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Crash Course Obstetrics and Gynaecology, 3E (2014) (PDF) (UnitedVRG) PDF
Crash Course Obstetrics and Gynaecology, 3E (2014) (PDF) (UnitedVRG) PDF
CRASH COURSE
SERIES EDITOR:
Dan Horton-Szar
BSc(Hons) MBBS(Hons) MRCGP
Northgate Medical Practice
Canterbury
Kent, UK
FACULTY ADVISORS:
Shreelata T Datta
LLM, MBBS, BSc (Hons), MRCOG
Consultant in Obstetrics and Gynaecology,
King’s College Hospital, London UK
Ruma Dutta
BSc, MBBS, MRCOG
Consultant in Obstetrics and Gynaecology,
Hillingdon Hospital NHS Trust, Middlesex, UK
Obstetrics and
Gynaecology
Chidimma Onwere
MBBS BSc
Specialist Registrar in Obstetrics and Gynaecology, St. Mary’s
Hospital, Imperial College Healthcare NHS Trust, London, UK
Hemant N Vakharia
MBBS BSc(Hons) MRCOG
Specialty Registrar in Obstetrics and Gynaecology, Barnet and
Chase Farm NHS Hospitals Trust, London, UK
Edinburgh London New York O xford Philadelphia St Louis Sydney Toronto 2014
Commissioning Editor: Jeremy Bowes
Development Editor: Fiona Conn
Project Manager: Andrew Riley
Designer: Christian Bilbow
Icon Illustrations: Geo Parkin
Illustration Manager: Jennifer Rose
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Se rie s e d it o r fo re w o rd
The Crash Course series first published in 1997 and now, 17 years on, we are
still going strong. Medicine never stands still, and the work of keeping this
series relevant for today’s students is an ongoing process. These new editions build
on the success of the previous titles and incorporate new and revised material,
to keep the series up to date with current guidelines for best practice, and recent
developments in medical research and pharmacology.
We always listen to feedback from our readers, through focus groups and student
reviews of the Crash Course titles. For the new editions we have completely
re-written our self-assessment material to keep up with today’s ‘single-best answer’
and ‘extended matching question’ formats. The artwork and layout of the titles
has also been largely re-worked to make it easier on the eye during long sessions
of revision.
Despite fully revising the books with each edition, we hold fast to the principles on
which we first developed the series. Crash Course will always bring you all
the information you need to revise in compact, manageable volumes that integrate
basic medical science and clinical practice. The books still maintain the balance
between clarity and conciseness, and provide sufficient depth for those aiming at
distinction. The authors are medical students and junior doctors who have
recent experience of the exams you are now facing, and the accuracy of the
material is checked by a team of faculty advisors from across the UK.
Dr Dan Horton-Szar
v
This pa ge inte ntiona lly le ft bla nk
Pre fa ce
As part of the Crash Course series, this third edition continues to give the essential
information in a clear concise manner, combining up-to-date text with tables,
figures and algorithms. It gives vital information as well as hints and tips that focus
on how important it is to take a good history. O bviously this is necessary in
any branch of medicine, but the personal nature of this specialty makes it even more
crucial. Similarly, examination of the patient is described in a sensitive manner.
After covering management for each topic, the popular self-assessment section has
been updated in line with current examination techniques.
Chidimma O nwere
Hemant Vakharia
Shreelata Datta
Ruma Dutta
vii
This pa ge inte ntiona lly le ft bla nk
De d ica t io n
To my excellent parents for all their encouragement and my dear husband Tochi for all
his love and support.
Chidimma O nwere
To my father, mother and brothers for all their amazing support, to my wife for her
endless love and patience and to my gorgeous daughter for making it all worthwhile!
Hemant Vakharia
To my grandfathers, who continually inspire me, to my parents who kept me going as a student
and to my patients, who keep me going as a doctor.
Shreelata Datta
To my dad, who would have been proud to see my name in print, and to my mum, who is. Also
to Paul, Jack and Sadie for all their patience and love.
Ruma Dutta
ix
This pa ge inte ntiona lly le ft bla nk
Co n t e n t s
xi
Contents
xii
Contents
xiii
Contents
xiv
Ta kin g a h ist o ry 1
O bjectives
2
History of presenting complaint 1
3
Taking a history
• Was th e on set associated with a previous obstetric • Menstrual cycle: usually denoted as 5/ 28, where the
or gyn aecological even t? For exam ple, stress incon- num erator is the length of the period in days and the
tinence and childbirth. denom inator is the length of the cycle in days from
• Are th ere an y relievin g or exacerbatin g factors? For 1 st day to 1 st day. If period and cycle length are var-
exam ple sym ptom s of prolapse are often worse on iable the shortest and longest are noted, e.g.
standing and better on lying down. 3–10/14–56
• Are th ere an y associated sym ptom s? For exam ple • Menstrual flow: whether light, norm al or heavy. This
the painful periods of endom etriosis are som etim es is often very subjective, therefore if heavy, the pres-
associated with deep dyspareunia (deep pelvic pain ence of clots, flooding, night tim e soiling and the
with intercourse). num ber of sanitary pads/towels used should be
If pain is the presenting com plaint, then the follow- noted
ing characteristics should be noted: • Menstrual pain or dysm enorrhoea: is the pain m ild,
m oderate or severe? Has it been present since m en-
• Site: is the pain pelvic or abdom inal? For exam ple
arche or is it of recent onset. Is the pain worse before
ovarian pain can be felt quite high in the abdom en.
(prim ary dysm enorrhoea) or during the period
• Severity: how severe is the pain and to what extent
(secondary dysm enorrhoea)?
does it disrupt everyday life? For exam ple the cyclical
• Associated symptom s: for exam ple bowel or bladder
pain of endom etriosis m ight necessitate regular tim e
dysfunction, nausea
off work.
• Other bleeding: interm enstrual bleeding (IMB),
• On set: sudden or gradual? For exam ple the pain
postcoital bleeding (PCB), pre- or postm enstrual
from a torted ovarian cyst is usually of very sudden
spotting
onset.
• Age at m enopause.
• Ch aracter: is the pain sharp/knife-like, dull, heavy/
dragging, colicky, stretching or twisting? Many adjec-
tives have been used to describe pain or discom fort HINTS AND TIPS
of gynaecological origin. For exam ple wom en with
uterine prolapse m ight describe a pulling or a dra- A useful way to ask sensitive questions may be to
gging pain/sensation, dysm enorrhoea m ight be consider a logical order: after menstrual cycle, ask
likened to labour pain. about bleeding between periods (IMB), then bleeding
• Duration : is the pain constant, interm ittent, what is after intercourse (PCB) and then pain with intercourse
the frequency if interm ittent? The pain of a degener- (dyspareunia) either superficial (around the opening
ating fibroid in pregnancy will be constant whereas of the vagina) or deep.
the pain of threatened prem ature labour will be
interm ittent and frequent.
• Radiation : does the pain radiate? For exam ple endo-
m etriosis pain m ight radiate to the back or into the CO M M UNICATIO N
upper thighs.
• Relievin g/ exacerbatin g features: does anything Particularly for women who come from countries in
m ake the pain better or worse and this should the Horn of Africa (e.g. Somalia, Eritrea, Ethiopia),
include self-prescribed analgesia? For exam ple endo- either themselves or their families, a history should
m etriosis sym ptom s are usually cyclical and associ- be elicited regarding female circumcision or female
ated with m enstruation. genital mutilation (FGM). This procedure usually
• Associated sym ptom s: for exam ple sym ptom s of
occurs as a child in their country of origin, being
peritonitis or advanced m alignancy.
illegal in the UK since 2003. It is defined as all
procedures involving partial or total removal of the
PAST GYNAECO LO GICAL external female genitalia or other injury to the
female genital organs, whether for cultural or other
HISTO RY
non-therapeutic reasons. As an adult, it can cause
significant problems including dyspareunia,
M e n st ru a l h ist o ry recurrent urinary tract infections, trauma and
The following characteristics of m enstruation and the haemorrhage during childbirth, as well as psychological
m enstrual cycle should be noted: issues. Such a history must therefore be approached
• Age at m enarche in a sensitive manner.
• Last m enstrual period (LMP) ¼ 1 st day of last period
4
Social history 1
5
Taking a history
6
Social history 1
7
This pa ge inte ntiona lly le ft bla nk
An t e n a t a l b o o kin g
a n d p re n a t a l d ia gn o sis 2
O bjectives
10
Antenatal booking 2
Haemoglobin electrophoresis
In pregnancy the most important antigen is the D
Haem oglobinopathies are disorders of haem oglobin
structure and are m ore com m on in certain ethnic antigen. Those patients who have one or two copies
groups. Thalassaemia and sickle cell disease are screened of the Rh-D antigen gene will be Rh positive. Those
for to allow identification of fetuses at risk of having the patients who do not have copy of the gene will be
condition. Both conditions are autosomal recessive so in Rh negative.
order for the individual to be affected they need to have In pregnancy, if a Rh negative patient has a partner
two defective copies of the gene. Patients can be asymp- who is Rh positive their offspring may be Rh positive.
tomatic carriers of the condition without knowing. For During the pregnancy fetal blood may enter maternal
example, in the UK there are estimated to be around circulation and cause antibodies to develop to the
240 000 carriers of sickle cell. D-antigen. In subsequent pregnancies these antibodies
may then cross the placenta and attack fetal red cells
Thalassaemia
The thalassaem ias are denoted either a - or b- depending causing anaemia and subsequent fetal hydrops þ / -
upon the affected haem oglobin chain. a -thalassaem ia is stillbirth.
com m on in people of South East Asian descent and To prevent this, a patient should be offered anti-D
b-thalassaem ia is com m on in people of Cypriot and immunoglobulin. This can be given:
Asian descent. During pregnancy, if the m other is • in one dose at 28 weeks or in divided doses at 28 and
found to be a carrier her partner should also be 34 weeks
screened. Based on his results, invasive testing m ay need • postnatally
to be considered. • if a potentially sensitizing event has occurred, i.e.
any event which may cause the passage of fetal cells
Sickle cell disease
into maternal circulation such as abdominal
Sickle cell disease is also an autosom al recessive condi-
trauma, bleeding in pregnancy after 12 weeks,
tion. People with one defective copy of the gene are
referred to as sickle cell trait. Around 1:10 people of amniocentesis and others.
African-Caribbean descent have sickle cell trait and
therefore screening can identify at-risk fetuses.
Both conditions can render the patient anaem ic and Screening for infection
supplem entation with iron and folate m ay be required.
In pregnancy a num ber of infections can have a detri-
It is, however, im portant not to iron overload these
m ental effect on the health of both the m other and
patients. Pregnant patients with sickle cell disease (i.e.
fetus. Therefore screening will allow m odification of
two defective genes) should be m anaged in a specialist
their m anagem ent to m inim ize the risk, not only in this
centre under a m ulti-disciplinary team .
pregnancy but also future pregnancies.
11
Antenatal booking and prenatal diagnosis
Hepatitis B Heartburn
Hepatitis B is a viral infection transm itted: Avoid large meals and lying supine soon after food
• sexually Reduce caffeine and foods with high fat content
Antacid preparations
• vertically (m other to fetus)
• via blood. Constipation
The patient should be referred to a liver physician if Increase fibre in diet, avoid dehydration
she has not been seen previously and her liver function
Haemorrhoids
tests m onitored. Again, partner testing is recom m ended
as well as any existing children she m ay have. Haemorrhoid creams, avoidance of constipation
Post-natal vaccination of the fetus has been shown to Varicose veins
reduce the risk of transm ission. Patients who have the
hepatitis E-antigen (HBeAg) carry the highest risk of Compression stockings can be helpful
Elevation of legs
transm itting the infection to the fetus. Avoid prolonged periods of standing
Hepatitis C is also a viral illness which is transm itted
sexually, vertically (m other to fetus) or via blood. Cur- Backache
rent guidelines, however, do not recom m end routine Advice on posture, massage and water exercising can help
screening.
Symphysis Pubis Dysfunction (SPD)
Human immunodeficiency virus Physiotherapy referral for advice and consideration of
Hum an im m unodeficiency virus (HIV) is a blood- pelvic support devices
borne virus also transm itted sexually, vertically and by
blood. Although incurable, m odern advances in m an-
agem ent have increased the life-expectancy of affected • working during pregnancy
individuals and significantly reduced the rate of vertical • dietary inform ation:
transm ission (see Chapter 23). • Advice on a m ixed diet with fruit, vegetables,
Screening for HIV allows patients to com m ence on fibre, lean m eat, fish, lentils, starchy foods
treatm ent if required and to assess how the patient (bread/pasta, etc.) and dairy
should deliver. All cases should be m anaged by a • Foods to avoid and why are shown in Figure 2.3
m ulti-disciplinary team involving obstetricians, HIV • sm oking and alcohol:
specialists and specialist m idwives. • Discussion about sm oking cessation is essential
plus referral to specialist services if accepted
Urinary tract infections • Alcohol consum ption should be avoided com -
Urinary tract infections (UTIs) m ay be sym ptom atic or pletely in the first trim ester and, ideally, through-
asym ptom atic. In untreated asym ptom atic cases, there out pregnancy. Those who choose to drink
is a significant risk of pyelonephritis and preterm birth. should be advised to drink no m ore than 1 – 2
Current guidelines recom m end screening for asym p- units a week and to avoid binge drinking.
tom atic bacteriuria in all pregnant wom en by m eans
of a m idstream urine (MSU) culture.
Fig. 2.3 Dietary precautions in pregnancy.
12
Antenatal booking 2
• m edications, vitam ins and supplem ents: their pregnancy and those who have had a baby before
• It is im portant to em phasize that m ost m edica- and are low risk will have seven visits. In patients
tions have insufficient data to be deem ed for whom issues have been identified, the schedule
100% safe in pregnancy and therefore their use of care will need to be m odified according to their indi-
should be lim ited to occasions when they are vidual needs.
absolutely necessary. Com plem entary m edicines
again have little or no safety data.
• Advise on the im portance of taking folic acid Scre e n in g fo r ch ro m o so m a l
(400 mg od) during the first 12 weeks to reduce a b n o rm a lit ie s
the risk of neural tube defects.
• driving/air travel: National guidelines recom m end offering all patients a
• Appropriate positioning of the seatbelt, i.e. wear- screening test for Down’s syndrom e (trisom y 21). In
ing it above and below the bum p NOT over. this disorder, the fetus has three copies of chrom osom e
• Long-haul flights are independently associated 21. Future problem s include severe learning difficulties
with an increased risk of venous thromboembo- and cardiac and gastrointestinal tract abnorm alities.
lism. Therefore, unless travel is essential it may
be advisable to avoid it especially when there are
other risk factors such as raised BMI. Com pression
Combined screening test
stockings have been shown to reduce this risk. Depending on the gestation, ultrasound com bined with
• exercise: certain blood tests is used as part of the screening pro-
• Moderate exercise is safe in pregnancy, although gram m e. Between 11 and 14 þ 0 weeks gestation,
patients should be informed of the risks with con- patients who opt to have the test will undergo an ultra-
tact sports and other form s of vigorous exercise. sound assessm ent (Fig. 2.4), which m easures the nuchal
• pets: translucency (NT). They will also have a blood test to
• Toxoplasm osis risk from cat faeces and contam - m easure serum levels of b-hum an chorionic gonadotro-
inated soil, therefore avoidance of handling cat phin (bHCG) and pregnancy-associated plasm a protein
litter and wearing gloves when gardening as well A (PAPP-A).
as hand washing should be advised. NT is an ultrasound observation and refers to the
black space seen on ultrasound within the back of the
fetus’neck. The width of this space is m easured – on aver-
age, fetuses affected with Down’s syndrome have an
Fu rt h e r a n t e n a t a l ca re increased NT. It should be remembered that not all
Depending upon the classification of risk, ongoing fetuses with an increased NTwill have Down’s syndrome.
antenatal care in pregnancy m ay be delivered by general Once the patient has undergone these tests, the results
practitioners, m idwives, obstetricians or a com bination are combined to calculate a risk score which denotes the
of all three. Generally low-risk patients in their first risk of the fetus of having Down’s syndrome, for example
pregnancy will have around 10 visits spread throughout 1 in 2000, i.e. this is only a screenin g test. In the UK
13
Antenatal booking and prenatal diagnosis
guidance has recomm ended a cut off of 1 in 150 for con- assessm ent of any structural anom aly. Although often
sideration as ‘high risk’ and these individuals are coun- not realized by patients, this indeed is a form of prenatal
selled about the option of invasive testing, i.e. do they diagnosis. Any anom aly identified m ay prom pt further
wish to proceed with a diagn ostic test. diagnostic interventions such as am niocentesis or fetal
blood sam pling.
Triple or quadruple test
For those patients who book late or have m issed the cut Amniocentesis
off for com bined screening, they can be offered second
trim ester screening in the form of the triple or quadru- The term am niocentesis is derived from the Greek words
ple test. These are blood tests following which a risk amnion (referring to the am nion of the fetal m em -
score is also generated. branes) and centesis, from kente¯sis a puncture, i.e. a
puncture of the am nion. The aim of the procedure is
to obtain a sam ple of am niotic fluid from which fetal
Ultrasound at 18–20 weeks cells can be harvested. The fetal cells are then cultured
Patients will also be offered another scan ideally and undergo testing to establish the fetal karyotype
between 18 weeks and 20 weeks þ 6 days, which is (the num ber and visual appearance of the chrom o-
known as the routine anom aly scan and looks for any som es in the cell). Results take:
problem s of developm ent in the fetus. Again, if abnor- • 2–3 days using the polym erase chain reaction (PCR)
m alities are detected, then it m ay be appropriate to offer technique
invasive testing and prenatal diagnosis. • up to 2 weeks from a culture.
Another use of am niocentesis is for diagnosis of sus-
pected fetal infection where the am niotic fluid can be
PRENATAL DIAGNO SIS sam pled and tested, e.g. cytom egalovirus infection.
The procedure is carried out after 15 weeks of preg-
The introduction of screening program m es and nancy; those done prior to this are associated with a
increased awareness of certain genetic conditions has higher risk of fetal loss and lim b abnorm alities. Under
led to the option of prenatal diagnosis becom ing a com - ultrasound guidance, a needle is passed through the
m on diagnostic tool. It is estim ated that around 5% of anterior abdom inal wall into the am niotic cavity. Am ni-
pregnant patients are offered invasive prenatal diagnos- otic fluid is then aspirated and the needle withdrawn.
tic tests (30 000 patients in the UK). Figure 2.5 shows the technique.
As m entioned above, patients are offered screening As with any m edical procedure there are associated
for chrom osom al abnorm alities such as Down’s syn- risks, therefore before undergoing the procedure it is
drom e. These tests are NOT diagnostic and only offer essential that patients understand the risks and weigh
a risk score. In individuals who are deem ed high risk, up whether the benefits outweigh the risks. An am nio-
prenatal diagnosis offers a way of establishing a diagno- centesis carries a 1% risk of m iscarriage and 0.1% risk of
sis as to whether the fetus does indeed have the condi- serious infection.
tion suspected by the screening. Also, parents who are
carriers for certain conditions m ay wish to know
HINTS AND TIPS
whether or not their child is affected by the condition.
Undergoing prenatal diagnosis allows the couple to be Both an amniocentesis and chorionic villous sampling
prepared for the needs of the child if they choose to con- are considered a potentially sensitizing event and
tinue with the pregnancy or indeed opt for a term ina- therefore the administration of anti-D immunoglobulin
tion of pregnancy. Furtherm ore, it allows m edical
to RH negative mothers is recommended.
team s to m odify antenatal care and to prepare for the
delivery and needs of the baby once born.
14
Prenatal diagnosis 2
Fu rt h e r re a d in g
Leslie, K., Papageorghiou, A., 2011. Invasive Procedures in
Fig. 2.6 Chorionic villous sampling (CVS) (A) Transcervical. Oxford Desk Reference Obstetrics & Gynaecology. Oxford
(B) Transabdominal. University Press, London.
15
Antenatal booking and prenatal diagnosis
Nelson-Piercy, C., 2010. Handbook of Obstetric Medicine, RCOG, 2010. Am niocentesis and Chorionic Villus Sam pling,
fourth ed. Informa Healthcare, London. Green-top Guideline No. 8. Royal College of Obstetricians
NICE, 2010. NICE Guidelines – Antenatal Care. National and Gynaecologists, London.
Institute for Health and Care Excellence, London. Available UK National Screening Com m ittee, 2013. Screening Tests for
online at: guidance.nice.org.uk. You and Your Baby Booklet. Available online at: www.
NHS Fetal Anom aly Screening Program m e. Available online at: screening.nhs.uk/annbpublications.
http://fetalanom aly.screening.nhs.uk.
16
Exa m in a t io n 3
O bjective
Number of fetuses
The num ber of fetuses present can be calculated by
transverse
assessing the num ber of fetal poles present. ‘Fetal pole’
is the term used to denote the head or the breech. In a
singleton pregnancy, two poles should be palpable
unless the presenting part is deeply engaged in the
oblique
20 weeks
oblique
Fig. 3.2 The fetal lie. The relationship of the long axis of the
Fig. 3.1 Fundal height in relation to abdominal landmarks. fetus to the long axis of the uterus.
18
Abdominal examination 3
Fig. 3.3 The fetal presentation. The relationship of the presenting part of the fetus to the maternal pelvis.
19
Examination
Liquor volume
Clinical assessm ent of liquor volum e is not as accurate
as objective assessm ent using ultrasound. However,
subjective assessm ent can alert the exam iner to the pos-
sibility of reduced or increased liquor volum e and insti-
gation of the necessary investigations. Reduced liquor
volum e m ight be suggested when the uterus is sm all
Engagement of the for dates with easily palpable fetal parts producing an
presenting part expressed
in fifths palpable above
irregular firm outline to the uterus. Increased liquor vol-
the pelvic inlet um e causes a large-for-dates uterus that is sm ooth and
rounded and in which the fetal parts are alm ost im pos-
1 sible to distinguish. If suspected, an ultrasound scan
2 should be ordered to assess objective m easurem ents
3 such as depth of deepest pool or am niotic fluid index.
4
20
Pelvic examination 3
O ccipitoanterior O ccipitoposterior
R L R L
21
Examination
22
Pelvic examination 3
A B
Bimanual examination
It is usual to perform an in tern al exam in ation usin g
th e lubricated in dex an d m iddle fin gers of th e righ t
h an d. In n ulligravid an d postm en opausal wom en
it m igh t be n ecessary to use on ly th e in dex fin ger.
Palpation of the vagin al walls is im portan t to exclude
scarrin g, cysts an d tum ours th at can easily be m issed
on in spection. Th e vagin al forn ices sh ould be exam -
in ed for scarrin g, th icken in g an d swellings th at will
suggest pelvic path ology. Th e size, sh ape, position ,
con sisten cy, an gle an d m obility of th e cervix sh ould Fig. 3.9 Positions of the uterus.
be assessed. Movin g th e cervix from side to side m igh t
elicit cervical m otion ten dern ess an d elevatin g th e
cervix an teriorly, th ereby stretch in g th e uterosacral its size, sh ape, con sisten cy, m obility an d wh eth er it
ligam en ts, m igh t cause pain in th e presen ce of en do- is fixed to th e uterus or n ot sh ould all be n oted.
m etriosis. Th e presen ce an d degree of ten dern ess sh ould be
Th e fin gers of th e righ t h an d are th en used to n oted.
elevate or steady th e uterus wh ile th e left h an d pal-
pates abdom in ally. An an teverted uterus is usually O b st e t ric p e lvic e xa m in a t io n
palpable between th e two h an ds. A retroverted uterus
is usually felt as a swellin g in th e posterior forn ix There are three com ponents to the obstetric pelvic
an d is n ot bim an ually palpable un less it is flipped exam ination:
forward in to an an teverted position an d elevated 1. External inspection of the vulva
in to th e an terior part of th e pelvis. Th e differen t com - 2. Internal inspection of the vagina and cervix
bin ation s of version an d flexion of th e uterus are 3. Vaginal exam ination.
sh own in Figure 3.9. Th e size, position , con sisten cy,
outlin e an d m obility of th e uterus sh ould all be
HINTS AND TIPS
n oted. A pregn an t uterus sh ould feel soft an d globu-
lar an d rough ly th e size of an apple, large oran ge An obstetric examination is incomplete without a
an d grapefruit at 6, 8 an d 12 weeks’ gestation , blood pressure check, urinalysis and auscultation of
respectively. the fetus.
To exam in e th e adn exa, th e fin gers of th e righ t
h an d sh ould be position ed in on e of th e lateral forn i-
ces an d th e adn exal region palpated between th e two
h an ds. Norm al prem en opausal ovaries are n ot always External examination of the vulva
palpable depen din g on th e size of th e patien t. Fallo- The blood flow through the vulva and vagina increases
pian tubes an d postm en opausal ovaries sh ould n ot dram atically in pregnancy. The vulva m ight look
be palpable. If an adn exal m ass is discovered, th en swollen and oedem atous secondary to engorgem ent.
23
Examination
Iliac crest
Vaginal examination
This should be perform ed under aseptic conditions in
the presence of ruptured m em branes. Once the cervix
has been identified, the following characteristics should
be determ ined:
• Dilatation
−3
• Length −2
• Station of presenting part −1
0
• Consistency +1 Ischial
+2 spine
• Position. +3
cm
24
Pelvic examination 3
Fig. 3.12 The Bishop scoring system for the uterine cervix.
Cervical characteristic Score
0 1 2 3
O ccipital bone
Defining the position of the presenting part
With a cephalic presentation, the anterior and posterior
fontanelles and the sagittal sutures should be identified.
Posterior The posterior fontanelle is Y-shaped and is form ed
fontanelle when the three sutures between the occipital and parietal
Parietal bones meet. The anterior fontanelle is larger, diamond-
bone shaped and formed by the four sutures between the
parietal and temporal bones meeting (Fig. 3.13). The
position of the presenting part can be defined as shown
Sagittal
suture in Figure 3.14. The presence of caput and m oulding
should also be assessed. Caput is the subcutaneous swell-
Anterior
fontanelle ing on the fetal scalp that can be felt during labour and
this increases if the labour is prolonged with failure of the
Frontal cervix to dilate. Moulding is the term used to describe the
bone overlapping of the skull bones that occurs as labour
progresses.
Fig. 3.13 The landmarks of the fetal skull including the
anterior and posterior fontanelles.
HINTS AND TIPS
Cervical consistency When assessing progress in labour one must
Softening of the cervix occurs as pregnancy progresses always comment on engagement of head, cervical
aiding cervical effacem ent and dilatation. The consis- dilatation, cervical effacement, station of head
tency of the cervix can be described as firm , m id-
in relation to ischial spines, position of head,
consistency or soft.
moulding, caput and liquor colour (e.g. meconium
Cervical position staining).
This describes where the cervix is situated in the antero-
posterior plane of the pelvis. As the cervix becom es
effaced and dilated it tends to becom e m ore anterior
in position.
HINTS AND TIPS
The Bishop score It has become increasingly recognized that the best
Using the above characteristics, Bishop devised a scor-
test of a pelvis is the dynamic process of labour
ing system to evaluate the ‘ripeness’ or favourability
itself, so formal pelvic assessment is no longer
of the cervix (Fig. 3.12). This system is used as an objec-
tive tool when inducing labour to assess the cervix. performed as a routine. The Bishop score is used in
The higher the score, the m ore favourable the cervix the assessment of cervical favourability prior to
and the m ore likely that induction of labour will be induction of labour.
successful.
25
Examination
Cephalic presentation
Breech presentation
Fu rt h e r re a d in g
RCOG, 2009. Fem ale Genital Mutilation Managem ent RCOG.
Green-top Guideline No. 53. Royal College of Obstetricians
and Gynaecologists, London.
26
Co m m o n in ve st iga t io n s 4
O bjectives
28
Imaging techniques 4
or adenom yosis. The m idline echo corresponds to the Ultrasound and pregnancy
endom etrial thickness and will vary depending on the
Early pregnancy ultrasound can be used to:
m enstrual cycle. Pathology of the endom etrial cavity,
such as endom etrial hyperplasia, endom etrial polyps • check the fetal heartbeat – the fetal heart is detectable
or subm ucous fibroids, m ight be detected. In som e cen- with ultrasound by 6 weeks’ am enorrhoea
tres, this is aided by hysterosonography, where saline is • confirm the num ber of fetuses – a gestation sac can
instilled into the uterine cavity to outline abnorm alities. be seen in the uterine cavity from as early as 5 weeks’
Intrauterine contraceptive devices (IUCDs) will show am enorrhoea when using a transvaginal probe
up as very bright echoes. • calculate the gestational age of the fetus – crown–
rum p length (CRL) is used to date the fetus up to
The ovaries 13 þ 6 weeks’ am enorrhoea (Fig. 4.3), after which
tim e CRL m easurem ent becom es inaccurate due to
The size and position of the ovaries can be assessed. In flexion of the fetus. After the first trim ester, the bipar-
polycystic ovary syndrom e (PCOS, see Chapter 16), the ietal diam eter (BPD) is a m ore accurate m easure-
polycystic ovary is on average twice the norm al volum e m ent with which to date the pregnancy.
with thickened central strom a and 10 or m ore peripher-
ally sited follicles. Follicular tracking is possible in
wom en trying to conceive.
Early pregnancy complications
Ovarian tum ours can be identified ultrasonographi- A delayed or m issed m iscarriage occurs if the em bryo
cally, but differentiation between benign and m alignant fails to develop or dies in utero (see Chapter 20). In
tum ours cannot be m ade with certainty. Figure 4.2 the presence of an ectopic pregnancy, a thickened endo-
shows som e of the ultrasound characteristics of benign m etrium is usually seen with an adnexal m ass. In about
and m alignant ovarian tum ours. 5% of ectopic pregnancies a viable pregnancy can be
seen outside the uterus with ultrasound.
The fallopian tubes The m ost im portant role of ultrasound in the m an-
agem ent of a suspected ectopic pregnancy is to confirm
The fallopian tubes are not norm ally visible by ultra- or exclude a viable intrauterine pregnancy.
sound. However, when they are blocked and distended
with fluid (hydrosalpinx) they will appear as cystic
structures that m ight be m istaken for ovarian cysts. Anomaly scans
Most obstetric units offer routine anom aly scans
HINTS AND TIPS between 18 and 22 weeks’ gestation. Different fetal
anom alies are best detected at different tim es through-
Ultrasound has a central role in characterizing ovarian out the pregnancy, but 18–20 weeks appears to be the
cysts and bleeding in post-menopausal women: optim um tim e for a screening scan. Apart from gross
• If an ovarian cyst is 5 cm or more, the cyst should anatom ical defects, certain ‘m arkers’, such as choroid
be monitored using repeat scans or surgically plexus cysts and renal pelvi-caliceal dilatation, can be
removed if the patient is symptomatic. identified which are associated with chrom osom al
• If the endometrial thickness in a post-menopausal abnorm alities.
woman is 5 mm or more, an endometrial biopsy
should be taken.
29
Common investigations
Fetal growth
Fetal growth is assessed clinically in a norm al singleton
pregnancy. Where uterine size is not com patible with
dates or clinical assessm ent is difficult, for instance in
the presence of obesity or m ultiple pregnancy, objective
m easurem ents of fetal head circum ference (HC), BPD
and abdom inal circum ference (AC) are m ade using
ultrasound and plotted on fetal growth charts. Scanning
at regular intervals allows the growth of the fetus to be
m onitored.
30
Urodynamics 4
31
Common investigations
A B Gas
Veress
needle
Loops
of bowel
Monitor
Telescope
Trocar
Fig. 4.6 Laparoscopic entry technique, using Veress needle insertion and gas insufflation. This is the gold standard for
diagnosing endometriosis. Risks include bowel and blood vessel perforation.
Detrusor
pressure
Urine flow
Fill
32
Ab n o rm a l u t e rin e b le e d in g 5
O bjectives
Abnorm al uterine bleeding is a com m on problem expe- tenfold increase in the num ber of periods that wom en
rienced by m ost wom en at som e tim e in their life. The experience during their reproductive life. This has m eant
causes can be physiological or pathological and, as long that excessive m enstrual bleeding has becom e one of the
as serious pathology is excluded, m ight not require m ost com m on causes of concern for health in wom en.
treatm ent. For norm al m enstruation to occur, the fol-
lowing are necessary:
• Hypothalam ic function Dia gn o sis
• Pituitary function
• Ovarian function Menorrhagia can be diagnosed using the following
• Endom etrial function techniques:
• Patent cervix and vagina. • Subjective assessm ent
Abnorm al uterine bleeding can be caused by m al- • Pictorial blood loss assessm ent charts (Fig. 5.2)
function or disease at any of these levels. • Objective assessm ent.
O n ly h alf of wom en com plain in g of h eavy periods
will h ave m en orrh agia, so relyin g on subjective assess-
m en t alon e will m ean th at m an y wom en are treated
M ENO RRHAGIA for a con dition th at th ey do n ot h ave. A visual m eth od
of assessin g m en strual blood loss usin g pictorial
Menorrhagia (heavy m enstrual bleeding) is defined as
ch arts h as been sh own to be m ore effective at diagn os-
heavy cyclical periods, which interferes with physical,
in g m en orrh agia th an subjective assessm en t alon e.
social and em otional quality of life. It can occur alone
This considers the degree to which each item of sanitary
or in com bination with other sym ptom s. Only about
protection is soiled with blood as well as the quantity
half of wom en com plaining of heavy periods actually
used, but, interestingly, the charts are not frequently used
have m enorrhagia, which is defined as m ore than
in practice.
80 m L of m enstrual blood loss (MBL) per period. This
Objective m easurem ent of m enstrual blood loss is
represents two standard deviations above the m ean
rarely perform ed and usually only during clinical trials.
MBL, which is about 40 m L per period. Two-thirds of
This is because collecting and storing soiled sanitary
wom en with genuine m enorrhagia will have iron-
protection for m easurem ent of m enstrual blood loss
deficiency anaem ia. Both local and system ic conditions
requires tim e and is inconvenient for m ost patients.
can cause m enorrhagia (Fig. 5.1).
In cid e n ce
Ae t io lo gy
The incidence of m enorrhagia is reported to be 9–15%
of population sam ples in Western Europe; however, as There are three categories for the aetiology of m enorrha-
m any as one-third of wom en regard their m enstrual loss gia (Fig. 5.1):
as heavy. Early m enarche, late m enopause, reduction in 1. System ic conditions
fam ily size with concurrent reduction in periods of lac- 2. Local pathology
tational am enorrhoea have all contributed to an alm ost 3. Iatrogenic causes.
Hist o ry
Clots/ A full gynaecological history should be taken. The
flooding length and frequency of m enstruation should be noted,
together with any interm enstrual and post-coital bleed-
Fig. 5.2 Pictorial blood loss assessment chart. ing. Although subjective assessm ent does not quantify
34
Menorrhagia 5
ated with m enorrhagia and usually occurs when the Thyroid function tests
flow is heaviest. Prem enstrual pain can indicate endo- Full blood count Clotting studies where
clinically indicated
m etriosis (see Chapter 8). Fever, pelvic pain, dyspareu-
nia and vaginal discharge are com m on sym ptom s of
pelvic inflam m atory disease (PID; see Chapter 13). Ultrasound scan and/ or
A history of PCOS increases the risk of endom etrial Clinical laparoscopy if pelvic
assessment
hyperplasia and carcinom a. Sym ptom s of thyroid dis- pathology suspected
ease or clotting disorders can indicate a system ic cause
of m enorrhagia. Clotting disorders presenting with
Transvaginal ultrasound
m enorrhagia usually do so in the teenage years. Hysteroscopy Or
plus for endometrial thickness
A contraceptive history is im portant. Norm al periods plus
endometrial biopsy
experienced after stopping the COCP m ay appear endometrial biopsy
heavier than the withdrawal bleeds associated with
the COCP. Sym ptom s of heavy or painful periods dat- Fig. 5.3 Investigating menorrhagia.
ing from the insertion of an IUCD would suggest that
it is the cause.
in the outpatient clinic or under general anaesthesia.
It might show endom etrium inappropriate to the
Exa m in a t io n menstrual cycle secondary to anovulation, endom e-
General exam ination aim s to identify signs of iron defi- trial hyperplasia or carcinom a. Acervical smear should
ciency anaem ia, thyroid or clotting disorders. Abdom i- also be perform ed where this is due, or sooner if there
nal exam ination m ight reveal a m ass (e.g. fibroid is a history of interm enstrual or postcoital bleeding
uterus) arising from the pelvis. • current m ethods of endom etrial sam pling – for
Speculum examination may reveal vaginal discharge exam ple pipelle biopsy. These appear to be at least
and cervical pathology, including cervicitis or frank malig- as accurate as D&C, have high levels of patient
nancy. Occasionally, endometrial polyps or pedunculated acceptability, lower com plication rates and do not
fibroids will be seen prolapsing through the cervical os. require inpatient adm ission or general anaesthesia.
Bim anual exam ination m ight reveal an enlarged However, they m ay m iss benign and m alignant
uterus due to fibroids, pelvic tenderness associated with endom etrial pathology and m ust therefore be con-
endom etriosis or PID and the presence of adnexal sidered inadequate for the further investigation of
m asses. m enorrhagia that has persisted despite m edical ther-
apy. In this instance, a hysteroscopy plus sam pling
should be perform ed either as an outpatient or
In ve st iga t io n s under general anaesthesia depending on facilities
Investigation (Fig. 5.3) is aim ed at excluding the sys- and patient preference
tem ic and local causes of m enorrhagia and includes: • diagnostic hysteroscopy – the m ost effective way of
• blood tests – a full blood count should be perform ed excluding intrauterine pathology. This can be per-
in all cases. Thyroid function and clotting studies form ed in the outpatient setting without analgesia
should only be perform ed if clinically indicated and will identify endom etrial polyps, subm ucous
• ultrasound – a pelvic ultrasound will identify uterine fibroids, endom etritis and m ost endom etrial carci-
enlargem ent caused by fibroids and adnexal m asses. nom as. Where appropriate, laparoscopy will be indi-
Endom etrial polyps or subm ucous fibroids should cated to exclude pelvic pathology.
be suspected if the endom etrial thickness is excessive N.B. Evidence suggests that a blind D&C, used as a
for the tim e of the m enstrual cycle diagnostic or therapeutic tool in the m anagem ent of
• an endometrial biopsy – should be perform ed on all m enorrhagia, is inadequate when used alone.
wom en aged over 45 years and in women under Abnorm al bleeding before the age of 40 does not
45 years if there are risk factors in the history such as usually require endom etrial sam pling unless the patient
persistent interm enstrual bleeding or suspicious find- is at high risk of endom etrial hyperplasia, e.g. PCOS and
ings on ultrasound scan. This can be performed either increased BMI.
35
Abnormal uterine bleeding
Fig. 5.4 Mean per cent reduction in measured menstrual blood loss in women with menorrhagia treated with medical
therapy.
Drug Mean % MBL reduction
36
Menorrhagia 5
The combined oral contraceptive pill • Intrauterine pathology such as endom etrial polyps
When taken in a cyclical fashion, the COCP inhibits and subm ucous fibroids should be rem oved hyster-
ovulation and produces regular shedding of a thin oscopically. This reduces MBL by 75%.
endom etrium . This m akes it an effective long-term m ed- • Open m yom ectom y m ay be required for large
ical treatm ent for som e wom en with m enorrhagia. fibroids, where the uterus is to be conserved.
Throm bogenic side effects should be discussed with • Endom etrial ablative m ethods are becom ing in-
older wom en and sm okers who are considering using creasingly popular due to rapid recovery and the
COCP for therapeutic reasons. possibility of outpatient treatm ent.
• Hysterectom y – this is reserved for wom en who con-
Danazol tinue to experience m enorrhagia despite trying other
Dan azol is a testosteron e derivative producin g a n um - treatm ents and is discussed below in detail.
ber of effects on th e h ypoth alam ic-pituitary-ovarian
axis. It is n ot com m on ly used. Th e optim um dosage
in th e treatm en t of m en orrh agia appears to be Endometrial ablation
200 m g daily, sign ifican tly reducin g m ean MBL as well
as reducin g dysm en orrh oea. Th e an drogen ic proper- Endom etrial ablation is a day-case procedure which
ties of dan azol produce un acceptable side effects in reduces m enstrual blood loss by producing an ‘iatro-
som e wom en . genic’Asherm an’s syndrom e. Endom etrium is destroyed
using laser, resection, therm al or m icrowave ablation
Gonadotrophin-releasing hormone agonists techniques and the ensuing intrauterine adhesions
GnRH agonists suppress pituitary–ovarian function and reduce endom etrial regrowth from deep within crypts
effectively produce a tem porary, reversible m enopausal or glands. It is therefore not suitable for wom en wishing
state. Because of the subsequent bone density loss their to conceive.
long-term use as a prim ary m edical treatm ent for m en- Although this does not guarantee am enorrhoea as
orrhagia is lim ited unless add-back horm one therapy is hysterectom y does, advantages include speed of surgery,
given. This relegates their clinical use to that of preoper- quicker recovery, rapid return to work and the use of
ative aid, allowing: local as opposed to general anaesthesia. Following
• correction of iron-deficiency anaem ia endom etrial ablation, MBL has been shown to be
• reduction in the size of fibroids reduced by up to 90%.
• reduction in surgical blood loss.
Medical m anagem ent of m enorrhagia should be tai- Complications of endometrial ablation
lored to the patient’s individual needs. Guidelines for The m ost com m on operative com plications are:
m anaging m enorrhagia are shown in Figure 5.5. • uterine perforation – this com m only occurs where
the uterine wall is thinnest, such as the cornual
regions and the cervical canal. It is associated with
Su rgica l t re a t m e n t o f m e n o rrh a gia fluid overload, traum a to the gastrointestinal and
The exact surgical procedure used to treat m enorrhagia genitourinary tracts and m ajor blood vessels result-
depends on the diagnosis: ing in peritonitis or haem orrhage.
37
Abnormal uterine bleeding
• fluid overload – the use of non-electrolytic solu- The m ortality rate following hysterectom y for benign
tions, such as 1.5% glycine, for electrosurgery and disease is very low — approxim ately 6 per 10 000 — and
the pressures needed to distend the uterine walls pre- is usually a consequence of cardiovascular disease and
dispose to the absorption of large quantities of fluid, sepsis.
which can result in hyponatraem ia due to dilutional
effects of the irrigating fluid. Congestive cardiac fail- Fever
ure, hypertension, neurological sym ptom s, haem o- This is the m ost com m on com plication following hys-
lysis and com a occur. terectom y, with one in three wom en experiencing this
• haem orrhage – this can occur if the m yom etrium is following the abdom inal approach. In one-quarter of
resected too deeply or if the uterus is perforated. cases the source of infection is not identifiable; the m ost
• infection – the true incidence of pelvic infection fol- com m on identifiable infection is urinary tract infection,
lowing endom etrial ablation is difficult to quantify. followed by wound or vaginal cuff infection. The use of
Infection can be overwhelm ing and m ight cause prophylactic antibiotics is associated with a lower rate of
long-term pelvic pain. infection of the urinary tract, abdom inal wound and
vaginal cuff.
Rarely, deaths have occurred after endom etrial abla-
tion; these have been due to air em bolism during laser Urinary tract damage
ablation, toxic shock following endom etrial resection, Dam age to the ureter occurs in approximately 1 in every
sepsis from bowel perforation and from haem orrhage 200 hysterectomies. The ureter is likely to be dam aged
following m ajor pelvic vessel transection. at the infundibulopelvic ligament, beneath the uterine
artery and adjacent to the cervix. Predisposing factors to
ureteric dam age include congenital anomaly of the renal
Hysterectomy tracts and distortion of normal anatomy from pelvic
Hysterectom y was one of the m ost com m only per- inflammatory disease, endometriosis and malignancy.
form ed operations in the UK. In 1993–4, 73 517 hyster- Traum a to the bladder occurs in approxim ately 1 in
ectom ies were perform ed in NHS hospitals and 100 hysterectom ies and is m uch higher following vagi-
approxim ately two-thirds of these were perform ed for nal hysterectom y. Predisposing factors include previous
m enorrhagia. By 2002, the num ber of hysterectom ies surgery and obesity.
had fallen to 44 000 due to better diagnostic abilities,
Bowel damage
better m edical treatm ent and the developm ent of focal
The incidence of bowel traum a is approxim ately 1 in
and ablative hysteroscopic techniques.
200 hysterectom ies. Risk factors predisposing to bowel
Hysterectom y can be vaginal, laparoscopic or
dam age are obesity, previous laparotom y, adhesions,
abdom inal, depending on the uterine findings. Total
intrinsic bowel problem s (e.g. chronic inflam m atory
abdom inal hysterectom y is useful for wom en with large
bowel disease) and irradiation.
uteri, m ultiple large fibroids, adenom yosis, pelvic adhe-
Bowel dysfunction following hysterectomy is well
sions and endom etriosis.
documented, with constipation occurring in up to half
Hysterectom y can be a ‘subtotal’ procedure, where
the patients during the first 2 weeks of the abdom inal
the cervix is left behind and can include rem oving the
approach. One in five patients will continue to experi-
ovaries, to reduce the risk of ovarian cancer (oophorec-
ence constipation in the first three postoperative months.
tom y). If the cervix is left behind, cervical sm ears m ust
be continued. Long-term complications of hysterectomy
When the uterus is rem oved, the pelvic floor and its
Complications of hysterectomy nerve supply are disrupted. This can predispose to pelvic
Alm ost half the wom en undergoing abdom inal hyster- floor laxity with subsequent prolapse, as well as bladder
ectom y and one-quarter of those undergoing vaginal and bowel dysfunction. Even when the ovaries are con-
hysterectom y experience a com plication. Although con- served, disruption of their blood supply can interfere
ditions such as throm boem bolic disease should not be with their function, and m ight even predispose to pre-
forgotten, the following are som e of the m ore likely m ature ovarian failure, a risk factor for cardiovascular
com plications to be encountered: disease and osteoporosis.
