). A stated prenatal
was almost two-fold higher among the obese women com- intention to not initiate breastfeeding was also strongly associ-
pared with those who had a normal BMI before pregnancy ated with non-initiation regardless of BMI.
(1.69, 95% confidence interval [CI] 1.44–1.98). The greater risk
Verret-Chalifour, J et al. Breastfeeding initiation:impact of obesity in a large Canadian perinatal
remained even after adjustment for prenatal and sociodemo- cohort study. BMC Public Health 2013,13:1070
Does breastfeeding reduce the risk of cardiovascular mortality?
Women who have given birth but who have not breastfed duration of breastfeeding and cardiovascular mortality among
their infant have a higher rate of cardiovascular mortality than 20,007 women aged 30–65 who were participants in a popu-
women who have breastfed, according to a recent study in lation-based prospective cohort study– the second Nord-Trøn-
Norway. delag Health Survey (HUNT2), which was performed between
Researchers studied the association between the lifetime 1995 and 1997. Data on mortality rates were collected from

JOURNAL REPORTS
the Cause of Death Registry (which was linked to the HUNT2

cohort) through to 2010.
In total, 96.7% of the women had breastfed at least
one infant; 1,246 women died as a result of cardiovascu-
lar disease. Women who were younger than 65 and who
had given birth but never breastfed an infant had a higher
cardiovascular mortality rate than those with a lifetime dura-
tion of breastfeeding of 24 months or greater (hazard ratio
[HR] 2.77, 85% confidence interval [CI] 1.28–5.99). Women
who had breastfed for 7–12 months had the lowest risk of
cardiovascular mortality, which was almost half the risk of
those who had breastfed for ≥24 months (HR 0.55, 95% CI
0.27–1.09).
The researchers conclude that further studies are neces-
sary as it is unclear whether breastfeeding has a protective ef-
fect against cardiovascular disease.
Fagerhaug TN et al. A prospective population-based cohort study of lactation and cardiovascular

disease mortality: the HUNT study. BMC Public Health 2013,13:1070.
Substantial improvement in breastfeeding rates in Cambodia
Rates of early initiation of breastfeeding and of exclusive

breastfeeding increased substantially in Cambodia between
2000 and 2010, but the increasing availability and use of
breast milk substitutes is of concern.
According to a cross-sectional analysis of data from
15,000 households included in the Cambodia Demographic
Health Surveys conducted in 2000, 2005, and 2010, rates of
exclusive breastfeeding among infants aged 0–5.9 months
increased from 11.1% in 2000 to 73.5% in 2010. Similarly,
65.8% of infants were breastfed within an hour of birth in 2010
compared with 11.1% in 2000. The practice of prelacteal feed-
ing declined over the same time period. In contrast, the use of
breast milk substitutes doubled between 2000 and 2005 (from
3.5% to 7%), particularly among women who gave birth in
private clinics. Public health campaigns promoting exclusive
breastfeeding may have halted the trend as numbers plateau-
ed between 2005 and 2010 among infants under 6 months
of age.
However, the use of breast milk substitutes increased
among children aged 6–23.9 months (4.8% in 2000 vs 9.3%
Prak S et al. Breastfeeding trends in Cambodia, and the increased use of breast-milk substitute—
in 2010). why is it a danger? Nutrients 2014;6:2920-2930.

A Review of Evidence
Around Postnatal Care
and Breastfeeding
Denis Walsh, RM MA PhD
Postnatal care and support for breastfeeding has been central to the United Kingdom
maternity care provision for over 100 years. Over that time the burden of care has
shifted from home to hospital and back to home again. In the last 10 years, an evi-
dence base has been distilled around the key components of optimum postnatal care
and breastfeeding support but the implementation of these has been hampered by
an ongoing tensions between a biomedical and social model and by changes in the
organization of community postnatal care. These issues are discussed in this paper
which concludes with some new developments in care provision.
INTRODUCTION The United Kingdom (UK) is unu-

Like all areas of childbirth care, postna- sual among western countries in having
tal care and breastfeeding support has a universal model of home visiting fol-
changed dramatically over the past 20 lowing birth, undertaken by community
years, especially in the western world. midwives. This model has been in place
In this paper, these changes will be de- since the early 1900s and coincided with
tailed and appraised. midwifery regulation and high rates of

Table 1 Canada and the USA have begun adopting a sim-

ilar model, calling them postnatal outreach pro-
grammes. The notable exceptions to this are The
Social Model Biomedical Model
Netherlands and New Zealand. The former adopt-
Whole person - physiology, Reductionism - powers, ed a national provision of independent group
psychosocial, spiritual passages, passenger
practices of primary care midwives servicing an
Respect and empower Control and manage extensive homebirth provision (around 30% na-
Relational/subjective Expertize/objective tionally) which continues to this day. Following
innovative legislation in New Zealand in the mid
Environment central Environment peripheral
1990s, a similar model was established there with
Anticipate normality Anticipate pathology
midwives being paid per mother booked.
Art Science
Local/community Centralized institution DEFINING THE PUERPERIUM
The traditional definition of the puerperium is the
Technology as a servant Technology as a partner
time from immediately after the end of the labour
Celebrate difference Homogenization
until the reproductive organs have returned as
Trust Risk nearly as possible to their pre-gravid condition,
Institution/meaning-making Guidelines/objective facts a period estimated to be around 6 to 8 weeks,
though there is debate over this. (Recent research
Connection Separation
suggests that adaption to motherhood and recov-
Feminine (matrescence) Masculine (paternalism)
ery from childbirth can take much longer.)
Self actualization Safety The Nursing & Midwifery Council for the UK
define the postnatal period as ‘the period after the
end of labour during which the attendance of a
midwife upon a woman and her baby is required,
homebirth. In the 1970s, when birth moved into being not less than 10 days and for such longer
maternity hospitals following the recommenda- period as the midwife considers necessary’.
tions of the Peel Report, community midwifery
services changed to largely providing an antena- UNDERPINNING MODELS
tal/postnatal service. The demand for postnatal OF CHILDBIRTH PROVISION
home services has increased as in-patient stays Changes in childbirth practices around an-
following hospital birth decreased, particularly tenatal and labour care are reflected to some
since the 1990s. This change shifted the burden extent in postnatal care. One of the most signifi-
of breastfeeding support to the community as cant and most widely written about has been the
women choosing to breastfeed have barely es- medicalization of childbirth that has contributed to
tablished feeding by discharge from hospital. increasing rates of caesarean section, induction
As already mentioned, the model of an in- of labour and epidural use. Advocates for normal
frastructure of primary care based maternity care birth have blamed the hospitalization of birth for
professionals, offering antenatal and postnatal also ‘pathologizing’ it, lead by increasing obstet-
care is not common in other western countries, ric involvement in antenatal and intrapartum care.
where, in the main, women self care initially up Obstetrics would point to concerns over neonatal
to 2 weeks postnatal following discharge from and maternal mortality as drivers for intervention.
hospital before accessing healthcare workers fo- The truth probably can be found somewhere be-
cussed on child health and development. In the tween these two views. Nevertheless there re-
past 10 years, some services in Australia, Ireland, mains tension over the primary model that should

be driving provision and these can be conceptu- Table 2

alized as a social or a biomedical model of care.
Below (Table 1) is how sociologists and mid-
Biomedical Model Social Model
wives have contrasted the differences between
the two models:
Physical care Emotional care
The aspects of these models that apply to Checking Supporting
postnatal care include the tensions between ho- Specialized skills Enabling innate skills
listic and patient-led needs assessment and the
Task-oriented focus Focusing on parenting
expert compartmentalizing assessment into phys-
iological systems e.g. genito-urinary, gastrointes- Circumscribed duration of Ongoing/tailing off contact/
contact linking to a social network
tinal, cardiovascular. There could also be tension
between affirming physiological processes of
adaption to motherhood and early recognition of
pathology. To some extent this tension is also re- care was quite ritualized and postnatal wards
flected in differences between trust and fear in the were run rather like military establishments with
professional attitude to the phases of birth. professional hierarchies, division of tasks and
Specifically in relation to postnatal care, timeregulated routines. Community midwives had
Walsh and Newburn suggest differences between more flexibility and autonomy in how they carried
the two models (see Table 2). out their care, though patterns of care were still
Their critique was aimed at ritualized and systematized according to standard note-keeping
routine in-patient hospital care that was premised proformas.
around a ‘top-to-toe’ physical checks of mother Since the early 1990s and in response to
and baby daily, though expected to be done by the publication of Changing Childbirth, continuity
the daytime ward shift and a similar regime after models were piloted in many centres across the
discharge home undertaken by community mid- UK. Though these all attempted to address conti-
wives on their round of visits. This model prior- nuity of care, they differed significantly in how they
itized physical assessment and advice giving by were organized. Caseload midwifery has been one
an expert. By way of contrast they suggested that of the most enduring and most heavily researched.
a social model would approach care more holisti- This model is based on an individual midwife or a
cally, responding to the mothers expressed needs small group practice of up to four midwives hav-
and mediating care through a relationship of ing a discrete caseload of women, usually booked
mutual respect and compassion. from the geographical area she/they cover(s). The
caseload midwife or group practice undertakes
ORGANIZATION OF POSTNATAL CARE all the care of women who at low obstetric risk or
Whether postnatal care is premised on a social share(s) care with an obstetric team if women have
or biomedical model is reflected in how midwives complications. In other words, a key component
organize themselves to undertake this care. Tra- of this model is intrapartum continuity, requiring
ditionally, hospital and community midwives community midwives to go on-call. This model has
worked in their respective environments to pro- been evaluated very positively, both in terms of
vide postnatal care and rarely crossed each other clinical outcomes and user satisfaction.
boundaries. Arguably this fragments the experi- Another variant of continuity is where com-
ence for women who have repeatedly complained munity midwives rotate into midwifery units for
about inconsistent advice regarding baby care intrapartum shifts. This does not deliver as tighter
and breastfeeding with these differences noted model of continuity because they may not be car-
between hospital and home. Hospital postnatal ing for their own women.

in the medicalization of childbearing; this provid-

ed a rationale for extended postnatal visiting and
care. However, since 2000, the number of visits
and the time spent visiting at home has actually
decreased.
CONTENT OF CARE
The constituents of the postnatal check have
varied little over the decades. The National Insti-
tute for Clinical Excellence (NICE) Guidelines is-
sued in 2006 state that the following routine care
should be offered by the midwife.
• Within the first 24 hours after birth, the blood
pressure (BP) should be checked once with-
in 6 hours of the first immediate post-birth BP.
Urine should be voided within 6 hours and all
women should be encouraged to mobilize.
• Between 2 and 7 days, women should be of-
fered information and reassurance about per-
ineal pain and perineal hygiene, urinary incon-
tinence and micturition, bowel function, fatigue,
headache, back pain, normal patterns of emo-
tional changes and contraception. There should
also be an enquiry into the woman’s general
From 2 to 8 weeks after birth, resumption of sexual activity should be discussed. health.
• From 2 to 8 weeks, resumption of sexual activi-
Both these models aim to reduce the num- ty should be discussed as well as advice given
ber of different carers a woman has in all phases if any concerns are raised about issues in bul-
of her care. For postnatal care, this would ideally let point 2. Finally a health profession should
be one or two as the number of visits a woman review the woman’s physical, emotional and
gets postnatally has traditionally been about four. social well-being at 6 to 8 weeks.
Studies performed in the early 1990’s by
sociologists uncovered the continuing health In practice, midwives tend to be more pre-
inequalities and struggles for women in poor- scriptive than this and a typical postnatal check in
er socioeconomic groups. Other studies also hospital could include the following:
demonstrated the continuing discrimination • Palpation of the abdomen to ascertain involu-
against childbearing women who were labelled tion of the uterus
as ‘neurotic’ and diagnosed as having ‘depres- • Enquiry into vaginal loss and characteristics of
sion’ when this was almost certainly the result of lochia
the major adaptations required of women without • Examination of the perineum if there has been
an infrastructure of support that earlier genera- trauma
tions had access to. Research performed in the • Enquiry into elimination patterns (micturition
1990s indicated that a psychiatric approach to and defaecation)
unhappiness and distress in the postnatal peri- • Encouraging mobility so as to lower the risk of
od may increase the iatrogenesis already seen deep vein thrombosis