• Short term com plications:
• Fever
• Haem orrhage requiring transfusion INTERM ENSTRUAL
• Unintended m ajor surgery because of: AND PO STCO ITAL BLEEDING
• Urinary tract dam age
• Bowel dam age Intermenstrual and postcoital bleeding are common
• Long-term com plications, e.g. pain, regret. symptoms that can indicate serious underlying pathology.
38
Postmenopausal bleeding 5
Fig. 5.6 Causes of intermenstrual and postcoital bleeding. PO STM ENO PAUSAL BLEEDING
Affected region/ system Specific cause
Postm enopausal bleeding (PMB) is vaginal bleeding
Cervical Ectopy occurring m ore than 12 m onths after the m enopause.
Polyps In clinical practice, the m enopause is a retrospective
Malignancy
diagnosis and it is therefore im portant to keep in m ind,
Cervicitis
and exclude, causes of secondary am enorrhoea such as
Intra-uterine Polyps pregnancy. PMB is a com m on disorder and requires
Submucous fibroids prom pt investigation to exclude m alignancy. Of all
Endometrial hyperplasia wom en in the UK with PMB 9% will be found to have
Endometrial malignancy
a m alignancy.
Endometritis
Figure 5.7 shows the causes of PMB using the anat-
Hormonal Breakthrough bleeding om y of the fem ale genital tract as a guide. Atrophic
changes to the genital tract are the m ost com m on cause
but m ust not be assum ed to be the cause until other
Interm enstrual bleeding occurs between the m en- pathology, especially m alignancy, have been excluded.
strual periods and can be caused by local lesions of
the cervix or intrauterine cavity (Fig. 5.6). HINTS AND TIPS
Postcoital bleeding is precipitated by intercourse and
is caused by sim ilar conditions. Always investigate PMB promptly to exclude
malignancy. Uterine malignancy is often detected early
Hist o ry a n d e xa m in a t io n because it presents with abnormal uterine bleeding.
History taking, exam ination and investigation are sim - Cervical malignancy can present with intermenstrual
ilar to m enorrhagia and should aim to exclude local and post-coital bleeding, or smear abnormalities.
causes and cervical pathology.
In ve st iga t io n Ae t io lo gy
In wom en with unexplained sym ptom s, the following
There are m any causes of PMB (Fig. 5.7), but the m ost
should be considered:
im portant causes to exclude are m alignancy of the endo-
• HVS, ECS – to exclude sexually transmitted infections m etrium , cervix and ovary.
• Cervical sm ear – to exclude CIN or cervical cancer
• Pelvic ultrasound – to identify uterine polyps or
fibroids Fig. 5.7 Causes of postmenopausal bleeding.
• Hysteroscopy – to obtain an endom etrial biopsy in Affected structure Cause of postmenopausal bleeding
wom en with persistent interm enstrual bleeding.
• Laparoscopy – to identify pelvic pathology such as O vary Carcinoma of the ovary
endom etriotic nodules which m ay cause post-coital O estrogen-secreting tumour
or interm enstrual bleeding. Uterine body Myometrium:submucous fibroid
Endometrium:
Tre a t m e n t atrophic changes
polyp
Treatm ent m ay involve: hyperplasia: simple or atypical
• antibiotics for sexually transm itted infections carcinoma
• cautery to the cervical surface Cervix Atrophic changes
• rem oval of uterine polyps/fibroids. Malignancy:
squamous carcinoma
HINTS AND TIPS adenocarcinoma
Vagina Atrophic changes
Intermenstrual and post-coital bleeding can be a sign of
cervical malignancy, so a history of cervical smears and Urethra Urethral caruncle
Haematuria
STIs must be taken. Clinical inspection of the cervix and
an up-to-date smear are essential (see Chapter 4 for Vulva Vulvitis
Dystrophies
taking a smear).
Malignancy
39
Abnormal uterine bleeding
Atrophic changes to the lower genital tract due to Profuse vaginal bleeding or the presence of a blood-
oestrogen deficiency can cause bleeding and, in fact, stained offensive discharge is an om inous sign and
are the m ost com m on cause of PMB. Atrophic changes can indicate cervical or endom etrial m alignancy. PMB
can occur to the endom etrium , cervix and vagina. Ure- is usually the only presenting sym ptom of other endo-
thral caruncle (prolapse of the urethral m ucosa) is also m etrial cavity pathology, such as endom etrial polyps
associated with oestrogen deficiency. or subm ucous fibroids.
Subm ucous fibroids or uterine polyps can cause Som e ovarian tum ours can stim ulate endom etrial
PMB, although these are likely to have existed from proliferation and therefore cause bleeding.
before the m enopause. The endom etrium should be Fam ily history, drug history (including the use of
inactive in the postm enopausal years and atrophic HRT) and sm ear history are particularly im portant.
endom etritis is a com m on consequence. Endom etrial Medical com orbidities such as obesity and coagulation
polyps m ight be benign, contain areas of atypical hyper- disorders should also be noted.
plasia or be m alignant.
Endom etrial hyperplasia can arise de novo, or be
secondary to oestrogen stim ulation. Exogenous unop- Exa m in a t io n
posed oestrogens and endogenous oestrogens arising
Inspect the patient for signs of iron-deficiency anaem ia.
from peripheral conversion of precursors in adipose
Abdom inal exam ination m ight reveal ascites or a
tissue, or from oestrogen-secreting ovarian tum ours,
m ass arising from the pelvis.
can result in endom etrial hyperplasia and adenocar-
Vulval lesions should be evident on vaginal exam ina-
cinom a.
tion. The vagina and cervix should be inspected using
Adenocarcinom a of the endom etrium is an im por-
a speculum , to exclude atrophic vaginitis and a bim an-
tant cause of PMB and m ust always be considered in
ual exam ination perform ed. Postm enopausal ovaries
the differential diagnosis.
should not be palpable on bim anual exam ination.
Cervical carcinom a and squam ous carcinom a of the
vulva can present with PMB and, although the non-
neoplastic epithelial disorders of the vulva (vulval
dystrophies) do not them selves usually cause PMB,
In ve st iga t io n
scratching because of pruritus vulvae m ay. The following investigations should be perform ed on
Disease of the ovary in postm enopausal wom en is all wom en with PMB:
uncom m on but can present with PMB. An oestrogen- • Ultrasound exam ination of the pelvis
secreting tum our causes PMB by stim ulating the endo- • Hysteroscopic exam ination of the uterine cavity
m etrium in the absence of progesterone. This can cause • Endom etrial biopsy.
hyperplasia and even carcinom a of the endom etrium .
Intrauterine pathology is best excluded by hystero-
Ovarian carcinom a usually causes PMB by direct inva-
scopic exam ination of the uterine cavity with endom e-
sion through the uterine wall.
trial biopsy, although ultrasound estim ation of the
endom etrial thickness com bined with endom etrial
HINTS AND TIPS sam pling can be used. The endom etrial thickness in a
postm enopausal wom an should be less than 5 m m .
There are several causes of PMB, but the easiest Although a negative endom etrial sam ple is reassuring,
way to remember them is to consider the causes the com m onest m ethod of taking the sam ple in the out-
anatomically – atrophic vaginitis, cervical patient setting is by using the ‘pipelle’ endom etrial sam -
abnormalities/ malignancy, uterine polyps/ fibroids/ pler, which sam ples only 4% of the uterine cavity.
malignancy, ovarian malignancy (rare). Ultrasound with biopsy can, therefore, m iss early focal
pathology. The ovaries can be assessed using ultrasound
and if an oestrogen-secreting tum our is suspected, circu-
lating oestradiol levels should be m easured.
Hist o ry When indicated the following investigations should
also be perform ed:
Atrophic changes to the genital tract usually present
with sm all am ounts of bleeding. Local sym ptom s of • Vulval biopsies
oestrogen deficiency include vaginal dryness, soreness • Cervical cytology or colposcopy
and superficial dyspareunia. Pruritus vulvae can indi- • Cystoscopy
cate the presence of non-neoplastic disorders of the • Sigm oidoscopy
vulva (traditionally known as vulval dystrophies) and • Oestradiol levels.
the presence of a lum p, whether painful or painless, Occasion ally, it is n ot always obvious wh eth er th e
can suggest a vulval neoplasm . bleedin g is vagin al, rectal or from th e bladder, an d in
40
Postmenopausal bleeding 5
Postmenopausal
bleeding Vulval biopsy
if vulval lesion
Clinical Cervical smear and/ or
examination colposcopy if indicated
Cystoscopy if
haematuria suspected
Exclude Exclude
intrauterine pelvic
pathology pathology
If abnormal
41
This pa ge inte ntiona lly le ft bla nk
Pe lvic p a in a n d d ysp a re u n ia 6
O bjectives
Acute Chronic
Pelvic inflammatory disease (see Chapter 26) Adenomyosis (see Chapter 22)
Tubo-ovarian abscess Endometriosis
post-termination of pregnancy
post-insertion of IUCD Adhesions
post-hysteroscopy gynaecological operation
pelvic inflammatory disease
appendicitis
44
Examination 6
Postmenopausal changes (see Chapter 29) Vulval and vaginal skin appears thin and atrophic. This can cause superficial
dyspareunia
Vulval dystrophies (see Chapter 25) There might be patches of inflammation, leukoplakia and ulceration, which
cause superficial dyspareunia
Episiotomy/ lacerations (see Chapter 40) Injury secondary to childbirth commonly causes superficial dyspareunia
Abscesses A Bartholin’s abscess is an abscess of the gland situated towards the posterior
fourchette; labial abscesses are commonly situated on the labia majora. Both
types cause acute pain and need incision and drainage
45
Pelvic pain and dyspareunia
Pre gn a n cy t e st
A urine pregnancy test is m andatory in a patient of Bio p sy
reproductive age with acute abdom inal pain. It m ust If the appearances of the vulva are abnorm al, biopsy is
be perform ed regardless of the date of the LMP or indicated. This can be perform ed under local anaesthe-
if the sym ptom s suggest a gastrointestinal cause. sia, depending on the size of the lesion.
46
Investigations 6
Pelvic pain
Acute Chronic
Associated with
Vaginal Positive O vulation O varian cyst Fibroid Urinary/ Vaginal Secondary Previous GI
discharge pregnancy GI discharge dysmenorrhoea surgery symptoms
test symptoms
PID Ectopic Mittelschmerz Rupture Degene- UTI PID Endometriosis Adhesions Irritable
pregnancy Torsion ration Renal calculi bowel
Miscarriage Haemorrhage Appendicitis syndrome
Diverticulitis
Dyspareunia
Superficial Deep
Length of Length of
Always
history history
Congenital anomaly
Vaginismus
47
This pa ge inte ntiona lly le ft bla nk
Fib ro id s 7
O bjectives
Uterine fibroids are benign tum ours of the m yom etrium . Ab d o m in o p e lvic m a ss
They are the m ost com m on benign tum ours found in
wom en, occurring in m ore than 50% of wom en over Large fibroids growing into the abdom inal cavity m ay
the age of 40 years. Histologically they are com posed cause abdom inal swelling or distension. The fibroids
of whorling bundles of sm ooth m uscle cells that resem - can press on the ureters, affecting renal function.
ble the architecture of norm al m yom etrium .
Although their aetiology is unknown, fibroids are Pa in
associated with exposure to oestrogens. Factors influenc-
Abdom inopelvic pain can be caused by:
ing the incidence of fibroids are shown in Figure 7.1. The
hyperoestrogenic state of pregnancy can stimulate the • degeneration of uterine fibroids
growth of fibroids already present, whilst the hypoestro- • the presence of associated pelvic varicosities
genic state of menopause can reduce their size. Fibroids • stretching of the uterine ligam ents.
can be categorized by their position within the myom e-
trium (Fig. 7.2). Su b fe rt ilit y
Fibroids com pressing the cornual region of the fallo-
pian tubes m ay contribute to infertility. Subm ucous
SYM PTO M S O F UTERINE fibroids, especially those that are horm onally active,
FIBRO IDS can affect im plantation and m ight result in m iscarriage.
There is now evidence that even intram ural fibroids that
Sym ptom s associated with uterine fibroids are shown in are not distorting the endom etrial cavity can reduce
Figure 7.3. em bryo im plantation and pregnancy rates following
IVF, possibly because of interference with the endom e-
No sym p t o m s trial blood supply.
Fig. 7.1 Risk factors and protective factors for fibroids. Fig. 7.4 Complications of fibroids.
Increased incidence with: Decreased incidence with: Gynaecological complications
African–Caribbean women Cigarette smoking Degeneration – may include red degeneration or
Increasing age Use of combined oral calcification
Nulligravidity contraceptive pill Torsion – of pedunculated fibroids
O besity Full term pregnancy Malignancy – the risk of leiomyosarcoma is 0.1-0.5%
Pregnancy related complications
Infertility
O bstructed labour
Risk of PPH
EXAM INATIO N
Fig. 7.2 Categorization of fibroids: subserosal fibroids impact
on the endometrial cavity, intramural fibroids lie within the Fibroids can be palpated during abdom inopelvic exam -
uterus wall, subserosal fibroids lie on the outer surface of the ination; classically the uterus feels enlarged, firm and
womb. Pedunculated fibroids are attached to the uterus irregular. If a fibroid is m obile on bim anual exam ina-
through a stalk.
tion the uterus m oves with it, although this can also
occur with an ovarian m ass adherent to the uterus.
Fig. 7.3 Symptoms associated with uterine fibroids.
• Asymptomatic
• Menstrual abnormalities
• Abdominopelvic mass INVESTIGATIO NS
• Subfertility
• Pressure symptoms Relevant blood tests include full blood count (FBC) (to
• Urinary symptoms secondary to pressure exclude anaem ia in patients with m enorrhagia) and
• Pregnancy complications U&Es (in patients with large fibroids which m ay com -
• Pain press the ureters or bladder).
Pelvic ultrasound is the m ain initial investigation
and is used to:
Pedunculated fibroids m ay undergo torsion and
present with an acute abdom en. • identify the location of individual fibroids
Urinary retention m ight occur with im paction of a • m easure the size of each fibroid.
pelvic fibroid. However, it m ay be difficult to distinguish som e
Sarcom atous (m alignant) change, usually within fibroids from ovarian m asses, particularly if the fibroid
very large or rapidly growing fibroids, is a rare (approx- is located in the broad ligam ent. MRI has becom e the
im ately 1:1000) but potentially fatal com plication. gold standard im aging m ethod for differentiating
50
Treatment 7
fibroids from other pelvic m asses. Laparotom y m ight be 6 m onths use. More data are required before GnRH ana-
required to be 100% certain in som e cases. logues with add back are licensed for longer-term use.
The m ost accurate m ethod of excluding subm ucous
fibroids is by hysteroscopy.
Su rgica l t re a t m e n t
HINTS AND TIPS Definitive surgery depends on the location of the
fibroids. This includes:
In women with fibroids and menorrhagia, always
• transcervical resection of fibroids (TCRF)
request a FBC to exclude anaemia. • m yom ectom y, or
• hysterectom y.
TCRF is suitable for subm ucous fibroids and involves
TREATM ENT rem oving them using an operative hysteroscope in the
uterine cavity.
Sm all, asym ptom atic fibroids do not require interven- Myom ectom y is the rem oval of pedunculated, sub-
tion. Indications for treatm ent include: serosal and intram ural fibroids with preservation of
• sym ptom atic fibroids the uterus and can be perform ed either at laparotom y
• rapidly enlarging fibroids (open m yom ectom y) or laparoscopically. Com plica-
• fibroids that are thought to be causing infertility. tions include haem orrhage, which m ight require blood
transfusion, and, potentially, hysterectom y. Adhesion
form ation m ay im pair future fertility and is m ost com -
M e d ica l t h e ra p y m on after open m yom ectom y, especially for posterior
wall fibroids. Fibroid regrowth is likely to occur in
Medical therapy is only useful as an adjunct to surgery 40% of patients with a reoperation rate of up to one-
and as an aid to correct anaem ia prior to surgery. fifth of cases.
Fibroids regrow to their original size within 3 m onths Hysterectom y is the surgical procedure of choice in
of ceasing m edical therapy without surgical inter- wom en who have com pleted their fam ilies, although
vention. not all wom en wish to have their uterus rem oved.
Surgical treatm ent by hysterectom y often causes less
m orbidity than m yom ectom y.
Go n a d o t ro p h in -re le a sin g
h o rm o n e a n a lo gu e s Ut e rin e a rt e ry e m b o liza t io n
Gonadotrophin-releasing horm one (GnRH) analogues This is a newer less invasive alternative to surgery and
produce a hypogonadotrophic hypogonadal state lead- involves the radiological em bolization of fibroids. This
ing to a tem porary, reversible, chem ical m enopause. is done with the patient under sedation, by inserting a
This results in a reduction in fibroid volum e by up to catheter into the fem oral artery. Sm all silicone m icro-
50% with a m axim um benefit within 3 m onths of start- beads are injected through the catheter into the arteries
ing therapy. supplying the fibroids, causing throm bosis and fibroid
GnRH analogues have several different uses prior to infarction. It is perform ed by radiologists, who m ust see
surgery. They can: and assess the patient to determ ine their suitability for
• increase the likelihood of performing surgery through the operation. Com plications include infection, pain
a transverse suprapubic incision rather than a m idline and failed treatm ent. It is not suitable for wom en
incision. This reduces the patient’s surgical m orbidity who wish to preserve their fertility.
• reduce surgical blood loss and the need for blood
transfusions
• reduce the risk of hysterectom y when m yom ectom y
Ad va n ce s in fib ro id t re a t m e n t
is planned. Other techniques for the treatm ent of fibroids are being
The long-term use of GnRH analogues has been developed to reduce the need for laparotom y and the
lim ited because of their side effects, which include risk of postoperative adhesion form ation and to avoid
m enopausal sym ptom s and bone density reduction large uterine scars. These include:
(osteoporosis). However, adding in low-dose horm one • interstitial laser photocoagulation: laser probes are
replacem ent therapy (HRT), used as ‘add back’, can inserted into the fibroid laparoscopically to produce
avoid m enopausal side effects and reduce loss of bone tissue degeneration and subsequent fibroid shrinkage
density while m aintaining the benefits of the GnRH • laparoscopic diatherm y
analogues. GnRH analogues are currently licensed for • directed high-energy ultrasound.
51
Fibroids
52
En d o m e t rio sis 8
O bjectives
Endom etriosis is the presence of endom etrial tissue out- (e.g. lungs). There is growing laparoscopic evidence to
side of the uterine cavity. Endom etriosis occurring in suggest that m ost wom en experience retrograde m en-
the m yom etrium is known as adenom yosis. The true struation, in which case the incidence of endom etriosis
incidence of endom etriosis is difficult to ascertain as would be expected to be higher. This theory m ay there-
not all wom en with endom etriosis are sym ptom atic. fore be too sim plistic.
Endom etriosis occurs in about 10% of the fem ale
population in their reproductive years but has been
defined in up to 25% of wom en undergoing gynaecolo- 2 . Lym p h a t ic a n d ve n o u s
gical laparoscopy. It is estim ated to be the m ost com - e m b o liza t io n
m on gynaecological condition after fibroids.
This theory hypothesizes that endometrial tissue is trans-
ported through the body by the lymphatic or venous
channels and would explain the rare cases of distant
AETIO LO GY sites for endometriosis. However, distant endometriotic
deposits would be expected to be more comm on if the
The aetiology of endom etriosis is unknown but several lymphatic and venous embolization theories were the
theories have been suggested (Fig. 8.1): only m echanism for the development of endom etriosis.
1 . Re t ro gra d e m e n st ru a t io n / 3 . Co e lo m ic m e t a p la sia
im p la n t a t io n t h e o ry
This theory relies on the principle that tissues of certain
During m enstruation, endom etrial tissue spills into the em bryonic origin m aintain their ability to undergo
pelvic cavity through the fallopian tubes: retrograde m etaplasia and differentiate into other tissue types.
m enstruation. This ectopic endom etrium then im plants This is certainly true of peritoneum of coelom ic
and becom es functional, responding to the horm ones origin, which can undergo m etaplasia and differentiate
of the ovarian cycle. This theory is supported by the into functional endom etrium . However, this does not
association between endom etriosis and increased m en- explain the distribution of endom etriosis within the
struation occurring with a short m enstrual cycle and peritoneal cavity itself (m ost com m on in the lower part
prolonged periods, and by the fact that the m ost com - of the peritoneal cavity) or the presence of endom etri-
m on sites for endom etriosis are the ovaries and the uter- osis in sites of the body that are not of coelom ic origin.
osacral ligam ents — areas in which retrograde m enses
spill. The im plantation theory would also account for
the rare cases of endom etriosis found in the surgical 4 . Ge n e t ic a n d im m u n o lo gica l
incision following surgery on the uterus, for exam ple,
following open m yom ectom y or caesarean section.
fa ct o rs
Im perforate hym en and other outflow obstructions that The role of a genetic influence is supported by the strong
exacerbate retrograde m enstruation are also associated fam ily history seen in endom etriosis sufferers, but its
with severe endom etriosis. exact role has not yet been characterized. It is possible
However, this theory does not account for the exis- that wom en with a genetic predisposition to endom etri-
tence of endom etriosis at the distant sites in the body osis have an abnorm al response to the presence of
(Pouch of Douglas)
54
Symptoms 8
Scores are: Stage 1 (mild)<5, stage II (mod) 6–15, stage III (severe) 16–30, stage IV (extensive)>31.
• ovulation pain The site of ectopic endom etrium dictates the location
• chronic fatigue of the pain. If the endom etriosis is severe, pain can be
• chronic pelvic pain (worse just before periods). continuous, with exacerbations at the tim e of m enstru-
Rupture of an ovarian endom etriom a will cause ation. Neural and intracranial endom etriosis produces
acute, severe lower abdom inal pain. The release of the continuous pain.
very irritant ‘chocolate’ m aterial from the cyst causes Endom etriosis of the lung, bladder, bowel or um bi-
peritonism . licus will produce cyclical bleeding from these sites asso-
ciated with m enstruation.
55
Endometriosis
56
Treatment 8
Progestogens Pseudopregnancy Break-through bleeding, weight gain, oedema, acne, abdominal bloating,
increased appetite, decreased libido
Danazol Pseudomenopause Increase weight, break-through bleeding, muscle cramps, decreased breast size,
hot flushes, emotional lability, oily skin, acne, hirsutism, headache, increased
libido, hoarseness or deepening of the voice
Gestrinone Pseudomenopause Similar to Danazol
LHRH-analogues Pseudomenopause Hot flushes, break-through bleeding, vaginal dryness, headaches, decreased
libido, bone density loss
sym ptom s of endom etriosis m ay be controlled by using without significantly reducing basal levels of gonadotro-
the COCP, but it is m ore often used as m aintenance phins. Clinical response is also similar to Danazol.
therapy following initial treatm ent.
Danazol
Progestogens Danazol is a testosterone derivative and used to be first-
Continuous progestogen therapy effectively induces a line m edical treatm ent for endom etriosis. It is now
‘pseudopregnancy’ state, causing endom etriotic rarely used. As well as its androgenic properties, Dana-
deposits to decidualize and then regress. Progestogens zol produces a hypo-oestrogenic and hypoprogesto-
can be taken orally or as depot preparations, and treat- genic state, and it is this pseudom enopausal state that
m ent should be for 6 m onths. induces endom etrial regression and atrophy.
The m echanism of action of Danazol is com plex; it
acts at pituitary, ovarian and target tissue levels. It
Mirena coil should be taken for 6–9 m onths and the dose should
The Mirena coil releases sm all am ounts of progesterone be titrated to the patient’s response and presence of side
into the uterus and can be used for up to 5 years. Its effects. Patients should be warned to stop treatm ent if
advantages include the fact that it sim ultaneously acts they develop deepening of the voice, as this could be
as contraception and m inim izes system ic side effects. irreversible.
Drawbacks are the im pact on fertility and pain upon
insertion. Studies have shown that it can reduce
endom etriosis-related pain.
Su rgica l t re a t m e n t
This can be conservative or radical and depends on the
GnRH analogues patient’s:
• age
This class of synthetic drugs is GnRH agonists. Continued
• sym ptom s
adm inistration desensitizes pituitary gonadotrophs,
• fertility requirem ents
leading to a tem porary, reversible state of hypogonado-
• response to m edical treatm ent.
trophic hypogonadism, in other words, a temporary
chemical menopause. GnRH analogues are as effective
as Danazol in reducing the symptoms and severity of Conservative surgery
endom etriosis and are usually used for 3–6 months. Conservative surgery can be perform ed through lapa-
Their menopausal side effects are often better tolerated roscopy or at laparotom y and aim s to:
than the androgenic side effects of Danazol and can
• return the anatom y of the pelvis to norm al
be reduced by using ‘add-back’ continuous com bined
• destroy visible lesions of endom etriosis
hormone replacement therapy (see Chapter 17).
• im prove fertility
• conserve ovarian tissue.
Gestrinone This includes division of adhesions, destruction of
Gestrinone is a synthetic steroid that has mild androgenic, endom etriotic lesions using diatherm y or laser, and
marked antioestrogenic and antiprogestogenic activity. rem oving endom etriom as, which do not respond well
It exhibits similar endocrine effects to those of Danazol to m edical therapy. Com plications include dam age to
57
Endometriosis
other pelvic structures including bowel, bladder and the endom etriosis. As m any of these wom en are rela-
ureters. Recurrence of sym ptom s m ight occur because: tively young, HRT is advised. Oestrogen replacem ent
• endom etriosis is a recurring disease m ay cause a recurrence of endom etriosis in a sm all per-
• endom etriotic deposits not visible to the naked eye centage of wom en and should, therefore, be kept to a
will not have been destroyed. m inim um . Continuous com bined oestrogen and pro-
gesterone replacem ent m ight further reduce the rate of
Diffuse peritoneal endometriosis might be better
recurrence because of the effects of progestogens on
treated medically. Pregnancy rates following conservative
endom etriosis.
surgery are directly related to the severity of the disease.
Radical surgery Fu rt h e r re a d in g
Radical surgery for endom etriosis is reserved for wom en Llewellyn-Jones, D., 2010. Fundam entals of Obstetrics &
who do not wish to m aintain fertility and in whom Gynaecology, ninth ed. Mosby, London.
other form s of treatm ent have failed. This m ay be per- McKay Hart, D., Norm an, J., 2000. Gynaecology Illustrated,
form ed in specialist centres in conjunction with bowel fifth ed. Churchill Livingstone, London.
surgeons. RCOG, Endom etriosis: Investigation and Managem ent.
Total abdom inal hysterectom y with bilateral Available online at: http://www.rcog.org.uk/guidelines
salpingo-oophorectom y is the procedure of choice. This (accessed 07.01.12.).
rem oves the ovaries, the m ain source of oestrogens, pro- Shaw, R.W., Soutter, W.P., Stanton, S.P., 1997. Gynaecology,
ducing a hypo-oestrogenic state and effectively treating second ed. Churchill Livingstone, London.
58
Be n ign o va ria n t u m o u rs 9
O bjectives
Luteal cysts
INCIDENCE
Corpus luteal cysts are less com m on than follicular
Benign ovarian cysts are com m on and often asym ptom - cysts. However, they are m ore likely to present with
atic, resolving spontaneously. Therefore, despite being a intraperitoneal bleeding secondary to rupture. This
frequent cause for adm ission to hospital, their exact occurs m ore com m only on the right side and typically
incidence is unknown. Alm ost all ovarian m asses and rupture occurs on day 20 to 26.
cysts are benign in prem enopausal wom en with an inci-
dence of m alignancy of 1:1000 which increases to
3:1000 at the age of 50. Theca lutein cysts
These are the least com m on of the functional ovarian
cysts. They are usually bilateral and occur with preg-
AETIO LO GY nancy including m olar pregnancy. They m ay be large,
up to 30 cm , they are usually m ulticystic and regress
Ovarian tum ours can be physiological (functional) or spontaneously.
pathological (benign or m alignant). Classification
depends on the ovarian tissue from which they arise
(Fig. 9.1). Excluding the physiological group, a germ cell Be n ign e p it h e lia l t u m o u rs
tum our is the m ore com m on diagnosis in a wom an less
The m ajority of ovarian cysts arise from the ovarian epi-
than 40 years of age, whereas an epithelial cell tum our is
thelium . They develop from the coelom ic epithelium
m ore likely in an older wom an.
over the gonadal ridge of the em bryo and are, therefore,
Risk factors for ovarian tum ours include obesity,
derived from any of the pelvic organs or the renal tract.
infertility, hypothyroidism , early m enarche and tam ox-
ifen therapy.
Serous cystadenoma
Ph ysio lo gica l cyst s
This is the m ost com m on tum our in this group. They are
These are often asym ptom atic and occur com m only in bilateral in about 10% of cases and they contain thin
younger wom en. serous fluid, usually within a unilocular cavity. Histo-
logically, they appear to have a tubal origin.
Follicular cysts
These are the result of either non-rupture of the dom i-
nant follicle during the norm al ovarian cycle or failure Mucinous cystadenoma
of atresia of a non-dom inant follicle. Sm aller cysts These tum ours are typically unilateral, larger in size
m ight resolve spontaneously, but intervention could com pared with serous cystadenom as, and m ultilocular
be necessary if the cyst causes sym ptom s (see below) with thick m ucoid fluid. The m ucus-secreting cells are
or if ultrasound follow-up shows an increase in size. likely to indicate an endocervical derivation.
60
Management of a benign ovarian tumour 9
ovarian tum our can rise up out of the pelvis and be pal-
Fig. 9.2 Differential diagnoses for ovarian tumours.
pated in the abdom en; this should be excluded by m ov-
Symptom Differential diagnosis ing the left hand distally from the xiphisternum towards
the pelvis (see Chapter 3). Ascites should be excluded by
Pain Ectopic pregnancy testing for shifting dullness.
Spontaneous miscarriage
Bim anual palpation of the pelvic organs, as
Pelvic inflammatory disease
described in Chapter 3 is essential. If the tum our has
Appendicitis
Diverticulitis presented acutely with abdom inal pain then adnexal
tenderness or an adnexal m ass will assist in excluding
Abdominal swelling Pregnancy gastrointestinal aetiology. Assessing the size of the
Fibroid uterus
uterus will help to exclude a fibroid uterus or intrauter-
Full bladder
ine pregnancy. If there seem s to be an adnexal m ass,
Pressure effects Constipation then its approxim ate size, consistency and the presence
Urine frequency of any tenderness should be elicited.
Vaginal prolapse
Hormonal effects Menstrual irregularity
Postmenopausal bleeding
Precocious puberty INVESTIGATIO NS
In line with the list of differential diagnoses in
and the regularity of the menstrual cycle, as well as current Figure 9.2, investigations include:
contraception, if appropriate. Any history of gastrointes- • haem oglobin
tinal sym ptoms might be important, for example, a • white blood cell count
patient with an ovarian torsion might present with sud- • CRP
den onset of right-sided abdominal pain associated with • HVS/endocervical swabs
nausea and vomiting, and appendicitis must be excluded. • urine pregnancy test and/or serum b-hCG level
• pelvic ultrasound scan (transvaginal scan m ore sen-
HINTS AND TIPS sitive than abdom inal)
• serum CA125 level which is an epithelial tum our
Benign ovarian cysts that undergo an accident (rupture
m arker. However, this m ay be raised with other
or torsion) can present as an acute abdomen. Always gynaecological pathology such as fibroids, or with
exclude an ectopic pregnancy in a woman of pregnancy
childbearing age. • chest X-ray/intravenous urogram / CT scan if m alig-
nancy is suspected (see Chapter 10)
• serum alpha fetoprotein (alphafetoprotein) and
Ask about risk factors for ovarian m alignancy and hum an chorionic gonadotrophin (hCG) if germ cell
family history of ovarian and breast cancer. tum our suspected in wom an under 40 years with
com plex ovarian m asses on USS.
EXAM INATIO N
M ANAGEM ENT O F A BENIGN
Initial exam ination m ust include the pulse and blood O VARIAN TUM O UR
pressure; rupture of an ovarian cyst can result in intra-
peritoneal bleeding that leads to hypovolaem ia. In a The patient’s m anagem ent depends on the:
young patient, this m ight present at first with tachycar-
• severity of presenting sym ptom s
dia and cold peripheries, with hypotension developing
• patient’s age
as a relatively late sign.
• future fertility needs
Distension m ight be seen on abdom inal inspection,
• risk of m alignancy.
resulting from the cyst itself or from ascites if the cyst is
m alignant. Look for any other signs of m alignancy
including cachexia. Determ ine the size, tenderness,
m obility and nodularity of the cyst. If the cyst has
Asym p t o m a t ic cyst s
undergone torsion, or if there is haem orrhage into the Ovarian cysts can be m anaged conservatively if they are
cyst so that the capsule stretches, abdom inal palpation asym ptom atic. This depends on the patient’s age and
will elicit tenderness. This is typically in the iliac fossa the size of the cyst (Fig. 9.3). In a younger wom an (usu-
and m ay be associated with signs of peritonism . A large ally taken as less than 40 years of age), the risk of the
61
Benign ovarian tumours
62
Gyn a e co lo gica l m a lign a n cie s 10
O bjectives
64
Endometrial cancer 10
En d o m e t ria l h yp e rp la sia
Endom etrial hyperplasia is a prem alignant condition
M a n a ge m e n t
which if left untreated can progress to cancer. It is Surgery is the m ainstay of treatm ent for patients with
divided into sim ple hyperplasia and com plex hyperpla- endom etrial cancer. In stage I disease com plete surgical
sia and can be treated with progesterone to encourage staging is recom m ended. This includes a laparotom y
regression. The presence of atypia has a high likelihood (or laparoscopy) with peritoneal washing being taken
of progression to cancer, and in m any cases m ight indi- for cytology, inspection of the pelvis and abdom en
cate that a carcinom a is already present in another part and a total abdom inal (or laparoscopic) hysterec-
of the uterus. tom y plus bilateral salpingo-oophorectom y. Stage II
65
Gynaecological malignancies
I Body of uterus: 85
A Endometrium only
B Extension into inner half of myometrium
C Extension into outer half of myometrium
II Extension from body of uterus to cervix: 60
A Endocervical glands only
B Cervical stroma
III 40
A Spread to adnexae, or positive peritoneal cytology
B Metastases in vagina
C Pelvic or para-aortic lymphadenopathy
IV 10
A Involvement of bladder or bowel mucosa
B Distant metastases
or high-risk disease is treated by a m idline laparotom y • Mixed Mullerian tum ours: derived from the glandu-
and stage III disease is again surgically m anaged with the lar cells within the strom a, these are aggressive
aim of debulking disease prior to radiotherapy. In stage tum ours that com m only spread to cervix and lym ph
IV disease a com bination of surgery, radiotherapy and nodes. Treatm ent is TAH þ BSO with postoperative
palliation m ay be required depending upon individual radiotherapy.
circum stances. The role of routine lym phadenectom y in
patients with endom etrial cancer is a m uch debated
topic, a study in 2009 failed to show any benefit of rou-
M yo m e t ria l sa rco m a
tine lym phadenectom y in patients with early disease. Leiom yosarcom a could be described as a ‘m alignant
fibroid’, although only 5–10% of them arise within
an existing fibroid, they are m acroscopically very sim i-
Pro gn o sis lar, being tum ours of sm ooth m uscle cells. Often diag-
nosis is not m ade until a TAH specim en is exam ined
The overall 5-year survival rates for all stages of endom e-
histologically, but lym ph node sam pling and BSO m ust
trial carcinom a are around 83–86%. Those with disease
be perform ed.
confined to the uterus, however, have a m uch better
prognosis with a 95–97% 5-year survival rate.
Pre -m a lign a n t d ise a se o f t h e
ce rvix a n d h u m a n p a p illo m a viru s
UTERINE SARCO M A In the United Kingdom approxim ately 2700 new cases
of cervical cancer are diagnosed each year. In term s of
Uterine sarcom as are a rare group of cancers associated incidence there appear to be two peaks in ages with
with an aggressive nature and poor prognosis. The sar- the first occurring between 30 and 34 years and the
com as can be of various types and are discussed below. second between 80 and 84 years.
The natural progression of the disease m eans that
squam ous cell cervical cancers (accounting for > 90%
St ro m a l sa rco m a of cervical cancers) exist in a pre-m alignant form , which
can be detected by cervical cytology. This is why
Tum ours of strom al cells can be divided into the follow- the United Kingdom has an established screening pro-
ing categories: gram m e that invites wom en to have cervical sm ears per-
• Low-grade sarcom as: look like fibroids, are slow- form ed on a 3 yearly basis between the ages of 25 and 49
growing. Treatm ent is TAH þ BSO with wide exci- and on a 5 yearly basis from the ages of 50–65 (in
sion of the param etria. England). Patients with abnorm al sm ears will be offered
• High-grade sarcom as: aggressive tum ours with less a colposcopy and m ay need m ore frequent sm ears
than 50% survival rates, treated with radiotherapy. depending upon findings and treatm ent.
66
Cervical cancer 10
Human papilloma virus low grade (CIN I) an d h igh grade (CIN II – CIN III)
(see Fig. 10.5).
Hum an papillom a virus (HPV) is a virus belonging to
Patients with an abnorm al sm ear result will then be
the papovaviridae fam ily and was first isolated in
referred for a colposcopy and, in som e cases, HPV test-
1933 by Richard E. Shope. There are over 100 different
ing. At colposcopy the cervix is washed with acetic acid
types which are known to cause warts as well as other
and then with iodine. The cervix is inspected for suspi-
conditions. In the 1980s HPV was linked with cervical
cious features (Fig. 10.6). Abnorm al areas can be biop-
cancer and since then research has identified certain
sied, m eaning that the patient will be invited back at a
types responsible. HPV can be transm itted by sexual
later date for treatm ent if appropriate, or treatm ent can
contact and, therefore, any fem ale who is sexually active
be perform ed at this point.
is at risk. HPV types 16, 18, 6 and 11 are all known to
Treatm ent consists of either excising or destroying the
cause cervical cancer with the form er (16 & 18) often
transform ation zone. Excision techniques include LLETZ
referred to as high risk.
(large loop excision of transformation zone), NETZ (nee-
Based on this research in the United Kingdom a vac-
dle excision of transformation zone) and cone biopsy;
cination program m e is in place to vaccinate young girls
these allow the tissue removed to be sent for histology
before their first sexual contact and prevent cervical
and examined to confirm the diagnosis and to check
cancer. Girls are invited to have the vaccination between
the margins, ensuring complete excision. Destructive
the ages of 13 and 14, which involves a course of three
techniques include cold coagulation, diathermy or laser.
injections. It should be noted, however, that vaccina-
Initial treatm ent has 95% success rate. Patients are
tion does not replace screening.
followed up with a sm ear.
67
Gynaecological malignancies
Fig. 10.6 Suspicious features at colposcopy. Fig. 10.8 Staging of cervical cancer.
As m entioned above HPVinfection is a major risk fac- desire for children. Stage Ia1 m ay be diagnosed on a
tor for cervical cancer and it is hoped that the vaccination LLETZ sam ple and if the lesion has been com pletely
programme along with com pliance with cervical screen- excised no further treatm ent m ay be necessary. In Stage
ing will help to reduce the incidence of the disease. 1a2 the incidence of lym ph node involvem ent is 5% so
lym phadenectom y is advised but in those wishing to
Clin ica l p re se n t a t io n preserve fertility a LLETZ or cone biopsy m ay be consid-
ered to rem ove the cancer.
Cervical cancer m ay be com pletely asym ptom atic or Stages Ib – IIa can be treated with surgery or radio-
m ay be identified by cervical cytology. Patients who pre- therapy with equivalent results, generally fit and
sent with post-coital bleeding, interm enstrual bleeding, healthy patients will undergo surgery whilst older
persistent vaginal discharge (m ay be blood stained) or or m edically unstable patients will be offered
postm enopausal bleeding should all be exam ined to radiotherapy.
identify any abnorm ality on the cervix and any features Stages IIb and above are treated with radiotherapy
of concern should prom pt referral for colposcopic com bined with chem otherapy.
exam ination.
In ve st iga t io n s a n d st a gin g
VULVAL CANCER
Once a tissue diagnosis has been m ade the next step
would be to stage the disease. The staging has tradition-
ally been clinical with the patients undergoing an exam - Vu lva l in t ra e p it h e lia l n e o p la sia
ination under anaesthesia (plus cone biopsy, to assess Sim ilar to CIN, vulval intraepithelial neoplasia (VIN) is
depth of invasion, chest X-ray, intravenous urogram a prem alignant condition which can progress to inva-
(IVU), cystoscopy and sigm oidoscopy), with a MRI. sive carcinom a. If VIN is present, CIN is often seen
Figure 10.8 shows the staging of cervical cancer. too with HPV being the causal factor.
Tre a t m e n t
In cid e n ce a n d a e t io lo gy
The treatm ent of cervical cancer can be by surgery,
radiotherapy and chem otherapy. Once all factors Vulval tum ours are rare, with an incidence of around 3
are taken into account such as patient age, staging in 100 000 wom en per year. The peak incidence is from
and any other m edical problem s a m ultidisciplinary the ages of 63 to 65.
team will usually advise on the best options for Predisposing factors include:
treatm ent. • history of CIN, VIN or HPV
In stage I disease the treatm ent m ay need to be tai- • im m unosuppression
lored to the patient’s individual circum stances and • lichen sclerosus (see Fig. 10.9).
68
Vulval cancer 10
I Confined to vulva:
A <1mm invasion
B <2 cm diameter, no groin nodes
II Confined to vulva, >2 cm diameter, no groin nodes
palpable
III Confined to vulva, suspicious nodes or beyond
vulva with no suspicious nodes
IV O bvious groin nodes or involving rectum, bladder,
urethra or bone or pelvic or distant metastases
Fig. 10.10 Squamous cell carcinoma of the vulva.
69
Gynaecological malignancies
Pro gn o sis M a n a ge m e n t
Stage I disease has a 92% 5-year survival rate, whereas Treatm ent is a com bination of external beam and intra-
advanced disease (Stage IV) has only a 13% 5-year sur- vaginal radiotherapy, with the com plications being fis-
vival rate. tulae (as with vulval radiotherapy) and stenosis of the
vagina and rectum .
70
Vu lva l d ise a se 11
O bjectives
The vulva extends from the m ons pubis anteriorly to the Exacerbating and relieving factors can give clues as to
perineum posteriorly and the labia m ajora laterally the aetiology. Sym ptom s of yeast and herpetic infection
(Fig. 11.1). The whole surface of the vulva up to the m ight worsen prem enstrually. A recent change in soap
inner aspect of the labia m inora is covered by stratified, or washing powder, or overzealous hygiene m ay suggest
keratinized squam ous epithelium with a superficial cor- contact derm atitis. Self-treatm ent with em ollients and
nified layer. The cornified layer is absent in the vagina antifungals is com m on and should be noted, as should
and there is a decreasing degree of keratinization the response.
(Fig.11.2). Cervical intraepithelial neoplasia (CIN) and vulval
intraepithelial neoplasia (VIN) are thought to share a
com m on aetiology, so a history of CIN should be noted.
SYM PTO M S Abnorm al vaginal discharge can suggest infection and, if
suspected, a detailed sexual history should be taken. The
discharge of infection with Trichomonas vaginalis and
Com m on signs and sym ptom s include pain and pruri-
tis. Itching or irritation of the vulval region is called pru- bacterial vaginosis has a typically ‘fishy’ odour.
ritus vulvae. This is a com m on sym ptom and can be Derm atological conditions such as psoriasis and
eczem a can affect the vulva and a history of these con-
caused by a whole host of conditions (Fig.11.3):
ditions elsewhere on the body m ight be relevant. A his-
• Vulval dystrophy tory of atopy and sym ptom s suggestive of diabetes
• Neoplasia m ellitus, renal and liver failure should be noted.
• Derm atological Drug history and fam ily history of any autoim m une
• Infection. conditions are also im portant.
Com m on skin changes include changes in texture
and colour. Generalized derm atological conditions
and system ic illness m ay present with vulval sym ptom s.
EXAM INATIO N
HISTO RY General examination of the patient includes assessment
of skin surfaces prone to dermatological conditions: face,
The age of the patient is im portant. Younger wom en are hands, wrists, elbows, trunk and knees. Signs of chronic
generally m ore likely to have an infectious cause, renal failure and liver disease should be looked for.
whereas vulval dystrophies and cancers are m ore likely Exam ination of the vulva, urethral m eatus and peri-
in older wom en. Acute onset of sym ptom s occurs fre- anal region in a good light is essential. The vagina and
quently with infection whereas other causes of pruritus cervix should be inspected carefully using a speculum .
vulvae can have a m ore chronic and insidious onset. Colposcopic exam ination of the vulva m ay also be use-
Em barrassm ent often delays presentation. A history of ful, particularly with a history of abnorm al sm ears.
postm enopausal bleeding is im portant to ascertain as Inguinal lym phadenopathy can occur secondary to
this m ay indicate an underlying m alignancy. infection or m alignancy.
A B
C D
Fig. 11.2 Histology. (A) normal, (B) lichen sclerosus, (C) squamous hyperplasia and (D) dysplasia. From Llewellyn-Jones D, 2010.
Fundamentals of O bstetrics and Gynaecology, 9th edn. London: Mosby, with permission.
In fe ct io n Vu lva l d yst ro p h ie s
Generalized vulvitis, vaginal discharge and ulcers sug- Labial fusion, adhesions, stenosis of the introitus, leuco-
gest an infective cause, although ulceration should alert plakia (literally m eaning ‘white plaque’) and atrophic
the exam iner to the possibility of m alignancy. Genital changes are frequent signs of lichen sclerosus, the m ost
warts m ight be seen on the vulva, perianally, in the com m on of the vulval dystrophies. The lesions of hyper-
vagina or on the cervix. plastic dystrophy can be localized or extensive, and
72
Investigations 11
Vulval Symptoms
biopsy persist
73
Vulval disease
Vulval dystrophies
Lichen sclerosus Any age but Common Topical steroids Frequent <5% develop squamous
usually and emollients carcinoma of the vulva
postmenopausal
Neoplasias
Vulval Any age but Relatively Usually surgical Up to 80% O verall low, but higher in
intraepithelial increasing in uncommon, more conservative will recur the elderly and
neoplasia the young but increasing in young women immunosuppressed
Paget’s disease Postmenopausal Rare Surgical Up to 33% Associated with
of the vulva women will recur adenocarcinoma in 25%
Malignant change in
lesion is rare
74
Dermatological conditions 11
75
This pa ge inte ntiona lly le ft bla nk
Va gin a l d isch a rge 12
O bjectives
78
Investigation 12
Age Age
Sexual history Weight loss/ anorexia
O dour/ irritation Irregular vaginal bleeding
Urinary symptoms Postmenopausal bleeding
Tachycardia
Cachexia
Pyrexia
Generalized lymphadenopathy
Abdominal tenderness
Abdominal/ pelvic mass
Cervical excitation
Vulval disease
Pelvic tenderness
Fu rt h e r re a d in g
Faculty of Sexual & Reproductive Healthcare (FSRH) and
The British Association of Sexual Health and HIV
(BASHH) Guidance (February 2012): Management of
Vaginal Discharge in Non-Genitourinary Medicine settings.
www.fsrh.org/pdfs/CEUGuidanceVaginalDischarge.pdf.
79
This pa ge inte ntiona lly le ft bla nk
Pe lvic in fla m m a t o ry d ise a se 13
O bjectives
AETIO LO GY
HISTO RY
PID is caused by sexually transm itted infections such as
Chlamydia trachomatis, Neisseria gonorrhea and Myco- The history m ay include one or m ore of the following
plasma genitalium. sym ptom s:
Chlamydia trachomatis is the m ost com m on cause of • Pelvic pain/lower abdom inal pain, usually bilateral
PID in the UK. Along with Neisseria gonorrhoeae, this • Bilateral pelvic pain – som etim es radiating to the
m icroorganism is responsible for at least 60% of cases legs
of PID. They are thought to act as prim ary pathogens, • Deep dyspareunia
causing dam age to the protective m echanism s of the • Dysm enorrhoea
endocervix and allowing endogenous bacteria from • Abnorm al or increased vaginal discharge
the vagina and cervix into the upper genital tract as • Fever.
82
Treatment 13
83
Pelvic inflammatory disease
84
Urin a ry in co n t in e n ce 14
O bjectives
Urinary incontinence is an objectively dem onstrable, passive effect of elastic and collagen fibres and active
involuntary loss of urine that is a social or hygienic striated and sm ooth m uscle, causes the urethra to
problem . The two m ost com m on causes of urinary rem ain closed at rest. In the resting state the urethral clo-
incontinence are stress urinary incontinence (SUI) sure pressure is higher than the relatively low bladder
and detrusor overactivity (DO), which account for pressure and continence is m aintained.
approxim ately 90% of incontinent wom en. These, Intra-abdom inal pressure is transm itted to the blad-
and other causes, are shown in Figure 14.1 in order of der and raised intra-abdom inal pressure, such as during
frequency of occurrence. coughing or straining, increases the bladder pressure.
Intra-abdom inal pressure is also transm itted to the
bladder neck and that part of the proxim al urethra
INCIDENCE which is intra-abdom inal (above the pelvic floor) m ain-
taining the positive pressure gradient and hence conti-
Fem ale urinary incontinence is a very com m on prob- nence (Fig.14.2B). If the bladder neck and proxim al
lem , with up to one-quarter of wom en leaking urine urethra are situated below the pelvic floor then the
occasionally. The prevalence of regular fem ale urinary raised intra-abdom inal pressure is no longer transm it-
incontinence increases with increasing age: ted to these structures, the positive pressure gradient
is lost and incontinence occurs (Fig. 14.2C).
• 8.5% of wom en under 65 years of age
SUI increases with increasing age as m axim al urethral
• 11.6% over 65 years
closure pressure decreases. Also, older wom en are m ore
• 43.2% over 85 years.
likely to be parous and postm enopausal. SUI increases
with increasing parity. Prolapse is com m only thought to
be associated with SUI, although this is only true if the
AETIO LO GY proxim al urethra is below the pelvic floor (see above).
Atrophic changes associated with the post-m enopausal
The bladder has two m ajor roles: the retention of urine state and vaginal surgery to cure prolapse are also asso-
and expulsion of urine. Failure to retain urine, or loss of ciated with SUI.
norm al voiding control, gives rise to two distinct aetiol-
ogies of incontinence:
• Stress urinary incontinence (SUI) – 50% of incon- De t ru so r o ve ra ct ivit y
tinence In wom en with DO, the urethra functions norm ally, but
• Detrusor overactivity (DO) – 40% of incontinence. if the uninhibited detrusor activity increases bladder
Urinary tract infection m ust always be excluded in pressure above m axim al urethral closure pressure, uri-
the presence of urinary sym ptom s. nary leakage occurs.
The m ajority of wom en with DO have an idiopathic
aetiology with no dem onstrable abnorm ality. DO can
St re ss u rin a ry in co n t in e n ce be caused by surgery to the bladder neck and proxim al
The bladder acts as a low-pressure reservoir. As the vol- urethra, especially following surgery for SUI, which
um e of urine increases, the bladder pressure rises involves dissection around these structures. Multiple
slightly. Urethral closure pressure, produced by the sclerosis, autonom ic neuropathy and spinal lesions lead
A B C
Fig. 14.2 Mechanism of stress urinary incontinence (SUI). (A) Bladder at rest. (B) Intra-abdominal pressure transmitted
to bladder and urethra (normal). (C) Intra-abdominal pressure not transmitted to bladder/ urethra (SUI).
86
History 14
HISTO RY
CO M PLICATIO NS A detailed h istory is m an datory because patien ts m ay
presen t with m ultiple sym ptom s of varyin g degrees.
Although incontinence itself is not life threatening, it
Th e two sym ptom s stress in con tin ence an d urge
does cause m ajor psychosocial problem s. Urgent refer-
in con tin en ce are com m on ly used syn on ym ously with
ral is warranted in patients with:
th e condition s SUI an d DO, respectively (see Fig.14.4
• m icroscopic haem aturia over the age of 50 for defin ition s of com m on urogyn aecological term s).
• m acroscopic haem aturia Th is is in accurate an d can lead to in appropriate treat-
• recurrent UTI with haem aturia m en t. Man y in con tin en t wom en will adm it to both
• suspected pelvic m ass arisin g from th e urin ary sym ptom s, but th ese m ay n ot correlate well with an
tract. un derlyin g bladder con dition . O bjectively, on ly 5%
87
Urinary incontinence
of wom en h ave both SUI an d DO. A patien t givin g a aggravates the sym ptom s of incontinence, urgency
h istory of stress in con tin en ce m ay h ave detrusor over- and frequency. Stress incontinence m ight be a present-
activity as th e un derlyin g path ology. ing sym ptom .
St re ss u rin a ry in co n t in e n ce Fist u la e
The m ost com m on sym ptom of SUI is usually sm all Fistulae are rare in the UK, but should always be sus-
am ounts of urinary leakage. However, one-third of pected when incontinence is continuous during the
wom en with SUI also experience urge incontinence day and at night, particularly where there is a history
and up to a half will experience urgency of m icturition. of operative surgery.
Frequency of m icturition and nocturia are also com m on
sym ptom s.
SUI is associated with the following factors and these
m ust be highlighted in the history: EXAM INATIO N
• Increasing age
• Increasing parity Chronic dam pness can cause excoriation of the vulva.
• Obesity The best way to dem onstrate stress incontinence is to
• Genital prolapse ask the patient to cough while standing with a m oder-
• Postm enopausal status ately full bladder. Stress incontinence is not always
• Previous pelvic floor surgery dem onstrable, especially with the patient in the supine
• Constipation position. Exam ination of the vaginal walls, using a
• Sm oking/ chronic cough. Sim s’ speculum with the patient in left lateral position,
will identify scarring from previous surgery and the
presence of uterovaginal prolapse or a cysto-
De t ru so r o ve ra ct ivit y urethrocoele. Bim anual exam ination should identify
Wom en with DO present with urgency, urge inconti- a pelvic m ass.
nence, frequency and nocturia. However, up to one- As neurological disease can present with urinary
quarter also com plain of stress incontinence because sym ptom s, including incontinence, a neurological
raised intra-abdom inal pressure can stim ulate an unsta- exam ination should be perform ed.
ble bladder to contract and produce the sym ptom of
stress incontinence.
The following factors should be highlighted in the HINTS AND TIPS
history: Uterine, urethral or vaginal wall prolapse should be
• Age excluded by examining the patient in left lateral
• History of nocturnal enuresis position using a Sims speculum.
• Neurological history
• Previous incontinence surgery
• Drug history.
INVESTIGATIO NS
Se n so ry u rge n cy Excluding a urinary tract infection (UTI), a com m on
Sensory urgency differs from detrusor overactivity cause of sensory urgency, is im portant because the
(m otor urgency) because the urgency occurs in the UTI m ight cause the presenting sym ptom s and infection
absence of detrusor activity. The presenting sym ptom s could be exacerbated by further invasive investigations
are the sam e as for detrusor overactivity, although (Fig. 14.5).
incontinence is not such a com m on feature. Wom en should be asked to com plete a bladder diary
for at least 3 days, to cover variations in their norm al
activities.
Vo id in g d iso rd e rs
Voiding disorders can result in chronic retention lead- HINTS AND TIPS
ing to overflow incontinence. As well as urgency and
frequency, the classic sym ptom s include hesitancy, Incontinence surgery should never be considered
straining to void, poor flow and incom plete em ptying. without performing urodynamic studies, as surgery
Large residual volum es of urine due to incom plete em p- may not be necessary.
tying predispose to urinary tract infection, which
88
Treatment 14
If
present
Exclude urinary Treat
tract infection appropriately
Urodynamic
investigations
89
Urinary incontinence
90
Treatment 14
In general, SUI is treated surgically (TVT), if m edical der has been overdistended then normal bladder function
m anagem ent and physiotherapy fails, and DO is treated is unlikely to occur imm ediately and free bladder drainage
m edically (antim uscarinics) which is why urodynam ic is required until norm al function returns. Residual vol-
investigation is so im portant in the m anagem ent of uri- umes can be m easured to assess progress.
nary incontinence. Chronic retention m ay require long-term indwelling
catheters which has a significant risk of sepsis. Interm it-
Drug therapy tent self-catheterization m ight be m ore appropriate in
those who are able to perform this technique. Subclin-
Drugs used to treat the sym ptom s of voiding difficulties ical sepsis is com m on, although treatm ent is usually
are often ineffective or have lim ited use due to side given only if sym ptom s are present.
effects. They work in two ways:
• Relax the urethral sphincter m echanism
• Produce detrusor contractions. Fist u la
The selective a -blocker indoram in increases the flow Sm all fistulae m ight close spontaneously by providing
rate and im proves obstructive sym ptom s by relaxing the continuous free drainage of the bladder. This m ight
sphincter m echanism . Side-effects include sedation, require stenting the ureters or catheterizing the bladder.
dizziness, tachycardia and hypotension and m ust be If spontaneous closure does not occur, or if the fistulae
used with extrem e caution in the elderly and in anti- are large, then surgical closure by a surgeon experienced
hypertensive users. in such techniques is required.
The parasym pathom im etics (bethanechol, carba-
chol and distigm ine) exhibit m uscarinic activity which
im proves voiding by increasing detrusor contraction. Fu rt h e r re a d in g
Side-effects include sweating, bradycardia and intestinal Cardozo, I., Staskin, D. (Eds.), 2006. Textbook of Fem ale
colic. Urology and Urogynaecology, second ed. Inform a
Healthcare, Tam pa.
Catheterization Llewellyn Jones, D., 2010. Fundam entals of Obstetrics &
Gynaecology, ninth ed. Mosby, London.
Acute urinary retention requires catheterization. If Stanton, S., Monga, A., 1998. Clinical Urogynaecology, second
caused by a gravid uterus, the catheter m ay be required ed. Churchill Livingstone, London.
until the uterus is abdom inally sited. If retention is due RCOG. Urodynamic Stress Incontinence, Surgical Treatm ent
to an ovarian cyst or fibroid, this m ay need to be (Green-top 35). Available online at: http://www.rcog.org.
rem oved surgically, although disim paction from the uk/guidelines.
pelvis is som etim es possible as an interim or palliative Urinary incontinence: the m anagem ent of urinary
m easure. incontinence in wom en. Clinical guidelines, CG40 – Issued:
Postoperative or postpartum retention usually resolves October 2006. NICE guidelines, http://publications.nice.
with free bladder drainage for 48 hours or so. If the blad- org.uk/urinary-incontinence-cg40 (last accessed 15.08.13).
91
This pa ge inte ntiona lly le ft bla nk
Ge n it a l p ro la p se 15
O bjectives
Genital prolapse is com m on. A cystourethrocoele is the • transverse cervical or cardinal ligam ents
m ost com m on type, next uterine descent and then rec- • uterosacral ligam ents
tocoele. The incidence increases with increasing age. • round ligam ents.
Prolapse is seen less com m only in Afro-Caribbean The transverse cervical and uterosacral ligam ents
wom en than in Caucasian wom en. consist of sm ooth m uscle and elastic tissue. They attach
to the pelvic side wall and the sacrum , respectively. The
round ligam ents pass from the cornu of the uterus
PELVIC ANATO M Y through the inguinal canal to the labium m ajus. They
contain sm ooth m uscle and m aintain flexion of the
Some knowledge of the pelvic anatomy, with particular uterus with only m inim al role in support.
reference to the pelvic floor muscles, fascia and liga-
ments, is necessary to understand the development of
genital prolapse. Weakness of these tissues, either con- AETIO LO GY O F GENITAL
genital or acquired, results in descent of the pelvic viscera.
PRO LAPSE
Pe lvic flo o r m u scle s
The pelvic floor consists of a m uscular, gutter-shaped, Co n ge n it a l
forward sloping diaphragm form ed by the: Som e wom en are born with a predisposition to genital
• levator ani m uscles prolapse, which is probably secondary to abnorm al col-
• internal obturator and piriform m uscles lagen production. Conditions associated with prolapse
• superficial and deep perineal m uscles. include:
The levator ani consists of two parts, the puboco- • spina bifida
ccygeal part anteriorly and the iliococcygeal part • connective tissue disorder.
© 2014 Elsevier Ltd. 93
DOI: http://dx.doi.org/10.1016/B978-0-7234-3650-8.00015-2
Genital prolapse
Pubococcygeus Urethra
muscle
Vagina
O bturator internus
muscle Rectum
Levator ani
muscle
Sacrum
94
Examination 15
HISTO RY
Pre se n t in g co m p la in t
Local discomfort or a feeling of ‘something coming
down’is a common sym ptom. This is usually worse with
standing or straining (cough, defecation) and relieved by
lying down. It m ay interfere with sexual function.
Rem em ber that your history should exclude sym p-
tom s related to the urinary and bowel system s.
Uterine descent
Can give sym ptom s of backache. However, other causes
of backache m ust be excluded, especially in the older
patient. A procidentia causes discom fort as it rubs on
the patient’s clothing and can cause a bloody, som e-
tim es purulent, discharge.
Other sym ptom s depend on the organ/organs
involved.
Urinary symptoms
These occur with a cystocoele or a cystourethrocoele,
such as frequency of m icturition. The patient m ight
notice incom plete em ptying of the bladder, which pre-
disposes her to urinary infection and even possibly over-
flow incontinence. Stress incontinence m ay be present if
there is descent of the urethrovesical junction (bladder
neck) associated with a cystocoele.
Bowel symptoms
Arectocoele can cause incom plete bowel em ptying. This
can be relieved if the patient pushes back the prolapse
Fig. 15.3 Factors that predispose to prolapse. digitally.
Figure 15.3 shows factors that should be elicited in
the history that m ay predispose the patient to prolapse
Chronically raised intra-abdominal in general.
pressure
Any factors that raise intra-abdom inal pressure in the EXAM INATIO N
long term can predispose to prolapse, including:
• intra-abdom inal or pelvic tum our • General exam ination
• chronic cough • Abdom inal palpation
• constipation. • Sim s’ speculum exam ination
• Bim anual pelvic exam ination.
Following abdom inal palpation to exclude a m ass,
Iatrogenic the patient should be exam ined in the left lateral posi-
Hysterectom y predisposes to future prolapse of the vag- tion using a Sim s’ speculum in order to exclude a vagi-
inal vault. In order to rem ove the uterus, the transverse nal wall prolapse. With the posterior vaginal wall
cervical and uterosacral ligam ents have to be divided retracted, any anterior wall prolapse will be dem on-
and the upper vaginal supports are weakened. strated if the patient is asked to bear down. Conversely,
Colposuspension (see Chapter 14) predisposes to if the anterior vaginal wall is retracted, then an entero-
developm ent of an enterocoele because the anterior coele or rectocoele will be seen.
vaginal wall is lifted anteriorly, which in turn pulls Abdom inal palpation and bim anual pelvic exam ina-
the upper posterior vaginal wall forwards. tion are m andatory to exclude a pelvic m ass.
95
Genital prolapse
Uterine descent is assessed by exam ining the position m inim ized. Appropriate m anagem ent of labour should
of the cervix within the vagina, again usually in the left include:
lateral position with the Sim s’ speculum . If the patient • avoiding prolonged first and second stages
has a full bladder, stress incontinence can be dem on- • postnatal pelvic floor exercises.
strated by asking the patient to cough.
The current decline in parity, as well as the increasing
use of caesarean section m ay influence the incidence of
INVESTIGATIO N prolapse.
No symptom
improvement
Surgically Surgically
fit unfit
Failed
pessary
Appropriate Pessary
surgery
96
Management 15
vagina so that it sits behind the pubic bone anteriorly Vaginal hysterectomy
and in the posterior fornix of the vagina posteriorly,
This operation is perform ed for uterine prolapse, as well
enclosing the cervix. The other type of pessary is the
as for other gynaecological pathology. It can be com -
shelf pessary, used for larger prolapses.
bined with one or both of the operations above.
The indications for the use of a vaginal pessary
include the following:
• The patient has not com pleted her fam ily.
• The patient prefers conservative m anagem ent. Manchester repair (Fothergill procedure)
• The patient is m edically unfit for surgery. This operation is rarely perform ed for uterine prolapse
With m ajor degrees of prolapse, especially where the nowadays. It consists of am putation of the cervix and
introitus is lax and the perineal body deficient, the pes- then apposing the cardinal ligam ents to lift the uterus,
sary m ay not be supported enough to stay in situ. It can followed by anterior and posterior colporrhaphy if nec-
also fall out if too sm all a size is fitted. The m ain essary. It m ay be offered to a wom an who wants to pre-
com plications of a pessary are vaginal discharge or serve the uterus.
bleeding, particularly if the pessary is not replaced every
6 m onths. Granulation tissue m ay develop, incarce-
rating the pessary, if it is not changed regularly. If the Sacrospinous fixation
pessary is too large it will cause discom fort and m ay
To treat the prolapsed vaginal vault, the apex is fixed to
ulcerate the vaginal walls.
sacrospinous ligam ent using a transvaginal approach.
This ligam ent runs from the ischial spine to the lower
Su rgica l t re a t m e n t lateral aspect of the sacrum . Care m ust be taken to avoid
Surgery should be considered with a severe degree of the pudendal nerve and vessels, as well as the sacral
prolapse or if conservative m anagem ent fails. Prior to plexus and the sciatic nerve.
surgery it is im portant to know whether a wom an is sex-
ually active, because the vagina m ight be narrowed and
shortened, potentially causing dyspareunia. Sacral colpopexy
Surgery is not recom m ended in a wom an who has This abdom inal procedure involves suspending the vag-
not yet com pleted her fam ily. In pregnancy, after pelvic inal vault from the sacrum or from the sacral prom on-
floor repair, caesarean section is indicated to reduce soft tory, using either strips of fascia or synthetic m esh. The
tissue traum a and the risk of recurrent prolapse. m ain com plications are intraoperative haem orrhage
and infection of the m esh.
Anterior colporrhaphy New procedures are currently being developed using
This operation, also known as an anterior repair, is indi- synthetic m esh to relieve prolapsed vaginal walls or the
cated for the repair of a cystocoele or a cystourethro- vaginal vault. At present, follow-up data regarding suc-
coele. A portion of redundant anterior vaginal wall cess rates are lim ited.
m ucosa is excised and the exposed fascia is plicated to
support the bladder. Postoperatively, there is a risk of
worsening urinary sym ptom s. Fu rt h e r re a d in g
Lopes, T., Spirtos, N., Naik, R., et al., 2011. Bonney’s Gynaecological
Posterior colporrhaphy Surgery, 11th ed. Wiley Blackwell, London.
RCOG, 2007. The Managem ent of Post Hysterectom y Vaginal
Also known as a posterior repair, this operation is used to Vault Prolapsed. Green-top Guideline No. 46. Royal College
repair a rectocoele or a rectocoele combined with an of Obstetricians and Gynaecologists, London. Available
enterocoele. Using a sim ilar technique to the operation online at:www.rcog.org.uk.
described above, a triangle of posterior vaginal wall RCOG, 2009. Pelvic Floor Repair and Vaginal Hysterectom y
mucosa – its apex behind the cervix and the base at the for Prolapse: Consent Advice 5. Royal College of
introitus – is removed. The underlying levator ani Obstetricians and Gynaecologists, London. Available online
muscles are plicated to support the perineum. If an ente- at:www.rcog.org.uk.
rocoele is present, the pouch of Douglas is opened and Shaw, R.W., Luesley, D., Monga, A., 2010. Gynaecolocy, fourth
the enterocoele sac of redundant peritoneum is excised. ed. Churchill Livingstone, London.
97
This pa ge inte ntiona lly le ft bla nk
Gyn a e co lo gica l
e n d o crin o lo gy 16
O bjectives
This chapter focusses on the aetiology and m anagem ent with an increased risk of osteoporosis and ischaemic
behind am enorrhoea, delayed puberty and precocious heart disease.
puberty. • Endom etrial hyperplasia and endom etrial carci-
nom a occur m ore frequently in wom en with poly-
cystic ovary syndrom e (PCOS) because of the
unopposed oestrogen effect on the endom etrium
AM ENO RRHO EA associated with chronic anovulation.
• Haem atocolpos is associated with an increased risk
This describes the absence of m enstruation. There are of endom etriosis due to retrograde m enstruation.
two types: • Am enorrhoeic wom en are usually subfertile.
• Prim ary am enorrhoea – where m enstruation has not
started by the age of 16 years. This is relatively
uncom m on. Hist o ry
• Secondary am enorrhoea – where m enstruation has
There are so m any causes of am enorrhoea that it is
occurred in the past, but has been absent for
im portant to focus the history onto the relevant
6 m onths or m ore. This can be com m on, and causes
system s.
m ay be physiological, m ost frequently pregnancy
and the m enopause.
The causes of am enorrhoea can be broken down into
the following five m ajor categories:
Gynaecological
• Central nervous system A full gynaecological history is m andatory. By defini-
• Gonadal dysfunction tion, m enarche will not have occurred in wom en with
• Genital tract disorders prim ary am enorrhoea. The tim ing of pubertal develop-
• Endocrine disorders m ent will establish whether this is norm al, precocious
• Drug therapy. or delayed.
Menstrual irregularity or oligom enorrhoea from the
A history of post-pill am enorrhoea is usually the
tim e of m enarche m ay be due to polycystic ovary syn-
result of pre-existing pathology that has been m asked
drom e, especially if associated with obesity and
by the com bined oral contraceptive pill (COCP).
hirsutism .
Cyclical pain m ight indicate congenital or acquired
Co m p lica t io n s o f a m e n o rrh o e a outflow obstruction to m enstrual fluid, resulting in pri-
m ary am enorrhoea.
Although am enorrhoea itself does not cause any com - Pituitary failure can occur after m assive postpartum
plications, som e of the underlying conditions do carry haem orrhage (Sheehan’s syndrom e) and so a full
certain risks: obstetric history should be taken. This should include
• Wom en who carry a Ychrom osom e (genotype XXY) early pregnancy loss with subsequent uterine curettage,
have a 25% chance of developing gonadal m alig- which can lead to Asherm ann’s syndrom e.
nancy, usually a gonadoblastom a or dysgerm inom a. Relevant gynaecological surgery includes cervical sur-
• Low oestrogenic states, seen in hypothalamic amenor- gery, which can cause stenosis and, m ore obviously,
rhoea and premature ovarian failure, are associated oophorectom y and hysterectom y.
100
Amenorrhoea 16
com m only with CAH or androgen-secreting tum ours of Having excluded physiological causes of secondary
the ovary or adrenal. am enorrhoea, further investigation includes m easuring:
The following group of investigations should be • serum gonadotrophins – levels of follicle stim ulat-
perform ed as indicated: ing horm one (FSH) and luteinizing horm one (LH)
• Chrom osom al analysis are greatly raised with ovarian failure, whereas with
• Horm one profiles ‘hypothalam ic’ am enorrhoea or hypogonado-
• Im aging studies. trophic hypogonadism the levels will be at the lower
lim its of norm al. In PCOS the LH: FSH ratio is usu-
ally greater than 2.5
Chromosomal analysis • androgen levels – serum testosterone levels m ight be
Chrom osom al analysis should be perform ed on norm al or raised with PCOS, although free testoster-
wom en with prim ary am enorrhoea where a chrom o- one is usually raised. If serum testosterone levels are
som al abnorm ality (e.g. Turner’s syndrom e) is sus- very high then an androgen-secreting tum our of the
pected. Buccal sm ears or blood sam ples can be taken ovary or adrenal should be suspected
for this purpose. • prolactin – serum prolactin levels are im portant to
exclude hyperprolactinaem ia. Thyroid stim ulating
horm one and free thyroxine levels should be tested
Secondary amenorrhoea if there is clinical suspicion of thyroid dysfunction or
if hyperprolactinaem ia is confirm ed.
The m ost com m on cause of secondary am enorrhoea in
wom en of childbearing age is pregnancy, and this Other useful investigations include:
should be excluded before further investigation is com - • pelvic ultrasound scan – this will identify the typical
m enced. Aurinary pregnancy test detects the presence of ultrasound appearances of polycystic ovaries
b-hum an chorionic gonadotrophin (hCG) and can be (enlarged ovaries with increased central strom a asso-
perform ed quickly in the outpatient setting. ciated with m ultiple peripherally sited follicles).
101
Gynaecological endocrinology
The presence of an intrauterine pregnancy, haem ato- • Wom en with a haem atocolpos can be treated by sur-
m etra or haem atocolpos can also be identified gical excision of the persistent vaginal m em brane,
• lateral skull X-ray, CT or MRI scan of the head – this thereby draining the build-up of m enstrual blood.
identifies a pituitary or CNS tum our (Fig.16.4)
• analysis of chrom osom e in wom en under 30 years of
age who have ovarian failure. Treatment of secondary amenorrhoea
In young wom en who have no pathology, the condition
HINTS AND TIPS m ay be tem porary and m ight not require treatm ent.
102
Amenorrhoea 16
Secondary
amenorrhoea
Exclude physiological
causes:
pregnancy
lactation
menopause
103
Gynaecological endocrinology
to be long term, oestrogen replacem ent m ight be advis- the com bined contraceptive pill or HRT to prevent oste-
able to prevent osteoporosis. Hypothyroidism should oporosis. In addition, replacem ent of other pituitary
be corrected with thyroxine replacem ent. horm ones m ight be necessary.
Asherman’s syndrome
Cervical stenosis can be treated by dilating the cervix.
Intra-uterine adhesions should be divided hysteroscopi- PRECO CIO US AND DELAYED
cally. Insertion of an intra-uterine contraceptive device PUBERTY
is advisable for at least 3 m onths to prevent rede-
velopm ent of adhesions. Stim ulation of endom etrial
re-growth using exogenous oestrogens, i.e. horm one Pre co cio u s p u b e rt y
replacem ent therapy is som etim es necessary. Precocious puberty occurs when sexual m aturation
takes place before the age of 9 years.
Hormone-secreting tumours
Ovarian and adrenal horm one secreting tum ours
should be surgically rem oved. As m uch ovarian tissue Aetiology
as possible should be preserved, especially in younger
wom en given the im plications to their fertility. The conditions that m ay cause precocious puberty
and their approxim ate incidence are sum m arized in
Sheehan’s syndrome Figure 16.5 and an algorithm for identifying the m ost
Sheehan’s syndrom e is postpartum infarction of the com m on causes is shown in Figure 16.6. Although it is
pituitary gland due to m assive obstetric haem orrhage. im portant to exclude androgen-secreting tum ours in the
This requires oestrogen replacem ent in the form of ovary and adrenal glands, m ost cases are constitutional.
104
Precocious and delayed puberty 16
Management Aetiology
• Endocrinological: the m ainstay of endocrine sup-
Som e of the causes of delayed puberty and their approx-
port is suppression of oestrogen and androgen pro-
im ate incidence are shown in Figure 16.5 and an algo-
duction by GnRH analogues to reverse the physical
rithm for identifying the com m oner causes shown in
changes. This can either be given as a daily sniff or
Figures 16.6 and 16.7.
m onthly depot preparation.
• Psychological support: this is vital, together with
counselling, because the affected girl will see herself Investigations
as being different from her friends. • Full history and exam ination including BMI
• Surgical: if a tum our is discovered then this m ust be • Full endocrine profile (FSH, LH, Prolactin, thyroid
dealt with, usually surgically. function tests, 17-OH progesterone)
105
Gynaecological endocrinology
Adrenal Adrenal
Congenital adrenal Congenital adrenal
hyperplasia hyperplasia
Cushing’s syndrome Cushing’s syndrome
Tumours
O varian
Polycystic ovary O varian
syndrome Tumours
Arrhenoblastomas
Iatrogenic Hiler cell
Androgens Pregnancy luteomas
Anabolic steroids
Danazol Iatrogenic
Norethisterone Androgens
Phenytoin Anabolic steroids
Danazol
106
Hirsutism and virilism 16
O estradiol O varian
androgens
Free
testosterone
107
Gynaecological endocrinology
Cushing’s syndrom e (excess cortisol) presents com - cases. Diagnosis is m ade from the history, biochem ical
m only with a gradual change in appearance associated tests and ultrasound im aging of the ovaries. A rapid
with a host of other sym ptom s, including central obe- onset of sym ptom s, especially where virilism is present,
sity, m uscle wasting and weakness, hypertension and would suggest high circulating levels of androgens sec-
purple striae. ondary to m ore serious pathology. Testosterone levels
A careful drug history is im perative as not only do m ore than twice the upper lim it of norm al suggest an
m any of the horm onal therapies used in gynaecology ovarian or adrenal androgen-secreting tum our, which
have androgenic properties but there is an increase in could be identified by im aging test such as ultrasound
the use of anabolic steroids even am ong wom en. or CT scanning. Sm all tum ours m ight be m issed so a
high level of suspicion is needed. Investigations for
CAH and Cushing’s syndrom e should be perform ed if
Exa m in a t io n sym ptom s and clinical signs suggest these diseases. Idi-
• Hirsutism can be objectively scored using scoring opathic hirsutism is a diagnosis m ade by excluding
system s, but sim ple descriptive assessm ents are m ore other pathology.
practical. Signs of virilism should be looked for.
• Wom en with PCOS are often obese, although not
always so. Acanthosis nigricans (pigm ented raised Co m p lica t io n s
patches found on the neck and skin flexures) is
• The m ain com plication of hirsutism is psychosocial.
som etim es present in wom en with PCOS associated
• Som e signs of virilism , such as deepening of the
with insulin resistance.
voice and cliterom egaly m ight be irreversible.
• Severe CAH will have been diagnosed during child-
• Com plications associated with PCOS include obe-
hood due to am biguous external genitalia or salt-
sity, insulin resistance and glucose intolerance.
losing conditions. Wom en with m ilder, late-onset
• Chronic anovulation affects fertility and can cause
form s of CAH have little to distinguish them from
endom etrial hyperplasia and adenocarcinom a as a
those with PCOS, that is, obese, hirsutism / virilism
result of the unopposed effect of oestrogens.
with m enstrual disorder.
• Wom en with Cushing’s syndrom e will have the typ-
ical appearance of central obesity, peripheral m uscle
wasting, hypertension and striae. Treatment
• Androgen-producing tum ours cause little in the way Idiopathic hirsutism can be treated cosm etically using
of system ic upset apart from m arked signs of viril- bleaching or electrolysis. Encouraging weight loss is
ism . They are usually too sm all to cause palpably im portant in PCOS.
enlarged ovaries. Medical treatm ent of hirsutism in wom en with PCOS
• Wom en with idiopathic hirsutism usually have no is m ost effective using a com bination of ethinyloestra-
abnorm al findings on exam ination. diol with an anti-androgen such as cyproterone acetate
(Dianette). Although im provem ent can take m any
m onths, the progestogenic effect of cyproterone acetate
In ve st iga t io n s will protect the endom etrium from the effects of unop-
Investigation is determ ined by the degree of sym ptom s posed oestrogen. Recent data suggest that PCOS m ight
(Fig. 16.10). Having excluded a history of exogenous be driven by insulin resistance – as such, good results
androgens, if hirsutism is the only presenting com plaint have been obtained by the use of the oral hypoglycae-
then PCOS is the likely cause accounting for 90% of m ic agent m etform in.
108
Hirsutism and virilism 16
Androgen-secreting ovarian and adrenal tum ours Phenytoin should not be stopped suddenly because this
should be surgically rem oved with preservation of the could precipitate status epilepticus.
ovary in younger wom en.
Glucocorticoid and often m ineralocorticoid replace-
m ent is the m ainstay of treatm ent in CAH. Hirsutism
and virilism should im prove with therapy but it is som e- Fu rt h e r re a d in g
tim es necessary to perform surgical reconstructive pro- Bain, C., Burton, K., Mcgavigan, J., 2011. Gynaecology
cedures to the external genitalia. Illustrated, sixth ed. Churchill Livingstone, London.
Treating the cause of excess cortisol production in Llewellyn-Jones, D., 2010. Fundam entals of Obstetrics &
Cushing’s syndrom e should result in norm al circulating Gynaecology, ninth ed. Mosby, London.
levels of adrenal androgens. Shaw, R.W., Soutter, W.P., Stanton, S.L., 1997. Gynaecology,
Wom en with gynaecological conditions requiring third ed. Churchill Livingstone, London.
treatm ent with drugs that have androgenic properties RCOG, 2007. Polycystic Ovary Syndrom e, Long-Term
should be forewarned of the potential virilizing side Consequences (Green-top 33). Available online at:
effects and the lowest therapeutic dose advocated. www.rcog.org.uk/guidelines.
109
This pa ge inte ntiona lly le ft bla nk
M e n o p a u se 17
O bjectives
M a kin g a d ia gn o sis
PATHO PHYSIO LO GY In m ost cases, m enopause can be diagnosed by history-
taking and exam ination. As this is an im portant point in
In order to understand the physiology of the m eno- a wom an’s life it should be dealt with sensitively.
pause it is necessary to briefly review the physiology
of the m enstrual cycle.
At around 20 weeks of gestation the developing Hist o ry
fem ale fetus can have up to 7 m illion oocytes within
When taking a history, key features include:
the ovaries; this num ber will eventually fall to around
2 m illion at birth with approxim ately 50% of these • any vasom otor sym ptom s and m ood disturbances
being atretic. The ovaries are then quiescent until • date of the last m enstrual period (LMP)
puberty when from a wom an’s first period (m enarche) • pattern of m enses in the past few years.
onwards, each m onth, her ovaries will recruit a cohort During the clim acteric periods m ay becom e irregu-
of oocytes. These oocytes then secrete oestrogen and lar and heavier, resulting in som e interm enstrual bleed-
progesterone and the whole process results in one ing. Urinary sym ptom s such as dysuria, frequency,
oocyte becom ing a dom inant follicle and releasing an incontinence should prom pt further investigation
egg ready for fertilization. (see below).
After 40 years of age as a result of successive cycles in A sexual history should be taken, including dyspar-
a wom an’s fertile period, only a few thousand oocytes eunia and contraception. It is still possible to get preg-
rem ain. The depletion of the rem aining oocytes coupled nant during the clim acteric and patients should
with their increased resistance to pituitary horm ones continue using contraception beyond the m enopause.
Remember that all of the above symptoms can be due Hormone replacement therapy
to other pathology, so the diagnosis should not be There are m any preparations available, both horm onal
based on one symptom alone. and non-horm onal which can be adm inistered by a
num ber of routes.
Oestrogen-based horm one replacem ent therapy
Exa m in a t io n (HRT) preparations were the first to be used to alleviate
m enopausal sym ptom s, but som e wom en developed
Im portant points include height, weight, blood pre- endom etrial hyperplasia (a precursor for endom etrial
ssure m easurem ent, abdom inal palpation and pelvic cancer). Progesterone was, therefore, added to
112
Clinical features 17
Side effects
Fig. 17.3 Investigating menopausal symptoms.
Side effects described are nausea, fluid retention, hir-
Urinary symptoms (dysuria, frequency, urgency) sutism , leg cram ps and breast discom fort. Modifying
Urine Dipstick the preparation, as well as reducing the dose, can be
þ / À Urine microscopy, culture and sensitivities beneficial. The progestogen com ponent m ust be altered
þ / À Urodynamic Testing particularly carefully as there is a risk of not adequately
protecting the endom etrium . The Mirena ® IUS can be
Intermenstrual/ post coital bleeding
beneficial as it secretes the progestogen locally with
Cervical Smear low system ic levels.
þ / ÀColposcopy
Low impact fractures/ family history of osteoporosis Contraindications
Figure 17.5 displays the contraindications to HRT use.
X-Ray
Dual energy X-ray absorptiometry (DEXA) scan
Risks
Over the past 20 years the use of HRT has com e under
preparations to protect the endom etrium . In patients intense scrutiny due to som e studies showing an
who have had a hysterectom y, progesterone is not increased risk of cardiovascular disease, breast cancer
required as there is no endom etrium to protect. and stroke in patients taking combined form s of HRT.
There are m any different types of oestrogen and prior In breast cancer it is thought that the risk increases with
to the m enopause the m ain circulating oestrogen is oes- the duration of use, but this increased risk is not seen
tradiol, produced by the granulosa cells of the develop- in those patients taking HRT for an early menopause. Evi-
ing follicle. Following the m enopause oestrone is dence around cardiovascular risk is somewhat conflicting,
produced by peripheral tissues. The aim of HRT is read-
dress this and, therefore, m ost preparations contain oes-
tradiol. Figure 17.4 shows the available routes of
adm inistration for HRT preparations as well as their Fig. 17.5 Contraindications to hormone replacement
potential advantages and disadvantages. therapy.
When prescribing HRT the lowest effective dose • Endometrial carcinoma
should be used. Oral preparations can be given as • Breast carcinoma
sequential preparations where patients will experience • Undiagnosed vaginal bleeding
a m onthly withdrawal bleed or continuous prepara- • Undiagnosed breast lumps
tions where there will be no m onthly bleed. In general • Severe active liver disease
cyclical preparations should not be continued for m ore • Pregnancy (always rule out before starting therapy)
• Personal history of venous thromboembolism – O RAL
than 5 years and in those patients experiencing sym p-
therapy is contraindicated but if benefits of treatment
tom s after a period of 1 year’s am enorrhoea with an
outweigh risks then TRANSDERMAL preparations
intact uterus, continuous com bined HRT should be can be used
com m enced.
Advantages Disadvantages
113
Menopause
Patient presents with a good clinical history of menopausal symptoms age >45
Yes Investigate
Symptoms possibly due to another cause?
and rule out
No
Concerns
General health and risk assessment
Benefits
No Concerns outweigh risks?
Yes
Symptoms
No
Lifestyle changes +/ –
Mild Moderate Severe Complementary Rx
Consider non-hormonal
Lifestyle changes +/ –
Consider HRT
Complementary Rx
No
Effective? Contraindications?
No Yes
Fig. 17.6 Hormone replacement therapy – patient pathway. Adapted from Panay 2011, with permission. (Adapted from Panay N
(2011) Menopause. In O xford Desk Reference: O bstetrics and Gynaecology. O xford University Press.)
although there appears to be a protective effect in the • selective serotonin reuptake inhibitors (SSRIs) and
younger age group of patients taking HRT (50–59) and selective noradrenaline reuptake inhibitors (SNRIs).
a detrimental effect in older patients (70–79 years).
CO NTRACEPTIO N
Non-hormonal pharmacological agents
Wom en in the clim acteric rem ain at risk of pregnancy.
If horm onal agents are not tolerated or contraindicated Wom en should continue contraception for 1 year after
for vasom otor sym ptom s, consider: their last m enstrual period if they are > 50 years old and
• clonidine – a centrally active alpha-2 agonist. for 2 years if they are < 50 years old.
Premature menopause (premature ovarian failure) 17
Fu rt h e r re a d in g
PREM ATURE M ENO PAUSE
Beresford, S., Weiss, N., Voigt, L., et al., 1997. Risk
(PREM ATURE O VARIAN FAILURE) of endom etrial cancer in relation to use of oestrogen
com bined with cyclic progestogen therapy in
Prem ature ovarian failure occurs in 1% of wom en. It is postm enopausal wom en. Lancet 349, 458–461.
diagnosed in patients under the age of 40 with second- British Menopause Society. Available online at: www.thebms.
ary am enorrhoea, with a high FSH on two separate occa- org.uk.
sions. Causes include chem o or radiotherapy or viral RCOG, 2011. Venous Throm boem bolism and Horm one
infections such as m um ps. Diagnosis is based on FSH Replacem ent Therapy. Green-top Guideline No. 19. Royal
and LH levels, whilst treatm ent is prim arily HRT and College of Obstetricians and Gynaecologists, London.
dietary advice to prevent osteoporosis. Wom en affected Available online at: www.rcog.org.uk.
115
This pa ge inte ntiona lly le ft bla nk
Su b fe rt ilit y 18
O bjectives
Drug history
Fig. 18.1 Pie chart of causes of subfertility. A drug history is essential (both prescription or other-
wise). Regular use of non-steroidal anti-inflam m atory
drugs and cannabis reduces the num ber of ovulatory
cycles. This is an opportunity to review any m edications
Fig. 18.2 Causes of female infertility. not recom m ended for use in pregnancy, considering
alternatives if appropriate. All wom en trying to conceive
Problem Cause
should take folic acid supplem ents.
O vulatory dysfunction Chronic systemic illness
Eating disorders
Polycystic ovarian syndrome Social history
Hyperprolactinaemia Sm oking reduces fertility so sm oking cessation should
Hypo/ hyperthyroidism be encouraged. Alcohol consum ption should be lim ited
Cannabis use
to 1–2 units once or twice a week. Regular exercise
NSAIDs
should be encouraged and those with a body m ass index
Tubal factor Pelvic inflammatory disease (BMI) > 29 should be advised to lose weight. Those with
Previous tubal surgery a BMI of < 19 who have oligo/am enorrhoea should be
Previous ectopic pregnancy advised that m oderate weight gain m ay increase concep-
Endometriosis
tion rates.
Uterine problem Fibroid
Uterine septae
Congenital anomaly Hist o ry fro m t h e m a n
Ashermann’s syndrome
Vaginismus
Past surgical history
Coital dysfunction
Dyspareunia Relevant operations include:
• inguinal hernia repairs, which m ay lead to obstruc-
tion of the vas deferens in its inguinal portion
• undescended testes – this affects sem en quality
• Asherm ann’s syndrom e – the presence of (regardless of tim ing of orchidopexy)
intrauterine adhesions that form after curet- • testicular torsion reduces fertility
tage or term ination of pregnancy. • bladder neck surgery, including transurethral resec-
• Dyspareunia is an im portant sym ptom , suggesting tion of the prostate (TURP) can cause retrograde
pelvic inflam m atory disease (PID) or endom etriosis ejaculation.
• Oligo- or am enorrhoea (few or absent periods) m ay
point to anovulation
• Any previous pelvic infections should be noted as Past medical history
they m ay have caused tubal dam age, in addition, • Cystic fibrosis (CF) – patients with CF may have agen-
any previous intrauterine contraceptive device esis of the vas deferens and therefore an obstruction.
118
Investigation 18
• Epididym o-orchitis, m ost com m only caused by sex- • Other syndrom es linked to infertility have other typ-
ually transm itted infections such as chlam ydia can ical facies (e.g. hyper/hypothyroidism , Cushing’s
also result in epididym al obstruction. syndrom e, Turner’s syndrom e).
• Post pubertal mumps orchitis can cause significant tes-
ticular atrophy resulting in very poor-quality sperm.
• Chronic m edical conditions (e.g. renal disease, dia- Abdominal examination
betes) im pair sperm atogenesis.
Initial inspection m ay reveal scars from previous surgery
which could raise the possibility of adhesions or indi-
cate previous treatm ent (e.g. laparoscopy for endom e-
Drug history triosis/PID). Palpation m ay reveal the presence of a
Several drugs are known to decrease sperm num ber m ass which m ay be due to a large fibroid uterus or ovar-
and/or function: ian cyst and lower abdom inal tenderness m ay be due to
endom etriosis or PID.
• Anabolic steroids, cannabis, cocaine, sulfasalazine
(taken for inflam m atory bowel disease), colchicine
(used to treat gout), nitrofurantoin and tetracyclines
(antibiotics) Vaginal examination
• a -blockers (used for treatm ent of benign prostatic • Vaginal discharge m ay be physiological or a sign of
hypertrophy) and som e antidepressants are known PID and if there is doubt, triple swabs should be
to interfere with ejaculation taken.