• Enquiry about the breasts related to engorge-

ment and/or feeding issues.
Each aspect of this more hand-on ap-
proach has been questioned. Bick and col-
leagues’ text on postnatal care is still the de-
finitive text for an evidence-bases approach to
the clinical components of postnatal care. They
challenged the notion that uterine involution is
linear and predicable in each women, noting
significant differences in the shrinking of the
uterus and in the characteristics of lochia. They
concur with NICE guidelines on postnatal care,
i.e. that involution should only be palpated if
there is a concern about endometritis and ab-
normal blood loss. A problem-based approach
can also be applied to other aspects of postna-
tal care, including perineal pain. They suggest
establishing a baseline observation of the peri-
neum to assess bruising, extent of trauma and
healing but from then on only to examine if the
woman expresses concern. Post-birth voiding
has been scrutinized by uro-gynaecologists
in recent years, with some hospitals introduc-
ing specific measures to ensure the bladder is Breastfeeding protects babies against gastrointestinal, urinary, respiratory and
emptied completely. These include accurate middle ear infection.
measurement of post-birth voids within 6 hours
of the birth and catheterization if voiding is not caesarean section wound care and breastfeed-
achieved. However, this intervention will only ing. They make a helpful distinction between
be required occasionally. Regarding bowel postnatal blues, postnatal depression and puer-
elimination, the problem-based approach cen- peral psychosis with increasing severity of clinical
tres on advice and treatment for constipation, features and increasing need to respond rapidly
painful/bleeding haemorrhoids, faecal urgen- to them as they escalate. Arguable, as Caesarean
cy/incontinence and anal sphincter injuries. rates climb, there needs to be increasing aware-
General principles here are to encourage ade- ness and vigilance with regard to wound compli-
quate fluids, a high fibre diet and optimum pain cations (infection is the principal one).
management.
Bick and colleagues due remind us of the BREASTFEEDING
common and underrecognized complaints of The evidence on the benefits of breastfeeding
tiredness, headache and backache following is beyond argument. Year upon year, new ev-
childbirth with a number of practical sugges- idence supports its benefit, with the latest be-
tions to address these. I would refer readers to ing breastfeeding’s link to reduced behaviour-
their helpful evidence based leaflets included in al problems in children. It has already been
the 2nd edition of Postnatal Care: Evidence and established that breastfeeding protects babies
Guidelines for Management. Their leaflets cover against gastrointestinal, urinary, respiratory and
depression and other psychological morbidity, middle ear infection and, if there is a family his-

breastfeeding, seen most visibly through the

Baby Friendly Initiative (BFI). This initiative came
from the WHO and UNICEF and was launched in
1992. Maternity hospitals achieve accreditation
by meeting 10 standards. These are:
1. Have a written breastfeeding policy that is rou-
tinely communicated to all healthcare staff
2. Train all healthcare staff in the skills necessary
to implement the breastfeeding policy
3. Inform all pregnant women about the benefits
and management of breastfeeding
4. Help mothers initiate breastfeeding soon after
birth
5. Show mothers how to breastfeed and how to
maintain lactation even if they are separated
from their babies
6. Give newborn infants no food or drink, other
than breast milk, unless medically indicated.
7. Practice rooming-in, allowing mothers and in-
fants to remain together 24 hours per day
8. Encourage breastfeeding on demand
9. Give no artificial teats or dummies to breast-
feeding babies
Training all health care staff in the skills necessary to implement breastfeeding 10.
Foster the establishment of breastfeeding
is important. support groups and refer mothers to them on
discharge from the hospital or clinic.
tory, atopic disease as well as juvenile-onset There is some evidence that this program in-
insulin-dependent diabetes. In addition, breast creases breastfeeding uptake and ongoing rates.
fed babies are less prone to obesity. The ma-
ternal benefits include reduced risk of premeno- EVIDENCE-BASED APPROACHES
pausal breast cancer and some forms of ovarian TO BREASTFEEDING PROBLEMS
cancer. Despite this evidence, breastfeeding in Bick et al have a helpful leaflet in their book on
the UK is relatively low compared with other de- these issues. They list painful nipples, engorge-
veloped world countries. Initiation rates are be- ment, insufficient milk, thrush/ infective mastitis/
tween 70 and 80% but fall away markedly in the breast abscess, blocked milk duct, noninfective
early postnatal weeks. mastitis and inverted or non-protractile nipples
The most common reasons given for stop- in their list and provide recommendations for all
ping breastfeeding include: based on best available research. Sore nipples
• The baby not sucking or rejecting the breast are caused by poor positioning of the baby on
• An insufficient milk supply the breast and should not be treated with topical
• Suffering with painful breasts or nipples preparations. If the areola is engorged, the moth-
• That breastfeeding took too long or was too er may need to express milk before a feed. Simple
tiring. analgesia like paracetamol may be required and
Both national policy initiatives and nation- unrestricted feeding will help relieve the problem.
al guidelines have, in recent years, prioritized Concerns about insufficient milk are best ad-

dressed by demand feeding, emphasizing the im- Practice Points

portance of fore milk and hind milk. There should
be no limit on the duration of feeds and obser- • Postnatal care is increasingly situated in the primary care setting.
vation made on the positioning and attachment
• There is a substantial evidence base for the treatment of common
of the baby to the breast. If there are concerns postnatal problems.
that the breast tissue is inflamed and/or infected,
• The Baby Friendly Initiative increases breastfeeding awareness,
referral to a medical practitioner should be made. breastfeeding support and tentatively breastfeeding rates.
Flat or inverted nipples are not a contraindication
• There is lack of evidence regarding where postnatal advice from
for breastfeeding.
the maternity services should be hosted.
Other additional guidance for breastfeeding
• Postnatal care should embrace a social model of health, rather
includes avoiding supplements. These should
than a medical model.
only be given if medically indicated. Skin-to-skin
should be encouraged immediately following • Women should direct the priorities around postnatal care.
birth as this have been shown to increase breast-
feeding rates.
Finally in this section, biological nurture has recommended that the community midwife should
been suggested as the best approach to breast- be encouraged to undertake a comprehensive
feeding initiation. This draws on observation data health assessment at 10 to 12 weeks and that this
suggesting that semi-reclined maternal positions should effectively replace the 6-week postnatal
draw out what have been referred to as primitive check traditionally undertaken by the GP, howev-
neonatal reflexes (rooting, sucking, swallowing), er, this recommendation was not taken up by the
thus releasing maternal instinctual behaviours. NICE guideline. The NICE guideline was not pre-
Conventional wisdom has it that the human ne- scriptive about the number of visits women would
onate is a dorsal feeder with pressure needed be offered, despite MacArthur’s finding that wom-
Postnatal care should embrace a social model of health,

rather than a medical model
along the baby’s back. However, observational en valued regular contact with their community
research suggests that the newborn is an ab- midwife. In practice, local services have begun
dominal feeder and displays anti-gravity reflexes rationing the number of visits under the slogan
which aid latching. Breastfeeding initiation may of ‘selective visiting’, based on the premise that
therefore be innate for mother and baby and not healthy women do not require as much support.
learned, thus challenging the routine skills-teach- Community midwives are encouraged to assess
ing currently central to breastfeeding support. the need of individual women and then adjust the
This has led to advice to immediately place the number of visits according to need. Anecdotally,
baby prone on the mother’s abdomen after birth, many community midwives have said that they
from where the baby will latch onto the breast with are being performance managed on reducing the
minimum coaxing. number of visits to three maximum/ woman. This
pressure to reduce the amount of home visiting is
NEW MODELS OF COMMUNITY driven by the need to reduce costs.
POSTNATAL CARE More controversially, community midwives
MacArthur’s cluster randomized controlled trial are now being required to offer women a choice

of whether they want a visit at home or come to CONCLUSION

community centre (either health centres or chil- Postnatal care in the UK has evolved over the past
dren’s centres) where effectively a postnatal clin- 20 years and now differs in both organization and,
ic is being held by the midwife. This change has to a less extent, in content from the 1980’s. These
been introduced without any evidence that wom- changes mirror an ongoing tension between a
en would prefer this model. Again, financial pres- social and biomedical model. The former looks
sures appear to be the motivation; a community to women themselves to prioritize and take steps
midwife has less travelling time if she sees a num- to meet their own needs as they define them,
ber of women in the same facility than travelling with the professionals facilitating this process for
to their individual homes. Ironically, other western them. Learning from each other and learning in
countries have started introducing home postna- groups are some of the changed structures that
tal visiting premised on what they perceive as an this ireflects.
excellent UK model. Nevertheless, a biomedical focus remains,
Changes in community care since 2006 in- especially in hospital, despite the dramatic fall in
clude the advent of maternity care support work- postnatal stays. The biomedical focus seeks to
ers to supplement and support the community identify signs of early complications like infection
midwife’s role. Their role concentrates on breast- and to ensure prompt treatment. Like other areas
feeding support, practical help around the home, of childbirth, rare catastrophic outcomes such as
the undertaking of screening tests and referral on puerperal sepsis leading to maternal death tend
to the midwife if there are concerns. Their role has to drive this focus.
been evaluated positively at pilot sites and is cur- Breastfeeding promotion is still the corner-
rently being rolled out across the country. Howev- stone of public health policy in the UK. Recent
er, there is no evidence that they free up communi- guidance urges exclusive breastfeeding for 6
ty midwives’ time, for midwives to spend more time months. There are now well established evi-
with the vulnerable and ‘hard to reach’ groups. dence-based guidelines for breastfeeding advice
Centering pregnancy is another innovation which maternity care professionals should be fol-
that is being piloted in the UK after successful lowing.
evaluation in the USA and Australia. Relying more
on a social model, centering pregnancy is based Further Reading
1. Bick D, MacArthur C, Knowles H, Winter H. Postnatal care: evidence
on the principle of community engagement of and guidelines for management. London: Churchill Livingstone, 2009.
2. Bick D. Contemporary postnatal care in the 21st century. In: Byrom S,
women, who meet to mutually support each oth- Edwards G, Bick D, eds. Essential midwifery practice: postnatal care.
London: Wiley-Blackwell, 2010.
er in the presence of a health professional (who 3. Broadfoot M, Britten J, Tappin D. The Baby Friendly Hospital Initiative
and breastfeeding rates in Scotland. Arch Dis Child Fetal Neonatal Ed
can answer queries or initiate health education 2005;90:F114–6
4. Johanson R, Newburn M, Macfarlane A. Has medicalisation of childbirth
sessions). These schemes were initially aimed at gone to far? BMJ 2002;321:892–895.
the antenatal period but have followed through 5. MacArthur C, Winter H, Bick D. Effects of redesigned community post-
natal care on women’s health 4 months after birth: a cluster randomised
into the postnatal period because women valued controlled trial. Lancet 2002;359:378–385.
6. MacKenzie H, van Teijlingen E. Risk, theory, social and medical models:
them so much. They utilize another movement a critical analysis of the concept of risk in maternity care. Midwifery
2010;26:488–496.
in healthcare towards patient empowerment and 7. Marchant S. The history of postnatal care; national and international
perspectives. In: Byrom S, Edwards G, Bick D, eds. Essential midwifery
self help. practice: postnatal care. London: Wiley-Blackwell, 2010.
8. National Institute for Clinical Excellence. Routine postnatal care for
Aligned to centering pregnancy is the bur- women and their babies. Clinical Guidelines 37 2006.
9. Walsh D, Newburn M. Towards a social model of childbirth Part 1. Br J
geoning interest in preparation for parenthood Midwif 2002;10:476–481.
10. Yelland J. Women’s and midwives’ views of early postnatal care. In: By-
education. This has been highlighted by health rom S, Edwards G, Bick D, eds. Essential midwifery practice: postnatal
care. London: Wiley-Blackwell, 2010.
policy as a priority area, not least because it seri-
ously engages with fathers and their responsibili-
© 2014 Elsevier Ltd. Initially published in Obstetrics, Gynaecology and
ties for co-parenting. Reproductive Medicine 2011;21(12):346–350.