• b-blockers m ay cause im potence. • The cervix should be visualized and concerns fol-
lowed up with a colposcopy. Previous cervical sur-
gery m ay have caused stenosis.
• The uterus is palpated; a non-m obile uterus m ay be
Social history due to adhesions from endom etriosis or PID; an
• Sm oking can im pair the quality of the sperm enlarged uterus is likely to be due to fibroids.
• Excessive alcohol intake reduces sem en quality • The practice of fem ale genital m utilation is wide-
• Occupational history is im portant. Sperm count spread in som e parts of the world and m ay cause dys-
m ight be affected in m en whose jobs result in raised pareunia and even apareunia.
testicular tem perature such as prolonged driving • Occasionally an intact hym en is discovered.
• Heavy m etals, solvents and agricultural chem icals
are all associated with oligosperm ia.
Examination of the man
HINTS AND TIPS • Calculate the BMI as obesity is known to decrease
testosterone levels.
Consultation with the subfertile couple should be • Look for secondary sexual characteristics –
carried out with compassion and dignity. The inability inadequate virilization could be due to abnorm al
to conceive may result in psychological, social, ethnic karyotype.
and religious pressures that may not always be • Scars from inguinal hernia repair m ight point to an
apparent but may have profound consequences for the obstructive problem .
individuals. • Consider the im pact of clothing; tight underwear
raises the scrotal tem perature and can im pair sperm
function.
• Measure testicular size using an orchidom eter, and
EXAM INATIO N palpate to check the presence of the vas deferens
on both sides.
Exa m in a t io n o f t h e w o m a n
General
• The presence or absence of secondary sexual charac- INVESTIGATIO N
teristics should be noted.
• The BMI should be calculated (weight (kg)/ height Target investigations for subfertility to a specific cause
(m 2 )). (if indicated from the history). In som e cases not all
• Hirsutism and acanthosis nigricans m ay indicate investigations are necessary. Investigations which m ay
PCOS. be required include:
119
Subfertility
Blo o d t e st s
The following should be checked in wom en:
• Mid-luteal phase progesterone: the level rises after
ovulation. The test should be perform ed a week
before the next period is due, e.g. day 21 of a 28-
day cycle, or day 28 of a 35-day cycle.
• Rubella im m unity: this is not an investigation of
subfertility but m ust be checked in any wom an
who is intending to conceive so that she can be vac-
cinated if not im m une to prevent infection in
pregnancy.
Pe lvic u lt ra so u n d
Perform ed to look for: Fig. 18.3 Hysterosalpingogram. From Letterie 2011, with
• congenital or structural abnorm alities of the uterus permission.
• fibroids
• bulky ovaries with m ultiple peripheral follicles in adhesions. Methylene blue dye is introduced
PCOS through the cervix and its progress through the
• Hydrosalpinx. uterus and out of the fallopian tubes can be directly
visualized. Lack of ‘fill and spill’ of dye indicates
tubal occlusion.
M icro b io lo gy • Infection screening should be done before any inves-
Screen for Chlam ydia in both wom en (endocervical tigations of tubal patency to prevent ascending infec-
swab/ urine) and m en (urethral swab). Infection is tion. Where it has not been done antibiotic cover
asym ptom atic in up to 70% of wom en so there m ight should be prescribed. A sem en analysis (see below)
not be any clues in the history. Treatm ent itself m ay is m andatory prior to laparoscopy as an abnorm al
not im prove fertility but failure to identify and treat sem en analysis m ay be the cause of subfertility
prior to hysterosalpingogram or laparoscopy and dye and m ake the operation unnecessary.
(see below) can exacerbate the infection, which m ay
worsen tubal disease
Se m e n a n a lysis
Te st in g t u b a l p a t e n cy Here, the patient is asked to provide a specim en after
Testing for tubal patency is a very im portant part of a 3 days’ abstinence and after a period of good health
work up in subfertility and is perform ed in the first half (a system ic illness within the previous 72 days can
of the cycle to ensure the patient isn’t already pregnant. reduce the quality of sperm produced).
The m ethod used will depend upon patient’s history: The sam ple should be exam ined within 1 hour of
production. The sperm are counted and evaluated for
• A hysterosalpingogram (HSG) is generally used in m otility, progression and m orphology, and the volum e
patients with no com orbidities (PID, previous of the specim en is recorded (Fig. 18.4 gives the norm al
ectopic, endom etriosis). Radio-opaque dye is intro- param eters). The presence of m ore than 106 white
duced through the cervix into the uterus and an blood cells suggests epididym o-orchitis. Ideally, at least
X-ray is taken to look for passage of the dye. Blockage two sam ples at least 12 weeks apart should be exam ined
inside or outside the tubes can prevent the dye flow- (to sam ple different populations of sperm ).
ing; however, tubal spasm in response to the dye can
also prevent flow (see Fig. 18.3).
• Hysterosalpingo contrast sonography (HyCoSy) is
an alternative. It is perform ed by ultrasound and Fig. 18.4 Normal parameters of semen analysis.
involves the passage of fluid through the cervix into Volume 1.5–5 mls
the uterus and tubes m onitored using Doppler.
• Where there is suspicion of pathology a laparoscopy Count >20 million/ ml
and dye is perform ed under general anaesthetic. It Progression >50%
enables direct visualization of the pelvis in order Normal forms >30%
to diagnose endom etriosis or PID and the resulting
120
Treatment 18
Ut e rin e , t u b a l a n d p e lvic p ro b le m s
TREATM ENT • Subm ucous fibroids, polyps and uterine septae, all
distort the uterine cavity. They can im pair fertility
Where identified, treatm ent for subfertility can be and m ay cause m iscarriage. Often they will be
aim ed at the specific cause. Many couples, however, suf- rem oved prior to in vitro fertilization (IVF) to m ax-
fer unexplained subfertility, but can still be helped by im ize the chances of success.
the m ethods described below. • Hydrosalpinges reduce the im plantation rate and can
be removed or drained for this reason prior to IVF.
An o vu la t io n • Surgical treatm ent of even m ild endom etriosis (i.e.
diatherm y or laser at tim e of laparoscopy) has been
Anovulation can be due to failure of the hypothalam o- shown to im prove fertility in the short term .
pituitary-ovarian (HPO) axis (GnRH deficiency), dys- • Tubal surgery – proxim al tubal blockage can be
function of the HPO axis (polycystic ovary syndrom e treated hysteroscopically using new cannulation
(PCOS)) or ovarian failure. Most com m only it is due techniques. Distal dam age m ay be treated by
121
Subfertility
laparoscopic salpingostom y. Tubal patency, how- and FSH but then cause down-regulation, leading
ever, does not guarantee function and these patients to reduction in oestrogen production and ‘m eno-
are at risk of an ectopic pregnancy. pausal’ side effects. These drugs are given by nasal
spray or subcutaneous injection
• Induction of m ultiple follicular developm ent using
M a le fa ct o r in fe rt ilit y gonadotrophins such as hum an m enopausal gonad-
If the sem en analysis is persistently abnorm al despite otrophin (hMG), which contains FSH and LH and is
advice regarding loose underwear and reduction of alco- prepared from the urine of m enopausal wom en,
hol and nicotine intake, assisted fertility can be consid- hCG, which is obtained from the urine of pregnant
ered. Up to six cycles of intrauterine insem ination (IUI) wom en and has a sim ilar action to LH, or recom bi-
m ay be tried before IVF or intracytoplasm ic sperm injec- nant FSH, an expensive but pure form of FSH
tion (ICSI), because it is less invasive. • Egg collection: perform ed transvaginally using ultra-
sound, under sedation (Fig. 18.5)
• Sperm preparation
Intrauterine insemination • In vitro fertilization of the oocytes with sperm
• Transfer of the healthy em bryos (m axim um of two)
IUI is a technique which is suitable for patients with back into the uterine cavity (Fig. 18.6).
m ild m ale factor infertility, unexplained infertility or
m ild endom etriosis. The m ale partner provides a sem en
sam ple. Fast-m oving sperm are selected and introduced HINTS AND TIPS
into the uterine cavity. In the fem ale partner the cycle
Pre-implantation genetic diagnosis (PGD) is a
ovulation can be stim ulated or unstim ulated.
technique whereby couples affected by a hereditary
disorder can screen embryos to see which may be
In vitro fertilization affected. Cells from each embryo are removed and
analysed so that only unaffected embryos are
In vitro (in glass) fertilization involves inducing ovula-
transferred to the patient.
tion followed by harvesting the oocytes and fertilizing
them in a laboratory using sperm from the partner or
donor. The subsequent em bryo is then transferred back
to the patient with the hope of an ongoing pregnancy. Intracytoplasmic sperm injection
IVF has advanced hugely over the past few years with Intracytoplasm ic sperm injection (ICSI) is an advanced
variations on techniques and protocols. It generally form of IVF where one sperm is directly injected into the
involves several steps: egg (Fig. 18.7). This technique has revolutionized treat-
• Down-regulation of the wom an’s own horm ones m ent for couples where the partner’s sperm count is very
using GnRH agonists. They initially stim ulate LH low or showing increased abnorm al form s. If there are
122
Risks of assisted reproductive techniques 18
RISKS O F ASSISTED
REPRO DUCTIVE TECHNIQ UES
• IVF has a well-known association with m ultiple
pregnancy and studies have shown children born
through IVF have a slightly lower birth weight com -
pared to spontaneous conceptions.
Fig. 18.7 Sperm injection into an egg. • ICSI has been shown to have an increased risk of
children being born with congenital m alform ations
especially affecting the urogenital system .
• Ovarian hyperstim ulation syndrom e (OHSS) which
no sperm in the sem en at all (due to obstruction or to is discussed below.
congenital absence of the vas) sperm can som etim es
be extracted from the vas, the epididym is, or even from
a testicular biopsy. It has recently been suggested that O va ria n h yp e rst im u la t io n
sperm atids (i.e. im m ature sperm atozoa) could be used,
but at present this has not been licensed by the Hum an
syn d ro m e
Fertilisation and Em bryology Authority (HFEA). Ovulation induction can lead to OHSS, which is a sys-
tem ic disease with potentially very serious conse-
HINTS AND TIPS quences. It occurs as a consequence of high levels of
oestrogen and increased vascular perm eability. This
The Human Fertilisation and Embryology Authority can lead to accum ulation of fluid in the ‘third space’
(HFEA) was established in 1991 and regulates all (abdom en, chest, etc.) and leads to intravascular fluid
centres in the UK that offer assisted conception. Their depletion.
website www.HFEA.gov.uk is an excellent source of In its m ild form the patient suffers only m ild abdom -
advice and information for couples. inal discom fort. In worse cases, however, nausea and
vom iting develop, there is pronounced, painful abdom -
inal distension, and fluid shifts resulting in ascites and
pleural effusions. Hepatorenal failure and adult respira-
Surgical options for male subfertility tory distress syndrom e (ARDS) can ensue and the
If the sperm count is suboptim al because of epididym al patient is at greatly increased risk of throm boem bolism .
blockage, surgery can be perform ed to restore patency. If Treatm ent is hospitalization and careful fluid balance.
a varicocoele is present this can be repaired. This has not Throm boprophylaxis is very im portant and som e
been proven conclusively to im prove sperm atogenesis patients m ay require therapeutic drainage of accum u-
but it is known that the incidence of varicocoele in lated fluid by an ascitic or chest drain.
123
Subfertility
As with m any conditions prevention is better than effective in those patients who have had a previous
cure and careful ultrasound m onitoring of patients pregnancy.
undergoing ovulation induction is very im portant. In
som e cases it m ay be necessary to abandon the cycle Re fe re n ce
if too m any follicles have developed to prevent OHSS
occurring. Letterie, G.S., 2011. Managem ent of congenital uterine
abnorm alities. Reprod. Biom ed. Online 23, 40–52. http://
dx.doi.org/10.1016/j.rbmo.2011.02.008, Epub 2011 Feb 17.
Prognosis
The age of the fem ale partner has been shown to be the Fu rt h e r re a d in g
m ost im portant prognostic factor in IVF. Wom en aged NICE, 2004. Clinical Guideline 11. National Institute for
between 23 and 35 years have a 20% chance of live birth Health and Care Excellence, London.
per IVF cycle com pared with 6% for those aged 40 years RCOG, 2006. Ovarian Hyperstim ulation Syndrom e. Green-top
or m ore. Older wom en m ay choose to use donor Guideline No. 5. Royal College of Obstetricians and
eggs, which can increase success rates. IVF is also m ore Gynaecologists, London.
124
Co n t ra ce p t io n , st e riliza t io n
a n d u n w a n t e d p re gn a n cy 19
O bjectives
Rh yt h m m e t h o d BARRIER M ETHO DS
The rhythm m ethod involves predicting the fertile and These m ethods include the m ale condom and, for
infertile tim es of the m enstrual cycle, by using several wom en, the diaphragm , the cervical cap and the fem ale
fertility indicators: condom . Their effectiveness increases with concom itant
• A m enstrual calendar use of a sperm icide such as nonoxynol-9, which alters
• Charting the basal body tem perature, which rises sperm m em brane perm eability resulting in sperm death
0.2–0.4 C when progesterone is released from the (use of sperm icides alone as contraception is not
corpus luteum recom m ended).
Disadvantages Disadvantages
They m ust be applied before penetration (which can The m ain risks of the COCP are throm boem bolism and
interrupt sex) and can reduce the level of sensation. cardiovascular com plications. These are exacerbated by:
The diaphragm and the cap have to be fitted and • age
checked regularly by a trained professional. In all these • obesity
m ethods, effectiveness is dependent on correct use and • cigarette sm oking
sustained m otivation.
126
Intrauterine contraceptive devices and mirena intrauterine system 19
• diabetes Disadvantages
• hypertension
• Because it is injected, it cannot be rem oved and any
• fam ilial hyperlipidaem ia.
side effects m ust be tolerated for 3 m onths.
Other m ore m inor side effects include weight gain, • Most wom en becom e am enorrhoeic but heavy,
decreased libido, breast discom fort, m ood disturbance unpredictable bleeding patterns can som etim es
and breakthrough bleeding. The effectiveness of the occur.
COCP is lim ited by som e antibiotics, hepatic-enzym e- • Being a slow-release depot preparation, there m ight
inducing drugs and by vom iting and diarrhoea. Use is be a delay in return to fertility of 12 to 18 m onths.
associated with an increase in cervical intraepithelial • Prolonged use is associated with an increased risk of
neoplasia and carcinom a of the cervix. This m ay be osteoporosis.
because of the increased risk of exposure to STIs with • Other side effects include headache, spotty skin,
a non-barrier m ethod of contraception. The effect on m ood changes and breast tenderness.
breast cancer is uncertain.
The COCP should be discontinued 4 weeks before
major surgery because of the risk of venous thromboem- Pro ge st in im p la n t (Im p la n o n )
bolism. Heparin prophylaxis may still be necessary This is an inert flexible tube, 2–3 cm in length that is
depending on other risk factors such as imm obility or inserted subderm ally, usually under the skin of the
BMI over 30. Alternative contraception should be advised. upper arm under local anaesthetic. It releases the m an-
m ade horm one progestin.
Pro ge st e ro n e -o n ly p ill
Although slightly less effective than the COCP, the Advantages
progesterone-only pill (POP) is used in wom en in
whom oestrogens are contra-indicated or who cannot Its effects last for 3 years but the device can be taken out
tolerate the side effects. This includes wom en aged over any tim e. It has the advantage over the depo preparation
35 who sm oke and those who are breast-feeding. of a quicker return to norm al fertility and regular m en-
The m ode of action differs from the COCP in that ses once discontinued. It is not intercourse-related.
ovulation is suppressed in only 50–60% of cycles, but
with sim ilar changes in cervical m ucus and in the endo-
m etrium , as well as reduced tubal m otility.
Disadvantages
Periods can be irregular and som e wom en gain weight.
Advantages Training is needed for insertion using a local anaesthetic
and tenderness, bruising and swelling m ay occur.
Without oestrogen, few serious side effects occur.
Disadvantages
Efficacy is reduced if the tim e of pill-taking is delayed by INTRAUTERINE CO NTRACEPTIVE
m ore than 3 hours. The m ain problem is a change in DEVICES AND M IRENA
m enstrual pattern, with spotting or breakthrough bleed- INTRAUTERINE SYSTEM
ing that does not settle despite continued use. There is a
sm all increase in the risk of ectopic pregnancy. Insertion of one of a variety of synthetic devices into the
uterine cavity (Fig. 19.3) is likely to ensure that blasto-
In je ct a b le p ro ge st o ge n s cyst im plantation is prevented. There is also som e for-
eign body reaction to the intrauterine contraceptive
(De p o -p ro ve ra ) device (IUCD) in the endom etrium , resulting in altered
Intram uscular injections of m edroxyprogesterone ace- cell num bers and fluid com positions, which m ay affect
tate given every 3 m onths ensure that high-dose proges- gam ete viability. There m ay also be changes in the cer-
togen is gradually released into the circulation and vical m ucus which reduce sperm penetration. The latter
inhibits ovulation; it is alm ost as effective as the COCP. effects are particularly applicable to the progestogen-
containing MIRENA intrauterine system (IUS), which
also acts to thin the endom etrium .
Advantages
This m ethod of contraception is highly effective and is
not intercourse related. It also does not require daily Contraindications
m otivation. Figure 19.4 lists the contraindications to IUCD/IUS use.
127
Contraception, sterilization and unwanted pregnancy
A B T frame C
Steroid
32mm
reservoir
Removal
threads
Fig. 19.3 Types of intrauterine contraceptive device: (A) Copper T. (B) Mirena IUS. (C) Gynefix.
128
Termination of pregnancy 19
129
Contraception, sterilization and unwanted pregnancy
130
Ea rly p re gn a n cy
co m p lica t io n s 20
O bjectives
Pa st o b st e t ric h ist o ry
A history of m iscarriage or ectopic pregnancy increases pregnancy has ruptured. Her pulse and blood pressure
the risk of these problem s happening again. should be m easured.
Miscarriage is unlikely to cause shock due to hypovo-
Pa st m e d ica l h ist o ry laem ia but, rarely, cervical shock is seen, in which there
is a vagal response to the dilatation caused by products
This should focus on any conditions that predispose to
of conception distending the cervical canal. In this case
ectopic pregnancy (see Fig. 20.2). Also, rem em ber that a
pulse and blood pressure would both be low.
wom an who has a non-viable or an ectopic pregnancy
Haem orrhage from a ruptured ectopic pregnancy can
m ight need an operation, so attention should be paid
be m assive; the pulse will be weak and tachycardic and
to conditions that m ay affect fitness for anaesthetic.
blood pressure will be low. The patient will look pale,
sweaty and unwell and m ight collapse.
EXAM INATIO N Ab d o m in a l e xa m in a t io n
With m iscarriage, the abdom en will be soft. If m ore
O b se rva t io n s than 12 weeks, or if the uterus is fibroid, it m ight be pal-
The wom an m ight be experiencing significant pain if the pable above the sym physis pubis. With ectopic preg-
uterus is expelling clots or products, or if an ectopic nancy the uterus will not be palpable abdom inally.
132
Miscarriage 20
Before it ruptures there will be tenderness on the size in weeks should be estim ated. The adnexa should
affected side, and there m ight be som e guarding and be exam ined – an ectopic pregnancy m ay cause fullness
rebound. Once ruptured, the entire abdom en will be and tenderness on the affected side. Cervical excitation
tense and tender with guarding and rebound. is present with an ectopic pregnancy.
Rem em ber to consider an ectopic pregnancy in any Cervical excitation pain is sudden severe pain that
wom an of reproductive age who presents to casualty occurs when the cervix is m oved at the tim e of vaginal
with shock and collapse. A pregnancy test m ust be done exam ination. This is different from the discom fort that
on all such wom en. m any wom en feel at the tim e of exam ination.
Cu sco ’s sp e cu lu m e xa m in a t io n
The cervix should be visualized and swabs taken from INVESTIGATIO N
the endocervix and vagina. An ectropion or, rarely, a cer-
vical carcinom a, m ight be visible. It m ight be possible to Blo o d t e st s
see if the os is open or closed but this is best determ ined
by palpation. • Full blood count: the wom an is unlikely to be anae-
An ectropion is not pathological – it is sim ply an m ic due to the bleeding of a threatened m iscarriage
extension of endocervical colum nar epithelium , which but there m ight be pre-existing anaem ia, which will
bleeds easily, onto the ectocervix and is com m on in be im portant from an anaesthetic point of view. An
pregnancy due to the influence of oestrogen. Bleeding ectopic, if ruptured, m ay result in severe anaem ia.
from an ectropion is usually light but can be heavier Electrophoresis, if appropriate, m ust also be
if provoked by intercourse or in the presence of infec- requested.
tion, so cervical swabs should be taken. No treatm ent • Blood group: wom en who are Rhesus negative will
is necessary unless infection is proven. require anti-D after an operation for ectopic preg-
nancy, after an evacuation of the retained products
of conception (ERPC) at any gestation or after an
Va gin a l e xa m in a t io n episode of bleeding after 12 weeks.
When perform ing a vaginal exam ination, check • The serum b-hCG level can be helpful in diagnosing
whether the os is open or closed. In early pregnancy, an asym ptom atic ectopic pregnancy. An intrauterine
if the wom an has had a labour in the past, the external pregnancy should be seen on a transvaginal scan
os m ay be open (‘m ultip’s os’), but the internal os with levels of above 1500.
should be closed, so this question refers to the internal
os. If it is open there will be no resistance, and the cervix Ult ra so u n d sca n
will adm it a finger. An open os indicates an inevitable
m iscarriage; a closed os m ight be seen with m iscarriage Transvaginal scans give the best view in early pregnancy
(see Fig. 20.3) or with ectopic pregnancy. The uterine (Fig. 20.4). The uterus is exam ined, looking for a gesta-
tion sac and fetal pole, and then for a fetal heartbeat. If
the uterus is em pty, raising the possibility of ectopic
pregnancy, the adnexa are scanned, looking for a m ass.
Som etim es a live ectopic is seen, where the ectopic ges-
tation sac contains a fetus with a heartbeat. Free fluid,
due to bleeding from the ectopic pregnancy, m ight be
seen in the pouch of Douglas. With a m iscarriage,
retained products of conception m ay be seen.
Once a fetal heartbeat is seen on ultrasound scan
there is a 90% chance of the pregnancy continuing
and the wom an can be reassured. Fetal heart activity
can be seen from around 6 weeks’ gestation.
M ISCARRIAGE
Miscarriage is the m ost com m on com plication of preg-
nancy and will be experienced by 1 in 4 wom en at som e
Fig. 20.3 Transvaginal scan showing intrauterine pregnancy, point in their lives. It is defined as the spontaneous loss
7-week-sized fetus. of a pregnancy before 24 weeks.
133
Early pregnancy complications
Ae t io lo gy M a n a ge m e n t o f m isca rria ge
It is often difficult to identify the cause of a m iscarriage
O n ce th e fetus h as died, th e uterus will expel th e prod-
but factors that have contributed can be noted. These
ucts of con ception . Th is process can take som e weeks if
include:
left to h appen spon tan eously. Because of th e fear of
• fetal abnorm ality: 50% of m iscarried fetuses are in fection of retain ed products wom en h ave tradition -
genetically (e.g. trisom y, m onosom y) or structurally ally been advised to h ave a surgical evacuation to
(e.g. neural tube defect) abnorm al. Multiple preg- em pty th e uterus (a procedure th at m an y wom en still
nancies are m ore likely to be affected in these ways th in k of as a ‘D&C’). Studies com parin g th e operative
• infection: Toxoplasma species, the rubella virus, route with expectan t m an agem en t h ave n ow con -
tuberculosis, Listeria species, m alaria, Salmonella spe- firm ed n o differen ce in in fection rates. Evacuation of
cies and cytom egalovirus are just a few of the poten- retain ed products of con ception (ERPC) is a m in or
tial causes. Bacterial vaginosis, where there is a operation th at can be perform ed as a day case; th e cer-
change in the natural flora of the vagina, has been vix is dilated to allow suction or sh arp curettage. Th e
linked to second trim ester m iscarriage pregn an t uterus is easily perforated, so curettage m ust
• m aternal age: the m iscarriage rate begins to increase be gen tle. Syn tocin on can be given in traven ously dur-
when the m other reaches the age of 35. The risks of in g th e procedure to en courage uterin e con traction
m iscarriage in relation to m other’s age are: an d to m in im ize blood loss. Products of con ception
• under 35: 6.5% are sen t for h istology after m atern al con sen t is
• 5 – 40: 15% obtain ed.
• over 40: 23%. If the patient is offered the choice of expectant m an-
• abnorm al uterine cavity: the presence of an intra- agem ent she should be booked for follow-up appoint-
uterine contraceptive device (IUCD or ‘coil’), sub- m ent and scan to confirm that the uterus is em pty.
m ucous fibroids, a congenital septum or adhesions She should be counselled with regards to the bleeding
(Asherm ann’s syndrom e) and pain she will experience. They, and wom en who
• m aternal illness, including Wilson’s disease, poorly have had an ERPC, should be warned of the possibility
controlled diabetes, thyroid or renal disease of endom etritis and told of the sym ptom s and signs to
• intervention: e.g. am niocentesis, chorionic villus watch out for. These are: fever, feeling unwell, lower
sam pling. abdom inal pain and a change in vaginal bleeding,
Antiphospholipid antibodies and cervical weakness which can becom e offensive sm elling and suddenly
(‘incom petence’) can result in second trim ester loss heavy.
(see the section ‘Recurrent m iscarriage’, below). Investi- If the wom an is Rhesus negative she needs anti-D
gation of the cause of m iscarriage is usually delayed after an ERPC or m iscarriage after 12 weeks.
until the wom an has had three consecutive m iscar- Unless investigation for recurrent m iscarriage is
riages. This affects 1% of couples (see the section ‘Recur- needed, no follow-up in hospital is necessary. Before
rent m iscarriage’, below). going hom e the wom an should be given a contact
134
Ectopic pregnancy 20
num ber for a local support group that can help her
answer the questions that will arise after the m iscarriage ECTO PIC PREGNANCY
(Fig. 20.5). If she is not going to try to get pregnant again
in the near future, m ethods of contraception should be This is a pregnancy that has im planted outside the uter-
discussed. ine cavity (see Fig. 20.6 for likely sites). The incidence of
ectopic pregnancy is increasing due to the rising num ber
of cases of pelvic inflam m atory disease (PID), asym p-
tom atic chlam ydial infection and as the num ber of
RECURRENT M ISCARRIAGE IVF pregnancies increase. Currently in the UK the inci-
dence is around 1 per 100 term deliveries; 10–15% of
A wom an who has had three or m ore consecutive
ectopics occur after IVF.
first trim ester m iscarriages sh ould h ave th e sam e his-
tory taken and un dergo th e sam e exam in ation as
above. A
Extra investigations should also be considered:
• Karyotyping of both partners and of products of con-
ception where appropriate
• An ultrasound scan (USS) to assess the uterine cavity
and the ovaries. This has been shown to be as useful
and m ore acceptable to patients as hysterosalpingog-
raphy. It is also, unlike the hysterosalpingogram
(HSG), without the risk of infection
• A high vaginal swab (HVS) to screen for bacterial
vaginosis
• Antiphospholipid antibodies assay on two occasions
B
at least 6 weeks apart. The test is perform ed twice to
avoid the false negatives that occur due to fluctua-
tions in antibody levels, and the false positives
caused by a tem porary rise in levels at tim es of viral
illness. If the two results are different, the test is
repeated. The diagnosis is m ade after two positive
results
• Cervical weakness is best diagnosed by careful his-
tory taking, where there will be a story of painless
cervical dilatation or spontaneous rupture of m em -
branes in the second trim ester. Transvaginal scan
of the cervical canal can aid diagnosis, showing an Fig. 20.6 Surgical options for treatment of tubal ectopic
open internal os and short canal. pregnancy.
135
Early pregnancy complications
136
Trophoblastic disease 20
O t h e r sit e s o f e ct o p ic p re gn a n cy De fin it io n s
Th ese h ave h igh rates of m atern al m ortality an d m or- See Figure 20.8.
bidity. Cervical, in terstitial an d in tram ural pregn an -
cies are best treated with m eth otrexate. Th e
h aem orrh age th at can en sue from rupture or from
In cid e n ce o f m o la r p re gn a n cy
attem pted surgical treatm en t can be severe, n ecessitat- In the UK, com plete m ole occurs around 1 per 1000
in g h ysterectom y an d som etim es provin g fatal. Cor- norm al pregnancies. Partial m ole is m ore com m on,
n ual pregn an cy is treated surgically, to rem ove th e but the exact incidence is harder to calculate as m any
rudim en tary h orn in wh ich th e pregn an cy h as go unreported. Three per cent of m olar pregnancies
im plan ted an d th e tube on th e affected side. O varian do not regress spontaneously and therefore require
pregn an cy can be treated surgically, perform in g wedge chem otherapy – this is m ore com m on with com plete
resection of th e ovary, or m edically. Abdom in al preg- m oles than partial m oles.
n an cy, if th e fetus survives, sh ould be delivered as Som e ethnic groups are m ore prone to m olar
soon as th e fetus is viable. pregnancy – it is m ore com m on in the Far East – but the
137
Early pregnancy complications
VESICLES urine sam ples are tested every m onth for b-hCG in case
of reactivation of trophoblast tissue.
If hCG levels return to norm al within 8 weeks,
follow-up is lim ited to 6 m onths. All other cases are fol-
lowed for 2 years. Wom en are advised not to use hor-
m onal contraceptives and not to becom e pregnant
until levels have been norm al for 6 m onths. In future
pregnancies serum b-hCG will be m easured at 6 and
10 weeks postpartum because of the possibility of cho-
riocarcinom a occurring.
If hCG levels rise, plateau or are still abnorm al
6 m onths after surgical evacuation, chem otherapy is
started. Most are given m ethotrexate and folinic acid,
although som e with adverse prognostic factors m ight
need different com binations of other chem otherapies.
The current survival rate of patients requiring chem o-
therapy is 94%. Metastases from choriocarcinom a are
seen in the lung, liver and brain.
138
An t e p a rt u m h a e m o rrh a ge 21
O bjectives
DEFINITIO N HISTO RY
Antepartum haemorrhage (APH) is defined as any bleed- When taking a history, it is im portant to elicit certain
ing from the genital tract that occurs after 24 þ 0 weeks points including:
gestation and before the birth of the infant. • am ount of bleeding
• association with abdom inal pain and/or contrac-
HINTS AND TIPS tions
• association with m ucoid discharge.
Antepartum haemorrhage (APH) is an important cause
The presence or absence of constant abdom inal pain
of increased maternal and perinatal morbidity and
is particularly im portant to differentiate between pla-
mortality. Up to 20% of very preterm infants are born
centa praevia and a placental abruption. With the latter,
in association with APH. there m ay also be uterine contractions as the m yom e-
trium is infiltrated with blood that m akes the uterus
irritable.
INCIDENCE There m ay be an obvious trigger event, for exam ple,
recent sexual intercourse can cause bleeding from a cer-
The incidence of APH is 3–5%. vical ectropion. The date of the patient’s last sm ear test is
relevant to exclude a cervical cause for the bleeding. The
patient should be asked about fetal m ovem ents.
INVESTIGATIO NS
PLACENTA PRAEVIA
Figure 21.2 lists the investigations appropriate for the
patient with an APH. De fin it io n
The placenta is wholly or partially attached to the lower
Blo o d t e st s uterine segm ent. The degree of attachm ent has tradi-
tionally been divided into four grades (Fig. 21.3), but
Blood should be cross-m atched if the bleeding is signif- should now be classified as either m inor – which
icant and ongoing, e.g. m ajor placenta praevia. Blood encom passes grades I and II – or m ajor – covering
group m ust be checked – anti-D im m unoglobulin grades III and IV.
should be given if the patient is rhesus negative, in order
In cid e n ce
Fig. 21.2 Investigations for a patient with an antepartum Placenta praevia occurs in 0.4–0.8% of pregnancies; this
haemorrhage. figure has altered with routine use of ultrasound scan-
• Haemoglobin ning. The incidence is increased with the following risk
• Group and save/ cross-match factors:
• Rhesus status • Previous caesarean section including previous pla-
• Coagulation profile centa praevia
• Kleihauer test • Advanced m aternal age
• Renal function tests
• Multiparity
• Liver function tests
• Multiple pregnancy
• Cardiotocograph
• Ultrasound scan • Presence of a succenturiate placental lobe
• Sm oking.
140
Placenta praevia 21
Exa m in a t io n Co m p lica t io n s
General observations including m aternal pulse and Placenta praevia is associated with an increased risk of
blood pressure m ust be perform ed. On abdom inal pal- postpartum haem orrhage (PPH) (see Chapter 33). The
pation, the uterus is soft and non-tender. The low-lying lower uterine segm ent where the placenta is sited is less
placenta m ay displace the presenting part from the pel- efficient at retraction following delivery of the placenta
vis so that a cephalic presentation is not engaged, or com pared to the upper segm ent. Thus occlusion of the
there is a m alpresentation. venous sinuses is less effective resulting in heavier blood
With a m inor degree of bleeding, a speculum can be loss. This m ay be further com plicated by the presence of
passed to exclude a lower genital tract cause for the APH. placenta accreta. Therefore, preparations should be in
A digital exam ination should be avoided because it m ay place for potential PPH. This includes cross-m atching
provoke m assive bleeding. blood and both consultant obstetrician and anaesthetist
input. The patient should be given adequate counselling
regarding the possible need for m edical and surgical
Dia gn o sis m easures to control bleeding including hysterectom y.
As described above, the placental site is localized as part
of the routine 20-week ultrasound scan. If a low-lying
placenta is noted then a follow-up scan in the third tri-
Fu t u re p re gn a n cy
m ester is usually perform ed to m ake the diagnosis of Placenta praevia has a recurrence rate of 4–8% with an
placenta praevia. increased risk of placenta accreta in each pregnancy.
141
Antepartum haemorrhage
142
Unexplained antepartum haemorrhage 21
A cardiotocograph (CTG) should be done to check of fetal red blood cells. However, this m ay delay delivery
fetal well-being. A sinusoidal pattern can be seen with inappropriately and should only be considered if the
feto-m aternal haem orrhage. The CTG will also m onitor CTG is norm al.
uterine activity, either contractions or a uterus that
m ight sim ply be irritable with irregular activity.
An ultrasound scan is of lim ited value since only a
large retroplacental haem orrhage will be seen. The diag- CIRCUM VALLATE PLACENTA
nosis of abruption is usually m ade on clinical grounds.
This type of placenta develops secondary to outward
M a n a ge m e n t proliferation of the chorionic villi into the decidua,
beneath the ring of attachm ent of the am nion and cho-
As for placenta praevia, m anagem ent of a placental rion. This does not interfere with placental function, but
abruption m ust start with assessm ent of the severity it is associated with antepartum and intrapartum
of the sym ptom s and prom pt resuscitation. Im m ediate haem orrhage.
delivery of the fetus m ay be necessary as a life-saving
procedure for the m other, regardless of gestation.
In a situation where the patient is clinically well and
the fetus is not com prom ised, expectant m anagem ent UNEXPLAINED ANTEPARTUM
m ight allow the sym ptom s to resolve. Again, steroids
should be considered to aid fetal lung m aturity. HAEM O RRHAGE
In up to 50% of cases of APH, no specific cause is found.
Co m p lica t io n s A history should be taken as described above including
Accurate assessm ent of blood loss is necessary to assess date of last sm ear test. The cervix should be visualized
the risks of developing dissem inated intravascular coag- with a speculum exam ination and referral to colpos-
ulation and renal failure. Post-partum haem orrhage copy considered if any abnorm ality is seen.
occurs in 25% of cases, which rarely leads to Sheehan’s However, overall, perin atal m ortality with an y type
syndrom e (pituitary necrosis secondary to hypovolae- of APH is double th at of a n orm al pregn an cy, suggest-
m ic shock – see Chapter 33). in g th at placen tal fun ction m igh t be com prom ised.
Th erefore, with recurren t APH, it is appropriate to
perform serial ultrasoun d scan s to m on itor fetal
Fu t u re p re gn a n cy growth an d to con sider delivery at term , by in ducin g
The risk of recurrence is about 8%. labour.
Fu rt h e r re a d in g
VASA PRAEVIA
Cham berlain, G., Steer, P., 2001. Turnbull’s Obstetrics,
third ed. Churchill Livingstone, Edinburgh.
This is a rare cause of antepartum haem orrhage, 1 in
Enkin, M.W., Keirse, M.J.N.C., Neilson, J., et al., 2000. A Guide
2000–6000 pregnancies. There is a velam entous inser-
to Effective Care in Pregnancy and Childbirth, third ed.
tion of the cord and the vessels lie on the m em branes Oxford University Press, Oxford.
that cover the internal cervical os, in front of the present- RCOG, 2011. Antepartum Haem orrhage. Green-top Guideline
ing part. When the m em branes rupture, either sponta- 63. Royal College of Obstetricians and Gynaecologists,
neously or iatrogenically, the vessels can be torn and London. Available online at: www.rcog.org.uk.
vaginal bleeding occurs. Unlike placenta praevia and RCOG, 2011. Placenta Praevia, Placenta praevia Accrete and
placental abruption, this blood is fetal blood and the Vasa Praevia: Diagnosis and Managem ent. Green-top
fetus m ust be delivered urgently before it exsanguinates. Guideline 27. Royal College of Obstetricians and
If the diagnosis is unclear, a Kleihauer test can be per- Gynaecologists, London. Available online at: www.rcog.
form ed on the vaginal blood loss to test for the presence org.uk.
143
This pa ge inte ntiona lly le ft bla nk
Hyp e rt e n sio n in p re gn a n cy 22
O bjectives
Urine output
146
Treatment 22
147
Hypertension in pregnancy
The aetiology of PET is still not fully understood, but Again, the severity of hypertension will influence
it is felt that failure of the norm al trophoblastic invasion whether or not anti-hypertensives are com m enced:
of m yom etrial spiral arteries leads to a high resistance • Mild PET 140/90 – 149/99 m m Hg does not always
circulation and utero-placental under perfusion. This require anti-hypertensives.
process then results in the release of antiangiogenic fac- • Moderate PET 150/100 – 159/ 109 m m Hg requires
tors into m aternal circulation causing vasoconstriction treatm ent (see Fig. 22.3).
(hence hypertension) and endothelial dam age causing • Severe PET > 160/110 m m Hg requires urgent treat-
proteinuria. m ent and if not responsive to first-line treatm ents
m ay require intravenous anti-hypertensives.
In severe cases where there is a real risk of eclampsia
Treatment (seizures), intravenous magnesium sulphate (MgSO4)
The process of PET can only be ended by delivery of the has been shown to be beneficial as prophylaxis. It is usu-
placenta. Therefore, when treating PET in pregnancy ally used if the mean arterial pressure (MAP; Fig. 22.5)
there is a fine balance between continuing pregnancy
(with an aim to allow m ore tim e for fetal m aturity)
Fig. 22.4 Risk factors for pre-eclampsia.
and risk to the m other.
High risk
• Previous PET
Fig. 22.3 Anti-hypertensives.
• Chronic kidney disease
Labetalol • Diabetes (Type I and Type II)
• Systemic Lupus Erythematosus, Antiphospholipid
α and β-Blocker – regarded as first line treatment. Has syndrome
direct cardiac effects and also lower peripheral vascular
resistance. Should be avoided in asthmatics. Moderate risk
• Primips
Nifedipine • Age > 40 yrs
Calcium channel blocker which causes arterial • BMI > 35 kg/ m 2
vasodilatation. Can cause headaches. • Family Hx of PET
• Twins
Methyldopa
α agonist which prevents vasoconstriction. It has been
used for many years with a good safety profile. Should
be stopped within two days of delivery and changed to Fig. 22.5 Calculation of mean arterial pressure.
another agent due to the risk of postnatal depression.
Mean Arterial Pressure (MAP) can be estimated by using
Hydralazine
the following formula:
Intravenous drug which causes vasodilatation. Can
ð2x Diastolic BPÞ þ Systolic BP
cause rapid hypotension so is often given after a bolus of MAP ¼
colloid. 3
148
Treatment 22
149
This pa ge inte ntiona lly le ft bla nk
M e d ica l d iso rd e rs
in p re gn a n cy 23
O bjectives
152
Epilepsy 23
m acrosom ic babies have an increased risk of shoulder pregnancy will be offered an earlier OGTT (usually
dystocia so senior assistance m ust be available. 16–18 weeks) followed by another at 28 weeks if negative.
Im m ediately following delivery the fetus will be at
risk of hypoglycaem ia as it is no longer in a hyperglycae-
m ic environm ent, although fetal insulin levels will still
Antenatal care
be high. Close m onitoring and early feeds are im por- Risks of gestational diabetes to both the m other and
tant. Also, once the placenta has been delivered, m ater- fetus are sim ilar to pregnancies in patients with pre-
nal requirem ents of insulin will fall and the doses of existing diabetes (Fig. 23.1) with the exception of m is-
insulin should return to pre-pregnancy levels or slightly carriage and congenital anom alies, as this period has
less than pre-pregnancy levels if breast-feeding. passed. Patients should be seen in joint obstetric dia-
betic clinics and advised to self m onitor with regular
pre- and post-prandial capillary blood glucose levels.
Ge st a t io n a l d ia b e t e s They m ay respond to changes in diet (consider referral
Gestational diabetes is described as a condition leading to a dietician) and exercise alone. If these m easures are
to im paired glucose m etabolism first recognized in insufficient, oral hypoglycaem ic agents þ /- insulin m ay
pregnancy. This will, therefore, include those patients be required. They should have serial growth scans to
who had unknown pre-existing diabetes, who will be look for m acrosom ia þ / - polyhydram nios.
found to have a high blood sugar level at booking.
Delivery and postnatal care
Diagnosis The planning of delivery is not always as rigid as in those
with pre-existing diabetes as the risk to the fetus m ay
In the UK, the gold standard for diagnosis is widely
be less. Each case should be assessed individually tak-
accepted as the 75 g oral glucose tolerance test (OGTT).
ing into account any com plications that m ay have
The World Health Organization (WHO) define frank
developed.
diabetes as a fasting glucose level of > 7 m m ol/l or a
Postnatally patients can discontinue their hypogly-
2-hour level of > 11.1 m m ol/l. Gestational diabetes
caem ic agents and should have an OGTT taken at
is defined as a fasting glucose level of > 7 m m ol/l or a
6 weeks. The fetus will still be at risk of hypoglycaem ia
2-hour level > 7.8 m m ol/l (Fig. 23.2).
in the im m ediate period post delivery and, therefore,
early feeds and close m onitoring is advised. Patients
HINTS AND TIPS with GDM should also be advised regarding weight
When undergoing an oral glucose tolerance test loss and m aintenance of a healthy diet with exercise
and told of the high possibility of recurrence in future
(O GTT) the patient is asked to starve the night before
pregnancies.
the test and will then have a venous blood glucose level
measured. Following this they will be asked to drink a
glucose load (75 g) and have a second glucose level
taken 2 hours later. EPILEPSY
Epilepsy affects around 1 in 200 wom en of child bearing
Screening for gestational diabetes is offered to ‘at-risk’ age. Sim ilar to diabetes, the m anagem ent of epilepsy
groups. Risk factors for gestational diabetes are shown should, ideally, begin pre-conceptually with the
in Figure 23.2 and patients with one or more risk factors counselling of patients about the risks to the m other
should be offered an OGTT at around 26–28 weeks. and fetus. It is very im portant that epileptic wom en
Patients who have had gestational diabetes in a previous who are of a child bearing age and wh o do n ot wan t
to con ceive be offered effective contraception.
153
Medical disorders in pregnancy
Fig. 23.3 Fetal and neonatal complications of anti- Hyp o t h yro id ism
epileptic drug use in pregnancy. Hypothyroidism affects around 1% of pregnancies and
O rofacial clefts is m ore com m on in those patients with a fam ily history.
Neural tube defects Sym ptom s in pregnancy are sim ilar to the non-pregnant
Congenital heart disease patient:
Haemorrhagic disease of the newborn.
• Lethargy
• Tiredness
should be carefully counselled against doing so and • Weight gain
warned about the risk of status epilepticus and sudden • Dry skin
unexpected death in epilepsy (SUDEP). • Hair loss.
The aim of treatm ent of epilepsy in pregnancy is to These may be confused with normal pregnancy sym p-
m aintain a seizure free status with m onotherapy at toms (cold intolerance, slow pulse rate and slow relaxing
the lowest possible AED dose. The approxim ate risk tendon reflexes are said to be discriminatory features in
for one AED appears to be around 6%, which is double pregnancy). A goitre may also be present and should
the background rate. In addition, data on sodium be carefully assessed when examining the patient.
valproate appears to show an increased risk of fetal m al- In cases of known hypothyroidism preconceptual
form ations. Figure 23.3 lists the known com plications optim ization of thyroid horm one levels with replace-
of AED use in pregnancy. Therefore, patients should m ent therapy is very im portant as hypothyroidism itself
undergo a detailed ultrasound scan with particular can lead to subfertility. Up until 12 weeks the fetus is
attention to: entirely dependent upon m aternal thyroid horm ones
• cardiac function and, therefore, if left untreated there is an association with
• neural tube status miscarriage, reduced intelligence, neuro-developmental
• skeletal condition delay and brain damage.