CASE STUDY PEER REVIEWED MIMS JPOG JUL/AUG 2015 153
Hysteroscopic Intrauterine
Morcellation of Large G1
Submucosal Fibroids in a
One-Step Procedure
Menelik MH Lee, MBBS MRCOG FHKCOG FHKAM (OG)
INTRODUCTION
Over 94.1% of menorrhagia due to submucosal fibroids are ef-
fectively controlled after complete hysteroscopic resections.1
Different types of hysteroscopic intrauterine morcellators (IUM)
have been developed as replacements of conventional resec-
toscopic techniques. Studies confirmed such techniques to be
safe and effective in particular to fibroids of <3cm size.2, 3 It has
also shown better visualisation, reduce risk of cervical lacera-
tion, uterine perforation and a faster procedure4 even for fibroid
size up to 4.5cm.5 However, despite its effectiveness, complete
removal of large submucosal myomas often requires a 2-step
procedure.
We report three cases in which the hysteroscopic mor- Figure 1. Sonohysterogram Confirming a G1 Fibroid
cellation technique was able to completely remove large
5cm G1 submucosal fibroids in a 1-step procedure. Cervix was dilated to 6mm. The fibroid was resected
by one of the hysteroscopic intrauterine morcellation device
CASE 1 available in the current market (MYOSURE). Using its 41mm
A 46-year-old lady was diagnosed with menorrhagia and anae- 2-blade at 6,500 rpm (rotational power per minute), the sub-
mia requiring transfusion due to a submucosal fibroid. mucosal fibroid was completely resected. The fluid pressure
Despite regular use of norethisterone and tranexamic acid, was maintained between 80 to 100mmHg while the suction
her heavy menstruation persisted. Sonohysterogram revealed pressure was set at 275mmHg throughout the proceedure. A
a 5cm submucosal fibroid with over 70% protrusions into the total deficit of 556ml of normal saline was calculated by the
cavity (Figure 1) (G1 myoma under the European Society for Aquilex fluid monitoring system.
Gynaecology Endoscopy (1) (Table 1). After counselling, patient The fibroid was completely excised after 12 minutes
opted for hysteroscopic resection of the submucosal fibroid. of morcellation and the procedure including the diagnostic
GnRH analogue and cervical priming were not given pre-opera- hysteroscopy was completed within 40 minutes with minimal
tively as patient was parous and concerned with the side effects. blood loss (Figure 3). Fibroid fragments measuring 3x4x5cm
Diagnostic and operative hysteroscopy under general were sent to histology confirming benign leiomyoma.
anaesthetics confirmed the 5cm submucosal fibroid to be on Patient was discharged the next day with no postoper-
the left lateral uterine wall with 70% protrusion at mid cavity ative complications. At 3 months follow up, patient had two
(Figure 2). regular periods with no anaemia.

154 MIMS JPOG JUL/AUG 2015 CASE STUDY PEER REVIEWED
CASE 2
A 40-year-old lady was diagnosed with menorrhagia second-
ary to a 6cm submucosal fibroid which could not be controlled
by transamin. GnRH was not given pre-operatively and the pro-
cedure was performed under general anaesthesia. The 6cm
submucosal fibroid was located at the mid-portion of the pos-
terior uterine wall and had 70% protrusion during diagnostic
hysteroscopy. Using the IUM device and settings similar to the
first case, the fibroid was completely resected in 25 minutes,
and the overall operative time was 72 minutes. Fluid deficit
reached the maximum recommended level of 2,500ml with ap-
proximately 100ml of blood loss. Histopathology of the fibroid
fragments revealed leiomyoma. Follow up at 3 months showed
no residual fibroid on ultrasound and the patient had two peri- Figure 2. Hysteroscopic View of a 5cm G1 Submucosal Fibroid
ods with minimal bleeding.
CASE 3
A 64-year-old menopausal lady with persistent post-menopau-
sal bleeding confirmed the presence of a large 6cm submu-
cosal fibroid arising from the posterior lateral wall of the uterus
with 80% protrusion at mid cavity after a diagnostic hysteros-
copy. As patient refused a hysterectomy, hysteroscopic mor-
cellation of fibroid with the same IUM device under general
anaesthetics, using the same settings, was performed. The
6cm fibroid was completely morcellated after 28 minutes of
morcellation and a complete operating time of 66 minutes with
minimal blood loss. The saline fluid deficit was 1,232ml and
the fibroid was completely resected. At 2 months follow up, Figure 3. Morcellation of Submucosal Fibroid – Near Completion
post-menopausal bleeding had completely subsided.

scored 0 to 4 (group 1) will require a low complexity hyeter-
DISCUSSION oscopic myomectomy. Scoring 5 to 6 (group 2) will require
Menorrhagia and reproductive failure remain the main indica- complex myomectomy with consideration of GnRH analogue
tions for surgical management of submucosal fibroids. Occa- preparation or 2-step surgery. Those who score 7 to 9 (group
sionally, persistent post-menopausal bleeding may also be 3) recommend an alternative non-hysteroscopic technique.
indicated for such procedure. Other than improving menorrha- Pre-operative treatment with GnRH analogue remains
gia, fertility rates are reported to increase after hysteroscopic controversial. A review by De Spiezio Sardo et al 7 supported
myomectomy of type 0 and type 1 fibroids in previously infertile the use of GnRH analogue for those fibroids with a diameter
women. Suitability of surgery and complete resection of the
6
>3cm and/or with intramural components. While a systemic
fibroid often depends on the location and classification of the review by Kamath et al showed insufficient evidence of their
submucosal fibroids. The European Society for Gynaecology routine use. Pre-operative GnRH use may reduce operative
Endoscopy (ESGE) considers hysteroscopic myomectomy time by a mean time of 5.34 minutes but does not increase
should only be performed for fibroids G0 and G1 that does not the likelihood of complete resection as a one-step proce-
exceed 5 to 6cm and 4 to 5cm. 7
dure.9 Moreover, these drugs are associated with high cost,
The Lasmar’s pre-surgical classification identifies the po- side effects, increase recurrence, and increased risk of uter-
tential complexity of the procedure (Table 1). Fibroids that
8
ine perforation.7, 9

Table 1. European Society of Gynaecology Endoscopy Classification of Submucous Myoma and Lasmar’s Pre-surgical
Classification of Submucous Myomas
European Society for Gynaecology Endoscopy Classification of Submucous Myoma

G0 Submucosal fibroid completely within the uterine cavity
G1 Submucosal fibroid has its larger part (>50%) in the uterine cavity
G2 Submucosal fibroid has its larger part (>50%) in the myometrium
Lasmar’s Pre-surgical Classification of Submucous Myomas

Points Peneration Size (cm) Base Third Lateral wall (+1)
0 0 ≤2 ≤1/3 Lower -
1 ≤50% >2-5 >1/3 to 2/3 Middle -
2 >50% >5 >2/3 Upper -
Score + + + + =
Score 0 to 4 (Group I): Low complexity hysteroscopic myomectomy
Score 5 to 6 (Group II): Complex hysteroscopic myomectomy, consider preparing with GnRH analogue and/or 2 stage surgery
Score 7 to 9 (Group III): High complexity hysteroscopic myomectomy, recommend an alternative non-hysteroscopic technique
Hysteroscopic Techniques leaving free water in the intravascular space which moves into
The choice of hysteroscopic technique mainly depends on the intracellular and extracellular space via osmosis. If left untreat-
location of the submucosal fibroid as well as surgeon’s person- ed, complications such as bradycardia, hypertension and sub-
al preference. sequently hypotension, pulmonary oedema, cerebral oedema,
cardiovascular collapse and death may occur.10 Guidelines
Resectoscopic Excision have indicated that the intervention must stop when fluid bal-
This classical resectoscopic technique involves repeated slic- ance exceeds 1,000ml.7
ing of the submucosal fibroid using the cutting loop monopo- Thermal injury to surrounding viscera leading to perito-
lar diathermy. Hypotonic glycine or sorbitol is used as a dis- nitis, sepsis and death are associated with such procedures.
tending medium and excision continues from the top until the Thermal injuries usually follow perforation but it can occur in
base of the fibroid. Resection is complete when the fasciculate the absence of uterine perforation.11
structure of the myometrium is visualised and the base of the To reduce most of the possible complications, bipolar
implant is smooth with the surrounding endometrial surface. 7
resectoscope have been introduced. Reports suggested suc-
However, this technique requires long operating time. cessful surgery with saline as a distending medium.12 However,
Loose tissue resected must be repeatedly removed from uterine postoperatively intrauterine adhesions are more likely to devel-
cavity by taking out the resectoscope otherwise the operative op after electro surgery, which in turn may impair fertility.1
maybe obscured. The longer operating time may leads to an
7
increased amount of fluid absorption and a possible 2-step pro- Ablation by Nd:yAG Laser and Vaporization
cedure for larger fibroids to avoid excessive fluid absorption. of Fibroid
Glycine and sorbitol are hypotonic fluid distending medi- The ablation Nd:yAG laser technique coagulates the surface
um. They are electrolyte free and nonconductive hence pre- vessels then the fibre is dragged repetitiously over the fibroid un-
ferred during electrosurgical procedures. However, because of til it is flattened. The vaporization technique is where spherical
its nature, excessive absorption causes hypovolaemic and hy- or cylindrical electrodes are used and the electrode is dragged
ponatraemia. After intravasation, these fluids get metabolised along the surface of the fibroid until complete resection.7

156 MIMS JPOG JUL/AUG 2015 CASE STUDY PEER REVIEWED
Table 2. Technical Details of the Three Cases of IUM Morcellation
Case 1 2 3
Size of Fibroid 5cm 6cm 6cm
Position Lateral Posterior Posterior/Lateral
Protrusion 70% 70% 80%
Lasmar Classification Score 6 5 6
Morcellation Time 12 minutes 25 minutes 28 minutes
Duration 40 minutes 72 minutes 66 minutes
Fluid Deficit 556ml 2,500ml 1,232ml
The main disadvantage of both techniques is the lack of metrium and beyond is generally prevented. Along with the
tissue sampling for pathology . 7
reduced need for cervical dilatation, the overall risk of uterus
perforation is less. The IUM device does not require electro-sur-
Office Hysteroscopic Myomectomies gery. Thus, saline can be used as the distending medium and
Office hysteroscopic techniques (such as grasping forceps intra-operative thermal injury is not of concern. Compare to
and bipolar electro-surgeries such as VERSAPOINT9) are all electro-surgery, postoperative adhesions are less likely to de-
effective if fibroids are <1.5-2.0cm. 7
velop. Thus, this is preferred by those with fertility wishes.1
Normal saline as distending medium decreases the risk
Ablation Techniques of hyponatraemia, hypo-osmolarity, hyponatraemic encepha-
Endometrial ablation techniques are effective treatments for lopathy and fluid overload.15 The American Association of Gy-
menorrhagia. Both HydroThermablator and NovaSure can ef- necologic laparoscopists (AAGL) practice guideline16 suggest
fectively remove submucosal fibroids up to 4cm13 and 3cm,14 the maximum limit for isotonic solution be 2,500ml compared
respectively. to maximum fluid deficit of 1,000ml when using the hypoton-
However, because of its simultaneous endometrial abla- ic solution (gylcine) during monopolar resectoscopic surgery.
tion, these techniques can only be offered to those who are The fluid absorption window and quicker operating time, a
troubled by menorrhagia and have completed their family. 1-step procedure is more likely achieved with this technique.
IUM devices, however, is not recommended for the treat-
Intra-uterine Morcellators (IUM) ment of submucosal fibroids >50% intramural extension (G2).7
IUM is a hysteroscopic morcellating device which morcel- As per the Lasmar’s classification (Table 1), the submu-
lates the submucosal fibroid while using saline as distending cosal fibroid in the reported three cases would have scored
medium. 6, 5 and 6 out of the possible 9 points available respectively
Emanuel and Wamsteker 1
conducted a retrospective (Table 2). Under the Lasmar’s classification recommendation,
comparison between this technique and conventional resec- a complex hysteroscopic myomectomy with the use of GnRH
toscopic technique. It has shown that morcellation by IUM was analogue and/or a 2-stage surgery should be considered. If
effective for the treatment of G0 and G1 fibroids. They are faster a conventional resectoscope was used, we would expect the
and less time consuming. The device provides preservation of operation time to be at least 67 mins in a one or two stage pro-
tissues for histology and with a smaller diameter (6mm to 8mm cedure.5 In our reported cases, despite not using pre-operative
depending on the brand of device used), the need for cervical treatment of GnRH analogues, the procedures were completed
dilatation is less and perforation during dilation is less likely.
10
with an average time of 59.3 minutes (40 to 72 minutes).
Given the design of the device, with its lateral morcellating We faced a few challenges while performing the proce-
window and appropriate surgical skills, cutting into the myo- dure. Maintaining adequate intrauterine fluid pressure to pre-

vent bleeding during fibroid morcellation was important to very large submucosal fibroids. In this case series, we demon-
sustain a clear hysteroscopic view. This was particularly chal- strated IUM to be a good and safe alternative option when
lenging with a parous cervix. Clamping the parous cervix with compared to loop resection. The IUM system makes the 1-step
various types of cervical clamps or sponge forceps is sufficient. resection of large G0 or G1 submucosal fibroids fesible. Fur-
Despite these challenges, all 3 procedures were performed ther studies are required to confirm these findings and the po-
safely without any complications using a 1-step process. tential benefits of the treatment of submucosal fibroids.
CONCLUSION Conflict of Interest

There are many different and effective hysteroscopic tech- None declared.
niques in the management of submucosal fibroids. However,
loop resection using electro surgery and hysteroscopic more- About the Author
Dr Menelik Lee is a specialist in the Department of Obstetrics and Gynecology, Queen Eliza-
cellators appear to be the feasible option when we encounter beth Hospital, Hong Kong.
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oni A, Bianchi S. IBS Integrated Bigatti 8) Lasmar RB, Barrozo PR, Dias R, Oliveira Surgical techniques and outcome in the ic distending media. J Min Inv Gynecol
Shaver versus conventional bipolar resec- MA. Submucous fibroids: a new presurgi- management of submucous fibroids. Curr 2013;20:137–148.