• orofacial structures. Most cases of hypothyroidism encountered in preg-
nancy are due to either autoim m une (Hashim oto’s/
The course of epilepsy is variable; from an im prove-
atrophic) thyroiditis or treated Graves’ disease, but it
m ent in seizure frequency to a deterioration. Levels of
can also be due to drugs or following treatm ent for
AEDs can decrease during pregnancy due to increased
hyperthyroidism .
hepatic m etabolism and renal clearance. Seizures m ay,
In patients who are adequately treated, it is usual to
therefore, be difficult to control and dose changes
continue the current dose of thyroxine and check levels
m ay be required. Patients on hepatic enzym e inducing
in each trim ester. Those who require m odifications of
drugs should be given vitam in K 10 m g orally and
their dosing will need m ore frequent thyroid function
the neonate should receive 1 m g of vitam in K IM soon
tests (TFTs). When interpreting TFTs, it is important to
after birth.
use pregnancy adjusted values (Fig. 23.4). The impor-
tance of compliance with m edication to m inim ize the
De live ry a n d p o st n a t a l ca re impact on the fetus should be em phasized to all patients.
There is an increase in the risk of seizures around the
tim e of delivery and the following 24 hours. This risk Hyp e rt h yro id ism
is sufficient enough to recom m end that patients deliver
in hospital. Hyperthyroidism , although less com m on than hypo-
Breast-feeding is generally regarded as safe and thyroidism , still affects around 1 in 800 pregnancies.
should be encouraged. Postnatal education about safety Approxim ately 50% of those suffering with the disease
m easures should be given to all epileptic m others such will have a fam ily history of thyroid disease.
as the avoidance of excessive tiredness, changing the Sym ptom s of hyperthyroidism are the sam e as in the
baby on the floor to prevent falls if a seizure occurs non-pregnant population and again can m im ic norm al
and also bathing the baby with another adult present,
again in case of seizures.
Fig. 23.4 Pregnancy specific thyroid hormone values.
154
Gastrointestinal disorders 23
pregnancy sym ptom s. These include sweating, palpita- progesterone is thought to be key. Given that a fam ily
tions, heat intolerance and vom iting. When exam ining history of the condition is often found (35%) genetic
the patient, look for the following signs: factors are thought to play a role.
• Tachycardia
• Trem or
• Eye signs (exopthalm os) Diagnosis
• Goitre OC is a diagnosis of exclusion, m ade in patients com -
• Palm ar erythem a. plaining of the classical sym ptom s of itchy palm s and
The presence of the first three signs are said to help soles in the absence of a rash, and abnorm al liver func-
distinguish hyperthyroidism from norm al pregnancy tion tests (LFTs). Alanine transam inase (ALT) levels and
sym ptom s. bile acids are usually raised. In som e cases there m ay be
Ninety-five per cent of hyperthyroidism encountered dark stools, pale urine, anorexia and steatorrhoea. All
in pregnancy is due to Graves’ disease, a condition other causes of deranged LFTS should be excluded.
where thyroid receptor antibodies stim ulate thyroid Occasionally patients m ay present with classical sym p-
horm one production. It can also be due to: tom s, but have norm al LFTs. These patients should have
• drugs LFTs repeated every 1–2 weeks.
• m ulti-nodular goitre
• thyroiditis.
Again if untreated patients m ay have difficulty con- Treatment
ceiving so pre-conceptual counselling and optim ization Treatm ent of the condition is usually with chlorphena-
is vital as untreated hyperthyroidism is associated with m ine (Piriton ®), aqueous cream s and ursodeoxycholic
m iscarriage, preterm labour and growth restriction. acid (UCDA) for sym ptom control. UCDAis unlicensed
Patients with hyperthyroidism should have their in pregnancy but no adverse effects have been reported.
TFTs m easured in each trim ester and assessed using It works by altering the bile acid pool balance by reduc-
pregnancy specific values (Fig. 23.4). Anti-thyroid drugs ing the num ber of hydrophobic bile acids which are
such as propylthiouracil (PTU) and carbim azole should thought to be hepatotoxic.
be continued. b-blockers m ay be required to im prove
sym ptom s of sweating, tachycardia and palpitations,
and rarely surgery m ay be required, especially if obstruc-
Antenatal care
tive sym ptom s from the goitre are present.
One per cent of fetuses or neonates can suffer from On ce diagn osed, patien ts n eed to be m on itored with
neonatal thyrotoxicosis due to transplacental passage weekly LFTs un til delivery. Bile acid levels of
of thyroid antibodies. The condition should also be > 40 mmol/l are associated with pregnancy complications:
considered in fetuses or neonates of patients who are • Stillbirth
now hypothyroid as a result of thyroid treatm ent for • Preterm delivery
Graves’disease. Fetuses will exhibit signs of tachycardia, • Passage of m econium
growth restriction and possibly a goitre, whilst neonates • Fetal anoxia.
m ay present with jaundice, failure to gain weight, irrita- Fetal surveillance with cardiotocograph (CTG) m on-
bility or in severe cases heart failure. itoring (although lacking evidence) is often offered to
ease anxiety. Discussion about induction of labour after
37 þ 6 weeks should take place, although this is associ-
ated with an increased rate of caesarean section. Those
GASTRO INTESTINAL DISO RDERS patients with severe derangem ents of their bile acids
and LFTs have a greater indication for intervention. Vita-
O b st e t ric ch o le st a sis m in K supplem entation should be provided for those
with abnorm al clotting.
Obstetric cholestasis (OC) is a condition in pregnancy
which presents with characteristic itching of the palm s
and soles of the feet. Classically there is no rash but
excoriations from excessive scratching m ay be present. Postnatal care
OC affects around 0.5% of pregnancies in the Once delivered it is im portant to ensure LFTs have nor-
UK and is m ore com m on in certain ethnic groups m alized (after at least 10 days). Patients should be
(1.2–1.5% Indian or Pakistani origin and up to 5% in warned of the likelihood of recurrence in a future preg-
Chileans). The cause is not clearly understood but a sus- nancy and advised to avoid oestrogen containing con-
ceptibility to the cholestatic effects of oestrogen and traceptive pills as these m ay trigger cholestasis.
155
Medical disorders in pregnancy
ACUTE FATTY LIVER O F Fig. 23.6 Risk factors for venous thrombo-embolism in
pregnancy.
PREGNANCY
Thrombophilia (Factor V Leiden, Protein C deficiency,
Acute fatty liver of pregnancy (AFLP) is a rare (1 in antiphospholipid syndrome)
20 000) potentially fatal condition, which needs prompt Age > 35
BMI> 30
recognition and management. Although the aetiology is
Parity > 3
poorly understood a disorder of mitochondrial fatty acid Smoker
oxidation may play a role. Risk factors include: Immobility (Surgery, disability)
• prim ips Gross Varicose Veins
• those carrying m ale fetuses Multiple pregnancy
Medical comorbidities
• m ultiple pregnancy. Systemic Infection
The condition m ay be the sam e spectrum as pre-
eclam psia and it m ay be difficult to distinguish from
HELLP syndrom e. It is a reversible condition which • decrease in fibrinolytic activity
affects both the liver and kidneys. • decrease in protein S and antithrom bin (endoge-
Patients may present with nausea, vom iting, anorexia, nous anticoagulants)
malaise, abdom inal pain or polyuria. Jaundice, ascites, • increased venous stasis in lower lim bs (left > right).
encephalopathy and m ild proteinuric hypertension
may also be present. The haematological and biochemi-
cal derangements are shown in Figure 23.5. Risk fa ct o rs
Confirmation of the diagnosis with imaging is not Risk factors for VTE are given in Figure 23.6 and consid-
always possible as changes may not be seen on ultra- eration should be given to prophylactic anticoagulation
sound, CT or MRI. Liver biopsy may be considered, but once a risk assessm ent has been m ade.
in practice is not usually done due to the coagulopathy.
Patients diagnosed with AFLP need m ultidisciplinary
input and urgent delivery. Supportive m easures with Th ro m b o p ro p h yla xis
fluids, correction of hypoglycaem ia and correction of
Given the increased risk of VTE in pregnancy, the Royal
coagulopathy are im portant and patients m ay need
College of Obstetricians and Gynaecologists (RCOG)
intensive care and dialysis. In severe cases, liver trans-
recom m end that all patients undergo a risk assessm ent
plant m ay be necessary.
in early pregnancy to identify those at high risk who
m ight benefit from prophylactic anticoagulation.
Obstetric patients adm itted to hospital should
THRO M BO EM BO LISM undergo a risk assessm ent and be offered prophylactic
LMWH, especially if they are going to be im m obile
Until the last confidential report into m aternal deaths for a period of tim e. Most patients should be offered
(see Chapter 35), venous throm boem bolism (VTE) graduated com pression stockings.
was the leading direct cause of m aternal death. It remains A key point to rem em ber is that the risk of VTE is not
an im portant cause and all clinicians must be alert to the abolished once the fetus is delivered, but rem ains high
signs, sym ptoms, investigations and treatment. until 6 weeks post delivery. Therefore, any prophylactic
The norm al physiological adaptations to pregnancy m easures should continue up until this point. In fact the
m ean that it is a prothrom botic state, increasing the puerperium is regarded as a particularly high-risk
risks of VTE. These include: period. Delivery by caesarean section poses a significant
• increase in certain clotting factors risk of VTE and all patients (except those who have an
• increase in fibrinogen levels uncom plicated elective operation with no risk factors)
are offered 7 days of LMWH.
156
Human immunodeficiency virus 23
oxim etry or low pO 2 on arterial blood gas ABG) need to • sexual intercourse
have a PE ruled out. In all cases a h igh in dex of suspi- • injecting drug use
cion is advised an d wh en suspected, treatm en t m ust • blood transfusion
be in itiated un til th e diagn osis is ruled out. • m other to fetus or neonate vertically during preg-
nancy or breast-feeding.
In ve st iga t io n s Infection with the virus leads to im m unosupression
Investigation of a DVT usually starts with a clinical and individuals becom e susceptible to infections and
exam ination followed by venous Dopplers. It is im por- certain m alignancies. However, advances in m odern
tant to bear in m ind that the throm bosis m ay be located m edicine and the production of anti-retroviral drugs
higher than the calf (propensity for ileofem oral DVT in (Highly Active Anti-Retroviral Treatm ent HAART) have
pregnancy com pared with popliteofem oral) and, there- led to a significant decline in the m orbidity and m ortal-
fore, im aging should include this area. ity from the illness.
PE in vestigation s usually begin again with a th or-
ough exam in ation followed by an ECG, ABG, FBC, Scre e n in g
ch est X-ray (CXR). On th e ABG th e patien t m ay be
In the UK all wom en are advised to have screening for
h ypoxic an d h ypercapn ic, th e ECG m ay reveal a sin us
HIV infection as part of their booking investigations.
tach ycardia an d th e CXR is im portan t to rule out oth er
Identification of HIV infected individuals then allows
poten tial causes of th e sym ptom s, such as in fection or
appropriate care to im prove m aternal health and reduce
pn eum oth orax.
the risk of transm ission to the fetus from approxim ately
If the CXR is norm al, the patient may proceed to
25% to less than 1%.
a ventilation/perfusion scan. This may identify an
Additional interventions for HIV positive wom en
area of under-perfusion indicating a PE. If the CXR is
include screening for hepatitis C, offering vaccinations
abnormal, a com puted tomographic pulmonary angio-
against hepatitis B and screening for genital infection
gram (CTPA) m ay be indicated. This is very sensitive at
in the 1st trim ester and at 28 weeks.
diagnosing a PE but involves high doses of radiation.
Testing for the patient’s partner and any other
children should be offered.
Tre a t m e n t
With a confirmed DVT or PE, patients require anticoagu-
HINTS AND TIPS
lation with therapeutic doses of low-m olecular-weight
heparin (LMWH). Warfarin is generally avoided as it A major barrier to compliance with testing and
crosses the placenta and is known to be teratogenic, as treatment is the fear of stigmatization and patients
well as carrying the risk of fetal intracranial bleeding. In should be reassured regarding confidentiality.
the puerperium patients can be converted to warfarin
even if they are breast-feeding as it is regarded as safe.
An t e n a t a l ca re
CEREBRAL VEIN THRO M BO SIS Care for patients with HIV should be given by a multidis-
ciplinary team composed of HIV specialists, obstetricians,
A cerebral vein throm bosis is an uncom m on yet fatal specialist midwives and paediatricians. The use of HAART
problem encountered by obstetricians. It is m ore com - has been shown to dramatically reduce the risk of vertical
m on in the puerperium and presents with headaches, transmission; therefore, if a patient falls pregnant whilst
seizures, vom iting, photophobia, reduced conscious- taking HAART, she should continue to do so. Patients
ness or even focal neurology. It is usually diagnosed who are not on HAART but require it (following assess-
with a m agnetic resonance im aging (MRI) venous ment) should commence treatment as soon as possible.
angiogram and treatm ent is usually with hydration Patients who are not on HAART (i.e. that do not require
and anticoagulation. treatment after assessment) should commence HAART
regardless from 20 weeks onwards until delivery.
157
Medical disorders in pregnancy
De live ry a n d p o st n a t a l ca re Fig. 23.7 Risk factors for depression during and after
The m ode of delivery is usually confirm ed at 36 weeks pregnancy.
of gestation. Patients will have their viral load m easured • History of postnatal depression
and if < 50 copies/m l will be offered a vaginal delivery. • History of depression unrelated to pregnancy
When the patient is in labour, however, to reduce the • IVF pregnancy
risk of transm ission, one should avoid perform ing inva- • History of abuse
sive procedures such as fetal blood sam pling or attach- • Multiple pregnancy
ing a fetal scalp electrode. • Drug misuse
Patients who have a high viral load will be offered a • Poor social support
• Low socioeconomic status
planned caesarean section with zidovudine cover (an
• Low educational achievement
antiretroviral 4 hours prior and continued until cord • Poor pregnancy outcome, e.g. illness in pregnancy,
clam ping). premature or difficult delivery, neonatal illness or death,
In resource rich countries the avoidance of breast- diagnosis of congenital anomaly antenatally or
feeding is recom m ended (to prevent transm ission) neonatally
and form ula m ilk used as an alternative. It is, however,
not always possible in developing countries.
Once delivered all neonates are treated with anti-
retrovirals as soon as possible (ideally within 4 hours).
The neonate will be tested at regular intervals and, if not Patients with a history of depression outside or dur-
breast-fed, a negative test at 18 m onths ensures the child ing pregnancy are at risk of postnatal depression (PND).
is not affected. PND can present as m ore m ild ‘baby blues’, which are
usually short lasting (24–72 hours) and begin around
the fifth day after delivery. Tearfulness, labile m ood
HINTS AND TIPS and irritability are possible sym ptom s. In m ore severe
Three steps known to reduce rates of vertical cases, especially with signs of neglect and suicidal idea-
transmission of HIV: tion, prom pt specialist intervention is im portant.
• Avoidance of breast-feeding
• Anti-retroviral medication (HAART) Pu e rp e ra l p sych o sis
• Elective caesarean section.
Puerperal psychosis is a serious disorder which affects
around 1 in 500 births. It usually starts abruptly around
2 weeks postnatally and presents with m ania, delusions
and hallucinations (both auditory and visual). Patients
PSYCHIATRIC ILLNESS appear agitated and m ay exhibit disinhibited behaviour.
Puerperal psychosis is m ore com m on in patients
Identifying psychiatric illnesses in pregnancy is a vital who have a previous psychiatric history. Treatm ent
part of assessing risk. Early specialist referral and m ulti- invariably involves adm ission to hospital for both the
disciplinary m anagem ent are very im portant. safety of the m other and baby, ideally to a specialist
m other and baby unit to prevent separation. Antipsy-
chotic m edications such as haloperidol m ay be
required. Organic causes of the sym ptom s (infection,
De p re ssio n drug withdrawals, etc.) m ust be excluded.
Sym ptom s of depression are thought to affect around 1
in 3 wom en at som e stage in their pregnancy and it can
be associated with suicide. Sym ptom s of low m ood,
Sch izo p h re n ia
anxiety, loss of appetite, insom nia, low self-esteem , lack Schizophrenia affects around 1 in 100 wom en of child-
of energy, failure to find enjoym ent and suicidal idea- bearing age and again needs specialist m anagem ent in
tion should be actively enquired about. pregnancy. As well as caring for the m other’s health,
Risk factors for depression are shown in Figure 23.7. an assessm ent m ust be conducted to identify any poten-
Any patient with a history of depression or who is cur- tial difficulties the patient m ay have in caring for the
rently suffering with depression should be referred for child and what risks an acute episode m ay pose.
specialist counselling, usually in the form of a perinatal Hallucinations, delusions or an abnorm al affect m ay
m ental health team . Both pharm acological and non- be encountered and should prom pt specialist help.
pharm acological (cognitive behavioural therapy CBT) Antipsychotic m edications m ay be indicated during
treatm ents m ay be required. the pregnancy, although the evidence regarding their
158
Substance abuse 23
safety is not clear. In practice the lowest dose is used Alcohol abuse is known to cause fetal anom alies and
with a reduction in the dose towards term to prevent fetal alcohol syndrom e. Safe am ounts of alcohol intake
toxicity in the neonate. Breast-feeding on antipsychotics are the subject of m uch continuing debate and m ost
is not advised. people would recom m end no alcohol at all, especially
in the first trim ester. Patients who wish to continue
Bip o la r d iso rd e r drinking alcohol should not exceed 1–2 units once or
twice a week and binge drinking should be strongly
Bipolar disorder (BD) is a condition characterized by discouraged.
episodes of acute illness m ixed with periods of relative
norm ality. Many of the drugs used to treat BD are tera-
togenic and, therefore, careful assessm ent m ust be m ade
to balance the risk of harm from a relapse in pregnancy Fu rt h e r re a d in g
against the risk of dam age to the fetus. Lithium use is Anaem ia, n.d. Collins English Dictionary - Com plete &
associated with cardiac defects. Again, m anagem ent Unabridged, 10th ed.
by specialist perinatal m ental health team s is advised De Swiet, M., 2002. Medical Disorders in Obstetric Practice,
and particular attention needs to be paid to the puerpe- fourth ed. Blackwell Publishing, London.
rium when acute episodes are com m on. Dhanjal, M., 2011. Thyroid and parathyroid disease in Oxford
Desk Reference Obstetrics & Gynaecology. Oxford
University Press, Oxford.
Murphy, V., Namazy, J., Powell, H., et al., 2011. A m eta-analysis
SUBSTANCE ABUSE of adverse perinatal outcom es in wom en with asth m a.
BJOG. 118, 1314–1323. h ttp:/ / dx.doi.org/ 10.1111/
Substance abuse in pregnancy poses a risk to the health j.1471-0528.2011.03055.x.
of the m other and the fetus. This risk is both direct, i.e. Myles, J., 2011. Substance Abuse in Pregnancy in Oxford Desk
from the abused substance itself and indirect, i.e. from Reference Obstetrics & Gynaecology. Oxford University
risk allied to drug use like the transm ission of infection Press, Oxford.
from injecting drug use. Nelson-Piercy, C., 2010. Handbook of Obstetric Medicine,
Booking assessm ents should be used as an opportu- fourth ed. Informa Healthcare, New York.
nity to screen for substance abuse. Early cessation will NICE, 2008. Guidelines – Antenatal Care. National Institute for
help to m inim ize risk and enable im plem entation of Health and Care Excellence, London.
other care such as screening for infection. This particular NICE, 2008. Guidelines - CG63 Diabetes in Pregnancy: Full
group m ay represent a challenge as their attendance for Guideline. National Institute for Health and Care, London.
antenatal care m ay be poor. RCOG, 2007. The Acute Managem ent of Throm bosis and
Cocaine abuse is associated with growth restriction, Em bolism During Pregnancy and the Puerperium , Green-
top Guideline No. 37b. Royal College of Obstetricians and
placental abruption, stillbirth and neonatal death. Opi-
Gynaecologists, London.
ates are associated with growth restriction, preterm
RCOG, 2009. Reducing the Risk of Throm bosis and
labour and neonate dependence. Again, referral to drug
Em bolism during Pregnancy and the Puerperium , Green-top
and alcohol treatm ent services is im portant. Guideline No. 37a. Royal College of Obstetricians and
Referral to drug and alcohol treatm ent services is Gynaecologists, London.
im portant and patients should be offered a detoxifica- RCOG, 2010. Managem ent of HIV in Pregnancy, Green-top
tion program where appropriate. Guideline No. 39. Royal College of Obstetricians and
Sm oking cessation advice should be offered at every Gynaecologists, London.
visit and when accepted, appropriate referral m ade. RCOG, 2011. Obstetric Cholestasis, Green-top Guideline No. 43.
Sm oking is associated with growth restriction, placental Royal College of Obstetricians and Gynaecologists, London.
abruption, cot death and childhood asthm a, and, there- William son, C., 2011. Obstetric Cholestasis in Oxford Desk
fore, educating patients about the risks posed by both Reference Obstetrics & Gynaecology. Oxford University
active and passive sm oking is very im portant. Press, Oxford.
159
This pa ge inte ntiona lly le ft bla nk
M u lt ip le p re gn a n cy 24
O bjectives
chorionicity determ ines the level of surveillance neces- diam niotic placentation. About two-thirds of m onozy-
sary in that particular pregnancy. gotic twins have m onochorionic diam niotic placenta-
tion: that is a single blastocyst im plants, developing a
single chorion; the inner cell m ass divides into two so
Dizygotic twins that each em bryo has its own am nion.
Two ova from the same or different ovaries are released The least comm on type of m onozygotic twins occurs
simultaneously and fertilized by two separate sperm. Each by later splitting of the inner cell mass, before the appear-
fetus has its own chorion, amnion and placenta — ance of the prim itive streak, to produce a single amniotic
dichorionic diamniotic placentation. The placentae can cavity — m onochorionic monoamniotic twins. Splitting
appear fused if implantation occurs close together. These even later than this results in conjoint twins.
twins can be of the sam e or different sexes and will have The incidence of m onozygotic twins is constant
different genetic constitutions, i.e. they have no more sim - around the world, at about 4 per 1000 births.
ilarities than any siblings.
The incidence of dizygotic twins varies widely
between different populations, probably for m ultifacto-
Trip le t s
rial reasons such as genetic and nutritional factors. It
also increases with increasing m aternal age and increas- Pregnancies of higher-order m ultiples (i.e. three or
ing parity. m ore fetuses) are less com m only form ed by separate
ova. In the case of a triplet pregnancy, there are usually
two ova, one of which splits as described above to form
Monozygotic twins a m onochorionic pair of twins.
A single ovum is fertilized by a single sperm and the With triplets or m ore, it is appropriate to counsel
zygote divides into two. This may occur at different stages the parents about selective fetal reduction (see below).
of embryonic development, giving rise to different struc- The chorionicity of the pregnancy m ust be known
tural arrangements of the m em branes (Fig. 24.1). in order to select the appropriate fetus. The procedure
A third of m onozygotic twins establish at the eight- cannot be perform ed on a m onochorionic twin because
cell stage, so that two separate blastocysts form and it shares placental circulation with its co-twin and,
im plant. These twins will thus have dichorionic therefore, the drugs would affect both fetuses.
Dizygotic Monzygotic
Early
split <d.3
d.3–8 d.8–13
Late Later
split split
A B C D
162
Complications 24
Fig. 24.2 Diagnosis of chorionicity. (A) The T sign is indicative of monochorionic diamniotic pregnancy. (B) The lambda sign
is indicative of dichorionic diamniotic pregnancy.
163
Multiple pregnancy
the fetuses and the developm ent of twin-to-twin trans- reaches a gestation with improved likelihood of survival.
fusion syndrom e (see below). Eighty per cent of surviving twins can be delivered
vaginally.
Pre t e rm la b o u r
HINTS AND TIPS
Spontaneous preterm labour occurs in 30% of twin
pregnancies. There is som e evidence to suggest that cer- The psychological sequelae of a multiple pregnancy
vical length screening by transvaginal ultrasound m ay on the mother and her family, including existing
be a useful screening tool. In higher-order m ultiple children, should be remembered.
pregnancies, som e physicians opt to put in an elective
cervical suture at the start of the second trim ester, to
reduce the risk of preterm labour.
If pre-term labour is diagnosed, tocolytics should be
considered to allow in utero transfer to a hospital with INTRAPARTUM M ANAGEM ENT
neonatal intensive care facilities and to allow tim e for O F A TW IN PREGNANCY
steroids adm inistered to the m other to im prove lung
m aturation (see Chapter 29). Figure 24.3 sum m arizes the m anagem ent of a vaginal
delivery in a twin pregnancy.
Pre gn a n cy-in d u ce d h yp e rt e n sio n
Hypertension is about three tim es m ore com m on in Delivery of twin pregnancy
m ultiple pregnancies than in singleton pregnancies Delivery of m ultiple pregnancies should be m anaged in
because of the larger size of the placental bed (see a unit with neonatal intensive care facilities. For a twin
Chapter 22). It often develops earlier and is m ore severe. pregnancy, the m ode of delivery depends on the presen-
National guidelines recom m end consideration for aspi- tation of the first twin; twin one is cephalic in m ore than
rin 75 m g daily to reduce the risk. 80% of pregnancies. If presentation of twin one is any-
thing other than cephalic, caesarean section is usually
An t e p a rt u m h a e m o rrh a ge the m ode of choice. In the case of higher-order m ultiple
pregnancies, delivery is alm ost always by caesarean
The incidence of placental abruption and placenta prae- section.
via is increased in m ultiple pregnancies. For a vagin al delivery, th e on set of labour can be
spon tan eous or in duced; in duction m igh t be advised
Tw in -t o -t w in t ra n sfu sio n for sim ilar reason s to a sin gleton pregn an cy (e.g. post
syn d ro m e dates) or for an in dication m ore specific to a twin
pregn an cy, such as IUGR. Th e wom an n eeds in trave-
This occurs in 15% of m onochorionic diam niotic twin n ous access an d a sam ple of serum saved in th e blood
pregnancies — blood is shunted across placental inter- tran sfusion laboratory because of th e risk of post-
fetal vascular anastom oses, such that the donor partum h aem orrh age (see below). An epidural block
becom es anaem ic and growth restricted, with oligohy- is often recom m en ded to allow for possible m an ipu-
dram nios, and the recipient becom es fluid overloaded lation of th e secon d twin in th e secon d stage of
with polyhydram nios. This syndrom e usually occurs labour.
in the second trim ester. It results in fetal death in up
to 80% of cases if left untreated and a 10% risk of hand-
icap in the surviving twin. Depending on the stage of the Fig. 24.3 The intrapartum management of twin
disease at diagnosis, up to 26 weeks, laser treatm ent to pregnancy.
the placental anastom oses is generally the advised treat- • Neonatal unit intensive care facilities
m ent in order to reduce discordant blood flow between • Allow vaginal delivery if normal pregnancy and twin 1
the fetuses (known as FLAP fetoscopic laser ablation of cephalic presentation
the placenta). Am niodrainage m ay be appropriate at • IV access/ full blood count/ group and save
later gestations. • Regional anaesthesia
With m onochorionic placentation, fetal death of a • Continuous CTG monitoring ± fetal scalp electrode to
twin in utero puts the surviving twin at risk of neurolog- twin 1
ical damage and the mother at risk of developing • IV syntocinon infusion to start after delivery of twin 1 to
maintain contractions
disseminated intravascular coagulation (DIC) as throm-
• IV syntocinon infusion for third stage to reduce risk of
boplastins are released into the circulation. The pregnancy PPH
can be managed conservatively until the surviving twin
164
Higher-order multiple pregnancies 24
165
This pa ge inte ntiona lly le ft bla nk
Ab d o m in a l p a in in t h e se co n d
a n d t h ird t rim e st e rs
o f p re gn a n cy 25
O bjectives
Blo o d t e st s
Ab d o m in a l p a lp a t io n Full blood count/ clotting studies
The abdom en should be inspected for any previous The full blood count can show a reduced haem oglobin
operation scars. In the presence of a gravid uterus, if the patient is bleeding, for exam ple in the case of a pla-
abdom inal palpation to establish the cause of the sym p- cental abruption. The platelet count is usually low in
tom s m ay not be straightforward. Com pared with association with pre-eclam psia or HELLP syndrom e
exam ining a non-pregnant patient, the site of the ten- (haem olysis, elevated liver enzym es, low platelets). This
derness m ight not be typical. For exam ple, exam ining m ay be associated with abnorm al clotting studies. A
a non-pregnant patient who has an ovarian cyst torsion group and save sam ple of serum is essential if there is
is likely to elicit tenderness and guarding in the iliac ongoing bleeding, in case cross-m atched blood is
fossa. Depending on the gestation, this m ight not be required for transfusion. With the non-obstetric causes
so specific in a pregnant patient because the gravid of pain, the white blood cell count and C-reactive pro-
uterus interferes with the usual anatom ical m arkings. tein will be raised if there is infection, for exam ple, with
Sim ilarly, tenderness at McBurney’s point, which is pyelonephritis or cholecystitis.
typical of appendicitis (see Crash Course in Surgery)
m ay be difficult to elicit in a patient who is late in the
second or in the third trim ester of pregnancy for a
Urea/ electrolytes/ glucose/ liver
sim ilar reason. function tests
In pre-eclam psia or HELLP syndrom e, urea, creatinine
and the liver transam inases can be raised. Serum uric
HINTS AND TIPS acid is also high in pre-eclam psia and in acute fatty liver.
The latter is associated with hypoglycaem ia.
When examining an obstetric patient, remember that
she might feel faint if she lies flat on her back for too
long, secondary to pressure on the large vessels
Urin a lysis/ m id st re a m u rin e
reducing venous return to the heart and causing supine sa m p le
hypotension. She should be examined with left In pre-eclam psia, there is proteinuria on dipstick urinal-
lateral tilt. ysis. A single sam ple protein/creatinine ratio or 24-h
urine collection will quantify the am ount of protein
168
Investigation 25
Labour (see Chapter 28) Intermittent pain, usually regular in frequency, associated with uterine
tightenings. The presenting part of the fetus is usually engaged.
Vaginal examination shows cervical change.
Placental abruption (see Chapter 21) Mild or severe pain, more commonly associated with vaginal bleeding.The uterus
is usually tender on palpation and can be irritable or tense. There might be
symptoms and signs of pre-eclampsia.
Symphysis pubis dysfunction Pain is usually low and central in the abdomen just above the symphysis pubis,
which is tender on palpation. Symptoms are worse with movement.
Ligament pain Commonly described as sharp pain, which is bilateral and often associated
with movement.
Pre-eclampsia/ HELLP syndrome Epigastric or right upper quadrant pain, associated with nausea and vomiting,
(see Chapter 22) headache and visual disturbances. O n examination, there is hypertension
and proteinuria.
Acute fatty liver of pregnancy Epigastric or right upper quadrant pain, associated with nausea, vomiting,
anorexia and malaise.
O varian cyst (see Chapter 9) Unilateral pain, which is intermittent and might be associated with vomiting.
Uterine fibroid (see Chapter 7) Pain is localized and constant. Fibroid may be noted on palpation and is tender.
Constipation Usually suggested by the history, can cause lower abdominal discomfort
and bloating.
Appendicitis Pain associated with nausea and vomiting. Tenderness with guarding and
rebound might be localized to the right iliac fossa depending on gestation.
Gallstones/ cholecystitis Right upper quadrant or epigastric pain, which might radiate to the back or to
the shoulder tip. Tenderness in the right hypochondrium, pyrexia present with
cholecystitis.
Pancreatitis Epigastric pain radiating to the back, associated with nausea and vomiting.
O ccurs more commonly in the third trimester.
Peptic ulcer Epigastric pain associated with food. There might be heartburn, nausea and
even haematemesis.
Cystitis Usually suggested by history of dysuria , with pain and tenderness in the low
abdomen or suprapubically.
Renal stones/ renal colic/ Loin pain that might radiate to the abdomen and groin, possibly associated
pyelonephritis with vomiting and rigors. Pyrexia is present with pyelonephritis.
in order to determ ine the severity of the disease. Protein- Ult ra so u n d sca n (u t e ru s/ o va rie s/
uria m ay also be present with a urinary tract infection
and m ay be associated with m icroscopic haem aturia,
kid n e ys/ live r/ ga llb la d d e r)
particularly in the presence of renal stones. Although generally a clinical diagnosis, an ultrasound
scan m ay show a retroplacental haem atom a in the case
of severe placental abruption. If preterm delivery is nec-
Ca rd io t o co gra p h essary, for exam ple in acute fatty liver, fetal well-being
Before 26 weeks gestation, the fetal heart should be aus- and growth should be assessed, and the fetal weight esti-
cultated with a pinard or a sonicaid. A cardiotocograph m ated to inform the paediatricians.
is perform ed after 26 weeks’ gestation (see Chapter 31) For the other system s, ultrasound exam ination can
and will help determ ine fetal well-being, particularly assist diagnosis and m anagem ent. An ovarian cyst
in the case of placental abruption. The recording will m ight be seen if haem orrhage, rupture or torsion of
also detect uterine activity including the presence and the cyst is suspected. Renal stones or gallstones can be
frequency of uterine contractions. visualized.
169
Abdominal pain in the second and third trimesters of pregnancy
170
La rge o r sm a ll fo r d a t e s
in p re gn a n cy 26
O bjectives
Yes No
Yes No
Yes No
Constitutional Increased
Fetal abnormality
Gestational
diabetes
Intrauterine infection
172
Investigation 26
No Yes
Hypertension in pregnancy
No Yes
173
Large or small for dates in pregnancy
174
St illb irt h 27
O bjectives
• Trisom y screening – trisom y screening is usually death can lead to m aternal sepsis and/ or coagulopathy.
offered to patients in the first trim ester, the results Exam ination should include:
should be checked. In patients found to be high risk, • m aternal pulse
a chrom osom al abnorm ality m ay be the cause. • blood pressure
• Ultrasound – the anom aly ultrasound scan and any • respiratory rate
subsequent growth scans should be reviewed as • tem perature
any abnorm ality, either structural or growth related, • looking for rashes (m ay indicate m aternal infection)
m ay indicate a potential cause. • or excoriations (m ay indicate obstetric cholestasis)
• Antepartum haemorrhage – recurrent bleeds or,
The uterus should also be palpated to assess its size,
indeed, a large bleed may indicate a placental abruption
tone and contour. A uterus which is larger than one
or vasa praevia (a situation where unprotected placental
would expect for the gestation m ay indicate polyhy-
vessels course through the membranes and if ruptured
dram nios, which can be secondary to m aternal diabetes.
can lead to rapid loss of fetal blood and fetal death.
A uterus which is sm aller than expected m ay indicate
• Ruptured m em branes – any history of vaginal
IUGR. A tender firm uterus m ay indicate a placental
fluid loss m ay indicate a breach in the fetal m em -
abruption whereas a tender but soft uterus m ay indicate
branes exposing the fetus to ascending infection
chorioam nionitis.
(chorioam nionitis).
• Itching – itching m ainly affecting the palm s and
soles m ay indicate obstetric cholestasis, which is
associated with an increased risk of stillbirth.
INVESTIGATIO NS
• Signs of m aternal illness – fever, rash or vom iting
m ay indicate an intercurrent illness as the cause of
Investigations in the setting of an intrauterine death are
the fetal dem ise. Listeria, toxoplasm osis and parvo-
aim ed at:
virus are all possible infections with can lead to
intrauterine death. 1. assessing the current state of m aternal well-being
2. identifying a potential cause of the stillbirth
3. possibly identifying any prognostic factors for future
EXAM INATIO N pregnancy.
It is im portant that parents are told that in around
A thorough general exam ination is im portant to iden- 50% of all cases, no cause will be found. However,
tify any potential signs of m aternal illness. Even in the investigation is still essential – if a cause is found, this
absence of a preceding m aternal illness, an intrauterine m ay be vital in preventing recurrence.
176
After delivery 27
177
Stillbirth
Fu rt h e r re a d in g Schott, J., Henley, A., Kohner, N., 2007. Pregnancy Loss and
the Death of a Baby: Guidelines for Professionals, third ed.
RCOG, 2010. Late Intrauterine Fetal Death and Stillbirth. Stillbirth and Neonatal Death Charity, London.
Green-top Guideline No. 55. Royal College of Obstetricians
and Gynaecologists, London.
178
La b o u r 28
O bjectives
190 190
180 180
170 170
fetal 160
heart 160
rate 150 150
140 140
130 130
120 120
110 110
100 100
90 90
80 80
liquor
10 10
9 9
8 8
7 7
cervix
dilatation 6 6
5 5
4 4
descent 3 3
of pp
2 2
1 1
0 0
5
contractions 4
per 10 min 3
2
1
syntocinon
units
drugs
and
IV fluids
200 200
190 190
180 180
170 170
160 160
blood 150 150
pressure 140 140
and
pulse 130 130
120 120
110 110
100 100
90 90
80 80
70 70
60 60
urine
protein
ketones
glucose
volume
temperature
comments
180
Normal progress in labour 28
Sacrum
Sacroiliac
joint
Transverse
diameter Iliopectineal
line
Antereoposterior Pubic bone
diameter
Pubic crest
Pubic
symphysis
Outlet (from below) Anterior
Pubic arch
Ischial
tuberosity
Transverse
diameter
Sacrotuberous
ligament with ischial
Antereoposterior spine above
diameter
Coccyx
Sacrococcygeal
joint
Posterior
fetus is pushed out of the uterus it passes into the vagina, Pa sse n ge r
which has become hypertrophied during pregnancy. It
reaches the pelvic floor, which acts like a gutter to direct The fetal skull consists of the face and the cranium. The
it forwards and allow rotation. The perineum is distal to cranium is made up of two parietal bones, two frontal
this and stretches as the head passes below the pubic arch bones and the occipital bone (see Fig. 3.13), held together
and delivers. by a m embrane that allows movement. Up until early
childhood, these bones are not fused and so can overlap
to allow the head to pass through the pelvis during labour;
this overlapping of the bones is known as m oulding.
Figure 28.3 shows the anatom y of the fetal skull,
including the sutures between the bones, and the spaces
known as fontanelles. These are im portant landm arks
that can be felt on vaginal exam ination in established
labour and enable the position of the fetus to be
assessed (see Fig. 3.14). The position is described in
term s of the occiput in a cephalic presentation, and
the sacrum in a breech presentation.
The degree of flexion and the position of the fetal skull
determine the ease with which the fetus passes through the
birth canal. Figure 28.4 shows the diameters of the fetal
skull. The diameter that presents during labour depends
on the degree of flexion of the head. The head usually
becomes more flexed with the increasing strength of the
Fig. 28.3 The fetal skull showing the landmarks. uterine contractions. Thus the smallest diameters for
181
Labour
182
Delivery of the fetus 28
A
Fig. 28.6 The second stage of labour. The head has
undergone internal rotation to bring the occiput into the
anterior position. The cervix is fully dilated.
Fig. 28.7 Delivery of the head. Extension of the fetal neck Fig. 28.8 External rotation (restitution). The head distends the
occurs as the head passes under the pubic symphysis to deliver perineum as it delivers in the occipitoanterior position and the
the head. external rotation occurs to allow delivery of the shoulders.
183
Labour
M a t e rn a l m o n it o rin g
As well as regular observations, the patient is encour-
aged to m obilize if possible and is allowed to
eat, depending on her risk of needing an operative
procedure. There is delayed gastric em ptying during
pregnancy and labour. Therefore, if an em ergency gen-
eral anaesthetic is needed, there is an increased risk
of inhalation of regurgitated acidic stom ach contents,
causing Mendelson’s syndrom e.
The need for analgesia during labour varies m arkedly
between different wom en, different ethnic groups and
depending on their antenatal preparation. Non-
pharm acological techniques include the use of psycho-
prophylaxis, hypnosis, m assage and transcutaneous
electrical nerve stim ulation (TENS). The pharm acologi-
Fig. 28.9 Delivery of the shoulders. The anterior shoulder
passes below the pubic symphysis, aided by downward traction cal m ethods are sum m arized in Figure 28.10.
of the head by the midwife or doctor. The posterior shoulder
delivers as the head is gently lifted upwards. Fe t a l m o n it o rin g
Interm ittent or continuous fetal m onitoring is appropri-
ate, depending on the clinical picture antenatally and in
labour. For exam ple, in the presence of IUGR or if there
M ANAGEM ENT O F THE FIRST is m econium -stained liquor, then continuous fetal
STAGE O F LABO UR m onitoring is advisable (see Chapter 31). In a low-risk
pregnancy, interm ittent m onitoring with a sonicaid or
When a patient presents in the first stage of labour, rou- with a Pinard stethoscope is sufficient, every 15 m in
tine assessm ent includes the m other and fetus. Regular during and after a contraction for 60 seconds in the
exam ination of the m other should include: 1st stage of labour, and every 5 m in in the 2nd stage.
• pulse, blood pressure, respiratory rate, tem perature In som e patients, abdom inal m onitoring can be dif-
• urinalysis ficult, for exam ple, if the patient is obese, and so a fetal
• analgesia requirem ents scalp electrode can be applied directly to the head once
• abdom inal palpation: sym physis-fundal height, lie, the cervix dilates and the m em branes are ruptured. If
presentation, engagem ent m onitoring suggests that the fetal heart rate pattern is
• contractions: strength, frequency, duration pathological, it m ay be appropriate to m easure the fetal
• vagin al exam in ation : degree of cervical effacem en t, pH by taking a blood sam ple from the fetal scalp (see
cervical dilatation , station of presen tin g part Chapter 31).
in relation to isch ial spin es, position of presen t-
in g part, presen ce of caput or m ouldin g (see
Ch apter 30). M ANAGEM ENT O F THE SECO ND
Th e fetus m ust be assessed by fetal h eart rate pat- STAGE O F LABO UR
tern , eith er by in term itten t auscultation or electron i-
cally depen din g on risk factors (see Ch apter 31). If Once the cervix is fully dilated, the patient is encouraged
th e m em bran es are ruptured, th en th e liquor m ust to use voluntary effort to push with the contractions. If
be docum en ted as clear, blood-stain ed or h avin g she has an epidural anaesthetic in situ she m ight be less
m econ ium presen t. aware of an urge to push, and so a further hour can be
allowed for the presenting part to descend with the con-
tractions alone. Without an epidural, the m other m ay
HINTS AND TIPS adopt various positions for delivery of the fetus. As
the head descends, the perineum distends and the anus
Descent of the presenting part is assessed by both
dilates. Finally, the head crowns: the biparietal diam eter
abdominal palpation (amount of head felt above
has passed through the pelvis and there is no recession
the pelvic brim expressed in fifths ¼ engagement) between contractions. The attendant can apply pressure
and vaginal examination (descent in relation to level on the perineum for support during delivery of the
of ischial spines ¼ station). head. Once delivered, the neck is felt to exclude the pres-
ence of the cord.
184
Management of the third stage of labour 28
O xygen/ Inhalation of 50:50 First stage < 50% Time of Does not relieve pain
nitrous mixture with onset Takes 20–30 s inhalation
oxide of contraction for peak effect only
Pethidine Intramuscular First stage <50% Approximately Nausea and vomiting –
injection Takes 3h give with an antiemetic
100–150 mg 15–20 min Respiratory depression
for peak effect in the neonate (this is
easily reversed with
intramuscular naloxone)
Pudendal Infiltration of right Second stage for Within 5 min 45–90 min —
block and left pudendal operative delivery
nerves (S2, S3 and
S4) with 0.5%
lidocaine
Perineal Infiltration of Second stage Within 5 min 45–90 min —
infiltration perineum prior to episiotomy
with 0.5% lidocaine Third stage for
at posterior suturing of perineal
fourchette lacerations
Epidural Injection of 0.25% First or second Complete pain Bolus injection Transient hypotension –
anaesthesia or 0.5% bupivicaine stage relief in every 3–4 h or give intravenous fluid
via a catheter into Caesarean approximately continuous load
the epidural space section 95% of infusion Dural tap
(L3–4) women Risk of haemorrhage if
within 20-30 mins abnormal maternal
clotting
Increased length of
second stage because of
reduced pelvic floor tone
and loss of bearing-down
reflex
Spinal Injection of 0.5% Any operative Immediate Single Respiratory depression
anaesthesia bupivicaine into the delivery; manual effect injection
subarachnoid space removal of the lasting 3–4 h
placenta
After external rotation, lateral flexion of the head • using an oxytocic drug
towards the anus dislodges the anterior shoulder from • clam ping and cutting the cord
behind the pubic sym physis with the next contraction. • controlled cord traction.
Lifting the head gently in the opposite direction delivers In m ost units, syntocinon (5 units of oxytocin) or
the posterior shoulder. Holding the shoulders, the rest syntom etrine (oxytocin with 0.5 m g ergom etrine) is
of the body is delivered either onto the bed or the given intram uscularly with delivery of the anterior
m other’s abdom en. Finally, the cord is divided and cut. shoulder; it takes about 2–3 m in to act. As the placenta
detaches from the uterine wall, the cut cord will appear
to lengthen. There is usually som e bleeding and the fun-
M ANAGEM ENT O F THE THIRD dus becom es hard. Brandt-Andrews’ m ethod of con-
STAGE O F LABO UR trolled cord traction is com m only used to deliver the
placenta once it has separated to reduce the incidence
Active m anagem ent of the third stage has been shown to of uterine inversion (Fig. 28.11). The placenta and
reduce the incidence of postpartum haem orrhage m em branes m ust be checked to ensure that they are
(PPH) (see Chapter 33). Managem ent involves: com plete.
185
Labour
Fig. 28.11 Controlled cord traction to deliver the placenta. Fig. 28.13 Complications associated with the use of
amniotomy and oxytocin.
Treatment Complication
Som e patients choose to have a physiological 3 rd Amniotomy Cord prolapse
stage. This m eans that they do not receive any routine Infection
oxytocic drugs, the attendant waits for the um bilical Bleeding from a vasa praevia
cord to stop pulsating before it is cut, and delivery of Placental separation
the placenta occurs passively. In situations where there Failure to induce efficient contractions
is an increased risk of PPH or depending on parental Amniotic fluid embolism
choice, active m anagem ent is advised as above. O xytocin Abnormal fetal heart rate pattern
Finally, the vagina, labia and perineum are exam ined Hyperstimulation of the uterus
for lacerations. The uterine fundus is palpated to check Rupture of the uterus
that it is well contracted, approxim ately at the level of Fluid overload
the um bilicus. The estim ated blood loss should be
recorded.