•
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158 MIMS JPOG JUL/AUG 2015 PAEDIATRICS PEER REVIEWED
Optimising Respiratory
Health in Children
with Cystic Fibrosis
Matthew N Hurley, BSc (Hons) MBBCh MRCPCH; Alan R Smyth, MA MBBS MCRP MD FRCPCH
Cystic fibrosis is a multi-system genetic disorder causing thick secretions,

lung infection and pancreatic insufficiency. Optimising respiratory health in
children with cystic fibrosis depends upon meticulous attention to maintaining
general health, in addition to preserving lung health. Maximising nutrition and
growth are essential as these are independent predictors of lung function and
survival.
Neonatal screening has enabled an earlier, more proactive approach to
optimising health. However the primary predictor of deterioration is the acqui-
sition of the opportunistic bacterium Pseudomonas aeruginosa. Eradication of
chronic infection with this organism is impossible, leading to lung destruction
and shortened life expectancy for individuals with CF. The optimal strategies
for managing this critical complication of cystic fibrosis are the subject of on-
going research, however these strategies may depend upon antibiotic regi-
mens to which the bacteria may gain resistance. Novel strategies, adopted
alongside continued improvements in care, are needed to further defer the
complications and deterioration experienced by patients with cystic fibrosis,
enhance quality of life and extend survival.

PAEDIATRICS PEER REVIEWED MIMS JPOG JUL/AUG 2015 159
INTRODUCTION
Cystic fibrosis (CF) is a multi-organ disease with
recurrent and chronic lung infection being the
critical life-limiting feature. The subsequent lung
destruction, accompanied by pancreatic insuffi-
ciency, alongside increased metabolic demands,
adversely affects growth and leads to respira-
tory failure, a reduced quality of life and prema-
ture death. In infants, treatment focuses on early
aggressive management of lung infection and
optimisation of nutritional status. This continues
alongside treatment of complications in later
childhood.
Cystic Fibrosis is the commonest life-limiting
autosomal recessive condition, in the UK approxi-
mately 10,000 people have manifest disease. For-
ty years ago, few children survived beyond infan-
cy however improvements in management have
led to dramatic changes in the life expectancy for
patients with CF. The mean life expectancy for a
baby born in 2003 was 42 years for a boy and
36 years for a girl. The aim of current research
and clinical care is to increase this to beyond 50
years. Traditionally the survival for girls with CF
appeared to be worse than that of their male In infants, treatment focuses on early aggressive management of lung infection
counterparts, however this may not necessarily and optimisation of nutritional status.
be universal.
There are numerous gene mutations that ef- tion and poor nutrition, skin salt loss, metabolic
fect a change in the presence or function of the abnormalities and biliary fibrosis. Nasal polyps,
cystic fibrosis transmembrane regulator (CFTR). congenital absence of the vas deferens and CF
This cell membrane protein acts directly as chlo- related arthritis further add to the effect the dis-
ride channel but is also responsible for regulat- ease has on quality of life.
ing the epithelial sodium channel (ENaC). The
net result being impaired chloride transport and INFLAMMATION AND INFECTION
excess sodium loss resulting in a depletion of Those with cystic fibrosis have an up-regulated
the airway surface liquid and thick mucus, en- inflammatory cascade, however it has been con-
trapping cell surface cilia. CFTR mutations also tentious whether this is due to an intrinsic pro-in-
may be responsible for facilitating infection with flammatory state, disproportionate inflammation
early non-mucoid Pseudomonas aeruginosa and in result to infection or a proportionate immune
reducing the efficacy of the adaptive immune re- response. In studies aimed at answering this
sponse to later mucoid P. aeruginosa. question extensive examination of Bronchoalve-
The effects upon the function of CFTR are olar lavage (BAL) fluid suggests that those with
not restricted to the lungs, resulting in the com- infection have significantly increased levels of
plications of pancreatic exocrine and eventual inflammatory mediators compared to those with-
endocrine insufficiency, abnormal intestinal func- out.

Attempts at ameliorating the lung damage Superficially, the early clinical course of
with oral corticosteroids and non-steroidal anti-in- children with CF can be split those diagnosed
flammatory drugs (NSAIDs) have demonstrated through screening and those diagnosed prior to
improvements in lung function. Concerns regard- the neonatal screening procedure due to an early
ing side effects have however, prevented the long complication. This group of patients largely pres-
term use of oral corticosteroids. ent due to meconium ileus.
The diagnosis of cystic fibrosis depends upon the presence

of one or more characteristic phenotypic features
EARLY CARE The Effect of Meconium Ileus

Age at diagnosis is significantly associated with The influence that meconium ileus has on out-
survival such that for each year increase in age at comes for children with CF has been controver-
diagnosis significantly increases the acquisition sial. A large study including the 27,703 patients
of P. aeruginosa and reduces lung function and on the Cystic Fibrosis registry between 1986 and
survival. 2000 (including the pre-screening era) concluded
that the risk of acquiring P. aeruginosa and mor-
Diagnosis tality was significantly higher in those who pre-
The diagnosis of cystic fibrosis depends upon the sented with meconium ileus compared to those
presence of one or more characteristic pheno- identified through screening. In the pre-screen-
typic features, a positive newborn screening test ing era it is possible that the disadvantage con-
result or a history of CF in a sibling and laborato- ferred by having meconium ileus was reduced by
ry evidence of a CFTR abnormality. CFTR abnor- the advantage of earlier diagnosis such that there
mality may be demonstrated by elevated sweat were no differences in lung function, weight and
chloride concentration, identification of mutations height and acquisition of P. aeruginosa in those
in each CFTR gene known to cause CF or in vivo early studies. Now we have entered the screen-
demonstration of characteristic abnormalities in ing era this ‘advantage’ may have disappeared.
ion transport across the nasal epithelium. In the An Australian head-to-head comparison with
UK however since the introduction of universal 39 children in each group of those diagnosed
neonatal screening, the vast majority of diagno- through screening or through presentation with
ses are made via this route. meconium ileus demonstrated that whilst having
The justification for neonatal screening re- meconium ileus appeared not to affect nutritional
volves around recent improvements in outcome status, or predispose to other complications of
that have been attributed to improvements in CF, lung function and Schwachman scores were
intervention. The natural suggestion is that if significantly worse in those who had presented
these improvements are instituted earlier, before with meconium ileus.
lung damage and nutritional status is impaired,
that clinical status will improve. There are obvi- CFTR Potentiation, Correction
ous confounders in outcomes of screening, an and Gene Therapy
intervention that was instituted at the same time In 2015 the results of the Gene Therapy Consorti-
as other improvements in management. How- um’s placebo controlled double blind randomised
ever US CF Registry data strongly suggest that controlled trial of liposomal delivery of wild-type
screening confers a survival advantage. CFTR will be available. This is the first multiple

dosing trial in a planned development programme

that could include viral delivery mechanisms. If
successful, and delivered sufficiently early prior
to lung damage, the natural history of CF may
change considerably. However, even if this first
trial demonstrates significant benefit, the devel-
opment process is likely to consist of incremental
improvements that will be some time before this
therapy is available to children with CF.
CFTR potentiation on the other hand, is de-
livering measurable benefit to a small subset of
patients with CF. Ivacaftor (Kalydeco), a small
molecule that potentiates the action of CFTR in
those with gating mutations (in particular G551D).
Available to those over 6 years old, through a Figure 1. Lung Infections in 2012. UK CF Trust (2013) UK Cystic Fibrosis Registry
Annual Data Report 2012
twice daily tablet, effects of Ivacaftor include nor-
malisation of sweat chloride, improvement in lung
function, body mass index (BMI) and pulmonary medical contact. However, as infants cannot ex-
exacerbation rate. pectorate, microbiological evidence of infection
At the end of 2014 the results will be avail- depends on oropharyngeal (OP) cultures which,
able for clinical trials (TRAFFIC and TRANS- whilst having good specificity (95%), have poor
PORT) assessing the combination of Ivacaftor sensitivity (44%) resulting in antibiotics being
with Lumacaftor (a CFTR corrector) in those ho- withheld in circumstances where a positive cul-
mozygous with dF508 mutation. The remaining ture would be accompanied by the prescription
questions regarding providing CFTR correction of antibiotics. The presence of symptoms is also
and potentiation concern how early it is possible a poor predictor of lung infection as up to 20% of
to administer these drugs to young children. In- asymptomatic infants have pathogens identified
deed it is conceivable that those receiving these at BAL.
medications from birth will experience the greatest Currently most patients have treatment guid-
benefits. However access to these transformation- ed by regular OP cultures. With evidence that in
al medicines is accompanied by economic and children younger than 6 years BAL is well tolerat-
ethical considerations with each year of Ivacaftor ed, with only 3% of procedures being associated
treatment costing £182,500 per patient (BNFc). with a clinically significant adverse effect related
to the procedure, it is likely that in future BAL will
Lung Infection become a more common undertaking and treat-
Whilst accounting for the effect of age of diagno- ment, as a result, will become more targeted.
sis upon outcome, acquisition of P. aeruginosa is
independently responsible for deterioration. It is Infections of the CF Lung
therefore a priority to aim to defer and even erad- The altered lung environment in those with CF
icate lung infection in those with CF. provides an ideal niche for bacterial growth.
There appears to be a recognizable sequence of
Identification of Infection escalation in the organisms isolated from children
Identification of infection so that treatment may with CF (Figure 1). One can speculate that this
be given for lung infection is therefore crucial. progression represents a change in competitive
Respiratory cultures are recommended at each advantage between species.