Prostaglandins
In d ica t io n s
Local application of a prostaglandin, usually prosta-
Th e rate of in duction varies widely between differen t glandin E2, given as a vaginal gel or tablet, has been
un its an d even with in differen t un its. Figure 28.12 shown to ripen the cervix as part of the induction pro-
sh ows possible reason s for in duction of labour, cess and reduce the incidence of operative delivery when
m atern al or fetal. In th e UK, th e m ost com m on in di- com pared to use of oxytocin alone. Used locally instead
cation is prolon ged pregn an cy, m ore th an 41 weeks’ of system ically, the gastrointestinal side effects are m in-
gestation . im ized. NICE guidelines have been produced to advise
on the dose of prostaglandin given, in order to reduce
the risk of uterine hyperstim ulation.
Methods
Prior to induction of labour, the favourability of the cer-
vix should be assessed. This is usually done by using the Amniotomy
Bishop score (see Fig. 3.12); a higher score suggests a Artificial rupture of the m em branes (ARM) is thought to
m ore favourable cervix. Com plications of am niotom y cause local release of endogenous prostaglandins. It is
and oxytocin are shown in Figure 28.13. done using an am nihook and m ay be part of the
186
Induction of labour 28
187
This pa ge inte ntiona lly le ft bla nk
Pre t e rm la b o u r 29
O bjectives
INVESTIGATIO N
Fig. 29.3 Pathogens implicated in preterm labour.
As abn orm al lie an d presen tation are far m ore com -
• Sexually transmitted: Chlamydia, Trichomonas, Syphilis,
Gonorrhoea m on in preterm pregn an cy, an ultrasoun d scan
• Enteric organisms: Escherichia coli, Streptococcus sh ould be perform ed (see Ch apter 30). Up to
faecalis 25 þ 6 weeks gestation , presen ce of th e fetal h eart beat
• Bacterial vaginosis: Gardnerella, Mycoplasma and sh ould be con firm ed with a son icaid. After th is gesta-
anaerobes tion , a cardiotocograph sh ould be perform ed, wh ich
• Group B streptococcus (if a very heavy growth) will assess fetal well-bein g as well as in dicatin g uterin e
activity.
Evidence of fetal fibronectin in the m other’s cervical
interests of fetal or maternal health, due, for example, to secretions can be checked using a specific kit; its absence
severe pre-eclampsia, or when scans have shown severe suggests that delivery is less likely and this m ay assist
intrauterine growth restriction (IUGR) of the fetus. with m anagem ent decisions such as the need for toco-
lysis. Transvaginal scans m ay be used to exam ine the
length of the cervix since cervical shortening is a predic-
HISTO RY AND EXAM INATIO N tor of preterm delivery (Fig. 29.4). Urinalysis m ust be
perform ed to look for nitrites, which suggest a urinary
Preterm labour m ay be rapid in onset and progress, and tract infection.
is alm ost always unexpected. Therefore, history taking
m ust be done as com prehensively as possible, taking
into account the fact that som e wom en will arrive in
an advanced state of labour. FETUS BLADDER
Th e h istory sh ould in clude th e tim in g of on set of
th e abdom in al pain (see Ch apter 25). In term itten t,
but regular abdom in al pain suggests uterin e con trac-
tion s. Frequen cy an d in ten sity over tim e sh ould be
assessed. Preterm labour m ay be associated with clear
watery vagin al disch arge, suggestin g possible rupture
of th e m em bran es, or bleedin g, as with an an tepartum
h aem orrh age (see Ch apter 21). A h istory of n orm al
fetal m ovem en ts sh ould be ch ecked. With regards to
possible in fection , urin ary an d gastroin testin al sym p-
tom s sh ould be elicited, as well as system ic sym ptom s
such as fever. A past m edical h istory an d a social h is-
tory sh ould be taken as for th e risk factors sh own in
Figure 29.1.
Exam ination m ust include baseline observations –
pulse, blood pressure, respiratory rate and tem perature –
to look for possible infection. Abdom inal palpation will
assess:
WIDTH LENGTH O F
• abdom inal tenderness – site, guarding, rebound O F INTERNAL CERVICAL CANAL
• uterine tenderness – site OS
• uterine tone – soft or irritable, e.g. abruption
• uterine contractions – frequency and strength Fig. 29.4 Transvaginal scan of cervical canal. From Chudleigh
• fetal lie, presentation and engagem ent. 2004, with permission.
190
Management 29
191
Preterm labour
section m ight have higher m orbidity for the m other, Where infection has been proved it should be treated
particularly at very early gestations because the lower and the m other screened regularly for recurrence during
segm ent is less well form ed increasing the necessity of subsequent pregnancies and treated as necessary.
having to use a classical uterine incision. Cervical incom petence can be treated by insertion of
a cervical suture, either electively in early pregnancy
(usually around 12 weeks after the high risk of early m is-
M a n a ge m e n t o f fu t u re carriage and once results of Downs syndrom e screening
tests have been obtained), or, if the cervix is m onitored
p re gn a n cie s regularly in pregnancy with transvaginal scanning,
Any wom an who has laboured prem aturely is m ore at when scan shows that the cervix is shortening.
risk of doing so again in her next pregnancy. In m any The prescription of prophylactic oral tocolytics to
cases there will be nothing that can be done to prevent wom en at increased risk of recurrent preterm labour is
this. Exceptions are when: not helpful, but som e clinicians prescribe prophylactic
• labour has been due to treatable, persistent infec- corticosteroids at a point in the pregnancy before the
tion, e.g. bacterial vaginosis last baby is delivered.
• there is cervical incom petence.
Appropriate suture
material (inert) e.g.
Mersilene tape
PRETERM PRELABO UR RUPTURE
O F M EM BRANES
Preterm prelabour rupture of m em branes (PPROM)
occurs in only 2% of pregnancies, but is associated with
40% of preterm deliveries. The principal issue is the risk
of sepsis, both m aternal and fetal. Maternal sepsis with
Cervix
ascending uterine infection can rapidly becom e over-
whelm ing if not m onitored and m ay affect future fertil-
ity. Sepsis in the infant is one of the three leading causes
of m ortality in the preterm infant, along with prem atu-
Fig. 29.7 The MacDonald suture. rity and pulm onary hypoplasia.
192
Preterm prelabour rupture of membranes 29
193
This pa ge inte ntiona lly le ft bla nk
O t h e r co m p lica t io n s o f la b o u r 30
O bjectives
Diagnosis
M ALPRESENTATIO N
The head can be felt as a hard lum p at the uterine fundus
Any presentation other than a vertex presentation is a by the exam iner and the patient. Auscultation of the
m alpresentation. The vertex is the area between the pari- fetal heart at a higher level than is usual with a cephalic
etal em inences and the anterior and posterior fonta- presentation m ight suggest a breech presentation,
nelles. The m ost com m on m alpresentation is the although this is not a reliable sign. Vaginal exam ination
breech presentation, but others include shoulder, brow in labour can confirm the diagnosis, although if there is
and face presentations. any doubt ultrasound exam ination is indicated, which
Malpresentation can occur by chance, but it can also will also determ ine the type of breech presentation.
be caused by fetal or m aternal conditions that prevent
the vertex from presenting to the pelvis (Fig. 30.1). In Complications
all cases, m anagem ent m ust begin by exclusion of
There is increased perinatal m ortality and m orbidity
im portant conditions such as fetal abnorm ality, pelvic
associated with vaginal breech delivery when com pared
m asses and placenta praevia.
with cephalic presentation of com parable birthweight
at term . This is usually associated with difficulty in deliv-
ering the aftercom ing head. The fetal trunk is softer than
Bre e ch p re se n t a t io n the head and can pass through a borderline pelvis.
Com pared with a cephalic delivery, there is relatively lit-
Apart from the general causes of m alpresentation, tle tim e for m oulding to occur, which m ay result in
breech presentation is particularly associated with pre- entrapm ent of the aftercom ing head. If the fetal arm s
m aturity. The incidence of breech presentation increases becom e extended behind the head during delivery
with decreasing gestation: (known as nuchal arm s) this m ay also reduce the avail-
• Term : 3% able space for the head. Rapid com pression and decom -
• 32 weeks: 15% pression of the head during delivery can produce
• 28 weeks: 25%. intracranial injury. Unfortunately, no m ethod of ante-
natal assessm ent, clinical, radiological or ultrasonic,
will guarantee easy delivery of the aftercom ing head.
Classification of breech presentation
There are three types of breech presentation: Perinatal morbidity and mortality
• Extended or frank breech approxim ately 50% Four m ajor causes account for the increased perinatal
• Flexed or com plete breech approxim ately 25% m orbidity and m ortality associated with vaginal breech
• Footling breech approxim ately 25%. delivery. The relative im portance of these depends on
With an extended breech, the hips are flexed and the the gestational age of the fetus:
knees extended with the feet situated adjacent to the • Prem aturity
fetal head. Flexed and footling breeches are flexed at • Cord prolapse
both the hips and knees, but in the latter the feet present • Birth traum a
to the m aternal pelvis not the breech (Fig. 30.2). • Congenital anom aly.
196
Malpresentation 30
197
O ther complications of labour
Fig. 30.4 Face presentation. Fig. 30.5 Vaginal examination findings in face presentation.
198
Failure to progress in labour 30
Fa ilu re t o p ro gre ss re la t e d t o t h e
Mechanism of labour b o n y p e lvis
The m em branes tend to rupture early in labour and Abnormal bony shape
there is an increased risk of cord prolapse. With a brow
presentation, the m entovertical diam eter of 13.5 cm Antenatal X-ray pelvim etry and routine pelvic assess-
presents (Fig. 28.4). An average-sized fetus will not m ent by vaginal exam ination are no longer perform ed.
engage with a norm al-sized pelvis and obstructed However, certain points in a patient’s history and exam -
labour results. When the fetal head is sm all in relation ination can give clues to the likelihood of failure to pro-
to the m aternal pelvis, descent m ight occur, allowing gress in labour due to an abnorm al pelvis (Fig. 30.7).
flexion of the head as it reaches the pelvic floor. In Although still rare, one of the com m on problem s is a
the absence of disproportion, labour should be allowed previous pelvic fracture.
to continue. Further extension m ight occur to a face pre-
sentation or flexion to a vertex position.
Cephalopelvic disproportion
With true cephalopelvic disproportion (CPD), the size
of the pelvis is not in proportion to the fetus. It should
FAILURE TO PRO GRESS be suspected antenatally if the head does not engage at
term , particularly in a wom an of short stature. Usually, a
IN LABO UR trial of labour is still appropriate, but in som e cases an
elective caesarean section is planned. During labour,
As described in Chapter 28, labour and delivery require CPD is diagnosed if the head rem ains unengaged on
the interaction of three com ponents – the passages, the abdom inal palpation. This is confirm ed assessing
passenger and power – as part of a dynam ic process:
• Passages: the shape and size of the hard bony pelvis
and soft tissues
• Passenger: the size, presentation and position of the
Fig. 30.7 Causes of abnormalities of the bony pelvis.
fetus
• Power: this is both involuntary (strength and fre- Congenital O steogenesis imperfecta
quency of uterine contractions) and voluntary (dia- Ectopia vesicae
phragm and abdom inal m uscles). Dislocation of the hip
Any of these factors can be involved in the failure of Acquired Kyphosis of the thoracic or lumbar spine
labour to progress norm ally, as sum m arized in Scoliosis of the spine
Spondylolisthesis
Figure 30.6. Once the diagnosis of labour has been
Pelvic fractures
m ade, a prim iparous patient is expected to progress at
Rickets/ osteomalacia
approxim ately 0.5–1 cm /h and a m ultiparous patient Poliomyelitis in childhood
at 1–2 cm /h.
199
O ther complications of labour
station on vaginal exam ination and by the presence of or haem orrhage (see Chapter 9). They do not cause slow
caput (swelling under the fetal scalp caused by reduc- progress in labour because they rise up out of the pelvis
tion in venous return) and m oulding. However, these as the uterus increases in size.
signs are m ore com m only found sim ply with m alposi-
tion rather than true CPD.
Fa ilu re t o p ro gre ss re la t e d t o t h e
Fa ilu re t o p ro gre ss re la t e d t o t h e p a sse n ge r
so ft t issu e s o f t h e p e lvis Fetal size
Uterus The possibility of a large fetus m ight be suggested by the
patient’s past m edical history, for exam ple, Type 1 dia-
A uterine m alform ation, such as the presence of a m id-
betes or from the antenatal history, with developm ent
line septum (a Mullerian or developm ental abnorm al-
of gestational diabetes or hydrops fetalis, e.g. with rhe-
ity), m ight prevent the fetus from lying longitudinally,
sus isoim m unization or parvovirus infection (see
so that a m alpresentation is responsible for failure to
Chapter 26). In a m ultiparous patient, it is useful to
progress. This can also be rarely caused by uterine
check the weights of previous deliveries as an assess-
fibroids, which m ay increase the SFH m easurem ent dur-
m ent of ability to deliver the current infant.
ing pregnancy and obstruct labour. The presence of
Abdom inal palpation is not always accurate as a
a cervical fibroid m ight even necessitate caesarean
m ethod of diagnosing a large fetus, although this
section.
should be done to assess engagem ent of the presenting
part in labour. Ultrasound is m ore accurate, provided
Cervix that gestational age has been correctly estim ated early
Failure of the cervix to dilate during labour despite ade- in pregnancy.
quate uterine contractions is rarely secondary to cervical During labour, on vaginal exam ination, the cervix
scarring causing stenosis. This could be the result of cer- m ay be felt to be increasingly oedem atous. Signs of
vical am putation or cone biopsy. caput or m oulding m ay be noted on the fetal head.
Caput is the boggy swelling on the fetal head as subcu-
taneous oedem a of the scalp develops. Moulding is
Vagina described in Chapter 28, when the fetal skull bones
Congenital anom alies of the vagina rarely cause prob- overlap.
lem s with respect to labour and delivery, except in
patients who have had reconstructive surgery. Other
types of surgery, such as a colposuspension for urinary Fetal abnormality
stress incontinence or repair of a vesicovaginal fistula, Routine ultrasound scanning is likely to diagnose
generally indicates the need for an elective caesarean abnorm alities such as a congenital goitre or a lym phan-
section at term , but m ore to prevent recurrent sym p- giom a. These extend the neck, so that the norm al pro-
tom s rather than because of possible slow progress in cess of flexion cannot take place. This m ay result in a
labour. face or brow presentation (see above). Abdom inal
enlargem ent caused by the presence of ascites or an
Vulva um bilical hernia m ay m ake delivery difficult. Abnor-
m alities of the fetal skull such as anencephaly should
Previous perineal tears or episiotom y should not pre- be suspected in labour if the head does not engage
sent difficulties during delivery. More problem atic is a and the sutures feel widely spaced on vaginal exam ina-
fem ale circum cision (FGM fem ale genital m utilation), tion. This condition is a type of spina bifida, again
which m ay necessitate an anterior episiotom y to pre- routinely diagnosed on ultrasound scan.
vent m ore severe tears and the risk of fistula form ation.
Ideally, this patient should have been assessed ante-
natally in order to m ake the appropriate plan of care Fetal malposition
including surgery for reversal of FGM before 20 weeks
The fetal head norm ally engages with an occipitotrans-
gestation.
verse position. With descent, the head rotates to an occi-
pitoanterior position as described in Chapter 28. Any
O vary position other than occipitoanterior can be associated
Ovarian cysts in pregnancy are usually incidental find- with failure to progress in labour, nam ely:
ings at routine ultrasound. They can present with • occipitoposterior position
abdom inal pain during pregnancy, secondary to torsion • occiptiotransverse position.
200
Shoulder dystocia 30
Approxim ately 20% of vertex presentations in early and lead to fetal hypoxia. Continuous electronic m on-
labour are occipitoposterior. Diagnosis is determ ined itoring is advisable.
by abdom inal palpation: Particular care is essential in a m ultiparous patient
• Maternal lower abdom en that is flattened or concave because the diagnosis of inefficient uterine action is
• Fetal back cannot be palpated anteriorly m uch less com m on than in a prim iparous patient. A
• Fetal lim bs that can be palpated anteriorly. fetal m alposition, m alpresentation or increased fetal
size should be considered as the cause of the slow pro-
On vaginal exam ination, the positions of the sutures
gress; inappropriate use of oxytocic drugs is associated
and fontanelles are determ ined (see Chapter 28). If the
with uterine rupture in this group.
anterior fontanelle is palpable vaginally, then the head
is deflexed. If only the posterior fontanelle can be
felt, then the head is flexed. This degree of flexion allows
the sm allest diam eter of the head to present. It will,
therefore, be m ore likely to rotate at the pelvic floor
M ANAGEM ENT O F FAILURE TO
and proceed to norm al vaginal delivery. The m ajority PRO GRESS
of OP positions will rotate during labour in the presence
of adequate contractions. The m inority will not rotate, This depends on the cause. Contractions m ay be
but deliver vaginally in the OP position (face to pubes) im proved with:
if the pelvis is large enough, whilst som e will need rota- • artificial rupture of m em branes (ARM)
tion either m anually or with an instrum ent (see • use of intravenous syntocinon.
Chapter 32). ARM is thought to release local prostaglandins and
can increase the rate of labour progression. The strength
Fetal malpresentation and frequency of the uterine contractions can also be
im proved by adm inistration of an infusion of intrave-
Malpresentation of the fetus is defined as a non-vertex nous syntocinon. However, caution m ust be exercised
presentation (see above). This can be: in a m ultiparous patient. Generally, labour proceeds
• breech m ore rapidly in a second pregnancy. Therefore, if pro-
• shoulder gress is slow, fetal size and position m ust be considered
• face so that excessive contractions do not put the patient at
• brow. risk of uterine rupture with syntocinon. Regular strong
contractions will help to correct a fetal m alposition by
rotating the head against the pelvic floor m uscles, as
Fa ilu re t o p ro gre ss re la t e d t o t h e well as im proving descent. Malpresentation m ay be
power m anaged as described above.
The presence of good contractions over several hours
Uterine palpation m onitors frequency, duration and
but without significant progression in term s of cervical
strength of the contractions. The cardiotocograph
dilatation and descent of the presenting part should
checks the frequency and duration. However, the
alert the physician to consider delivery by caesarean
recording of the strength can be altered by position of
section.
the m onitor on the abdom en and m aternal obesity
Failure to progress in the second stage of labour
and so this m ust be assessed on palpation. In som e cen-
should be assessed in the m anner already described
tres, intrauterine pressure catheters are used to m onitor and instrum ental delivery considered (see Chapter 32).
contraction pressure. Inefficient uterine action can be
If the head is alm ost crowning then an episiotom y
diagnosed if labour is prolonged and the contractions
m ight be all that is necessary to expedite vaginal
are:
delivery.
• uncoordinated
• fewer than 3–4 in 10 m in
• lasting less than 60 s
• pressure less than 40 m m Hg (using a pressure SHO ULDER DYSTO CIA
catheter).
After thorough abdom inal and vaginal exam ina- Shoulder dystocia is a problem of the pelvic inlet pre-
tions, and with norm al fetal m onitoring, careful use venting delivery of the shoulders once the head is
of oxytocic drugs, usually intravenous syntocinon infu- out. This occurs because the shoulders fail to pass
sion, can im prove the contractions. Caution m ust be through the pelvic inlet; it is not a problem with the
taken to avoid too frequent contractions because this outlet or the perineum . The essential point is not to
can reduce the oxygen exchange in the placental bed use excessive traction on the fetal head to facilitate
201
O ther complications of labour
delivery of the shoulders since this risks dam age to the m aternity unit. A senior paediatrician should be called
brachial plexus nerve roots in the neck. Increasing hyp- to attend urgently in order to assess the baby at delivery.
oxia occurs while the fetus is lodged in the vagina, with
pressure on the um bilical cord. The m ore com m on
injury to the fetus is Erb’s palsy caused by dam age to Fu rt h e r re a d in g
nerve roots C4, 5 and 6, which can have serious long- Hannah, M.E., 2000. Planned caesarean section versus
term neurological sequelae. Manoeuvres to aid delivery planned vaginal birth for breech presentation at term : a
include: random ized m ulticentre trial. Lancet. 356, 1368–1369.
• lie the patient flat NICE, 2007. Intrapartum Care. National Institute for
• McRoberts position — the hips are flexed in knee- Health and Care Excellence, London. Available online at:
chest position in order to widen the anteroposterior www.nice.org.uk.
RCOG, 2006. Breech Presentation, Managem ent. Green-top
diam eter of the pelvis
Guidelines No. 20b. Royal College of Obstetricians and
• suprapubic pressure to dislodge the anterior
Gynaecologists, London. Available online at: www.rcog.org.uk.
shoulder
RCOG, 2009. Female Genital Mutilation, Management. Green-top
• internal rotation techniques to try and rotate the
Guidelines No. 53. Royal College of Obstetricians and
anterior shoulder from under the pubic sym physis Gynaecologists, London. Available online at: www.rcog.org.uk.
• deliver the posterior arm . RCOG, 2012. Shoulder Dystocia. Green-top Guidelines No.
This situation is an em ergency and should therefore 42. Royal College of Obstetricians and Gynaecologists,
be practised as a regular drill by all the staff on the London. Available online at: www.rcog.org.uk.
202
Fe t a l m o n it o rin g in la b o u r 31
O bjectives
Abnormal <100 <5 for ≥90min Atypical variable decelerations None present
>180 Late decelerations
Single deceleration >3 m in
Fig. 31.4 Late decelerations occurring after uterine contractions with reduced baseline variability.
of m econium -stained liquor, for exam ple, the CTG Chapter 21). If this is suspected, the uterus will typically
should be acted upon prom ptly as hypoxia m ay cause feel hard and tender.
the fetus to gasp and inhale the m econium . The uterine contractions should be palpated, espe-
cially if the patient’s labour is being stim ulated by intra-
venous oxytocic agents. Hyperstim ulation can cause an
abnorm al FHR. There should be resting tone between
EXAM INATIO N O F THE PATIENT contractions.
W HO PRESENTS W ITH AN
ABNO RM AL
CARDIO TO CO GRAPH IN LABO UR Va gin a l e xa m in a t io n
As well as assessing the dilatation of the cervix to deter-
Ba se lin e m a t e rn a l o b se rva t io n s m ine the progress in labour and the ability to perform a
fetal blood sam ple, the presence of the fetal cord m ust
Temperature be excluded. A cord prolapse, as it is known, is associ-
Araised m aternal tem perature m ight explain fetal tachy- ated with a fetal bradycardia as the blood vessels in
cardia, for exam ple, if there is ruptured m em branes for the cord spasm . This is an em ergency situation requiring
> 24 h increasing the risk of infection. im m ediate delivery by caesarean section if the cervix is
not fully dilated.
A vaginal exam ination m ay also be indicated to
Pulse apply a fetal scalp electrode (FSE) if the CTG could be
This m ight be raised in conjunction with m aternal recording m aternal pulse instead of fetal.
pyrexia. In the presence of fetal bradycardia, m aternal
pulse should be checked to ensure that the m onitoring
is recording FHR and not the m other. This can be
excluded by applying a fetal scalp electrode, provided INVESTIGATING THE ABNO RM AL
the cervix is at least 1–2 cm dilated and the m em branes
are ruptured.
CARDIO TO CO GRAPH
If the CTG is categorized as suspicious, the patient can
Blood pressure be m anaged conservatively (Fig. 31.5), for exam ple,
Adm inistering epidural anaesthesia can be associated by changing m aternal position or reducing the dose
with m aternal hypotension. This results in reduced of syntocinon.
blood flow to the uterus and can cause fetal bradycardia. If the CTG is pathological, fetal blood sam pling
Therefore, intravenous fluids are adm inistered and (FBS) should be perform ed if there are the appropriate
blood pressure regularly checked when the m edication facilities. The procedure involves taking a sam ple of cap-
is given. illary blood from the fetal scalp with the m other in the
left lateral position and the cervix dilated at least 2–
3 cm . A sam ple of blood from the fetal scalp gives the
Ab d o m in a l p a lp a t io n fetal pH (i.e. a m easure of acidosis). The result m ight
• Uterine size indicate that delivery is necessary (pH 7.20), that
• Engagem ent of presenting part the test should be repeated within 30 m in (pH 7.21–
• Scar tenderness in a patient with a previous 7.24) or 60 m in (pH 7.25).
caesarean section If FBS is not possible, delivery should be expedited by
• Uterine tone. caesarean section. Contraindications to FBS are given in
The size of the m aternal abdom en should be assessed Figure 31.6.
to check if it is large or sm all for dates (see Chapter 26).
The engagem ent of the presenting part is im portant to
assess progress in labour (see Chapter 28). In a patient Fu rt h e r re a d in g
who has previously had a caesarean section, the pres- Gibb, D., Arulkum aran, S., 2008. Fetal Monitoring in Practice,
ence of scar tenderness should be elicited; scar rupture 3 rd ed. Churchill Livingstone, London.
is com m only associated with an abnorm al CTG and NICE, 2007. Intrapartum Care, Guideline CG55. National
vaginal bleeding. Another cause of vaginal bleeding Institute for Health and Care Excellence, London. Available
with an abnorm al CTG is placental abruption (see online at: www.nice.org.uk.
206
Investigating the abnormal cardiotocograph 31
Suspicious Pathological
Abnormal pH≤7.20
207
This pa ge inte ntiona lly le ft bla nk
O p e ra t ive in t e rve n t io n s
in la b o u r 32
O bjective
210
Forceps delivery 32
caput on the fetal head. Along with the KIWI cups, they
Fig. 32.5 Complications of instrumental delivery.
are useful in the presence of a fetal m alposition. Both
the m etal and silicone cups are available in different Type of complication Description
diam eters depending on the gestation of the fetus. It
Maternal Genital tract trauma
is not an appropriate instrum ent at less than 34 weeks’
(cervical/ vaginal/ vulval) with
gestation.
risk of haemorrhage and/ or
Indications for use of the ventouse cup are: infection
• m aternal – delay in the 2 n d stage of labour due to Fetal Ventouse delivery is likely to
m aternal exhaustion cause a chignon (scalp
• fetal – abnorm al cardiotocograph (CTG) or slow oedema) or, less commonly,
progress in the 2nd stage of labour due to fetal a cephalohaematoma
m alposition. (subperiosteal bleed)
Forceps can cause bruising if not
appropriately applied, or
rarely facial nerve palsy or
Te ch n iq u e fo r ve n t o u se depression skull fracture
The criteria shown in Figure 32.4 m ust be fulfilled.
Instrum ental delivery should not be attem pted if the
head is above the ischial spines because of the risks of
excessive traction to the fetus – a caesarean section is FO RCEPS DELIVERY
indicated.
All types of cup rely on th e sam e tech n ique. Th e cup Over the last three to four centuries, forceps have been
is applied in th e m idline over or just an terior to th e used for delivery. There are two m ain types of forceps
occiput, avoidin g th e surroun din g vagin al m ucosa. (Fig. 32.6):
Th e pressure in th e con n ectin g pum p is raised to • Non-rotational or traction forceps (Sim psons,
-0.8 kg/ cm 2 . Th is m ech an ism is ‘all-in -on e’ with th e Andersons, Neville-Barnes or Wrigleys)
KIWI cup. • Rotational forceps (Keillands).
Traction with the m aternal contractions and with
m aternal effort should be along the pelvic curve, that
is, initially in a downwards direction and then changing
In d ica t io n s fo r fo rce p s
the angle upwards as the head crowns. This action basi- These are shown in Figure 32.7. They differ slightly from
cally m im ics the passage of the fetal head during a nor- those for the ventouse, m ainly because the ventouse
m al delivery, but uses the vacuum pum p to increase
traction and flexion.
Th e operator sh ould judge wh eth er an episiotom y
is n eeded an d th e procedure sh ould be com plete
with in approxim ately 15 m in of cup application .
Th e CTG sh ould m on itor th e fetal h eart rate th rough -
out an d, in m ost un its, it is stan dard practice for a pae-
diatrician to be presen t. Com plication s are listed in
Figure 32.5.
211
O perative interventions in labour
Te ch n iq u e fo r lo w e r se gm e n t
ca e sa re a n se ct io n
requires m aternal effort and adequate contractions.
An elective LSCS is usually perform ed at 39 or m ore
Non-rotational forceps are suitable only for certain
weeks gestation. Delivery at this gestation reduces the
positions of the fetal head – direct occipitoanterior or
respiratory m orbidity in the infant – transient tachyp-
direct occipitoposterior. By contrast, the m ode of action
noea of the newborn (TTN). With regional analgesia
of the ventouse cup allows rotation to take place during
m ore com m only than general, a low transverse skin
traction and so it is suitable for a m alposition (see
incision is m ade. The rectus sheath is cut and the rectus
Chapter 30).
m uscles divided. The uterovesical peritoneum is incised
With a decline in the use of rotational forceps in
to allow the bladder to be reflected inferiorly. The lower
som e units due to fetal and m aternal com plications
uterine segm ent is incised transversely and the fetus is
such as extended vaginal wall tears, it is essential to
delivered m anually.
define the fetal position before attem pting delivery, so
In traven ous oxytocin is given by th e an aesth etist
that the appropriate instrum ent is chosen and the cor-
an d th e placen ta an d m em bran es are rem oved. Th e
rect technique used.
an gles of th e uterin e in cision are secured to en sure h ae-
m ostasis an d th en th e uterus is closed with an absorb-
Te ch n iq u e fo r fo rce p s able suture, usually in two layers. Th e rectus sheath is
closed to avoid in cision al h ern ias an d, fin ally, th e skin
As for the ventouse, the necessary criteria m ust be ful- is closed with eith er an absorbable or n on-absorbable
filled (Fig. 32.4). The blades of non-rotational forceps suture.
are applied to the head, avoiding traum a to the vaginal
walls. The direction of traction is sim ilar to that of the
HINTS AND TIPS
ventouse, with episiotom y perform ed when the head
crowns in order to give m ore space (Fig. 32.8). It is not appropriate to attempt an instrumental delivery
Use of the rotational forceps involves a slightly differ- if the fetal head is above the ischial spines. An LSCS
ent technique: the knobs on the blades m ust always should be performed.
point towards the occiput; asynclitism can be corrected
using the sliding m echanism of the handles and then
rotation achieved prior to traction in the m anner
described above. Co m p lica t io n s o f lo w e r se gm e n t
ca e sa re a n se ct io n
Although LSCS has becom e an increasingly safe proce-
CAESAREAN SECTIO N dure, particularly with the introduction of regional
anaesthesia, there is still significant m orbidity associ-
Caesarean section was first described by the ancient ated with it:
Egyptians. It was used increasingly throughout the • Haem orrhage: all patients should have a group and
twentieth century such that rates of 25% are now com - save sam ple sent; cross-m atch blood for certain
m on in units in the UK. The lower segm ent procedure patients, e.g. those with placenta praevia
212
Caesarean section 32
C D
E F
213
O perative interventions in labour
214
Po st n a t a l co m p lica t io n s 33
O bjectives
216
Investigations 33
M a n a ge m e n t
Se co n d a ry p o st p a rt u m
Treatm ent m ust start with basic resuscitation (ABC)
h a e m o rrh a ge depending on the patient’s condition and the extent
Basic observations should include pulse, blood pres- of the bleeding. It is im portant to m ake an accurate esti-
sure, respiratory rate and tem perature. Tachycardia m ation of the blood loss; it is frequently underesti-
and pyrexia m ay be present with endom etritis. The m ated. Intravenous access m ust be established. Blood
height of the uterine fundus should be checked because is sent for haem oglobin, platelets, clotting and cross-
the uterus will usually rem ain poorly contracted if there m atching. In cases of m assive obstetric haem orrhage,
are retained products of conception. Tenderness should generally classified as > /¼ 2000 m L, a m ultidisciplinary
be excluded to rule out endom etritis. approach to m anagem ent is very im portant, involving
Speculum examination excludes vaginal discharge if liaison between the obstetrician, the anaesthetist and
there is suspicion of infection. Bimanual palpation exam- the haem atologist. The cause of the bleeding m ust be
ines the size of the uterus, because it might be bulky with identified so that appropriate m anagem ent can be
retained products or with a molar pregnancy. Tenderness instigated.
217
Postnatal complications
Placenta retained
Suckling stim ulates two reflexes: prophylactic antibiotics at the time of a caesarean section
1. The anterior part of the pituitary gland releases to decrease the incidence of wound and uterine infection.
prolactin into the bloodstream , which induces the Infection in the perineum can also present with vagi-
alveoli to secrete m ilk. nal discharge, as well as localized discomfort. There is
2. The posterior part of the pituitary gland releases oxy- usually a history of a vaginal tear or an episiotomy. Acute
tocin into the bloodstream , which causes contrac- mastitis, or infection of the breast, typically presents at
tion of the m yoepithelial cells surrounding the the end of the first week after birth, as organisms that col-
alveoli so that the m ilk is ejected. onize the baby affect the breast. Infection presents with
pain in one or both breasts associated with fever.
220
Postnatal mental illness 33
221
Postnatal complications
222
M a t e rn a l co lla p se 34
O bjectives
224
Causes of maternal collapse 34
Collapsed patient
Yes
O pen airway
Head tilt & chin lift
Assess A: Airway
B: Breathing
C: Circulation VF/ VT Defibrilate
Chest
compressions
Commence 30:2 Assess Consider reversible Continue
Signs of life? No causes
CPR rhythm CPR x 2mins
Left lateral tilt 4H’s & 4T’s
Fig. 34.2 Algorithm for the initial management of the collapsed obstetric patient.
225
Maternal collapse
226
Causes of maternal collapse 34
Eclampsia
Intracranial haemorrhage
Ilicit drugs
Anaphylaxis
Pulmonary embolism
Amniotic fluid embolism Aortic dissection
Haemorrhage: Hypoglycaemia
hepatic rupture
splenic artery rupture
uuterine
(antepartum haemorrhage/
postpartum haemorrhage) Sepsis
4H’s Hypovolaemia Bleeding (may be concealed) (obstetric/ other) or relative hypovolaemia of dense
spinal block; septic or neurogenic shock
Hypoxia Pregnant patients can become hypoxic more quickly
Cardiac events: peropartum cardiomyopathy, myocardial infarction, aortic dissection,
large-vessel aneurysms
4T’s Thromboembolism Amniotic fluid embolus, pulmonary embolus, air embolus, myocardial infarction
Toxicity Local anaesthtic, magnesium, other
Tension pneumothorax Following trauma/ suicide attempt
Tamponade (cardiac) Following trauma/ suicide attempt
O t h e r ca u se s Fu rt h e r re a d in g
There are a huge num ber of other causes of m aternal RCOG, 2011. Maternal Collapse in Pregnancy and the
collapse in addition to those listed above, Figure 34.4 Puerperium. Green-top Guideline No. 56. Royal College of
sum m arizes the m ain possible causes as well as the Obstetricians and Gynaecologists, London.
4 H’s and 4 T’s which are used to rem em ber the revers-
ible causes of a cardiac arrest.
227
This pa ge inte ntiona lly le ft bla nk
M a t e rn a l d e a t h 35
O bjectives
s
e
i
t
i
n
r
e
400
t
a
m
0
0
0
300
,
0
0
1
r
e
200
p
s
e
t
a
r
100
h
t
a
e
d
0
1865–74 1925–30 1951–55 1971–75 1997–99 2003–05
1905–14 1946–50 1961–65 1988–90 2000–02 2006–08
230
Causes of maternal death 35
231
Maternal death
the diagnosis m ust always be considered in wom en of suicide and the im portance of identifying patients with
child bearing age. In som e cases, an ectopic pregnancy a history of psychiatric illness was em phasized.
can present as gastro-intestinal upset and the patient In addition it was recom m ended that all patients
m ay not know they are pregnant. It is for this reason with a history of psychiatric illness should be referred
that any fem ale of reproductive age that presents with to specialist services as a priority. A key finding from
gastrointestinal sym ptom s should have a pregnancy the report was that over half of the m aternal suicides
test perform ed and if positive, an ectopic pregnancy were: white, m arried, em ployed, living in com fortable
ruled out. circum stances and aged 30 years or older. It recom -
A high index of suspicion is required in all patients m ended that when assessing a patient’s risk of suicide,
who present with pain and bleeding in early pregnancy care should be taken that this m ay not necessarily
and education about signs and sym ptom s of an ectopic equate to their socio-econom ic status. A significant per-
should be given to all patients as well as inform ation on centage of deaths from suicide were late m aternal deaths
how to seek help. Any patient that presents with a pos- indicating the im portance of extended specialist postna-
itive pregnancy test with an intrauterine device in situ tal follow-up in at-risk groups.
(Mirena ® or copper coil) should be treated as an ectopic
until proven otherwise. Coincidental maternal deaths
This category includes a large num ber of varied causes of
In d ire ct ca u se s death, with road traffic accidents and m urder being the
two m ost com m on. Dom estic violence rem ains a m ajor
Cardiac disease cause for concern to all clinicians caring for obstetric
Cardiac disease has now becom e the leading cause of patients and should be actively screened for at each con-
indirect m aternal death and in the m ost recent report tact. Patients suffering from dom estic violence are likely
was responsible for 53 deaths. The exact causes of death to be:
included aortic dissection, m yocardial infarction and • late bookers
cardiom yopathy. • have a poor attendance record
In view of the rising trend in cardiac deaths, recom - • have repeated adm issions for seem ingly trivial
m endations were m ade and the following highlighted: m atters.
• Those patients with a known history of cardiac dis- Partners m ay appear to be dom ineering, constantly
ease to be referred early for consultant led care in a present during all visits and those who do not let the
joint obstetric/cardiology clinic patient answer questions should raise concerns about
• Low threshold for investigation of patients com - dom estic violence. Where indicated, professional inter-
plaining of chest pain particularly that which radi- preters should be used rather than fam ily m em bers and
ates to the jaw, back or arm any concerns acted upon.
• Be alert to those with risk factors such as obesity,
sm okers and those with hypertension. Fu rt h e r re a d in g
Cantwell, R., Clutton-Brock, T., Cooper, G., et al., 2011. Saving
Psychiatric illness
Mothers’ lives: reviewing m aternal deaths to m ake
Maternal deaths from psychiatric illness accounted for m otherhood safer: 2006-2008. The eighth report of the
67 deaths in the latest report. This figure also includes confidential enquiries into m aternal deaths in the United
late m aternal deaths which were attributed to psychiat- Kingdom . BJOG. 118 (Suppl. 1), 1–203. http://dx.doi.org/
ric illness. The m ajority of these deaths were due to 10.1111/j.1471-0528.2010.02847.x.
232
SELF-ASSESSM ENT
Sin gle b e st a n sw e r q u e st io n s (SBAs) 235
Ext e n d e d -m a t ch in g q u e st io n s (EM Q s) 243
SBA a n sw e rs 259
EM Q a n sw e rs 265
This pa ge inte ntiona lly le ft bla nk
Sin gle b e st a n sw e r q u e st io n s
(SBAs)
1. Which of the following statements is incorrect? C. Pelvic infection screen (high vaginal and
A. Premature menopause is defined as the last period endocervical swabs)
before the age of 45 (but after 40 years) of age D. Thyroid function tests
B. The average age of menopause is 51 E. Day 21 progesterone
C. All patients should receive HRT
D. Where there is a uterus both oestrogen and 7. Which of the following is NO T a risk factor for
progesterone should be given as HRT cervical cancer?
E. Endometrial cancer is a contraindication to HRT A. Human papilloma virus
B. Smoking
2. Transdermal HRT is becoming increasingly popular. C. Multiple sexual partners
Which statement regarding transdermal HRT is D. Early age of first intercourse
incorrect? E. History of endometriosis
A. Avoids first-pass metabolism
B. Reduced risk of VTE 8. Mary is 55-years-old and has not had a period for
C. Continuous administration 4 years. She had an ultrasound because she was
D. O nly contain oestrogen feeling bloated which showed bilateral multilocular
E. Can cause skin reactions cysts and her CA125 was 80. What is her risk of
malignancy index?
3. Clonidine is a centrally acting alpha-2 agonist used in A. 240
the menopause, which of the following symptoms has B. 80
it been shown to be useful in treating? C. 0
A. Hair loss D. 720
B. Loss of libido E. 411
C. O steoporosis
D. Hot flushes
E. Mood swings 9. Agatha is 66 and underwent her last period over
15 years ago. O ver the last week she has noted
4. Which of the following statistics reflects the success some blood spotting on her underwear. She has
rate of conception for a couple trying for 1 year? a body mass index of 34 and her GP organized
A. 60% will conceive within 1 year with regular an ultrasound, which showed an endometrial
unprotected sexual intercourse thickness of 12 mm. What is the most important
B. 84% will conceive within 1 year with regular investigation she should have next?
unprotected sexual intercourse A. MRI pelvis
C. 15% will conceive within 1 year with regular B. Chest X-ray
unprotected sexual intercourse C. Hysteroscopy and endometrial biopsy
D. 20% will conceive within 1 year with regular D. CT abdomen and pelvis
unprotected sexual intercourse E. Cervical smear
E. 96% will conceive within 1 year with regular
unprotected sexual intercourse 10. Which of the following examination findings is
most suggestive of endometriosis?
5. Which of the following is NO T known to cause A. Cervical excitation
subfertility in either the male or the female partner? B. Adnexal mass
A. Chlamydia infection C. Nodules in the posterior fornix
B. Polycystic ovarian syndrome (PCO S) D. Generalized tenderness
C. Epididymo-orchitis E. Uterine tenderness
D. Endometriosis
E. Varicose veins 11. Which of the following aspects of the history is
most suggestive of endometriosis?
6. Which of the following investigations should ideally A. Deep dyspareunia
be performed before a patient attends for a B. Vaginal discharge
hysterosalpingogram? C. Cyclical pelvic pain
A. Rubella immunity D. Subfertility
B. Full blood count E. Gastrointestinal symptoms
235
Single best answer questions (SBAs)
12. A patient presents with right iliac fossa pain 18. Which of the following is not a pathological cause
and cervical excitation. Her last menstrual of vaginal discharge?
period was 6 weeks ago. What is the most likely A. Cervical carcinoma
cause? B. Cervical ectropian
A. Tubo ovarian abscess C. Candida albicans
B. O varian cyst D. Chlamydia trachomatis
C. Appendicitis E. Fistula
D. Fibroid
E. Ectopic pregnancy 19. A patient has been diagnosed with candida
infection. Which of the following supports this
13. A patient gives a history of cyclical pelvic diagnosis?
pain associated with secondary A. Grey, fishy-smelling discharge
dysmenorrhoea. What is the most likely B. Thick, itchy, white discharge
diagnosis? C. Dysuria
A. PID D. Urinary frequency
B. Endometriosis E. Lower abdominal pain
C. Fibroid
D. Adhesions 20. A patient presents with abnormal vaginal discharge.
E. Vulval dystrophy Which aspect of her history is most helpful to rule out
an infective cause?
14. A 27-year-old woman with a known benign A. Age
ovarian cyst is admitted to Accident and B. Weight loss
Emergency department with an acute C. Irregular vaginal bleeding
abdomen. What is the most important D. Anorexia
test to do? E. Sexual history
A. Full blood count
B. Group and save 21. Which of the following in a patient’s history is known to
C. Mid-stream urine predispose them to Pelvic Inflammatory Disease (PID)?
D. Pregnancy test A. Monogamous relationship
E. Pelvic ultrasound scan B. > 25 years of age
C. Use of Mirena IUS
15. How is the RMI (risk of malignancy index) D. History of sexually transmitted infection (STI)
calculated? E. Later onset of sexual activity
A. U(ultrasound score) x M (menopause score) x
Ca125 level 22. A patient with pelvic inflammatory disease (PID)
B. U(ultrasound score) þ M (menopause score) þ presents with offensive, fishy smelling par vagina
Ca125 level discharge. High vaginal swab confirms:
C. U(ultrasound score) / M (menopause score) x A. Chlamydia
Ca125 level B. Gonorrhoea
D. U(ultrasound score) x M (menopause score) / C. Anaerobes including Gardnerella and Mycoplasma
Ca125 level D. Candida
E. U (ultrasound score) þ M (menopause score) / E. Trichomonas vaginosis
CA19-9 level
23. Which of these is not an appropriate
16. A woman diagnosed with a benign epithelial first-line investigation for pelvic inflammatory
tumour presented with irregular vaginal bleeding. disease (PID)?
What is the likely diagnosis? A. White cell count (WCC)
A. Serous cystadenoma B. C-reactive protein (CRP)
B. Mucinous cystadenoma C. Erythrocyte sedimentation rate (ESR)
C. Brenner tumours D. Laparoscopy
D. Endometrioid tumours E. STD screen
E. Dermoid cyst F. Pelvic ultrasound scan
17. Which of the following examination findings is most 24. A patient is diagnosed with acute PID.
suggestive of malignancy in a woman with vaginal Which of the following signs does NO T support
discharge? that diagnosis?