Immunisation is at the forefront of attempts to prevent infection in all children and this is as important in those with CF.
In infancy Staphylococcus aureus predom- life-expectancy. Burkholderia cepacia is a similar

inates as the most common organism isolated opportunist although the prevalence has reduced
(50%) with the prevalence peaking in the 6-10 age over time.
group. Haemophilus influenzae and P. aeruginosa
are similarly prevalent until about age 5 (30-35% Prevention of Lung Infection
prevalence) when the prevalence of P. aeruginosa Immunisation is at the forefront of attempts to
increases such that it is the most common organ- prevent infection in all children and this is as im-
ism isolated in the 11-17 age group with a preva- portant in those with CF. Immunisation has also
lence increasing to 37.8% in the late-teens. been recommended for the prevention of viruses
The opportunist P. aeruginosa eventually that may provoke an exacerbation or respiratory
establishes a chronic infection causing reduced deterioration. This includes an annual influenza
growth, faster deterioration of lung function and vaccination although the evidence to support this
progression to end-stage lung disease as evi- is lacking. Similarly there is little evidence to sup-
denced by lung transplantation or death. Decline port the use of palivizimab to prevent respiratory
in lung function is largely responsible for the syncytial virus (RSV).
morbidity and mortality in CF and over the last P. aeruginosa is comprised of many highly
two decades more efficient treatment of pulmo- immunogenic proteins and therefore the search
nary infections has accompanied the increase in for a vaccine and antibodies to prevent infection

Table 1
UK - Cystic Fibrosis Trust USA - Cystic Fibrosis Foundation

Antistaphylococcal antibiotic prophylaxis (flucloxacillin) Recommends against the use of oral prophylactic
(should be commenced upon diagnosis and continued until antistaphylococcal antibiotics.
the age of 3 years).
Sputum samples or cough swabs should be sent for culture -
at every medical contact. The culture of P. aeruginosa in
a patient who was previously free of P. aeruginosa should
receive an appropriate eradication regime in a timely
fashion.
All patients with chronic P. aeruginosa infection should It is recommended that those of 6 years and older with
have long term nebulised anti-pseudomonal therapy, unless chronic P. aeruginosa infection, receive long-term
contra-indicated. nebulised tobramycin.
Pulmonary exacerbations should be treated promptly with There is insufficient evidence to recommend the use
oral or intravenous antibiotics-intravenous if the patient’s of single antibiotics instead of antibiotics given in
condition does not improve with oral treatment. combination.
A six-month trial of azithromycin should be considered For patients of 6 years and older with chronic P. aeruginosa
in those who are deteriorating on conventional therapy infection, the chronic use of azithromycin is recommended.
regardless of infection status. It is recommended that patients of 6 years and older
receive chronic dornase alpha. It is recommended that
all patients of 6 years and older receive chronic inhaled
hypertonic saline.
Nutrition and physiotherapy support should be intensified Recommends that airway clearance therapy be increased
during exacerbations. as part of treatment of an acute exacerbation.
is closely pursued. However at present there are nosis until 3 years of age. If breakthrough infec-
no available vaccines or antibodies that can be tion occurs this is treated in a step-wise manner
recommended. up to the administration of intravenous antibiot-
S. aureus is the predominant infection in ics. However the US Cystic Fibrosis Foundation
early life and is associated with inflammation and (CFF) remains concerned regarding P. aeruginosa
clinical deterioration. Antibiotics given prophylac- infection and so recommends against the use of
tically for the first three years to prevent S. aureus prophylactic antistaphylococcal antibiotics. The
infection are effective in reducing the isolation guidelines from both agencies are summarised
of the organism, but an improvement in clinical (Table 1).
outcome has not been found. However there is As the acquisition of P. aeruginosa is spe-
an argument that prophylactic antibiotics provide cifically associated with deterioration in clinical
an advantage to other competing organisms and status and increased mortality, it appears ration-
there is concern that P. aeruginosa gains such al that early treatment of lung infection and pre-
an advantage. This remains debatable with a vention of chronic colonisation should result in
Cochrane review meta-analysis indentified that improved clinical outcomes. Indeed, eradication
prophylaxis tended to benefit at least up to the of P. aeruginosa infection is possible if instituted
age of three years and the UK CF Trust recom- early and reduces the sequelae of lung deterio-
mends that flucloxacillin be instituted from diag- ration and the emergence of antibiotic resistant

strategy. Many units use a combination of colis-

tin and ciprofloxacin for three months. If early
re-growth is identified inhaled tobramycin is rec-
ommended. The clarification of the optimal treat-
ment strategy to eradicate P. aeruginosa in early
infection is being sought through the TORPEDO
randomised trial where the effect of 3 months
colistin accompanied by either 2 weeks intrave-
nous ceftazidime and tobramycin OR 3 months
ciprofloxacin is being sought.
For those that favour tobramycin, the ELITE
study (EarLy Inhaled Tobramycin for Eradication)
has recently demonstrated equivalence between
a short (28 days) and long (56 days) duration of
inhaled tobramycin therapy. The timing of treat-
ment is critical however as eradication of P. aerug-
inosa once conversion to a mucoid phenotype is
difficult, if not impossible. Trials of azithromycin
in those uninfected with P. aeruginosa have not
yielded an improvement in lung function, but
have reduced the number of exacerbations in this
group over a six-month period.
When it comes to treatment of established infection in CF, the poor quality of
the current evidence base makes determining the optimal treatment strategy Patient Segregation
impossible. Segregation of patients with P. aeruginosa is by
its nature divisive and interferes with the support
strains. However, with the concern that respira- network that would be available otherwise. Some
tory sampling in the very young is challenging, a question the utility of segregation, not least be-
schedule of antibiotic administration at the time cause the origin of most patients’ P. aeruginosa
of positive P. aeruginosa cultures was compared is the environment. However the absence of such
to routine, cycled antibiotic administration (the segregation policies have resulted in the dissemi-
EPIC trial). Additionally the trial compared the nation of virulent epidemic strains and significant-
outcomes for those who received inhaled to- ly increased acquisition among patients in clinics
bramycin alone and tobramycin in combination with a considerable difference identified once a
with oral ciprofloxacin. There was no difference segregation policy had been adopted. The seg-
between the culture based and time-cycled anti- regation policy requires complete separation in
biotic administration in terms of bacterial culture, time and space such that common areas are not
pulmonary exacerbations or growth rate and no used by multiple patients.
difference between those who received tobra-
mycin and ciprofloxacin and those who received Treatment of Established Infection
tobramycin alone. In terms of treatment of established infection in
Various strategies are used in eradication CF, the poor quality of the current evidence base
including ciprofloxacin, colistin and tobramycin, makes determining the optimal treatment strategy
usually in combination, however there is insuf- impossible. There is a consensus that S. aureus
ficient evidence regarding which is the optimal and H. influenzae should be treated with appro-

priate antibiotics in a step-wise approach with effi-

cacy of treatment being confirmed with follow-up
respiratory cultures. Treatment should be esca-
lated up to intravenous antibiotics should the at-
tempts at eradication not be successful. However
following a controlled trial of long term cephalexin
demonstrating a significant increase in isolates
of P. aeruginosa, it is advised that cephalospor-
ins should be avoided. Treatment of those with
chronic P. aeruginosa infection may be split into
maintenance phase chronic treatment and treat-
ment of exacerbations.
Treatment of chronic P. aeruginosa: chronic
P. aeruginosa infection may be defined as the
isolation of P. aeruginosa in more than half of
samples taken that year. For those chronically
infected with P. aeruginosa, it is recommended
that regular inhaled anti-pseudomonals be insti-
tuted, initially with nebulised colistin. Thereafter
nebulised tobramycin should be considered, giv-
en for 28 days followed by a 28 day break and
then repeated. Dry powder formulations of colistin
and tobramycin for inhalation are also available.
In patients who appear to be deteriorating, a trial Treatment should be escalated to intravenous antibiotics if attempts at eradication
of azithromycin is recommended as this may pro- are not successful.
vide improvement in some patients. There may
also be benefits of long term azithromycin use for Initially a trial of oral antibiotics may be rea-
those not yet infected with P. aeruginosa. sonable however if these are unsuccessful, then
Treatment of infective exacerbations in a course of intravenous antibiotics is recommend-
those with P. aeruginosa: for those chronically ed. Committing to a prolonged course of antibiot-
infected with P. aeruginosa an ‘infective exacer- ics is a significant undertaking and is associated
bation’ essentially refers to a period of increased with adverse effects from the drug regimen itself
symptoms that would include at least four of - and impact on family life. However due to the lack
•
Increased productive cough or breathless- of a quality evidence base, it is not possible to
ness determine the optimal combinations of antibiotics
• Decreased exercise tolerance or duration of a treatment course. The only firm
• Absence from school or work recommendation is that where aminoglycosides
•
Changes in the appearance or volume of are used tobramycin, in once-daily dosing, is pre-
sputum ferred. There is an option on an individual patient
• New signs on auscultation basis to opt for home intravenous antibiotic ad-
• New chest radiographic signs ministration. The evidence base again is limited
• Loss of appetite however there appears to be unique benefits and
• Fall in respiratory function disadvantages to this approach which need to be
•
Fever requiring treatment with intravenous assessed in the context of the individual patient
drugs and family.

viscosity of mucus by digesting the DNA released

from neutrophils and while expensive, significant-
ly improves lung function. Nebulised hypertonic
saline can improve mucus clearance by restor-
ing airway surface liquid volume and enhancing
mucociliary clearance. While this may not have a
sustained effect on lung function, quality of life is
much improved in those taking hypertonic saline
and they suffer less pulmonary exacerbations.
Both DNase and hypertonic saline are recom-
Figure 2. Median FEV1 (% predicted) vs BMI among Patients Aged 16 Years and mended by the Cystic Fibrosis Foundation for all
Older. UK CF Trust (2013) UK Cystic Fibrosis Registry Annual Data Report 2012
those above 6 years with CF.
MULTIDISCIPLINARY MANAGEMENT Nutrition

CF should continuously be regarded a mul- Pancreatic insufficiency and related malabsorp-
ti-system disease. A variety of specialists should tion, cystic fibrosis-related diabetes mellitus
be available to offer support to the care of such (CFRD), anorexia due to chronic ill health and
children. The optimal CF team would consist of increased energy demands make optimization
nurse specialists and physicians, physiother- of nutrition critical to the management of children
apists, dieticians, pharmacists, social workers with CF. The aim is to maintain normal growth ve-
and psychologists, with access to specialist locity for age. Those patients with nutritional opti-
microbiology advice and investigation, an en- misation have better weight, height and survival.
docrinologist, gastroenterologist and other ter- Lung function is intimately related to BMI, with
tiary specialists when required. This is largely an almost linear association (Figure 2) with FEV1
achieved either by patients attending specialist being most conserved in those with BMI values
tertiary centres or attending their local hospital greater than the 50% centile.
with care shared with a specialist centre. Pancreatic insufficiency should first be con-
Physiotherapy is effective in increasing clearance of mucus,

at least in the short term
Airway Clearance firmed by measuring pancreatic elastase in stool.

Physiotherapy is effective in increasing clearance To achieve optimal growth, the effect of pancreat-
of mucus, at least in the short term. As with much ic insufficiency is reduced by pancreatic enzyme
of the CF literature, the effect upon long-term replacement therapy being administered from
benefit and the optimal approach is unclear but diagnosis. The diet may need supplementation
suggests that positive expiratory pressure (PEP), with, fat soluble vitamins, and multivitamins. To
noninvasive ventilation (NIV) for patients with res- optimise calorie intake aiming for 110-200% of
piratory failure and additional physical training are that of the healthy population, if oral feeding is in-
likely to confer benefit. Adjuncts to optimise the sufficient patients should be provided with entera
effectiveness of mucus clearance by physiother- (either by nasogastric or gastrostomy) or paren-
apy (or vice versa) include recombinant human teral nutrition. Surveillance is important not only
DNase and hypertonic saline. DNase reduces the of nutritional state but also of sequelae includ-

ing delayed puberty, and reduced bone mineral

density.
Cystic Fibrosis Foundation guidelines on nu-
trition recommend-
• From age 2 years, energy intakes greater than
the standard for the general population
•
For children with growth deficits nutritional
supplements in addition to usual dietary in-
take (although a Cochrane review found no
evidence of this recommendation)
• Maintenance of normal ranges of weight for
height using age-appropriate BMI in older
children
•
That children diagnosed before the age of
2 years, reach a weight-for length status of
≥50th centile by age of 2 years
•
Pancreatic enzyme supplementation appro-
priate for weight In addition the UK CF Trust
nutrition working group recommend
• Monitoring of bone mineral density by DEXA
scan in those over 10 years of age
•
Supplemental vitamin A, D and E in those
pancreatic insufficient
• Invasive nutritional support should commence Optimising the well-being of children from early diagnosis is essential to maintain
lung function, quality of life and improve long-term survival.
when oral methods of maintaining an ade-
quate nutritional status have failed
• A combination of the CF and diabetes diet in tion routes. The difficulty is that in the CF lung plugs
those with CF related diabetes mellitus of mucus block the free passage of nebulised mol-
ecules and systemically administered agents may
FUTURE DIRECTIONS not reach the biofilm which ‘float’ on the damaged
It is clear that infection and inflammation are the epithelial surface, away from the circulation. Even
primary influencing factors of lung function and if the agent does get to the site of infection, pene-
survival with the acquisition of P. aeruginosa be- trating the biofilm to reach the protected bacteria
ing uniquely responsible for clinical deterioration. within is a challenge. If the antibiotic reaches the
The difficulty posed by P. aeruginosa is its inher- bacterial cell the concentration of antibiotic within
ent diversity and ability to adapt during a single the cell needs to exceed the minimum inhibitory
antibiotic treatment course. Antibiotic resistance concentration (MIC) in order to kill the organism. P.
is widespread and there are no new antibiotics aeruginosa however hosts efflux pumps that act to
on the horizon that exert a novel mechanism of remove toxic substances from within the cell. Ad-
action. In the absence of new antibiotics, focus ditionally it may upregulate the expression of these
turns to ways in which our existing armoury of an- efflux pumps to increase its virulence. This is par-
tibiotics may be made more effective. ticularly the case with epidemic strains.
The aim is to achieve an adequate concentra-
tion of antibiotic at the site of infection. Administra- Drug Delivery Mechanisms
tion is achieved via the oral, intravenous or inhala- Manipulation of antibiotics to increase delivery

Practice Points thelia. This leads to dry epithelial surfaces that in

the lungs predispose to infection and inflamma-
• Early diagnosis of cystic fibrosis through screening enables a tion. It is infection, often with P. aeruginosa, that is
proactive management strategy and family education. the primary predictor of clinical deterioration. At
present acquisition of these devastating bacte-
• Provision of CFTR potentiator (Ivacaftor) in those with G511D
mutation significantly improves clinical outcomes. ria is not predictable, is challenging to detect at
an early stage before chronic infection is estab-
•
Optimising nutrition and airway clearance defers clinical
deterioration. lished, at which point the bacteria can no longer be
eradicated.
• Eradicating early Pseudomonas aeruginosa infection and deferring
Optimising the well-being of children from
chronic colonization postpones the adverse sequelae of reduced
lung function and quality of life. early diagnosis is essential to maintain lung func-
tion, quality of life and improve long-term surviv-
• Bronchoalveolar lavage may be necessary in order to obtain
representative microbiological samples from the lungs. When this al. Improvements over recent years have led to
is not practicable clinicians should be aware that upper respiratory maintaining lung function over a longer period
specimens may fail to detect lower respiratory infection. and deferring the morbidity associated with CF
into the late teens and third decade of life. More
recently, the development of small molecule
through the biofilm is of therefore of interest. Li- CFTR potentiators have generated significant im-
posomal preparations, polymer-based nanopar- provements in a small proportion of those affect-
ticles and ultrasound enhancement of passage ed by CF. Comprehensive proactive management
of drug across the biofilm are under investiga- using the biopsychosocial model within a multi-
tion. Aerosolised antibiotics are under develop- disciplinary team is essential to improving quality
ment and trials including nebulised levofloxacin of life and survival such that, even when facing a
and liposomal amikacin are underway. seemingly well child in clinic, there is no room for
complacency.
Antibiotic Adjuvants
Antibiotic adjuvants are agents that themselves Further Reading
1. Emerson J, Rosenfeld M, McNamara S, Ramsey B, Gibson RL. Pseu-
may not exhibit bactericidal activity, but act to domonas aeruginosa and other predictors of mortality and morbidity in
young children with cystic fibrosis. Pediatr Pulmonol 2002;34:91–100.
potentiate the activity of a coadministered antibi- 2. Flume P, O’Sullivan B, Robinson K, et al. Cystic fibrosis pulmonary guide-
lines: chronic medications for maintenance of lung health. Am J Respir
otic. Bacteriophages, quorum sensing inhibitors Crit Care Med 2007;176:957–969.
3. Flume PA, Mogayzel Jr PJ, Robinson KA, et al. Cystic fibrosis pulmonary
and vitamins may exert a beneficial effect over guidelines: treatment of pulmonary exacerbations. Am J Respir Crit Care
Med 2009;180:802–808.
and above the effect of the antibiotic, however 4. Kerem E, Conway S, Elborn S, Heijerman H. Standards of care for
many of these studies are in their infancy. A re- patients with cystic fibrosis: a European consensus. J Cyst Fibros
2005;4:7–26.
cent Cochrane review demonstrated that these 5. Lai HJ, Cheng Y, Cho H, Kosorok MR, Farrell PM. Association between
initial disease presentation, lung disease outcomes, and survival in pa-
antibiotic adjuvant strategies remain novel with tients with cystic fibrosis. Am J Epidemiol 2004;159:537–46.
6. Langton Hewer SC, Smyth AR. Antibiotic strategies for eradicating Pseu-
few being examined in the context of a rigorous domonas aeruginosa in people with cystic fibrosis.
7. O’Sullivan BP, Freedman SD. Cystic fibrosis. Lancet 2009;373(9678):
clinical trial and so cannot be recommended cur- 1891–904.
8. Sagel S, Gibson R, Emerson J, et al. Impact of Pseudomonas and Staph-
rently. It is likely that improvements in the future ylococcus infection on inflammation and clinical status in young children
with cystic fibrosis. J Pediatr 2009;154:183–188.
however will be dependent upon these, or similar 9. Smyth AR, Bell SC, Bojcin S, et al. European cystic fibrosis society
standards of care: best practice guidelines. J Cyst Fibros 2014;13(suppl
novel interventions. 1):S23-S42. http://dx.doi.org/10.1016/j.jcf.2014.03.010, http://www.sci-
encedirect.com/science/article/pii/S156919931400085X.
10. Trust CF. Standards for the clinical care of children and adults with cystic
SUMMARY fibrosis in the UK. Cystic Fibrosis Trust, 2001.
11. UK Cystic Fibrosis Nutrition Working Group. Nutritional management of
Cystic fibrosis is a multi-system disorder medi- cystic fibrosis. Cystic Fibrosis Trust, 2002.
ated by a gene mutation that causes an error

© 2014 Elsevier Ltd. Initially published in Paediatrics and Child Health
of electrolyte and water transport across epi- 2015;25(4):165-171.

15
20 SINGAPO RE MARCH 2015 •
AR
CH
NEWS & INSIGHTS
R E •M
A PO
NG
SI
in
st
he
hig FORUM
al CONFERENCE
rviv SINGAPORE FOCUS Alcohol in all policies
FORUMsu
er Fracture risk in diabetics
S nc Rise in TB incidence in Singapore
W h ca Alcohol
sia in all policies underestimated
NE ac t Am a s
Sto uthe
s reported
So
IBD ineon the rise in Asia, most case

t-l
tic
S ILE sta
HT sin OF eta ta-

mu is
SIG f i r Chin a
PR for m er
UG ept nc
DR erc tal ca tor
GF
R] ng
[E “Tes ich o-
.
ti
h
is
rd
ep une g, w vs flu in
IN
ib c
Afl lore rec ib in st ed
co tor gy Tr stain r co y us
da CLC
c
&
fa olo l
E a we assa the highest r-
rea st incidence of IBD at
3.44 per
AG wth nc mic lo
WS
ER
ELVIRA MANZANO gro ld O che and ation ne o Ulcerative colitis (UC) was more
n
al to to y ge in m fir
100,000. st
OV s in say rm he ohis itivit ridiz
5
al-
K ,” Crohn’s disease (CD),
NE a
de ,”been AL prevalentive ted than
T
201
C n s hyb increase
na progressive
t
s LC -
S
, u n
CE sicia are lu tes the
here o has n m r se itu d of CD was rapidly
ti an of exc though SC Dincidence e
es eN
EN phy ve c y im ila inand
in the bincidence s prevalence e
.” ons ally ill b in N K’sin certain areas. [Gastroenterol
ER ti im
s nc e 1 4 ti
ta (IBD) in increasing
n H
CH
ily of cebowel 0disease utu ns w mo CU s-

O NF fam pallia inflammatory
s by E 1 mu
ILcomplicated re
mdisease tio com 2013;145:158-16 of pre5]ts
C olv nit e y Asia, characterized re F R a ta m n of IBD was less
• MAR
O F ts tie history
om sitiv
u ore an i La g“Although is family
u PR “EG morbidity, n R m says y. pa rd–inas g
Inv mm behavior and significant mePacific F Digestive
m
re k-Ch cocommon lo ent inC Asia o e were extra-intestinal
co pert s Asia e G a m L c u
expert at the recentrang s. E ey Kwo l On nge SC Ac – complicated d CD [penetrat-
c
r-
ex
th r.
e seIndonesia. a amanifestations
N ). bly mo
Week conference heldcains Bali, D linic arr t ofstricturing 6 ba perianal rydisease] was more
e
u e
ca d C as are ing, n =0.3 pro oraus isto i-
o
RE
“IBD has been traditionally eknown

be lain t of ne ercecommon
colit t
rc West,” said Ng.

en
c thanhin the
is
S p
o b -p
d case- later in life.
sity
isin Asia
E
CU lls xp relatively n grare e in

p ; all- 66; oca 7: In a more recent population-base
to disease of the West and eis me 5 0.82 , InthisHong There are also differences in the
genetic
cera agem
of Kong,
TIC
a study
PO
-5 enfor example,
FO ce ays art LK from ;2 - where Ng was the prin-
Asia. However, time trendpstudies to Ja-
R, rs rate :561 ad 2009 disease 68 was 29.2 control study in Asia, and Cau-
RE es to er, w
A mutations of IBD between Asians
b t ALK
3
(H tigatoshowed
tive
48 rate of perianal ;9:2 87]

AC
the l breastfeeding, having pets

low 7;4 have ncowith1215.8
GA
collectively
PO ng anc pan, Korea and Hong Kong have t in sis 7percent in Aus- cipal investigator,
re ul an
the development
en lyin
s 0 compared O l 20 80-2 with to casians, which may impact
GA l cha te c invein-tivelypercent sanitary conditions were shown
PR
a ethe 20 and
m
a two-to-three fold increase o n Hepatol and better Ng. NOD2 and autophagy
i
shown 7
S IN
n lin c [J Gastroenterolt that child- of IBD, added

SIN sica dica a thethpastre10 la tutraliare , (p=0.001).
C On 2:2 sen rga
seve the
cidence and prevalence of IBD to

in a king [J be protective of IBD, suggesting
obe
16L1 and IL 23) are not asso-

CY
lin 014;3 pre r o said
n
y the from important role variants (ATG
r
Ph uld in t it
[N 2012; o y. 27:1266-1280]
ti
Chien Ng C plays an
in
years,” said Professor Siew . m v 2 jo ” to hood environment

s log or, been due
MA
to y [Gut ciated with CD in Asians.

Re cochanges ly may ma have
o
co ven ht to “These l on
of ac llenges
lit
Therapeu- po in modulating disease development.
the Department of Medicine and ta lig his Nincreased at varia-
izo y f
pre On cocontact mm andwithisthe West, western- “Understanding of the genetic
AR
tics, Chinese University of Hong o oma 253 lin oftsdiet,

Kong f in our ; is pii: gutjnl-2014-307410. doi: 10.1136/ help us to
th nos hygiene, increasing 2014; tion and mutations [of IBD] will
ute
C en wimproved
PH
n -4 ization 10]
47 rog pathways causing the
Cr rap
gro pimmune dysregulation and gutjnl-2014-3074
Cha
Hong Kong. 42 d ; Jantibiotic ti

the impor- identify biological
pa r use, The results, Ng said, highlight
In the first large scale population-base e 2in77 se o he microbiota,” Ng said. hygiene disease and to discover
better drugs for
tum nt.inT the gut
ing
as
countries he changes tance of childhood immunological, are warranted to
study of IBD involving seven dise “T id e with CD have altered microbi- of patients. More studies
Asianmpatients
rap lve and dietary factors in the pathogenesis
e
Hong Kong, Macau, n Thailand, g etiologic factors for
- Asia (China, o n with their Caucasian counter- determine the critical
n up sti Aus- vo compared markers of altered in-
not man said sw siana, ter, Lo n-
inota
th
sta ts and u ld suggesting that
Malaysia, Singapore, ibSri Lanka)l, te ed k. ted microbiota in IBD c oIBD,
eepi US, ui-
ng
Loui h Cen the Pe
Mo Mucosa-associa d microbiota may modulate risk of IBD IBD,” Ng said.

chan d
me tien - tin ita from orm 0.54 d- parts.

g-
an
varied
co a o tralia, the incidence zo of IBD osp perf ng a i- may also differ geographically. te
is testinal
tient ith lif tients
be r p mph g c ia s
ro
cri th
eat
le
m per 100,000 H is China

individuals. lu had ep id s s o g ra m n ,
vula wer
need
fo ly n to i 3.44 les nt ced for

esty
to La e sa
ll lu pe-
e ne
eiv a ro
Ju
d y Wa eme o
F
AU c
m
ise rap sti Ch p rt a ti s o -

pa
ce rec n Ng es
rA
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nval to lo
po the apla mall g su o- ok- of