A. Raised temperature A. Raised temperature > 37.5 C
B. Cervical excitation B. Tachycardia
C. Tachycardia C. Vulval pruritis
D. Generalized lymphadenopathy D. Abdominal tenderness
E. Cachexia E. Adnexal mass
236
Single best answer questions (SBAs)
31. A 42-year-old woman is requesting sterilization. She has 38. In order to perform a routine diagnostic laparoscopy
completed her family, does not want to use an IUCD the following are essential:
and her husband has refused to have a vasectomy. A. Normal saline to distend the peritoneal cavity
What is the lifetime failure rate of sterilization? B. Indwelling catheter
A. 1:20 000 C. Verress needle
B. 1:20 D. Pregnancy test
C. 1:200 E. Diathermy
237
Single best answer questions (SBAs)
39. In order to perform a transvaginal ultrasound scan the 46. What are the possible medical treatments of
following are essential: endometriosis:
A. A full bladder A. O varian drilling
B. Bowel preparation B. Combined oral contraceptive pill
C. Ultrasound gel C. Corticosteroids
D. A sedated patient D. Tranexamic acid
E. A light source E. Metronidazole
40. The following can be diagnosed during a routine 47. A 45-year-old woman presents with pruritus vulvae.
hysteroscopy: The following are suggestive of an infective cause:
A. Endometrial polyp A. Progressively worsening symptoms over 6 months
B. Endometriosis B. Menorrhagia
C. Polycystic ovaries C. A thick creamy white discharge
D. Meig’s syndrome D. Red plaques in the vulval area
E. Subserous fibroids E. Fused labia
41. The following should be performed in the assessment 48. The following are important in the management of a
of all patients with abnormal vaginal bleeding: woman with pruritus vulvae:
A. Eliciting a menstrual history A. Administering antibiotics
B. Coagulation studies B. A speculum examination of the cervix and smear
C. High vaginal swab test
D. Thyroid function tests C. All women should be seen in colposcopy clinic
E. Abdominal X-ray D. Excision of the area of the discomfort
E. An abdominal X-ray
42. A 55-year-old woman presents with a 3-day mild
vaginal bleed. Her last menstrual period was at the age 49. The following are possible methods of investigation of
of 52 years. The following would be appropriate with vulval disease:
regards to differential diagnosis and subsequent A. CRP
management: B. Biopsy of vulva
A. The most likely cause is atrophic vaginitis so no C. Ultrasound scan
further action is required D. Hysteroscopy
B. An ultrasound scan would be appropriate E. Endocervical swabs
C. A hysteroscopy should be performed
D. A full blood count should be taken 50. The following are correct about lichen sclerosis:
E. A normal pipelle excludes endometrial A. The vulval skin always appears white
carcinoma B. Skin biopsy shows thinning of the epidermis
C. A biopsy is not necessary as the diagnosis is usually
43. Which of these are the possible symptoms caused by a obvious
3 cm submucosal fibroid: D. Surgical excision is first-line treatment
A. Hirsutism E. A short course of antibiotic treatment is usually
B. Subfertility required
C. Detrusor instability
D. Deep vein thrombosis 51. A multiparous 55-year-old woman presents with a
E. Dysmenorrhoea 6-month history of stress incontinence on coughing
and sneezing:
44. What are the commonly associated complications of A. She therefore has ‘genuine stress incontinence’
fibroids in pregnancy: B. An obstetric history is unhelpful in making the
A. Diabetes diagnosis
B. Chorioamnionitis C. A bimanual pelvic examination is always
C. Malpresentation diagnostic
D. Intrauterine growth restriction D. A midstream sample of urine may help in
E. Pre-eclampsia making the diagnosis
E. Urodynamic studies are unnecessary
45. Which of these are common sites for endometriotic
deposits: 52. A 26-year-old woman complains of recurrent
A. Pouch of Douglas episodes of frequency, urgency and nocturia:
B. Fallopian tube A. A neurological history is important
C. Femur B. The likely cause is detrusor overactivity
D. Scars C. A pelvic examination will usually show an
E. Lungs abnormality
238
Single best answer questions (SBAs)
D. A high vaginal swab is mandatory to exclude 60. Which of the following is NO T a risk factor for
infection gestational diabetes?
E. Prolapse is usually found on examination A. Body Mass Index > 30 kg/ m 2
B. South Asian origin
53. Effective treatments for genuine stress incontinence in C. Family history of Type 2 diabetes in a first degree
women wanting more children include: relative
A. Pelvic floor exercises D. Previous gestational diabetes
B. Anticholinergics E. Husband with Type 2 diabetes
C. Behaviour therapy
D. Tension free vaginal tape 61. When should an amniocentesis be performed?
E. Antibiotics A. Before 12 weeks
B. After 15 weeks but before 19 weeks
54. Effective treatments for detrusor instability include: C. After 20 weeks
A. Pelvic floor exercises D. After 12 weeks but before 13 weeks
B. Antimuscarinics E. After 15 weeks
C. Colposuspension
D. Treating chlamydia 62. A 22 year old woman with a history of drug misuse
E. Myomectomy presents to the Labour Ward at 26 weeks gestation
with a 6 hour history of constant abdominal pain and
55. The following are possible causes of precocious puberty: some vaginal bleeding. What is the most likely
A. Congenital adrenal hyperplasia diagnosis is?
B. Hyperprolactinaemia A. Symphysis pubis dysfunction
C. Hypothyroidism B. Preterm labour
D. Turner’s syndrome C. Uterine fibroid degeneration
E. Cystic fibrosis D. Placental abruption
E. Acute fatty liver of pregnancy
56. Which of these drugs can cause hirsutism: 63. A 34 year old woman is seen in antenatal clinic
A. H2 antagonists, e.g. cimetidine complaining of 2 weeks of lower abdominal
B. Prednisolone discomfort. O n further questioning, she has no urinary
C. Combined oral contraceptive pill symptoms or vaginal discharge but is passing hard
D. Penicillin stools. What is the most likely diagnosis?
E. Progestogens A. Peptic ulcer disease
B. Ligament pain
57. An 18-year-old girl presents with a history of C. Constipation
primary amenorrhoea. The following conditions D. O varian cyst rupture
usually present in this way: E. Cystitis
A. Fibroids
B. Testicular feminization 64. A 26 year old woman with no medical or
C. Premature ovarian failure gynaecological history of note presents with a history
D. Polycystic ovarian syndrome (PCO S) of fresh vaginal bleeding within the last 12 hours. O n
E. Lichen sclerosis further questioning, the bleeding started after sexual
intercourse. What is the most likely diagnosis?
58. A 40 year old primiparous woman attends antenatal A. Cervical polyp
clinic at 12 weeks gestation. She has a history of B. Vulval varicosities
essential hypertension, with a family history of multiple C. Cervical ectropion
pregnancy. She is allergic to penicillin. Which factor in D. Cervical carcinoma
her history is the most important in the antenatal risk E. Vaginitis
assessment?
A. Maternal age 40 65. Ultrasound scan is useful in the diagnosis of which of
B. Primiparity the following causes of antepartum haemorrhage?
C. Essential hypertension A. Cervical polyp
D. Family history of multiple pregnancy B. Vasa praevia
E. Allergy to penicillin C. Circumvallate placenta
D. Placental abruption
59. Which of the following is not a routine booking E. Placenta praevia
investigation?
A. Full Blood Count 66. In a low risk primiparous woman, which of the
B. Blood Group following indications necessitates continuous fetal
C. Hepatitis B status monitoring in labour?
D. High Vaginal Swab A. Irregular contractions
E. Urine Microscopy, Culture and Sensitivity B. Mucoid show
239
Single best answer questions (SBAs)
240
Single best answer questions (SBAs)
78. A 19 year old woman attends the Labour Ward at B. Age > 35
28 weeks gestation with increasingly regular C. BMI> 30
tightenings every 10 mins. O n cervical assessment, D. Parity > 3
there is cervical effacement and dilatation of 1 cm. E. Age < 20
Which is your 1st line of management?
A. Urinalysis 85. Anaemia in pregnancy should be identified and treated
B. Administration of steroids where necessary. What levels of haemoglobin are
C. Liaising with the paediatric team acceptable at booking and at 28 weeks?
D. Tocolysis A. > 11.0 g/ dl at booking and > 10.5 g/ dl at
E. Caesarean section 28 weeks
B. > 11.0 g/ dl at booking and > 9.5 g/ dl at 28 weeks
79. In obstetric palpation, which factor is the most C. > 10.0 g/ dl at booking and > 10.5 g/ dl at
important for assessing progress in labour? 28 weeks
A. Symphysis-fundal height D. > 9.0 g/ dl at booking and > 11.g/ dl at 28 weeks
B. Fetal presentation E. > 7.0 g/ dl at booking and > 10.5 g/ dl at 28 weeks
C. Engagement
D. Fetal position 86. What three steps have been shown to reduce the
E. Liquor volume vertical transmission of HIV from mother to fetus?
A. Antibiotics, elective caesarean section and
80. In vaginal examination, which factor is the most breastfeeding
important for assessing progress in labour? B. Hand washing, vaginal delivery and steroids
A. Presence of caput C. Avoidance of breastfeeding, anti-retroviral
B. Presence of moulding medication (HAART), elective caesarean section
C. Fetal position D. Avoidance of intercourse, avoidance of
D. Cervical dilatation breastfeeding and antibiotics
E. Station E. Steroids, elective caesarean section and antibiotics
241
Single best answer questions (SBAs)
242
Ext e n d e d -m a t ch in g q u e st io n s
(EM Q s)
F. O varian torsion
1. Bleeding in the second and third G. Pre-eclampsia
trimesters of pregnancy: H. Urinary tract infection
I. Gallstones
A. Molar pregnancy
J. Labour
B. Vasa praevia
C. Ectopic pregnancy For each of the clinical findings below, select the patholog-
D. Placenta praevia ical process most likely to account for them from the list of
options given above. Each option may be used once, more
E. Placental abruption
than once, or not at all.
F. Cervical ectropion
G. Retained placenta 1. O n abdominal palpation, hard tender uterus, difficulty
H. Vaginal tear defining the fetal parts.
2. Nitrites on urinalysis.
I. Uterine atony
3. Regular contractions palpated on abdominal
J. Cervical tear examination, cervical change on vaginal
For each scenario described below, choose the single examination.
most likely diagnosis from the list of options given above. 4. The uterus palpates large-for-dates, with tenderness
Each option may be used once, more than once, or not elicited over a specific site.
at all. 5. The patient is hypertensive and hyperreflexic, with
tenderness over the right hypochondrium.
1. A 35-year-old woman, who has had two previous
caesarean sections, presents with vaginal spotting and
a transverse lie at 35 weeks.
2. A 22-year-old woman has artificial rupture of 3. Stillbirth:
membranes during labour and there is heavy vaginal
A. Maternal ALT¼ 60 iu/ L
bleeding in association with an abnormal CTG. The
uterus is soft and non-tender. B. Maternal HbA1c ¼ 15%
3. A 28-year-old woman has a history of 16 weeks C. Fetal Hb ¼ 3 g/ dL, positive Coombs test
amenorrhoea. She has severe nausea and vomiting. D. Parvovirus IgM positive, IgG negative
O n abdominal palpation the uterus is 24 weeks in size. E. Maternal rubella IgG positive
No intrauterine sac can be seen on ultrasound scan. F. 24-hour urinary protein 2.1 g/ L
4. A 32-year-old woman is 28 weeks pregnant. She has a
G. Fetal karyotype 47XY
2-hour history of vaginal bleeding. She also complains
H. Fetal karyotype 45XO
of a headache and constant abdominal pain. O n
I. 24-hour urinary protein 0.2 g/ L
examination, the uterus is firm and tender.
5. A 30-year-old woman presents with a post-coital
The conditions below are the underlying diagnoses of
bleed at 22 weeks’ gestation. causes of stillbirth, made on the basis of investigations per-
formed soon after delivery
For each of the diagnoses below, match the test result from
2. Abdominal pain in the second and the list of options given above. Each option may be used
third trimesters of pregnancy: once, more than once, or not at all.
244
Extended-matching questions (EMQ s)
7. Hypertension in pregnancy:
8. Maternal collapse:
A. Pregnancy induced hypertension (PIH)
B. Pre-eclampsia A. Placental abruption
For each scenario described below, choose the single most For each scenario described below, choose the single most
likely diagnosis from the list of options given above. Each likely diagnosis from the list of options given above. Each
option may be used once, more than once, or not at all. option may be used once, more than once, or not at all.
1. A 19-year-old primigravida booked with a blood 1. A 25-year-old woman was found collapsed at home at
pressure of 90/ 60 mmHg at 12 weeks. She had an 8 weeks gestation. Her past history includes a deep
uneventful pregnancy until 38 weeks’ gestation, when vein thrombosis at the age of 18 years following which
she presented with swelling of the lower legs. Her BP she was found to carry the Factor V Leiden mutation.
was noted to be 160/ 95 mmHg and urinalysis revealed 2. A 26-year-old woman underwent a caesarean section
þ þ proteinuria. in her first pregnancy for fetal distress. This current
2. A 39-year-old primigravida books at 13 weeks’ pregnancy was uneventful and she went into
gestation. Her blood pressure was 150/ 90 mmHg at spontaneous labour. She requested an epidural for
booking and there was no proteinuria. She was started analgesia. At 7 cm dilatation she felt unwell and
on methyldopa 500 mg t.d.s which maintained her BP collapsed at the same time that the fetal heart rate
within the normal range for the rest of the pregnancy. pattern became bradycardic.
3. A 25-year-old primigravida books at 16 weeks’ 3. A 34-year-old grand multiparous woman presented to
gestation with a BP of 155/ 95 mmHg. She has a the labour ward at 34 weeks gestation having
history or ureteric reflux and recurrent UTIs as a child experienced a small APH at home. By the time she
245
Extended-matching questions (EMQ s)
arrived she was experiencing severe abdominal pain. examination, the fetal head is not palpable
Abdominal examination revealed a tender, hard uterus abdominally, the vertex is at þ 1 below the ischial
and the fetal heart could not be heard with the spines in the right occipito-transverse position with no
sonicaid. During the examination she collapsed and caput or moulding. The CTG is normal.
was unresponsive.
4. An unbooked woman was admitted via ambulance
10. Complications of labour:
unconscious. The only history available is that she was
feeling unwell for the previous few days with A. Failure to progress
headaches and had collapsed at home ‘shaking’. O n B. Meconium-stained liquor
examination, she was unconscious, her BP was 180/ C. Placental abruption
110 mmHg and urinalysis revealed proteinuria. D. Post-partum haemorrhage
5. A 35-year-old multiparous woman spontaneously
E. Cord prolapse
ruptured her membranes at term in her third
F. Ruptured uterus
pregnancy. 48 hours later she went into labour and
G. Uterine hyperstimulation
had a normal delivery. She went home after 6 hours.
72 hours later she started feeling unwell and feverish. H. Shoulder dystocia
She collapsed at home and was brought into hospital I. Face presentation
by ambulance. O n examination she was unconscious J. Fetal bradycardia
with central cyanosis. Her temperature was 39 C,
For each scenario described below, choose the single most
pulse 120 beats per minute and she was profoundly
likely diagnosis from the list of options given above. Each
hypotensive. option may be used once, more than once, or not at all.
246
Extended-matching questions (EMQ s)
12. Complications of the antenatal 1. Vaginal bleeding more than 500 ml from 24 hours
period: post delivery up to 6 weeks.
2. 2 weeks after delivery, a primiparous patient
A. O bstetric cholestasis complains of low mood and feeling unable to cope
B. Gestational diabetes with caring for her baby.
C. Recurrent antepartum haemorrhage 3. 2 weeks after delivery, a primiparous patient
D. Symphysis pubis dysfunction complains that she cannot sleep because she is worried
E. Iron deficiency anaemia a neighbour is trying to take her baby. O n further
questioning with her partner, the neighbour has
F. Intrauterine growth restriction
simply been offering to help with babysitting.
G. Pyelonephritis 4. 6 days after emergency caesarean section, a patient
H. Preterm labour complains of increasingly constant severe lower
I. Preterm ruptured membranes abdominal pain. The lochia are offensive-smelling. O n
J. Deep vein thrombosis examination, the patient is pyrexial and the uterus is
tender.
For each scenario described below, choose the single 5. After a prolonged labour and delivery with epidural
most likely diagnosis from the list of options given above.
anaesthesia, a patient complains of being unable to sit
Each option may be used once, more than once, or not
at all. upright because of a severe headache.
247
Extended-matching questions (EMQ s)
I. Placenta accreta
J. Uterine inversion 16. Multiple pregnancy:
For each scenario described below, choose the single most A. Consultant-led hospital care
likely diagnosis from the list of options given above. Each B. Chorionicity
option may be used once, more than once, or not at all.
C. Homebirth
1. The patient has had a forceps delivery with an D. Intra-uterine growth restriction
episiotomy after a prolonged labour. O n examination, E. Postpartum haemorrhage
the episiotomy has extended into the external anal F. Zygosity
sphincter and the patient is bleeding heavily from the G. Multiple fetal pregnancy reduction
area. H. Primiparity
2. The patient has just had a normal vaginal delivery of a
I. Maternal age > 40 years
twin pregnancy. She is bleeding heavily.
J. Twin-to-twin transfusion syndrome
O n examination, the uterine fundus is above the
umbilicus and poorly contracted. For each statement below, choose the single most appropri-
3. A woman has previously had two caesarean sections. ate option from the list given above. Each option may be
At the time of caesarean section in this pregnancy, the used once, more than once, or not at all.
placenta was morbidly adherent to the uterine wall.
4. Bleeding more than 500 mLwithin the first 24 hours of 1. The most important factor in defining the risks
delivery of the baby. associated with different types of twin pregnancy.
5. At the time of controlled cord traction in the 3rd stage of 2. An essential part of counseling a couple with higher
labour, the patient suddenly complains of severe order multiple pregnancies such as triplets, in order for
abdominalpain and bleeding. The uterine fundus cannot informed decisions regarding possible birth outcomes.
be palpated on abdominal examination. 3. A complication of 15% of monochorionic
pregnancies.
4. The appropriate location for care of any multiple
15. Large-for-dates and small-for- pregnancy.
dates: 5. A risk factor in any multiple pregnancy which must be
monitored by regular growth scans.
A. Gestational diabetes
B. Gestational trophoblastic disease
C. Placental insuffiency
D. Twin pregnancy 17. Antenatal investigations:
E. O esophageal atresia A. Serum electrophoresis
F. Renal agenesis B. Serum antibody screen
G. Uterine fibroid C. Rubella
H. Trisomy 18 D. Toxoplasmosis
I. Cytomegalovirus infection E. Hepatitis B
J. Maternal ovarian cyst F. Glycosylated haemoglobin
G. Blood glucose level
For each scenario described below, choose the single most
likely diagnosis from the list of options given above. Each H. HIV
option may be used once, more than once, or not at all. I. Hepatitis C
J. Urea and electrolytes
1. Fetal ultrasound scan at 20 weeks shows
anhydramnios. For each scenario described below, choose the single most
2. Persistant glycosuria with a macrosomic fetus on likely test from the list of options given above. Each option
ultrasound scan. may be used once, more than once, or not at all.
3. IVF pregnancy with a symphysio-fundal height at the
umbilicus at 14 weeks’ gestation. 1. Check the result of this test if a patient appears to have
4. Maternal history of chronic hypertension measuring a microcytic anaemia.
small-for-dates at 30 weeks’ gestation. 2. This test should be performed at booking in a patient
5. An Afro-Caribbean woman who measures large-for- with established diabetes since it is associated with
dates at 20 weeks’ gestation. the risk of congenital malformations.
248
Extended-matching questions (EMQ s)
249
Extended-matching questions (EMQ s)
250
Extended-matching questions (EMQ s)
251
Extended-matching questions (EMQ s)
For each scenario described below, choose the single most 29. Pruritus vulvae:
likely diagnosis from the list of options given above. Each
option may be used once, more than once, or not at all. A. Candidal infection
B. Contact dermatitis
1. A 55-year-old multiparous woman presents with a 6- C. Lichen sclerosus
month history of loss of urine on coughing and
D. Carcinoma of the vulva
bending. Urodynamic investigations show no
E. Herpetic lesion
evidence of detrusor instability.
2. A 26-year-old woman presents with a 5-day history of F. Psoriasis
worsening urinary frequency, nocturia and dysuria. G. Vulval intraepithelial neoplasia
Urinary testing indicates the presence of leukocytes. H. Enterobius
3. A 60-year-old woman presents with a 6-week history I. Trichomonas vaginalis
of urgency nocturia and urge incontinence. J. Bechets syndrome
4. A 30-year-old woman, 6 weeks postpartum and
recently arrived from Somalia, gives a history of For each scenario described below, choose the single most
continually feeling damp ‘down below’. likely diagnosis from the list of options given above. Each
5. A 52-year-old woman presents with a 6-week history option may be used once, more than once, or not at all.
of hot flushes, sweats and vaginal dryness and urinary
1. A 65-year-old presents with pruritus vulvae. She has
frequency.
noticed a lump growing on the vulva for the last
6 months. Examination confirms an ulcerated, hard,
28. Primary amenorrhoea: raised lesion 1 cm in diameter.
A. Haematocolpos 2. A 16-year-old has recently become sexually active.
She complains of intense pruritus vulvae associated
B. Androgen insensitivity syndrome
with an offensive discharge with a fishy odour. O n
C. Hypothalamic hypogonadism
examination she has a marked vulvo-vaginitis and a
D. Constitutional amenorrhoea
frothy greenish vaginal discharge.
E. Late-onset congenital adrenal hyperplasia 3. A 60-year-old presents with intermittent episodes of
F. Anorexia nervosa pruritus vulvae. O n examination the labia have fused,
G. Premature ovarian failure the tissues are thin and leukoplakia is present.
252
Extended-matching questions (EMQ s)
4. A 35-year-old has developed pruritus vulvae since For each scenario described below, choose the single most
changing her soap and bubble bath. Examination likely treatment from the list of options given above. Each
reveals vulvitis with no discrete lesion visible. option may be used once, more than once, or not at all.
5. A 42-year-old develops an itchy lesion of the left
1. A 49-year-old woman who is para 9 presents with
vulva. Examination reveals an erythematous plaque on
heavy periods and a genital prolapse. Her GP has
the left labium majora and scaly plaques on her
treated her with mefenamic acid with some
elbows.
improvement. The prolapse is interfering with her sex
life. O n examination she has a bulky uterus with
desent and the cervix is protruding through the vaginal
30. Gynaecological definitions: introitus.
2. A 24-year-old nulligravid woman presents with a short
A. Postmenopausal bleeding history of irregular heavy periods. She is otherwise
B. Menorrhagia fit and well with no significant family history. She
C. Total abdominal hysterectomy has just started a new relationship and is currently
D. Sub-total abdominal hysterectomy using condoms as contraception. Examination is
normal.
E. Endometriosis
3. A 39-year-old woman has had a 6-year history of
F. Threatened miscarriage
heavy periods. Tranexamic acid has not helped. She
G. Inevitable miscarriage had a Mirena IUS fitted by the GP 6 months ago, but is
H. Total abdominal hysterectomy and bilateral salpingo- still getting erratic and prolonged bleeding. She has a
oophorectomy family history of thrombo-embolism and does not
I. Intermenstrual bleeding
want any more children. Pelvic examinations normal.
J. Pelvic inflammatory disease 4. A 41-year-old woman has a 10-month history of heavy
periods associated with iron deficiency anaemia.
For each scenario described below, choose the single most
Hysteroscopy reveals a 3 cm submucous fibroid.
likely definition from the list of options given above. Each
5. A 48-year-old woman has had a long history of heavy
option may be used once, more than once, or not at all.
periods. O ne year ago she underwent an endometrial
1. The loss of more than 80 mL blood per period ablation, which has not improved her periods
2. The surgical removal of the uterus and the cervix significantly. She has a strong family history of ovarian
through via laparotomy cancer. Her uterus is enlarged to the equivalent of a
3. The presence of functioning endometrium outside the 12 weeks’ gestation.
uterine cavity
4. Vaginal bleeding in pregnancy before 24 weeks’
gestation 32. Gynaecological investigations:
5. Vaginal bleeding occurring more than 1 year after the
last period A. Pelvic ultrasound scan
B. Abdominal X-ray
C. Urodynamics investigation
D. Hysterosalpingogram
31. Treatment of heavy periods:
E. Hysteroscopy
A. Mefenamic acid F. Laparoscopy
B. Tranexamic acid G. Laparotomy
C. Combined oral contraceptive pill H. Hysterosonography
D. Mirena inter-uterine system I. MRI scan
E. Endometrial ablation J. Lateral X-ray pelvimetry
F. Vaginal hysterectomy
G. Total abdominal hysterectomy For each scenario described below, choose the single most
relevant investigation from the list of options given above.
H. Sub-total abdominal hysterectomy Each option may be used once, more than once, or not at all.
I. Total abdominal hysterectomy and bilateral salpingo-
oophorectomy 1. A woman is referred to the gynaecologist for removal
J. Hysteroscopic myomectomy of her IUCD. She reports that when it was inserted
253
Extended-matching questions (EMQ s)
she experienced a lot of pain. O n examination the 5. A 39-year-old woman notices headaches, a change in
IUCD strings were not visible. An ultrasound scan of her peripheral vision when driving and milky nipple
the pelvis showed no evidence of the IUCD in the discharge. Pregnancy test is negative.
uterine cavity.
2. A 63-year-old woman presents with postmenopausal 34. Treatment for gynaecological
bleeding. She is not taking HRT and clinical
disorders:
examination is normal.
3. A 23-year-old woman presents with a history of A. Blood transfusion
secondary dysmenorrhoea and deep dyspareunia. B. Metronidazole
Clinical examination reveals pelvic tenderness and an C. Corticosteroids
ultrasound scan of the pelvis is normal.
D. Tranexamic acid
4. A 55-year-old woman presents with frequency and
urgency of micturition and having to get up at night E. O ral contraceptive pill
many times. She also notices that she leaks urine if she F. Endometrial ablation
coughs or sneezes or does not get to the lavatory G. Mirena coil
quickly enough. A mid-stream specimen of urine is H. Myomectomy
negative on culture. I. Transcervical resection of fibroids
5. A 35-year-old woman and her husband present with J. Total abdominal hysterectomy and bilateral salpingo-
2 years’ subfertility. Semen analysis is normal and a oophorectomy
day-21 progesterone suggests ovulation.
For each scenario described below, choose the single most
likely diagnosis from the list of options given above. Each
option may be used once, more than once, or not at all.
254
Extended-matching questions (EMQ s)
For each scenario described below, choose the single most tachycardic (pulse 104 beats/ min), has reduced skin
relevant management plan from the list of options given turgor and some epigastric tenderness. An ultrasound
above. Each option may be used once, more than once, scan shows 2 fetal heartbeats.
or not at all. 2. Miss M, a mother of 2 children, is 9 weeks pregnant
1. A 24-year-old woman complains of weight gain over and complaining of a 2 day history of heavy PVB and
the last 5 months with intermittent lower abdominal suprapubic pain. She had a scan 1 week ago and a fetal
pain. She cannot remember the exact date of her last heartbeat was seen. Her observations are stable. She is
period. afebrile, mildly tachycardic and anxious. The bleeding
2. A 19-year-old woman presents with a history of has now settled and the cervical O s is closed.
irregular periods and hirsutism. Her BMI is 33. Urinanalysis shows haematuria and a positive
3. A 64-year-old woman presents to Accident and pregnancy test. An ultrasound scan showed multiple
Emergency with a history of a heavy menstrual bleed. ‘hyperechoeic areas’ within the endometrium.
She is not on hormone replacement therapy and 3. A 37 year old woman presents with vaginal bleeding at
underwent the menopause at the age of 55. 7 weeks, 3 days’ gestation. This is her first pregnancy.
4. A 32-year-old woman presents with severe abdominal She noticed bright red par vaginum (PV) spotting for
pain with some vaginal bleeding. Her heart rate is the last 5 days. She has also been complaining of
108 bpm and blood pressure is 70/ 40. She is lying flat excessive vomiting, struggling to keep food or fluids
and unable to move because of the pain. Pregnancy down. O n examination her abdomen is soft and non-
test is positive. tender. Speculum reveals a normal closed cervix with a
5. A 37-year-old woman presents with a two year history small amount of fresh blood in the posterior fornix.
of deep dyspareunia. She has not changed her partner Bimanually the uterus feel bulky and soft,
and a STI screen has been reported as normal. She has approximately 14 weeks size. There is no cervical
previously been treated for chlamydia and has had excitation or adenexal tenderness or masses. BP 110/
two caesarean sections. 70mmHg, Pulse¼72/ min. TV USS shows ‘bunches of
grapes’ appearance.
4. A 21 year old woman presents to the A&E department
with a 4 hour history of abdominal pain, initially in the
36. Early pregnancy complications: lower abdomen but now generalized. She feels
A. Inevitable miscarriage nauseous, dizzy and constipated. She has not had any
B. Molar pregnancy vaginal bleeding or discharge. She was treated for
C. Ectopic pregnancy Chlamydia 2 years ago which was diagnosed when she
D. Retained products of conception attended for a surgical termination of pregnancy. She
cannot recall her LMP – she thinks it was 5 weeks ago.
E. Recurrent miscarriage
She has a positive pregnancy test today. BP 94/
F. Heterotopic pregnancy
52mmHg, Pulse 120 b/ min. On examination, her
G. Possible normal pregnancy
abdomen is rigid with guarding and generalized rebound
H. Septic miscarriage tenderness. She is pale, clammy and looks unwell.
I. Threatened miscarriage 5. Miss Smith is 13 weeks gestation and has presented to
J. Complete miscarriage the accident and emergency department with a 2 day
K. Hyperemesis gravidarum history of lower abdominal pain, diarrhoea, vomiting
and offensive, brownish PV discharge. She is a single
For each scenario described below, choose the single mother with a 4 year old son who is recovering from
most likely diagnosis from the list of options given above.
tonsillitis. She is febrile and tachycardic. She has
Each option may be used once, more than once, or not at all.
uterine tenderness on palpation and USS shows no FH.
1. A 40-year-old executive has conceived with IVF and is
currently 10 weeks gestation. She has been referred by
her GP complaining of a 2 week history of feeling 37. Contraception, sterilization and
unwell, lethargic and dizzy. The GP referral letter unplanned pregnancy:
mentions significant ‘ketonuria’. You see her in the
Accident and Emergency and she explains that her GP A. Combined oral contraception
had been giving her oral medication but now is unable B. Mirena
to tolerate this. O n your assessment, she is mildly C. Progestogen only pill
255
Extended-matching questions (EMQ s)
256
Extended-matching questions (EMQ s)
257
This pa ge inte ntiona lly le ft bla nk
SBA a n sw e rs
1. C. Patients should only take HRT if clinically indicated. 16. C. Brenner tumours can secrete oestrogen, causing
2. D. Transdermal patches provide both oestrogen and irregular vaginal bleeding.
progesterone. 17. E. All the other options are not specific to
3. D. Clonidine is a useful second line agent for hot malignancy and may be seen in cases of sepsis.
flushes. Cachexia is more specific to malignancy and other
4. B. 84% of couples will conceive within one year if the catabolic states.
woman is under 40 years old and they have regular 18. B. An ectropian is not pathological. It is simply an
unprotected sexual intercourse. extension of endocervical columnar epithelium,
5. E. Varicose veins of the legs do not affect fertility. which bleeds easily, onto the ectocervix and is
6. C. It is important to exclude infections such as common in pregnancy due to the influence of
Chlamydia, which can lead to secondary infertility. oestrogen. No treatment is necessary unless a
7. E. Endometriosis may increase CA125 levels, and most co-existing infection is proven.
commonly affects the ovaries, pouch of douglas, 19. B. The thick, white discharge of Candida infection has
uterosacral ligaments and ovarian fossae. However, a typical appearance of ‘cottage cheese’ noted on
it does not increase the risk of cervical cancer. speculum examination. It is treated easily with
8. D. RMI is calculated by multiplying the CA125 level by Clotrimazole pessary or cream.
menopausal status and ultrasound score. 20. E. A detailed sexual history is imperative to exclude
9. C. Hysteroscopy and Biopsy is important to visualise sexually transmitted infections.
the endometrial cavity and obtain a tissue sample 21. D. Most common organisms held responsible for PID
to exclude endometrial cancer. are Chlamydia and Gonorrhoea neisseria, both
10. C. All the other options are not specific to sexually transmitted infections. Hence any history
endometriosis. Nodular deposits in the posterior of previous STI would predispose a patient to PID.
fornix are highly suggestive of endometriosis and 22. C. This describes Bacterial vaginosis, which is treated
should be sought at speculum examination and with a course of antibiotics (metronidazole).
digital vaginal examination within the context of a 23. D. Although described as a gold standard investigation
consistent clinical history. for making the diagnosis of PID – it is not the first-
11. C. All the other options are recognized features of line investigation in view of surgical risks. There are
several differential diagnoses, e.g. PCO S, PID. less invasive, effective alternatives available as listed
Cyclical pelvic pain is unique to endometriosis, above. The aim should be to effectively diagnose
reflecting the hormonal influence of the menstrual and treat PID without going into the operating
cycle on disease activity. theatre, unless it is absolutely necessary, e.g.
12. E. Although all the other options have these symptoms, diagnosis not clearly defined (possibility of ectopic
an ectopic pregnancy is relatively more common and pregnancy/ appendicitis), clinical condition
a life-threatening condition that must be ruled out deteriorating, failed initial medical management.
first. Always work on the assumption that all women 24. C. Vulval pruritis is not characteristically associated
of child-bearing age with pelvic pain have an ectopic with PID.
pregnancy until proven otherwise. The presence of 25. C. Diarrhoea is not a recognized risk factor for genital
cervical excitation suggests peritonism, which makes prolapse. Constipation is. O ptions B & E cause
the diagnosis most likely. prolonged periods of raised intra abdominal pressure
13. B. Cyclical pelvic pain is characteristic of endometriosis. hence risk of prolapse. O ptions A & D cause laxity in
14. D. It is essential to rule out ectopic pregnancy in the the pelvic floor supporting the pelvic organs.
first instance in a woman of child-bearing age with 26. D. Vaginal pessaries can be used as definitive
an acute abdomen. O ther possible gynaecological management or as a temporary measure by
differentials include miscarriage, sepsis or cyst patients on an elective waiting list for surgery. They
accident/ haemorrhage. can remain in situ for up to 6 months before they
15. A. Risk of malignancy index is an important tool used need to be changed.
to triage women with ovarian cysts to the most 27. E. None of the other options indicate deficiency in
appropriate place for further investigation and the posterior vaginal wall. Management will
management. depend on the severity and impact on the patient’s
259
SBA answers
quality of life, as well as patient’s choice. indicated. Direct insertion of the trocar is possible
Sometimes reassurance and a good explanation of by dissection under direct vision. A diathermy is not
this benign condition is all that is required. usually required for diagnostic laparoscopy.
28. A. Patients will often present with urinary symptoms 39. C. Ultrasound gelto allow transmission of sound waves.
in association with the prolapse. These can include A full bladder is only required for transabdominal
voiding difficulty and recurrent UTIs. ultrasound. Bowel preparation is not a usual
29. B. The IUCD is the ideal form of emergency requirement and the procedure does not usually
contraception here, as it not only prevents a third cause discomfort. As ultrasound relies on sound
unplanned pregnancy, but also can remain in situ waves and not light, a light source is not required.
as an effective contraception for a further 5 years. 40. A. Endometrial polyps can be diagnosed during a
It can be inserted upto 120 hours (5 days) after the routine hysteroscopy. These have a typical polypoid
earliest episode of unprotected sexual intercourse. appearance. By definition, endometriosis is aberrant
30. D. This is the best option for a woman in stable uterine tissue lying outside of the uterine cavity and,
relationship who specifically wants to avoid therefore, will not be seen on hysteroscopy.
hormonal contraception. Trained practitioners are Polycystic ovaries and the peritoneal fluid/ pleural
required to insert the coil. Since she has never effusions and benign ovarian tumours of Meigs’
been pregnant, a narrow cervical canal may syndrome cannot be seen via hysteroscopy. Sub-
impede the smooth transit of the copper coil mucous fibroids can be diagnosed via hysteroscopy,
into the uterus causing some discomfort and but subserous fibroids cannot.
requiring local anaesthetic. 41. A. A menstrual history is essential in a patient with
31. C. Interestingly this is the same risk quoted when abnormal bleeding. Coagulation studies should
counselling women who want to use Levonorgestrel only be performed if a clotting disorder is
(Mirena). IUS which avoids surgery altogether and suspected. Although useful in investigating
has the added advantage of being reversible and intermenstrual and post-coital bleeding, a high
making menstrual periods lighter. vaginal swab is not clinically indicated in
32. E. It is vitally important that a detailed history and menorrhagia. Thyroid function tests are not an
pregnancy test is taken prior to commencing any essential part of the routine work up for the
contraception. investigation of abnormal periods unless other
33. B. Molar pregnancy is a histological diagnosis. symptoms suggest a thyroid disorder. An
34. E. PV bleeding in early pregnancy with a closed cervix abdominal X-ray is not usually required for
(threatened miscarriage) is managed investigation of abnormal genital tract bleeding.
conservatively. Cause is not known – there is some Caution should be exercised if one is ordered as the
suggestion that undiagnosed marginal placental patient could be pregnant.
bleeds are responsible. 42. B. An ultrasound scan is the standard investigation for
35. D. History of late miscarriages, previous (repeat) postmenopausal bleeding for endometrial
cervical surgery are risk factors for cervical thickness. Action is always required for
weakness. If there is a high clinical suspicion of postmenopausal bleeding. Hysteroscopy should
cervical weakness patients can have serial cervical only be performed if clinically indicated or if
length measurements in pregnancy. ultrasound reveals pathology. A full blood count is
36. C. The progesterone-only pill is a recognized only indicated in a symptomatic patient or heavy
aetiological factor of ectopic pregnancy, not bleeding. A pipelle sample of the endometrium is
combined oral contraceptive pill. reassuring, but does not absolutely exclude
37. B. A light source is essential to view the inside of the malignancy.
uterine cavity. Not all patients need to have an 43. B. A 3 cm submucosal fibroid may be the cause of due
ultrasound before undergoing hysteroscopy. The interference with implantation mechanism.
media used to distend the uterine cavity include Fibroids are not associated with hirsutism. They
normalsaline or glycine. Distilled water is not normally may press on the bladder leading to urinary
used. Outpatient hysteroscopy under local an- frequency or stress incontinence, not detrusor
aesthesia is possible. There is no need to catheterize – instability. Subserous or large submucosal fibroids
it does not facilitate insertion of telescope. may cause deep vein thrombosis. Fibroids may
38. D. A pregnancy test must be performed prior to cause menorrhagia, but are not associated with
undertaking a laparoscopy or hysteroscopy. CO 2 , dysmenorrhoea.
rather than saline, is inserted into the peritoneal 44. C. Malpresentation can be due to obstruction by
cavity to avoid injury to organs and facilitate view. fibroid in the lower segment/ cervix. There is no
The bladder must be emptied to avoid injury to the association between fibroids and pre-eclampsia.
bladder, but an indwelling catheter is not Both fibroids and pregnancy may cause urinary
260
SBA answers
frequency, but there is no association between are essential to exclude detrusor overactivity as a
fibroids and chorioamnionitis. Intrauterine growth cause for the symptoms.
restriction and pre-eclampsia are not recognized 52. A. A neurological examination is important to exclude
complications of fibroids. causes such as multiple sclerosis. In this age group
45. A. The Pouch of Douglas is a common site common the likely diagnosis is sensory urgency where DO is
sites for endometriotic deposits. Fallopian tubes, absent. It is unlikely that a pelvic abnormality will be
femur, scars, lungs are all rare. found. A midstream urine will exclude a urinary tract
46. B. The combined oral contraceptive pill provides infection as the cause of the symptoms. Genital
ovulation suppression plus continuous prolapse is unlikely to be found in this scenario.
progestogenic activity. O varian drilling is a surgical 53. A. Pelvic floor exercises improve the tone of pelvic
intervention used to treat polycystic syndrome. floor muscles to prevent loss of urine.
Corticosteroids have no known benefits for Anticholinergics are indicated for detrusor
endometriosis. Tranexamic acid is used to treat instability to prevent involuntary muscle
menorrhagia. There are no known benefits for contraction. Bladder drills are used to treat detrusor
antibiotics in treating endometriosis. instability. Tension free vaginal tape may be used in
47. C. A thick creamy white discharge supports a women who have completed their families.
diagnosis of infection, possibly candida. An acute Antibiotics are only helpful for detrusor instability
onset, rather than progressively worsening caused by a urinary tract infection.
symptoms over 6 months suggests infection. There 54. B. Antimuscarinics to relax the detrusor muscle. Pelvic
is no association between menorrhagia and floor exercises are used to treat GSI.
pruritus vulvae. Red plaques in the vulval areas Colposuspension is indicated for GSI. Treating urine
suggest psoriasis or eczema. Fused labia suggest tract infections may improve detrusor instability,
lichen sclerosis. but pelvic infections do not affect detrusor
48. B. CIN is often associated with VIN. Antibiotics should instability. A myomectomy is performed to remove
only be prescribed where infection is found. fibroids. This may help relieve stress incontinence.
Women should be referred to colposcopy only 55. A. Congenital adrenal hyperplasia due to adrenal
where clinically indicated. Surgical intervention is hyperandrogenism. Hyperprolactinaemia causes
not common practice. Abdominal X-ray is not a amenorrhoea. Hypothyroidism, Turner’s syndrome
usual part of the routine work-up for pruritus and cystic fibrosis cause delayed puberty.
vulvae. 56. E. Most synthetic progestogens can have androgenic
49. B. Biopsy of vulva for histological diagnosis. CRP does side effects due to stimulation of androgen
not identify a cause, but provides a marker for receptors. H2 antagonists can cause
infective causes only. Ultrasound is not commonly gynaecomastia in men. Prednisolone, although a
used to investigate vulval disease; CT and MRI are steroid, is not associated with hirsutism. The
more sensitive when considering vulval combination of oestrogen and progesterone in the
malignancy. Hysteroscopy alone does not identify combined oral contraceptive pill counteract the
vulval pathology, but an examination under androgenic side effects of progesterone alone.
anaesthetic may. Endocervical swabs will exclude There is no link at all with progestogens!
endocervical infection only. 57. B. The genotype for testicular feminization is XY,
50. B. The epidermis is usually thin and hyalinized. Lichen therefore, by definition there is primary
sclerosis can appear as white or reddish plaques. A amenorrhoea. Fibroids cause menorrhagia.
skin biopsy is mandatory to exclude malignant Premature ovarian failure can occur at this age, but
change. 50% of symptoms of pruritus vulvae can it usually presents as secondary amenorrhoea.
recur following surgical excision. A long course of Polycystic ovary syndrome usually presents as
steroids is often required. secondary amenorrhoea. Lichen sclerosis is a vulval
51. D. A midstream urine sample will exclude a urinary skin condition, which does not cause primary
tract infection as the cause of the urinary amenorrhoea.
symptoms. The diagnosis of genuine stress 58. C. A history of essential hypertension is the most
incontinence can be made only in the absence of important factor since this, in conjunction with
detrusor overactivity on urodynamic investigation. a and b, increases the risk of developing
An obstetric history indicating traumatic deliveries pre-eclampsia.
of large infants would support a diagnosis of 59. D. There is currently no recommendation by the
genuine stress incontinence. O ccasionally, stress National Screening Committee to perform a high
incontinence can be due to pressure from a large vaginal swab at booking. However, it is currently
pelvic tumour, e.g. fibroid, ovarian cyst, but this being considered, in order to diagnose Group B
may not always be the case. Urodynamic studies Streptococcus infection.
261
SBA answers
60. E. The husband’s medical history is not relevant to his 73. C. Although a fetal chromosomal anomaly can be
partner’s risk of gestational diabetes. associated with low birth weight, the more
61. E. Amniocentesis can be performed from 15 to approx common reason for being small for dates in an
22 weeks, or possibly later in the pregnancy after Asian woman is constitutional. The standard
32 weeks. There is a 1% risk of miscarriage growth charts used in the UK are based on a
associated with the procedure. Caucasian population.
62. D. A placental abruption classically presents with 74. E. TTTS complicates 15% of monochorionic twin
vaginal bleeding associated with abdominal pain. It pregnancies. Therefore scans should be performed
can occur at any stage in pregnancy. It is associated every 2 weeks from 16 weeks. Stage 1 disease
with cigarette smoking and cocaine use. presents with discrepant liquor volumes.
63. C. The effect of increasing serum progesterone in 75. A. Due to the larger placental site in a multiple
pregnancy causes a slowing of gastrointestinal pregnancy, postpartum haemorrhage is more
motility, commonly resulting in symptoms such as common and therefore a prophylactic syntocinon
heartburn and constipation. infusion should be used for the third stage.
64. C. During pregnancy, the normal tube-like shape of 76. D. A 3 rd degree tear involves the external anal
the cervix everts to expose the columnar sphincter and may also involve the internal anal
epithelium within the cervical canal. This type of sphincter. A 4 th degree tear goes through to the
epithelium is prone to bleeding from pressure anal mucosa.
during intercourse. 77. E. Any intervention in labour, including amniotomy,
65. E. Placental abruption and vasa praevia are more has been shown to increase the risk of scar rupture.
commonly clinical diagnoses which necessitate Answers a-c are all indicated, whilst d is optional
urgent delivery rather than awaiting scans . A scan depending on the woman’s choice.
for placental location will diagnose placenta praevia 78. B. Although a-d are all part of the management plan,
and determine the grading, either major or minor. steroids should be given first since the woman
66. E. Provided the course of the pregnancy antenatally already appears to be in labour.
and during delivery has been normal, meconium- 79. C. Assessment of whether the widest diameter of the
stained liquor is the only indication given for presenting part has entered the pelvic brim is
continuous fetal monitoring. It can occur post-term essential in monitoring the progress of labour to
or it can be associated with fetal hypoxia. vaginal delivery.
67. A. In the absence of contraindications such as 80. E. All answers a-e are important in assessing progress
maternal hepatitis or HIV infection, or prematurity, in labour, but station is the most important – even
a fetal blood sample should be performed if fetal at full dilatation, vaginal delivery is not possible if
monitoring is diagnosed as pathological. the presenting part does not descend past the
68. B. Strength of contractions is determined by palpation ischial spines.
rather than electronic monitoring. The latter is 81. B. The history and examination findings suggest that
can assess the frequency of contractions. The this patient may have pre-eclampsia. This must be
other answers are determined by vaginal urgently investigated further with liver function
examination. tests, a platelet count, clotting studies and urine
69. D. Abduction of the mother’s legs is usually necessary protein quantification.
to allow delivery of the baby but this is not part of 82. D. Labetalol is recommended by NICE guidelines as
the mechanism that occurs with the maternal 1st line treatment for hypertension in pregnant
pelvis for delivery of the head. non-asthmatic patients.