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g g . e n g ti o n s p o
Kw to ion. nce rran h ad neg as ms
ho
of th
TIN is n m
supp iden cces t can
in
RIS
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, a n-s ati che dy. Dr. r s ri a wit n tt in a ll a n e
ber e Uni ical R yan
rc
sw
ib lin s e c h b il it tr a g ti m ro g ra h to
ove gres e P e re nts cree
n
tin st- ced e no nstr let
ort. tify pa sful w
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tu k,
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“The combination of linagliptin
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pri xed 7.0 o a metformin
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n th re e re it c m n
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ticos drug d di
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CONTINUING MEDICAL EDUCATION MIMS JPOG JUL/AUG 2015 169
Placenta Accreta—An Updated

and Management 5 SKP
Charleen Sze-Yan Cheung, MBBS(HK), MRCOG, FHKAM(O&G); Ben Chong-Pun Chan, MBBS(HK), FRCOG, FHKAM(O&G), FHKCOG, Cert RCOG (Maternal and Fetal Med)
INTRODUCTION
Morbidly adherent placenta involves
a spectrum of abnormal placental im-
plantation. Placenta accreta occurs
when chorionic villi attach to the myo-
metrium. Placenta increta refers to the
invasion of villi into the myometrium.
Placenta percreta is defined by inva-
sion extending deep beyond the uter-
ine serosa. It may also involve adjacent
organs, commonly the urinary bladder.
Placenta accreta and its associated
spectrum are often collectively de-
scribed in the literature.1,2
Placenta accreta is associated with
substantial maternal risks, including
life-threatening obstetric haemorrhage,
dilution or consumptive coagulopathy,
massive transfusion and reactions,
injuries to surrounding organs, prolonged A previous caesarean delivery is a major risk factor for placenta accreta.
hospitalization, and increased risks of
intensive care admission.3–5 It accounts Repeated dilatation and curettage and caesarean section rates worldwide,
for 38–50% of emergency peripartum other corrective uterine surgeries may especially in developed countries. In the
caesarean hysterectomies.6–8 It is a result in myometrial trauma and scarring, US, the incidence of placenta accreta
leading cause of maternal morbidity and contributing to the risk of developing was reported to be 8.3 per 10,000
mortality. Inevitably, there is high demand abnormal placental adherence. deliveries and had doubled over a 12-
for health resources as well as concerns Advanced maternal age has been year period.15 It is anticipated to continue
about adverse obstetric outcomes. 9
identified as an independent risk factor. as a growing health problem.
The two most important risk Other risk factors include smoking, Women at risk for placenta accreta at
factors of placenta accreta are previous uterine anomalies, grand multiparity, term are also at risk in earlier gestations.
caesarean section and placenta praevia. and recurrent miscarriages.4,13,14 Placenta accreta has been reported
The risk increases with the number The incidence of placenta accreta but occurs less frequently in the first
of previous caesarean sections. 5,10–12
continues to rise with increases in trimester. This is usually a retrospective
JPOG_JULAUG_2015_Final_CME_ID_Placenta Accreta An Updated Approach to Diagnosis and Management.indd 169 9/7/15 2:12 pm
170 MIMS JPOG JUL/AUG 2015 CONTINUING MEDICAL EDUCATION
diagnosis, when massive bleeding is 71–97%, and positive predictive value of Magnetic Resonance Imaging
noted during dilatation and curettage 65–88%.1,20,21 Magnetic resonance imaging (MRI) and
procedures and placental invasion of the Sonographic features suggestive of ultrasonography are comparable in diag-
myometrium is found.16 At any gestation, placenta accreta include the following: nosing placenta accreta. Magnetic reso-
prior scarring from uterine incision can obliteration of the retroplacental sono- nance imaging carries additional value in
result in myometrial thinning. Women lucent zone, presence of vascular detecting the depth of placental invasion
may present with uterine rupture, acute lacunae (large, irregular ‘Swiss cheese’ and depicting posterior placenta accre-
abdomen, and shock.17,18 appearance), myometrial thinning (less ta, and in cases where ultrasonography
Reliable antenatal diagnosis of than 1 mm), interruption of bladder line, is inconclusive.9 Uterine bulging, het-
placenta accreta is needed as unexpected and presence of extrauterine placental erogeneous signal intensity within the
encounter of morbidly adherent placenta parenchyma in extreme cases.3,5,9,22 placenta, dark intraplacental bands on
can lead to catastrophic outcomes as While obliteration of retroplacental T2-weighted images, tenting of the blad-
described above. It is also essential in sonolucent zone in isolation has a der, and direct visualization of placental
allowing both patients and physicians to high false-positive rate-up to 50% is invasion into pelvic structures have been
prepare for the potential complications of reported23-the combination of vascular reported as the MRI features of placenta
pregnancy and delivery. lacunae and myometrial thinning is rather accreta.29,30 Nonetheless, the use of MRI
predictive of morbidly adherent placenta, does not seem to improve the manage-
DIAGNOSTIC APPROACH with sensitivity reaching 100%, specificity ment and obstetric outcome. There is
A careful review of history and a high 72–79%, and positive predictive value insufficient evidence to support its rou-
index of suspicion are necessary in 73%.3,9,24 Given that none of these tine use in sonographically suspected
alerting health care providers to the sonographic signs is pathognomonic, placenta accreta.9,20,31,32
possibility of placenta accreta. Various they should be interpreted with caution
types of imaging modalities have been in a clinical setting. OBSTETRIC MANAGEMENT
utilized in an attempt to predict placen- Application of colour Doppler STRATEGIES
ta accreta. further improves the diagnostic accuracy. Antenatal Management
Features include preD, turbulent high- Treating placenta accreta is a real ob-
Ultrasonography velocity flow (>
15
cm/s) extending stetric challenge. Anticipation and iden-
Ultrasonography is a non-invasive, widely from the placenta into the surrounding tification of risk factors form the corner-
available, and cost-effective modality for tissues was found to be sDDensitive stones of safe management strategies
diagnosis of placenta accreta in clinical in identifying individuals with placenta in placenta accreta. It has been recom-
practice. Transvaginal ultrasonography accreta.16,19,25,26 Hypervascularity of the mended that women with previous cae-
overcomes the limitations of transab- vesicouterine serosa interphase also sarean section should have placental
dominal approach due to maternal body increases the possibility of placenta localization to exclude placenta prae-
habitus and suboptimal view of the lower accreta, although bladder varicosities via and further investigation to identify
uterine cervix or placental invasion. Its from previous caesarean sections can accreta, if necessary.33,34 Women who
use and safety in placenta praevia have give rise to false positives. Using three-
26
have had previous caesarean section
been well accepted.19 Over the years, nu- dimensional power Doppler, visualization and placenta praevia, especially ante-
merous ultrasound imaging techniques, of ‘numerous coherent vessels’ in the rior placenta, should be managed as if
including greyscale, colour, and three-di- basal view was the best single criterion they have placenta accreta until proven
mensional power Doppler sonography, for the diagnosis of placenta accreta, with otherwise.28
have been developed to assist in diag- sensitivity of 97% and specificity of 92%. A multidisciplinary care bundle
nosing morbidly adherent placenta an- Inseparable cotyledonal and intervillous for placenta accreta has been
tenatally. Nowadays, ultrasonography is circulations, chaotic branching, and advocated. Elements of good care
the recommended first-line investigation detour vessels may also be observed on consist of preoperative planning by a
with a sensitivity of 77–93%, specificity of lateral view. 27,28
multidisciplinary team, involvement of the
consultant obstetrician and consultant

anaesthetist for planned and directly
supervised delivery, possible input from
urology, gynaecological oncologist, and
vascular surgeons, availability of blood
bank and blood products, intensive care,
and discussion and consent including
possible interventions.28
While maternal haemorrhage is
likely and blood product transfusion
is anticipated, it is beneficial to
prevent anaemia and optimize the
haemoglobin level antenatally. Oral iron
supplementation should be considered
to improve the iron stores and oxygen-
carrying capacity.5
Delivery should ideally be planned
under elective and controlled conditions,
with adequate ancillary support. Optimal
timing of scheduled delivery depends
on various clinical factors. Emergency
preterm delivery may be necessary
because of obstetric complications, for
instance, antepartum haemorrhage.
The maternal benefits of earlier elective
delivery must be balanced against the
neonatal morbidity associated with
premature birth. In the absence of
antepartum hemorrhage or pregnancy
complications, elective late preterm
Management of placenta accreta requires a multidisciplinary team approach.
delivery at around 36–37 weeks of
gestation (with potential corticosteroid
cover) is an acceptable compromise interventional radiological procedures), contact persons in case perioperative
to reduce the likelihood of emergency should be discussed as well. Fertility assistance is required.9
delivery at term.9,28 wish and acceptance of the extent
Detailed preoperative counselling of procedures should be explored. Intrapartum Period
is essential. Involvement of the Adoption of conservative versus Rapid mobilization of trained operating
partner is advisable. They should be early resort to radical treatment is an team and assistant staff is essential, espe-
counselled on the risks of operation, important decision to be made during cially in the event of emergency. In many
including life-threatening haemorrhage the planning process. A standardized institutions, surgeries are performed in
and visceral injuries. Possible information sheet and preoperative the main operating room as opposed to
perioperative interventions, such as check list would be helpful in the labour and delivery wards. Proper equip-
hysterectomy, cystotomy, ureteric management, confirmation of necessary ment should be in place before the com-
stenting, and conservative measures communication and understanding, mencement of an operation.35
(cell salvage, leaving placenta in situ, preparation, and identification of the Dorsal lithotomy positioning
Cystoscopy and prophylactic retrograde

stenting may be considered.35 Midline
skin incision is often preferred, in
preparation for possible exploration
of the upper abdomen. Careful
inspection of the abdominal cavity
allows identification of the site and
extent of placental invasion (Figure 1).
Anatomical distortion and the difficulty
in subsequent surgical dissection of the
bladder plane and in the isolation of the
ureters or pelvic vasculature should be
anticipated. Uterine incision should be
made away from the placenta during
entry into the uterine cavity. One should
avoid incision through the placenta
and subsequent haemorrhage. It is
also unwise to attempt to remove the
placenta at this juncture, as it can lead
to disruption of the highly vascular
lower uterine segment and the infiltrated
placental bed, and increase maternal
morbidity.9
Traditionally, caesarean hysterect-
omy is the gold standard for treating
placenta accreta. In women who have
completed their family, a lower threshold
for hysterectomy is desirable. It is
Figure 1. Thin and very vascular uterine lower segment at the time of caesarean section.
sensible to complete the delivery of the
the rich vascularity usually correlates with the position of placentation
infant and proceed to the closure of the
hysterotomy and planned hysterectomy
with hip abduction but limited flexion is of foetal advantage but limits the with placenta in situ expeditiously to
enables direct evaluation of vaginal manipulation of abdominal contents. control ongoing blood loss.34 Total, rather
bleeding during the operation and General anaesthesia may be appropriate than subtotal, hysterectomy is advocated
allows placement of the uterine balloon, in most cases because of the likelihood because of risks of haemorrhage from
if necessary. 9
of prolonged operating duration and lower-segment invasions. There is also
Anaesthetic considerations include severe haemorrhage.5,35 the concern of carcinoma developing
large-bore venous access, availability It is good practice to have in the cervical stump and the need for
of high flow rate infusion and suction preoperative ultrasound mapping of the continuation of cervical screening after
devices, central and peripheral placental location to guide the surgical subtotal hysterectomy. In cases in which
haemodynamic monitoring capabilities, decisions. When placental invasion to subtotal hysterectomy is performed,
avoidance of hypothermia, and the parametrium is suspected, major peritoneal closure over the cervical
thromboembolic prophylaxis. 5,36
The obstetric haemorrhage is likely to stump should be avoided as further
decision of anaesthetic technique is further increase struggle in ureteric haemorrhage may be concealed and go
individualized. Regional anaesthesia identification, and risk of injury is high. unnoticed.1
With advancements in obstetric