70. A. It is not uncommon for uterine contractions to be 83. E. An international multicentre study (MAGPIE trial)
inco-ordinate in a primiparous labour resulting in recommended that magnesium sulphate should be
the need for augmentation with intravenous used in the immediate management of an
syntocinon. eclamptic seizure.
71. D. With the possibility of a big baby secondary to 84. E. O lder age, rather than younger age, is associated
gestational diabetes, the fetal head may not be with an increased risk of venous thromboembolism
engaged in the maternal pelvis until late in labour in pregnancy.
in this woman and therefore, there is a risk of cord 85. A. These indices are generally agreed as appropriate
prolapse at the time of amniotomy. If it occurs, it normal values for these gestations.
results in a fetal bradycardia. 86. C. These 3 factors have been proven to reduce HIV
72. B. External cephalic version is more likely to be vertical transmission, although with an
successful in a multiparous patient since the undetectable viral load, there is increasing
maternal abdominal wall muscles are usually more evidence that vaginal delivery has a similar risk to
relaxed. caesarean section.
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SBA answers
87. D. Folic acid 5 mg is recommended from pre- haemorrhage needs urgent treatment to improve
conception until 12 weeks gestation in order to the uterine contractility.
reduce the incidence of neural tube defects. 94. E. The key to diagnosis in this patient is the history of
O verall, fetal anomalies are increased in patients her unwell son – the patient should have a throat
with diabetes. swab sent to exclude Group A streptococcus
88. C. Vitamin K should be prescribed in the 3 rd trimester infection and appropriate antibiotics.
of pregnancy, usually from 36 weeks gestation and 95. C. The history, in conjunction with the positive
should be advised for the neonate. pregnancy test, are strongly suggestive of an
89. B. The history and the investigations, with the very ectopic pregnancy. The patient must be
high uric acid and hypoglycaemia, are in keeping resuscitated and taken to theatre urgently as this
with a diagnosis of acute fatty liver of pregnancy. may have ruptured requiring urgent
90. E. The history fits with a diagnosis of puerperal salpingectomy.
psychosis. Treatment should involve admission to a 96. B. The history and examination indicate a likely
mother and baby unit and antipsychotic placental abruption. The examination suggest
medication. severe internal bleeding - the patient needs
91. C. Although all the options are required to manage resuscitation and urgent transfer to theatre for
postpartum haemorrhage, the first, most important caesarean section.
step is to ensure that the woman’s airway (A), 97. C. The patient is likely to be having an eclamptic
breathing (B) and circulation(C) are intact and seizure. She needs urgent stabilisation when help
maintained. Make sure you are well acquainted the arrives.
ABC of basic resuscitation - the essential first 98. C. The leading cause of direct maternal death in
response in every emergency situation. 2006-08 was sepsis, in contrast to previous
92. A. Maintain a high index of clinical suspicion for reports which showed thromboembolic disease.
secondary PPH if a woman presents several weeks 99. D. Cardiac disease, a combination of congenital and
postpartum with heavy PV bleeding. Causes acquired, was the leading cause of indirect
include retained products of conception, maternal death.
endometritis and molar pregnancy or 100. B. The CMACEreport 2006-08 highlighted maternal
choriocarcinoma. deaths in the pueperium from Group A
93. E. The history is in keeping with uterine atony with the Streptococcus, and clinicians should be viligant
risk factors including a fiboid uterus, prolonged especially with a history of illness such as a sore
labour and a large baby. This primary postpartum throat in the patient’s other children.
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This pa ge inte ntiona lly le ft bla nk
EM Q a n sw e rs
1. 5.
1. D Placenta praevia. 1. A A long labour, the need for syntocinon augmentation
2. B Vasa praevia. and a big baby allpredispose to poor uterine contraction
3. A Molar pregnancy. after delivery leading to post-partum haemorrhage.
4. E Placental abruption. 2. C This multipara is predisposed to anaemia, which will
5. F Cervical ectropion. have been exacerbated by her blood loss at caesarean
section. The standing up has led to her fainting.
3. E Pregnancy, obesity and immobility are all risk factors
for thromboembolic disease.
2. 4. H This woman has developed chorioamnionitis, with
1. D Placental abruption. infection ascending up and around the baby,
2. H Urinary tract infection. producing a systemic illness. She needs antibiotic
3. J Labour. treatment and delivery.
4. A Fibroid degeneration. 5. G Hypertension and proteinuria raise suspicion of
5. G Pre-eclampsia. pre-eclampsia, which can rapidly deteriorate into an
eclamptic episode. Fits in pregnancy, even in those
previously labeled epileptic, should always be
3. suspected of being related to pre-eclampsia.
1. G A normal karyotype is 46XX or 46XY. This analysis
shows 47XY, indicating that the fetus is male and
has an extra chromosome – trisomy 21 is seen in 6.
Down’s syndrome. 1. C Position of the presenting part of the fetus.
2. F Proteinuria of greater than 0.3 g/ L is significant 2. H Antepartum haemorrhage.
and can point to a diagnosis of pre-eclampsia. 3. G Maternal mortality rate.
3. D Parvovirus infection can pass across the placenta and 4. I Labour.
cause fetal anaemia, leading to cardiac failure and 5. D Station of the presenting part of the fetus.
fetal death. Positive IgM and negative IgG confirms
recent infection.
4. A Transaminases are often raised in cholestasis, as are 7.
bile acids. However, the levels of liver function tests 1. B
Pre-eclampsia.
alone do not make the diagnosis, which must also be 2. D
Essential hypertension.
based on the clinical picture and the absence of 3. C
Hypertension secondary to renal disease.
hepatitis. 4. E
Essential hypertension with superimposed pre-
5. C Rhesus disease causes fetal haemolysis, and therefore eclampsia.
anaemia. Coombs test proves the presence of 5. J HELPP syndrome.
antibodies.
6. B This level of glycosylated haemoglobin indicates poor
control, which predisposes to congenital anomalies
8.
1. I Pulmonary embolism.
and intrauterine death.
2. C Uterine rupture.
3. A Placental abruption.
4. E Eclampsia.
4. 5. H Puerperal septic shock.
1. D Fetal macrosomia.
2. E Irregular contractions.
3. A Cervical fibroid. 9.
4. I Transverse lie. 1. D Fetal scalp electrode.
5. J Brow presentation. 2. E Fetal blood sample.
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EMQ answers
15.
1. F Renal agenesis. 22.
2. A Gestational diabetes. 1. E Essential hypertension.
3. D Twin pregnancy. 2. D Pre-eclampsia.
4. C Placental insuffiency. 3. F Pregnancy induced hypertension or gestational
5. G Uterine fibroid. hypertension.
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EMQ answers
4. G HELLP Syndrome (haemolysis, elevated liver enzymes 2. B Symptoms of frequency, dysuria and nocturia are
and low platelets). often due to a urinary tract infection and this diagnosis
5. C Eclampsia. is supported by presence of protein in the urine.
6. B Epileptic seizure. 3. D Symptoms of urgency, nocturia and urge incontinence
in this age group are often due to detrusor
overactivity – the diagnosis should be confirmed
23. with urodynamics.
1. F Glucose tolerance test. 4. G This is a recognized complication of prolonged
2. D Folic acid supplementation and detailed cardiac scan. obstructed labour and leads to continuous
3. B Antenatal and postnatal low molecular weight heparin. incontinence due to the presence of a urinary fistula,
4. C Liver function tests and bile acids. often connecting to the vagina. It is a particular
5. E Haemoglobinopathy screen. problem in Somalia where women often have to walk
miles to reach the nearest hospital.
5. J Detrusor overactivity (DO ) symptoms are common
in the menopause due to deterioration of the collagen
24. in the urethra and bladder from oestrogen deficiency.
1. F Placental abruption.
2. D Anaphylactic shock.
3. H Hypovolaemic shoc.
4. C Amniotic fluid embolism. 28.
5. B Acute myocardial infarction 1. H Polycystic ovary syndrome.
2. J Turner’s syndrome.
3. C Hypothalamic hypogonadism.
25. 4. E Late-onset congenital adrenal hyperplasia.
1. C Ruptured ectopic pregnancy. 5. D Constitutional amenorrhoea.
2. A Sepsis.
3. F Intracranial haemorrhage.
4. B Pulmonary embolism. 29.
5. E Puerperal psychosis. 1. D Carcinoma of the vulva.
2. I Trichomonas vaginalis.
3. C Lichen sclerosus.
26. 4. B Contact dermatitis.
1. B O ne of the classic ways in which endometriosis 5. F Psoriasis.
presents is with increasingly heavy and painful
periods. The pain typically commences before the
period and/ or lasts for a few days after the period 30.
(secondary dysmenorrhoea). 1. B Menorrhagia.
2. F Cervical carcinoma typically presents with painless 2. C Total abdominal hysterectomy.
post-coital bleeding and is particularly likely in this age 3. E Endometriosis.
group. 4. F Threatened miscarriage.
3. A Lower abdominal pain and tenderness (typically 5. A Postmenopausal bleeding.
bilateral) associated with a temperature and vaginal
discharge are commonly due to PID.
4. I A bulky uterus in this age group associated with heavy
periods is often due to uterine enlargement secondary 31.
to fibroids. 1. F Vaginal hysterectomy.
5. H This must not be forgotten as a possible medical cause 2. C Combined oral contraceptive pill.
of menorrhagia, particularly in the perimenopausal era. 3. E Endometrial ablation.
Two of the commonest symptoms are increasing 4. J Hysteroscopic myomectomy.
tiredness and weight gain. 5. I Total abdominal hysterectomy and bilateral salpingo-
oophorectomy.
27.
1. C It is essential that urodynamic investigations have been 32.
performed to exclude detrusor overactivity as a cause 1. B Abdominal X-ray.
of incontinence during laughing, sneezing, etc. 2. A Pelvic ultrasound scan.
267
EMQ answers
3. F Laparoscopy.
4. C Urodynamics investigation. 36.
5. D Hysterosalpingogram. 1. K Hyperemesis gravidarum. This typically presents in
the first trimester and is commonly associated with
multiple pregnancies. In this example, there is evi-
dence of severe dehydration and gastritis secondary
33. to the excessive vomiting.
1. D Sheehan’s syndrome typically presents post-
2. D Retained products of conception. Although the history
pregnancy and is associated with massive blood loss
and findings are consistent with an incomplete miscar-
at the time of delivery.
riage, this is not on the list of options. The scan findings
2. B Athleticism and stress can induce amenorrhoea.
give the diagnosis of retained products of conception.
This is reversible.
3. B Molar Pregnancy. Molar pregnancy is a known cause
3. F Radiotherapy/ chemotherapy can cause iatrogenic
of hyperemesis and a uterus which is large for dates.
amenorrhoea. Therefore, all women of child-bearing
The ultrasound appearance is also characteristic of
age should be counselled on this prior to commencing
molar pregnancy.
treatment.
4. C Ectopic Pregnancy. This lady is in clinical shock — most
4. E Polycystic ovarian syndrome can cause irregular
likely secondary to a ruptured ectopic pregnancy. She
periods or secondary amenorrhoea. This can lead to
needs urgent transfer to theatre for life-saving surgery.
endometrial hyperplasia in the long-term if
5. H Septic Miscarriage. The most likely causative agent is
untreated.
Group A Streptococcus which may have been trans-
5. C Prolactinoma can cause tunnel vision, headaches and
mitted from her son. The importance of hand hygiene
breast discharge.
BEFO RE and after using the toilet can not be over
emphasised, especially in pregnant women looking
after young children.
34.
1. I Transcervical resection of fibroids treats the cause of
her menorrhagia without affecting her ability to
become pregnant. 37.
2. C Low-dose steroids may be effective in treating 1. G Depot Provera. Depot provera is the most appropriate
lichen sclerosis. choice. It can be administered promptly by a health-
3. B Metronidazole is used to treat bacterial vaginosis. care professional. O ther options H, I require specialist
4. E The oral contraceptive pill allows cycle referral and training to be administered. Intrauterine
regulation as well as reducing menstrual blood options such as B, E, F are offered only after 6 weeks
loss. postpartum, when the uterus has involuted.
5. J Total abdominal hysterectomy and bilateral salpingo- 2. H Implanon. Implanon is the most appropriate choice of
oophorectomy is the definitive treatment for long-acting reversible contraception. This is prefera-
severe and unremitting endometriosis in women who ble over the copper IUCD and Mirena as it avoids the
have tried medical treatment. risk of ascending uterine infection and subsequent
pelvic inflammatory disease (PID).
3. E Copper IUCD. This lady is perimenopausal and so her
fertility is reduced, thus increasing the effectiveness of
a copper IUCD. This option will also solve the problem
35. of her dislike of needles and hormonal options.
1. D Given the history, it is important to exclude 4. I Laparoscopic Sterilisation. This woman needs effec-
pregnancy. tive long-term, irreversible contraception. A Mirena
2. F The diagnosis is likely to be PCO S, which can be IUS is not an option in this case as it may have been
diagnosed by a high LH:FSH ratio. tried already and it does have the known issue of
3. G If the endometrial thickness is 5 mm or more, an irregular unscheduled bleeding when initially inserted
endometrial biopsy must be taken. which would be difficult for a busy mother of 5 to deal
4. A The diagnosis is likely to be a ruptured ectopic with. A laparoscopic sterilisation would enable
pregnancy. As the patient is haemodynamically inspection of her endometriosis and treatment if
unstable, the first step is to resuscitate. needed, which Essure cannot do.
5. I Laparoscopy is the choice of investigation 5. C Progesterone-only pill. It would not be safe to put this
to exclude endometriosis or other causes of chronic woman on the CO CP, however since she is keen to
pelvic pain such as adhesions or pelvic inflammatory take an oral hormonal contraceptive a progesterone
disease. only pill is a reasonable option.
268
EMQ answers
269
This pa ge inte ntiona lly le ft bla nk
In d e x
Note: Page num bers followed by acute fatty liver of pregnancy (AFLP) am niotom y (artificial rupture of
b indicate boxes and f indicate figures. 156, 156f, 169f m em branes, ARM)
adenocarcinom a com plications 186f
A endom etrium 65
Paget’s disease of vulva and 69
induction of labour 186–187
slow progress of labour 201
abdom inal distension, ovarian adenom yosis 53, 56 transverse lie 198
tum ours 61 adhesions, intrauterine see Asherm an’s anabolic steroids 107, 108
abdom inal exam ination 17–20 syndrom e anaem ia
auscultation 18 adnexa, bim anual exam ination 23 in early pregnancy 10
early pregnancy bleeding/pain adnexal m asses iron deficiency 34, 151
132–133 ectopic pregnancy 136 in pregnancy 151, 151b, 216
inspection 17 exam ination 23, 61 anaerobes 82f
palpation see abdom inal palpation adrenal androgens, excess production analgesia
subfertility 119 107 episiotom y 209
abdom inal m asses adrenal tum ours labour 184, 185f
fibroids 49 androgen-secreting 107, 108, 109 anaphylaxis, m aternal collapse 226–227
inspection for 17 horm one-secreting 104 androgens
palpation 17 age excess circulating 106–107
pelvic pain/dyspareunia 45 IVF success rates and 124 serum 101, 108
abdom inal pain at m enopause 111 anencephaly 200
2nd and 3rd trim esters 167–170 m iscarriage and 134 anosm ia 100
algorithm 170f ovarian cyst m anagem ent and anovulation 121
differential diagnosis 167, 168f, 61–62 antenatal booking visit 9–14
169f vulval disease and 71, 74, 74f exam ination 10
exam ination 167–168 air travel, antenatal advice 13 history taking 9–10
history 167 alcohol consum ption investigations 10–12
investigation 168–169, 170f antenatal advice 10, 12, 159 antenatal care
m anagem ent 170, 170b effects on fertility 118, 119 diabetic pregnancy 152
antepartum haem orrhage with 139, fetal growth effects 172 gestational diabetes 153
139b, 142 allergies 5, 10 HIV infection 157
early pregnancy 131, 132 alpha-fetoprotein (AFP), serum 61, 63 m ultiple pregnancy 163–164
fibroids 49 a -blockers 91, 119 obstetric cholestasis 155
pre-eclampsia 145, 146f, 169f am enorrhoea 99–104 schedule 13
preterm labour 190 com plications 99 screening for chrom osom al
see also pelvic pain exam ination 100 abnorm alities 13–14
abdom inal palpation 17 history 99–100 transverse lie 198
abdom inal pain in pregnancy 168 hypothalam ic 102 antenatal education 12–13
abnormal CTG in labour 206 investigations 100–102 antepartum haem orrhage (APH)
hypertension in pregnancy 146 post-pill 99 139–144
obstetric 18–20, 18f prim ary 99 aetiology 139, 140f
ovarian tum ours 61 investigations 100–101, 102f definition 139
pelvic pain/dyspareunia 45 treatm ent 102 exam ination 139–140
placental abruption 142 secondary 99 history 139
preterm labour 190 algorithm 103f incidence 139
vaginal discharge 78 investigations 101–102 investigations 140, 140f
abdom inal pregnancy 137 treatm ent 102–104 m ultiple pregnancy 164
abnorm al uterine bleeding 33–42 treatm ent 102–104 revealed and concealed 142, 142f
abortion, term inology 131 am niocentesis 14, 14b, 15f stillbirth 176
Abortion Act (1967) 129 am niotic fluid em bolism (AFE) unexplained 143
acanthosis nigricans 108 224–225, 231–232 see also placenta praevia; placental
acetowhite changes 27 am niotic fluid index (AFI) 173 abruption
272
Index
abdom inal pain in pregnancy 169 vulval intraepithelial neoplasia CIN see cervical intraepithelial neoplasia
abnormal, in labour 205f and 71 ciprofloxacin 82f
exam ination 206 cervical shock 132 circum vallate placenta 143
history 205–206 cervical sm ears 27, 28b, 28f clerking see history taking
investigation 206 cervical intraepithelial neoplasia clom iphene 121
algorithm 207f (CIN) grading 67, 67f clonidine 115
antepartum haem orrhage 140, 143 early pregnancy com plications and coagulation (clottin g) disorders 34,
categorization 204, 205f 131 35, 216
features 203–204, 203b, 205f m anagem ent of abnorm al 67 coagulation (clotting) studies 168, 177
indications 203, 204f national screening program m e 66 cocaine use 159, 225
instrum ental delivery 211 cervical weakness (’incom petence’) coelom ic m etaplasia theory,
intrauterine growth restriction 174 m iscarriage 134, 135 endom etriosis 53
m onitoring uterine contractions 205 treatm ent 192 coitus interruptus 125
non-reassuring 205f cervix colostrum 219
norm al trace 204, 204f biopsy 28b colpopexy, sacral 97
pathological trace 204, 205f, 206 Bishop score 25, 25f, 186, 186b colporrhaphy
physiology 204–205 causes of failure to progress in labour anterior 97
presenting 204b 200 posterior 97
preterm labour 190 consistency, assessm ent 25 colposcopy 27–28, 67, 68f
reassuring 205f ectropion 133 vulval disease 71
suspicious 204, 206 effacem ent 24, 24f colposuspension 90, 95
cardiovascular disease 112f, 113–115 excitation 45, 56, 133 com bined oral contraceptive pill
catheterization, urinary 91 gynaecological exam ination 22, 23 (COCP) 126–127
cats, toxoplasm osis risk 13 length, assessment 24, 190 contraceptive effectiveness 126f
cefixim e 82f obstetric exam ination 24–25 contraindications 126f
ceftriaxone 82f position, assessm ent 25 disadvantages 126–127
central nervous system (CNS) disorders, chaperones 17b endom etriosis 56–57
am enorrhoea 100, 102 chem otherapy functional ovarian cysts 62
Centre for Maternal and Child Enquiries ovarian cancer 64 m enorrhagia 35, 36f, 37
(CMACE) 223, 229 trophoblastic disease 138 polycystic ovary syndrome 102
cephalic presentation 18–19, 19f chest infection, postnatal 220 com bined screening test, chrom osom al
defining position 26f chest pain 225, 232 abnorm alities 13–14
cephalopelvic disproportion (CPD) chest X-ray, pulm onary em bolism 157 com puted tom ographic pulm onary
199–200 chicken pox 10 angiogram (CTPA) 157
cerebral vein throm bosis 157 childbirth, recent 44, 45f conception 117
cervical cancer 67–68 chin (m entum ) 198 condom s 125–126, 126f
clinical presentation 39b, 40, 68 chlam ydia infections 82f cone biopsy 67
hum an papillom a virus (HPV) and screening 120 Confidential Enquiries into Maternal
67, 68 treatm ent 83 and Child Health (CEMACH)
incidence 66 Chlamydia trachomatis 81 229
pre-m alignant lesions 66, 67 chlorphenam ine 155 congenital adrenal hyperplasia (CAH)
risk factors 68f chocolate cysts, ovarian 107, 108, 109
screening 5, 27, 66 see endom etriom as, ovarian congenital fetal abnorm alities see fetal
staging 68, 68f cholecystitis, in pregnancy 169f abnorm alities
treatm ent 68 cholestasis, obstetric 155, 176 consent, inform ed 209
cervical cap 125–126 chorioam nionitis 176, 193 constipation 12f, 169f
cervical cerclage (suture) 191, 192, choriocarcinom a 137f, 138, 216 contact derm atitis 71, 75
192f chorionic villus sam pling (CVS) 14–15, contraception 125–130
cervical cytology 22b, 27 14b, 15f barrier m ethods 125–126
see also cervical sm ears chorionicity 161–162 breast-feeding and 129
cervical dilatation diagnosis 163, 163f effectiveness 125, 126f
assessm ent 24 chrom osom al abnorm alities horm onal 126–127
failure 200 antenatal screening 13–14 IUCDs see intrauterine contraceptive
rate, norm al labour 179 m ultiple pregnancy 163 devices
cervical incom petence see cervical stillbirth 176 m enopausal wom en 111, 115
weakness chrom osom al analysis (karyotyping) natural fam ily planning m ethods
cervical intraepithelial neoplasia prim ary am enorrhoea 101, 102, 125
(CIN) 67 102b pelvic pain/dyspareunia and 45
colposcopy 27–28, 67 recurrent m iscarriage 135 postcoital (em ergency) 129
grading 67, 67f stillbirth 177 vaginal discharge and 78
m anagem ent 67 subfertility 121 controlled cord traction 185, 186f, 216
273
Index
274
Index
endom etrial hyperplasia 40, 65 m ultiple pregnancy 161 engagem ent 19–20, 182
atypical 65b obstetric cholestasis 155 extension 182–183, 183f
horm one replacement therapy and evacuation of retained products of external rotation (restitution)
112–113 conception (ERPC) 133, 134 183–184, 183f
polycystic ovary syndrom e 102 exam ination 17–26 fifths above pelvic brim 19–20, 20f
endom etrial polyps antenatal booking visit 10 flexion, early labour 182, 182f
abnormal bleeding 34, 35, 40 general 17 internal rotation 182–183, 183f
subfertility 121 see also abdom inal exam ination; landm arks 25, 25f
treatm ent 37 pelvic exam ination station 20f, 24, 24f
endom etrial strom al sarcom a 66 exercise, antenatal advice 13 see also fetal presenting part; fetal skull
endom etrial thickness extended breech 195, 196f fetal heart, early pregnancy 29, 133
postm enopausal wom en 40 external cephalic version (ECV) fetal heart rate (FHR)
ultrasound m easurem ent 28–29, 29b breech presentation 196–197 accelerations 204, 204f, 205f
endom etrioid tum ours, ovarian 60 second twin 165 baseline 203, 205f
endom etriom as, ovarian 56, 60 transverse lie 198 baseline variability 203, 205f
rupture 55, 56 external genitalia categorization 204, 205f
endom etriosis 53–58 exam ination 20–22, 22f decelerations 204, 205f
aetiology 53–54, 54f see also vulva fetal heart rate (FHR) m onitoring
Am erican Fertility Society continuous electronic
Classification 54, 55f see cardiotocography
clinical signs 56 intermittent auscultation 203
com plications 56
F twin pregnancy 165
differential diagnosis 56 face presentation 19, 19f, 198–199 fetal hypoxia
exam ination 45, 46 m anagem ent of labour 198–199, acute 204
infertility 56 198f chronic 205
investigations 56 m echanism of labour 198, 198b, 198f fetal lie 18, 18f
sites 54, 54b, 54f fallopian tubes fetal m acrosom ia
subfertility 56, 117 patency tests 30, 30f, 31b, 120 diabetic pregnancy 152–153
sym ptom s 34, 43, 54–55, 55f ultrasound scanning 29 failure to progress in labour 200
treatm ent 56–58, 121 fam ily history 5 risk factors 171
endom etritis 134, 217 antenatal booking visit 10 see also large-for-dates
engagem ent 19–20, 182 see also genetic factors fetal m onitoring in labour 184,
enterocoele 94f, 95, 97 fam ily planning, natural m ethods 125 203–208
epididym al surgery 123 fem ale genital m utilation (FGM) continuous electronic
epididym o-orchitis 119, 120–121 (fem ale circum cision) 4b, 22, see cardiotocography
epidural anaesthesia 185f 23–24 indications for continuous 203, 204f
m aternal collapse 225, 226 failure to progress in labour 200 intermittent auscultation 203
m aternal hypotension 206 subfertility 119 physiology 204–205
second stage m anagem ent 184 fem ale sterilization 126f, 128–129 uncomplicated pregnancy 203
twin pregnancy 164 fertility treatm ent fetal parts, difficulty palpating 20, 22f
epigastric pain 145, 146f history of 9 fetal pole 18
epilepsy 153–154 m ultiple pregnancy and 121, 121b, fetal position 20, 21f
episiotom y 209 165 see also m alpositions, fetal
dyspareunia 44, 45f see also assisted reproductive fetal presentation 18–19, 19f
forceps delivery 212, 213f techniques; ovulation induction see also m alpresentations, fetal
indications 210f fetal abnorm alities fetal presenting part
repair 209, 210f failure to progress in labour 200 defining position 25, 26f
techniques 209, 210f m iscarriage 134 descent, assessing 184b
epithelial ovarian tum ours m ultiple pregnancy 163 engagem ent 19–20, 20f
benign 59–60 fetal blood sam pling (FBS) 15 position 20
m alignant 63 abnormal CTG 206 station 20f, 24, 24f
Erb’s palsy 201–202 contraindications 207f see also fetal head
erect lateral pelvim etry (ELP) 30 during labour 184 fetal reduction, selective 165
erythrom ycin 82f, 191, 193 fetal growth m onitoring 30 fetal scalp electrodes 184, 206
estim ated date of delivery (EDD) 9, 9b, large- and sm all-for-dates 173 fetal size
10f, 171 m ultiple pregnancy 163–164 estim ation, vaginal breech delivery
estim ated fetal weight (EFW), vaginal see also intrauterine growth restriction 197
breech delivery 197 fetal head failure to progress in labour and 200
ethnic differences aftercom ing, of breech 195 fetal skull 181–182
fetal growth 172 delivery 183–184, 183f abnormalities 200
m olar pregnancy 137–138 descent 182–183, 183f diam eters 181–182, 182f
275
Index
276
Index
277
Index
intrauterine growth restriction (IUGR) m anagem ent 184–185 liver function tests (LFTs) 28
171 m echanism of delivery 182–184, abdom inal pain in pregnancy 168
assessment 173, 174 183f, 184f obstetric cholestasis 155
risk factors 171–172 third stage 185–186 stillbirth 177
see also fetal growth m onitoring; active m anagem ent 185, 216 locked twins 165
sm all-for-dates physiological 186 longitudinal (fetal) lie 18f
intrauterine insem ination (IUI) 122 see also delivery; intrapartum Lovset’s m anoeuvre 197
intrauterine system s m anagem ent low-m olecular-weight heparin (LMWH)
m enorrhagia 36 lactate dehydrogenase 148f 156, 157
Mirena see Mirena intrauterine system lactation 219–220 lower genital tract, postm enopausal
investigations 27–32 see also breast-feeding atrophy see postm enopausal
antenatal booking visit 10–12 lam bda sign 163, 163f atrophy
bedside tests 27 laparoscopy 31 luteal ovarian cysts 59
iodine, colposcopic exam ination 27 abnormal bleeding 39 luteinizing horm one (LH), serum 101,
iron-deficiency anaem ia 34, 151 com plications 31 121
iron supplem ents 151 and dye 31b, 120 luteom a, pregnancy 107
ischaem ic heart disease 99 ectopic pregnancy 136 lym phangiom a, fetal 200
itching endom etriosis 56, 57–58 lym phatic em bolization theory,
generalized, obstetric cholestasis 155, pelvic inflam m atory disease 83 endom etriosis 53
176 pelvic pain/dyspareunia 46 Lynch II syndrom e 63
vulval see pruritus vulvae technique 31, 32f
IUCDs see intrauterine contraceptive large-for-dates (LFD) 171–174
devices differential diagnosis 171, 171b
exam ination 172
M
history 171–172 MacDonald suture 191, 192f
K investigation 172–174, 172f m acrosom ia, fetal see fetal m acrosom ia
see also fetal m acrosomia m agnesium sulphate (MgSO 4 )
Kallm ann’s syndrom e 100
large loop excision of transform ation 148–149, 149f
karyotyping see chrom osom al analysis
zone (LLETZ) 67, 68 m agnetic resonance im aging (MRI)
Keilland’s forceps 211f
laser photocoagulation, uterine fibroids endom etrial cancer 65
KIWI cup 210–211
51 uterine fibroids 50–51
Kleihauer test 140, 142, 143, 177
last m enstrual period (LMP) 4, 9, 131 m ale factor infertility 122–123
left lateral tilt position, m aternal exam ination 119
collapse 223, 224f
L leiom yom as, uterine see fibroids,
investigations 120–121
relevant history 118–119
labetalol 148f uterine m ale sterilization 126f, 129
labial abscesses 45f leiom yosarcom a, uterine 66 m alignancies, gynaecological
labour 179–188 leucoplakia, vulval 74, 75 see gynaecological m alignancies
analgesia 184, 185f levator ani 93, 94f, 180–181 m alpositions, fetal 21f
assessing progress 25b Levonelle 129 failure to progress in labour 200–201
augm entation 201 levonorgestrel-releasing intrauterine m alpresentations, fetal 19, 19f,
com plications 195–202 system see Mirena intrauterine 195–199
diagnosis 179 system causes 195, 196f
failure to progress 199–201 LH see luteinizing horm one failure to progress in labour 201
causes 199–201, 199f LHRH-analogues see gonadotrophin- Manchester repair 97
m anagem ent 201 releasing horm one agonists m assive obstetric haem orrhage 215, 217
fetal m onitoring see fetal m onitoring lichen planus 74 m astitis, acute 220
in labour lichen sclerosus 69f, 74, 74f m aternal collapse 223–228
first stage, m anagem ent 184 diagnosis 72–73, 72f, 74 causes 226f, 223–227
induction see induction of labour treatm ent 74 initial m anagem ent 223, 224f
m echanism of 182–183, 182f, 183f ligam ent pain, in pregnancy 169f m aternal death 229–232
norm al progress 179–182, 180f linea nigra 17 audits and confidential enquiries 229,
obstructed 77, 86 liquid-based cytology 22b, 27 230f
onset 179 liquor volum e causes 230–232, 231f
operative interventions 209–214 causes of increased/decreased 173b, coincidental 229, 232
pain 169f 173f definitions 229
passages 179–181, 199 clinical assessm ent 20 direct 229, 230–232
passenger 181–182, 199 ultrasound assessment 30, 173 haem orrhage 223, 231
power 182, 199 see also oligohydramnios; indirect 229, 232
second stage polyhydramnios late 229
failure to progress 201 lithium 159, 221–222 sepsis 220, 229, 230
278
Index
m aternal m ortality rates 229, 230f m ethyldopa 148f m ultifetal pregnancy reduction 162,
Mauriceau-Sm ellie-Veit m anoeuvre m etronidazole 82f 165
197 m icrobiological tests (including swabs) m ultiple pregnancy 161–166
McBurney’s point 168 27 abdom inal palpation 18
McRoberts position 202 pelvic inflam m atory disease 83 aetiology 161–163
m ean arterial pressure (MAP) 148–149, postnatal infection 220 com plications 163–164, 163b
148f recurrent m iscarriage 135 diagnosis 161
m edical disorders in pregnancy stillbirths 177 diagnosis of chorionicity 163, 163f
151–160 subfertility 120 fertility therapy and 121, 121b, 165
m edical history, past 5, 10 vaginal discharge 78, 78f fetal death in utero 164
m edications see drugs m idstream urine (MSU) 46, 168–169 higher order 165
m edroxyprogesterone acetate, injectable m ifepristone 130 incidence 161
127 Mirena intrauterine system 36b, intrapartum m anagem ent 164–165,
m efenam ic acid 36, 36f 127–128, 128f 164f
Meigs’ syndrom e 60 contraceptive effectiveness 126f postpartum haem orrhage 215
m em branes disadvantages 128 see also twin(s); twin pregnancy
postpartum exam ination 217 endom etriosis 57 m ultiple sclerosis (MS) 86
rupture see rupture of horm one replacement therapy with m um ps orchitis 119
m em branes 113f Mycoplasma infections 81, 82f
Mendelson’s syndrom e 184, 213 m enorrhagia 36, 36b, 36f m yocardial infarction, acute 225
m enopause 111–116 m iscarriage 131, 133–135 m yom ectomy 37, 51
clinical features 111–115, 112f aetiology 134 m yom etrial sarcom a 66
contraception 111, 115 am niocentesis-related risk 14 m yom etrium 182
definitions 111 chorionic villus sam pling risk 15
investigations 112, 113f com plete 132f
osteoporosis 115 exam ination 46, 132–133 N
pathophysiology 111, 112f history 5, 131, 132
Naegele’s rule 9, 10f
prem ature 111, 115 incom plete 132f
nausea and vom iting, in pregnancy 12f
treatm ent 112–115 inevitable 131, 132f, 133
needle excision of transform ation zone
see also postm enopausal wom en m anagem ent 134–135, 134f
(NETZ) 67
m enorrhagia 33–38 m issed/delayed/silent 132f
Neisseria gonorrhoeae (gonorrhoea) 81,
aetiology 33–34, 34f, 49 previous history 132
82f
com plications 34, 117 recurrent 134, 135
neurological disorders, urinary
diagnosis 33, 34–35 threatened 132f
incontinence 86, 87f
incidence 33 ultrasound scanning 29, 133
nifedipine 148f, 192f
investigations 35, 35f m isoprostol 218
night sweats 112f
treatm ent 36–38, 37f Mittelschm erz 43
nitric oxide donors 192f
m enstrual blood loss (MBL) m ixed Mullerian tum ours, uterine 66
nitrous oxide/oxygen 185f
assessment 33, 34f m ode of delivery
nocturia 87f
defining m enorrhagia 33 HIV infection 158
nocturnal enuresis 87f
m edical therapies reducing 36–37, intrauterine death 177
non-steroidal anti-inflam matory drugs
36f postpartum haem orrhage and
(NSAIDs)
surgical m ethods of reducing 215–216
m enorrhagia 36, 36f
37–38 prem ature babies 191–192
tocolysis 192f
m enstrual disorders twin pregnancy 164–165
nonoxynol-9 125, 126
fibroids 49 see also caesarean section; vaginal
nuchal translucency (NT) 13, 13f, 14
see also am enorrhoea delivery
nucleic acid am plification tests
dysm enorrhoea; m enorrhagia m olar pregnancy 137–138, 138f
(NAATs) 83
m enstrual history 4 com plete m ole 137, 137f
m enstruation, retrograde 53 diagnosis and evaluation 138, 217
m ental illness see psychiatric illness
m entoanterior position 198b
partial m ole 137, 137f
postpartum haem orrhage 216
O
m entoposterior position 198–199, m ood disturbances, perim enopausal obesity, endom etrial cancer risk 65
198b 112f oblique lie 18f
m entovertical diam eter 181–182, Mothers and Babies: Reducing Risk obstetric abdom inal palpation 18–20
182f, 199 through Audit and Confidential obstetric cholestasis (OC) 155, 176
m entum 198 Enquiries across the UK obstetric factors, genital prolapse 94
m etform in 102–103 (MBRRACE) 229, 230f obstetric history, past 5, 9–10, 10b
m ethotrexate m oulding 25, 181 obstetric pelvic exam ination 23–25,
ectopic pregnancy 136, 137 MRI see m agnetic resonance im aging 23b
trophoblastic disease 138 m ucinous cystadenoma, ovarian 59 obstetric wheel 9
279
Index
obstructed labour 77, 86 see also ovarian tum ours parity 5, 9–10
occipitoanterior (OA) position 20, 21f, ovarian drilling 121 partogram 179, 180f
26f ovarian hyperstimulation syndrom e patient details 1
occipitofrontal diam eter 182f (OHSS) 123–124 peak expiratory flow rate (PEFR) 152
occipitolateral/occipitotransverse ovarian pregnancy 137 Pearl Index 125
positions 20, 21f, 26f ovarian tum ours pelvic abscesses, dyspareunia 45f
failure to progress in labour 200 abnormal uterine bleeding 40 pelvic exam ination 20–25
occipitoposterior (OP) position 20, 21f, androgen-secreting 107, 108, 109 bim anual see bim anual pelvic
26f benign 59–62 exam ination
failure to progress in labour 200–201 aetiology 59–60 endom etriosis 56
oedem a, facial 146, 146f classification 59, 60f gynaecological 20–23, 20b
oestradiol 113 epithelial 59–60 obstetric 23–25, 23b
oestrogen exam ination 61 see also speculum exam ination;
horm one replacement therapy 113 germ cell 60 vaginal exam ination
role in lactation 219 history 60–61 pelvic floor
topical vaginal 41, 113f incidence 59 anatomy 93, 94f
oligo-terato-asthenosperm ia (OAT) investigations 61 in labour 180–181
121b m anagem ent 61–62 m uscles 93, 94f
oligoam enorrhoea 107 sex cord strom al 60 pelvic floor exercises 89–90, 90b, 96
oligohydramnios, causes 173b, 173f differential diagnosis 61f pelvic inflam m atory disease (PID)
oligozoosperm ia 121b horm one-secreting 104 81–84
oocytes 111 m alignant see ovarian cancer aetiology 81
oophorectom y, benign ovarian tum ours oestrogen-secreting 40 asym ptom atic 82
62 ultrasound scanning 29, 29f, 61, 62 com plications 83, 83f
operative interventions in labour see also ovarian cysts definition 81
209–214 ovaries diagnosis 81
opiate users 159, 225 bim anual exam ination 23 exam ination 45, 82–83
oral contraceptive pill see com bined oral endom etriom as see endom etriom as, history 43, 44, 81–82
contraceptive pillprogesterone- ovarian incidence 81
only pill excess androgen production 107 investigations 83
oral glucose tolerance test (OGTT) 153, ultrasound scanning 29 IUCD-associated 128
153b, 172 ovulation, pelvic pain 43 m enorrhagia 34
osteoporosis ovulation induction 121 prevention 84
postm enopausal 112f risks 123–124 risk factors 82f
predisposing factors 99 oxybutynin 90 subfertility 118b
prevention 115 oxygen/nitrous oxide 185f treatm ent 83
ovarian cancer 63–65 oxytocic drugs vaginal discharge 77
risk factors 63, 64f failure to progress in labour 201 pelvic inlet 179, 180, 181f
screening 64–65 third stage of labour 185, 216 pelvic m asses 45–46, 49
staging 64f uterine atony 218 pelvic outlet 179, 181f
ovarian cystectom y 62 oxytocin (Syntocinon) pelvic pain 43–48
ovarian cysts caesarean section 212 algorithm 47f
abdom inal pain in pregnancy 168, com plications 186f chronic 43, 45
169, 169f failure to progress in labour 201 differential diagnosis 43, 44f
benign 59–62 induction of labour 186f, 187 exam ination 45–46
asym ptom atic 61–62, 62f role in lactation 220 fibroids 49
classification 60f third stage of labour 185, 216 history 43–45
exam ination 61 oxytocin receptor antagonists 192f investigations 46, 46f
history 60–61 see also abdom inal pain
incidence 59 pelvim etry 199
m anagem ent 61–62
chocolate see endom etriom as,
P erect lateral (ELP) 30
pelvis
ovarian Paget’s disease of vulva 69, 74f, 75 anatomy 93, 94f
epithelial 59–60 pain bony 179–180, 181f
physiological (functional) 59, 62 history 4 abnorm alities 199, 199f
progress of labour and 200 relief see analgesiaabdom inal pain; antenatal assessm ent 25b, 199
risk of m alignancy index (RMI) 62, dysm enorrhoea; dyspareunia; causes of failure to progress 199–200
64, 65f pelvic pain ligam ents 93
rupture 45, 61 pancreatitis, in pregnancy 169f peptic ulcer, in pregnancy 169f, 170
torsion 43, 61, 168 papilloedem a 146 perinatal m orbidity, breech
ultrasound scanning 29b, 29f, 61, 62 parasym pathom im etic agents 91 presentation 195–196
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Sheehan’s syndrom e 99, 104, 143, stress incontinence 87–88, 87f history 5
216 stress urinary incontinence (SUI) 85, m ethods 129–130
Shirodkar suture 191 87f testes, undescended 118
shock, in early pregnancy 132 aetiology 85, 86f testicular fem inization 100–101
shoulder dystocia 201–202 history 88 testosterone, serum 101, 108, 121
shoulder presentation 19f investigations 32f, 89 thalassaem ia 11
shoulders, delivery 183–184, 184f prolapse and 85, 95 theca cell tum ours 60
sickle cell disease 11 treatm ent 89–90 theca lutein cysts 59
Sim pson’s forceps 211f stretch m arks 17 throm boem bolism (venous
Sim s’ speculum exam ination 22, 23f striae gravidarum 17 throm boem bolism , VTE)
skin pigm entation, in pregnancy 17 subfertility (and infertility) 117–124 156–157
skull, fetal see fetal skull anovulation 121 caesarean section and 213
sm all-for-dates (SFD) 171–174 causes 118f investigations 157
differential diagnosis 171, 171b definitions 117 m aternal collapse 223–224
exam ination 172 endom etriosis 56, 117 m aternal deaths 229, 231
history 171–172 exam ination 119 oral contraceptive pill users
investigation 172–174, 173b, 173f fibroids 49, 117, 121 126–127
sm all for gestational age (SGA) 171, history 117–119 postnatal 222
173 investigation 119–121 prophylaxis 156
sm oking m ale see m ale factor infertility risk factors 156, 156f
antenatal advice 10, 12, 159 treatm ent 121–123 sym ptom s and signs 156–157
effects on fertility 118, 119 uterine, tubal and pelvic problem s treatm ent 157
fetal growth effects 172 121–122 throm bophilia screen 177
social history 5–6, 10 subm entobregm atic diam eter 181–182, throm boprophylaxis 156, 222, 223
spectinom ycin 82f 182f, 198 thyroid disease
speculum exam ination suboccipitobregm atic diam eter am enorrhoea 100
early pregnancy bleeding/pain 133 181–182, 182f in pregnancy 154–155
genital prolapse 95 substance abuse 159 see also hypothyroidism
gynaecological 22, 23f suicide 232 thyroid function tests (TFTs) 28
m enorrhagia 35 supine hypotension syndrom e 17, 168b am enorrhoea 101
obstetric 24 surgical scars 17 in pregnancy 154, 155, 156f
pelvic pain/dyspareunia 45, 45f sutures, fetal skull 25, 25f, 181, 181f subfertility 121
urinary incontinence 88, 88b swabs, m icrobiological thyrotoxicosis see hyperthyroidism
vaginal discharge 78 see m icrobiological tests tocolysis
see also Cusco’s speculum sym physis–fundal height (SFH) 18, m ultiple pregnancy 164
exam ination 171, 171b preterm labour 191, 192f
sperm icide 125, 126 sym physis pubis dysfunction (SPD) 12f, prophylactic 192
spinal anaesthesia 185f 169f tolterodine 90
squam ous cell carcinom a sym ptom s, com m on, of pregnancy 12f total abdom inal hysterectom y with
cervix 66 Syntocinon see oxytocin bilateral salpingo-oophorectom y
vagina 70 Syntom etrine 185, 216 (TAH þ BSO)
vulva 69, 69f, 75 syphilis, antenatal screening 11–12 endom etrial cancer 65–66
squam ous hyperplasia, vulva 72f system s enquiry 5 endom etriosis 58
station, fetal presenting part 20f, 24, 24f ovarian cancer 64
stigm ata of pregnancy 17 uterine sarcom a 66
stillbirth 175–178 toxoplasmosis 13
causes 176f
T tranexam ic acid 36, 36f
definitions 175 T sign 163, 163f transcervical resection of fibroids
diabetic pregnancy 152–153 Tanner staging, puberty 100, 101f (TCRF) 51
diagnosis 175 tem perature, body transient tachypnoea of the newborn
exam ination 176 basal, ovulation prediction 125 (TTN) 212
follow-up 177b m aternal, during labour 206 transvaginal ultrasound scanning 28
history 175–176 tension-free vaginal tape (TVT) 90 early pregnancy 133, 133f
incidence 175 teratom a preterm labour 190, 190f
investigation 176–177 m ature cystic 60 transverse cervical ligam ent 93
m anagem ent 177 m ature solid 60 transverse lie 18f, 197–198, 197f
see also intrauterine death teratozoosperm ia 121b traum a see birth traum agenital tract
Stillbirth & Neonatal Death Charity terbutaline 192f traum a
(SANDS) 177 term ination of pregnancy 129–130 Treponema pallidum, antenatal screening
stress, em otional, am enorrhoea 100, com plications 130 11–12
102 counselling 130 Trichomonas vaginalis infection 71
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