care and interventional modalities, it
is now feasible to offer conservative
management to women who wish
to retain fertility rather than to adopt
an aggressive surgical approach.37
Conservative management aims to
avoid hysterectomy by leaving a part
or the whole placenta in situ, with or
without additional measures, such as
application of compression sutures,
arterial embolization, and segmental
resection of the myometrial tissues,
followed by repair of the defect or
uterine reconstruction. This lowers the
risk of subsequent hysterectomy from
85% to 15%.1 Prerequisites include
haemodynamic stability without
significant blood loss, wish to preserve With advancements in obstetric care and interventional modalities, it is now feasible to
offer conservative management to women who wish to retain fertility.
fertility, possibility of preoperative
consultation, and the availability of
resources and expertise to follow up and the internal iliac or uterine arteries, with pressure to prevent continual bleeding.
manage late postpartum complications. or without balloon inflation at the time of Of the balloon tamponade devices, the
Careful selection and preoperative delivery, or embolization after caesarean Bakri balloon was specifically designed
counselling are essential. 9
section can be performed. A recent for postpartum haemorrhage and was
Various haemostatic methods systematic review of uterus-preserving first described in the management
can be applied to control postpartum treatment modalities reveals that uterine of placenta praevia accreta during
haemorrhage. Placement of compression artery embolization for placenta accreta caesarean section. It is least invasive,
sutures and pelvic devascularization could achieve a subsequent menstruation relatively easy to apply, effective, and
can be used accordingly. Compression rate of 62%, pregnancy rate of 15%, and rapid in action. It carries the advantage
sutures, such as B-Lynch38 or Cho secondary hysterectomy rate of 18%.41 of having a large-bore drainage channel,
square, 39
are particularly effective in Most of these studies are limited by their which is less likely to be blocked by
dealing with uterine atony in general. small series, and so larger prospective fibrin formation. Substitutes include
Hwu et al described two parallel vertical
40
series are awaited. Sengstaken-Blakemore tube and Rusch
sutures, which were placed in the lower It is worth noting that, in placenta balloon, uterine Foley or condom
segment to compress the anterior and praevia accreta, there are additional tamponade can be considered in
posterior walls, that may be more effective arterial supplies by the cervical, vaginal, resource-limited settings.42,43
in targeting the source of bleeding in and inferior vesical arteries to the In contrast to leaving the placenta in
placenta accreta. lower uterine segment. Internal iliac situ, resection of the invaded myometrium
Interventional radiology serves an artery ligation alone or embolization together with the placenta and repair
important role in managing placenta is associated with significant risks of or reconstruction of the non-invaded
praevia accreta. It offers prophylactic failure.1 myometrial defect can be practically
measures to reduce uterine flow Balloon tamponade acts by performed. Lack of comparative studies
and prevent ongoing haemorrhage. exerting an inward-to-outward pressure also resulted in wide variation in the
Preoperative placement of a catheter in that is greater than systemic arterial surgical approaches adopted.1
Transfusion is unavoidable and hage, and disseminated intravascular sarean section should be well informed
constitutes a key step in managing coagulopathy.15 Prophylactic broad- about this complication risk, especially
major obstetric haemorrhage. Although spectrum antibiotics and uterotonic if the operation is not the only delivery
cell salvage could theoretically re- agents are often recommended, option. Identification of risk factors,
infuse fetal debris and possibly result although a consensual guideline has accurate antenatal and preoperative
in alloimmunization, its use and safety yet to be established. Ready access to diagnostic imaging, dedicated multi-
in obstetrics have been supported. medical assessment and resuscitation disciplinary team management, and
Use of other tissue sealants or even are prerequisites to conservative appropriate counselling will all aid in
mesh has been reported; but to date, management, as women are still at risk for the overall management of women with
there is insufficient evidence on their interval hysterectomy should conservative placenta accreta, and their importance
effectiveness and safety.1 Recombinant management fail and complications arise. cannot be emphasized enough. Elective
factor VIIa has been approved for use It is controversial whether the placenta caesarean delivery at near-term should
in patients with haemophilia A and with should be removed postpartum, left to be arranged in an institute with ade-
inhibitors of coagulation. It induces absorb, or be expelled spontaneously. quate intrapartum anaesthetic, haema-
coagulation at sites of active bleeding in Serum human chorionic gonadotrophin tological, and interventional radiological
the presence of tissue factor. However, and Doppler ultrasound may be utilized support. Early resort to hysterectomy
it is associated with high cost and to assess the cessation of placental may help to avoid further haemody-
significant thrombotic risk, and should vascularity for consideration of interval namic deterioration while combating a
therefore be reserved as a last resort. 35
removal, but the clinical correlation major maternal haemorrhage. Conserv-
remains undetermined. Hysteroscopic ative management may be considered
Postpartum Period retrieval of retained trophoblastic tissues for women who desire to retain fertility.
Patients with placenta accreta and ma- has been described. It achieves similar Women should ideally be closely moni-
jor postpartum haemorrhage are at risk surgical and reproductive outcomes, but tored in intensive care or high-depend-
for intrapartum hypotension and persis- carries the advantage of direct visualization ency unit postoperatively and followed
tent coagulopathy. Close monitoring of and reduces the risk of uterine perforation up for late complications. A designated
vital signs and organ functions postop- compared with blind curettage.44,45 care bundle and local protocol would
eratively is of utmost importance. Input Methotrexate, a folate antagonist, be beneficial for management of this
from intensive care physicians is inval- has been proposed as a conservative high-risk obstetric condition.
uable. Further imaging by computed medical measure for retained placenta Last but not least, psychological
tomography or MRI is necessary should with morbid adherence. It is effective assessment and appropriate support
there be alteration in haemodynamics or against proliferating trophoblasts, but after major obstetric events are often
signs of haemoperitoneum. Exploratory its action on degenerative placenta overlooked in busy clinical settings.
re-laparotomy must not be delayed if after delivery remains questionable. Debriefing sessions with the patient and
clinically indicated. Physicians should be In general, outcomes do not differ family at appropriate intervals, provision
alerted of possible unrecognized urinary significantly with or without the use of adequate explanation, and effective
tract injury, which may present as per- of methotrexate. Methotrexate is communication would help to reduce
sistent haematuria or anuria. Sheehan contraindicated in breastfeeding and is patient dissatisfaction and risks of
syndrome, transient or permanent, is a not routinely recommended for use. medical litigation.
known complication of massive postpar-
tum haemorrhage. Hyponatraemia may CONCLUSION About the Authors
Dr Cheung is Resident in the Department of Obstetrics and
be an early sign for this. 9,34
Placenta accreta is an evolving chal- Gynaecology, Queen Mary Hospital; and Honorary Clinical
Assistant Professor in the Department of Obstetrics and Gy-
While the placenta is left in situ, lenge in modern obstetrics. It is an iatro- naecology, University of Hong Kong, Hong Kong. Dr Chan is
Specialist in Obstetrics and Gynaecology in the Hong Kong
patients should be monitored and genic consequence of change in obstet- Maternal and Fetal Medicine Clinic; Part-time Consultant in
the Department of Obstetrics and Gynaecology, Queen Mary
followed up for possible secondary ric practice and increasing caesarean Hospital; and Honorary Clinical Associate Professor in the
Department of Obstetrics and Gynaecology, University of
infection, sepsis, postpartum haemorr- section rates. Patients undergoing cae- Hong Kong, Hong Kong.
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risk factors and complications. Am J Obstet 17. Dahiya P, Nayar KD, Gulati AJ, Dahiya K. naecologists. Placenta praevia, placenta 1997;104:372–375.
Gynecol 2005;193:1045–1049. Placenta accreta causing uterine rupture in praevia accreta and vasa praevia: diagnosis 39. Cho JH, Jun HS, Lee CN. Hemostat-
5. Publications Committee, Society for second trimester of pregnancy after in vitro and management. Green-top Guideline No. ic suturing technique for uterine bleeding
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2010;203:430–439. 18. Roca LE 2nd, Hoffman MC, Gaitan LF, RR. Placenta accreta: spectrum of US 40. Hwu YM, Chen CP, Chen HS, Su TH.
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176 MIMS JPOG JUL/AUG 2015 CME QUESTIONS
Program pendidikan kedokteran berkelanjutan ini dipersembahkan oleh

MIMS, bekerjasama dengan Ikatan Dokter Indonesia.
Setelah membaca artikel ‘Placenta Accreta—An Updated Approach
to Diagnosis and Management’, jawab pertanyaan berikut kemudian
kirimkan dengan menggunakan formulir jawaban yang sudah disediakan
ke CME MIMS Journal of Paediatrics, Obstetrics & Gynaecology, untuk
mendapatkan 5 SKP.
ARTIKEL CME 5 SKP
Placenta Accreta—An Updated

and Management
Jawab pertanyaan di bawah ini dengan Benar atau Salah.
1. The incidence of placenta accreta has plateaued in recent decades.

2. All women with prior caesarean delivery should have an ultrasound scan for placental location.
3. Presence of retroplacental sonolucent zone is a feature of placenta accreta.
4. When ultrasonography finding is indicative of placenta accreta, magnetic resonance imaging should be
arranged to confirm the diagnosis.
5. Elective caesarean section for placenta accreta must be arranged after 38 weeks of gestation to reduce
the risk of neonatal respiratory distress syndrome.
6. It is advisable to remove as much placental tissue as possible at the primary operation to avoid risk of
secondary haemorrhage due to retained placenta.
7. Subtotal hysterectomy is always preferred in placenta accreta.
8. Additional arterial supplies to the lower uterine segment help explain the high failure rate of uterine artery
embolization.
9. Methotrexate is unlikely to be effective on the degenerating placenta.
10. Persistent haematuria or anuria postoperatively is a sign of unrecognized urinary tract injury and
necessitates further investigation.

Mims Jpog August 2015 Id

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JPOG

INDONESIA – ISSN 2411-0183 • JUL/AUG 2015 VOL. 41 NO. 4

JOURNAL OF PAEDIATRICS, OBSTETRICS & GYNAECOLOGY Online Mobile Print Live

JUL/AUG 2015 VOL. 41 NO. 4

Board Director, Obstetrics and Gynaecology

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JUL/AUG 2015 VOL. 41 NO. 4

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iv MIMS JPOG JUL/AUG 2015

JUL/AUG 2015 VOL. 41 NO. 4

REVIEW ARTICLE SPECIAL FEATURE

158 Journal Reports

Sam Shum, Designer

JPOG_JulAug 2015_Final_TOC_ID.indd 4 9/7/15 2:54 pm

JPOG_JulAug 2015_Final_Combine.indd 133 9/7/15 2:22 pm

Cerebroplacental small-for-gestational-age (SGA) foe- exercise, including home-based activ-

JPOG_JulAug 2015_Final_Combine.indd 134 9/7/15 2:22 pm

Ngui EM et al. Evaluation of a social marketing campaign to

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Sexual intercourse decreases org/10.1155/2015/685281

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RADIOLOGY MEETS OBSTETRICS

INTRODUCTION unwanted. The whole concept of moth-

JPOG_JulAug 2015_Final_Combine.indd 137 9/7/15 2:22 pm

JPOG_JulAug 2015_Final_Combine.indd 138 9/7/15 2:22 pm

domen. Women may feel even more trapped and

ly in the pregnancy and then again later is ideal.

JPOG_JulAug 2015_Final_Combine.indd 139 9/7/15 2:22 pm

Diminished concentration - more detailed psychiatric history is warranted.13

JPOG_JulAug 2015_Final_Combine.indd 140 9/7/15 2:22 pm

JPOG_JulAug 2015_Final_Combine.indd 141 9/7/15 2:22 pm

Both depression and the use of antidepressants are linked

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infants of anxious mothers have high cortisol lev-

JPOG_JulAug 2015_Final_Combine.indd 143 9/7/15 2:22 pm

Key Points atrician. The role of the GP throughout this pe-

sant medication ideally should delivery at a

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 MIMS Annual 2015 Rp. 200.000,-

Isi Data Lengkap Anda

Nama (dr/Apotek/RS) : ________________________________________

Email : _____________________________________________________ HSBC Indonesia

INTRODUCTION managing the menopause, both from the

JPOG_JulAug 2015_Final_Combine.indd 145 9/7/15 2:22 pm

• Nonhormonal treatments for menopausal symptoms used as an opportunity to proactively educate

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• A proportion of the 80% of women who experi-

Should a Menopause Symptom Score

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Box 3. Menopause Symptom Score Sheet*

AMS Diagnosing Menopause: Symptom Score Sheet

New facial hair

Crawling feelings under the skin

Less sexual feelings

SEVERITY OF PROBLEM IS SCORED AS FOLLOWS

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All women at menopause can benefit from a review of lifestyle

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Nonhormonal Pharmacological Options Key Points

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FACILITATING INFORMED There is no set minimum or maximum duration

up consultation to update their medical history,

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• A proportion of the 80% of women who experi-

• WHO recommends exclusive

• Breastfeeding reduces the risk

• At six months of age, mashed

• Enquiry about the breasts related to engorge-