COMPREHENSIVE GUIDELINES SUMMARY

GAfatih

COMPREHENSIVE
GUIDELINES
SUMMARY
Dr;Alfatih Aadaik

[REVISED AND UPDATED UPTO MARCH 2016]

 CONTENTS Page
No.

1 CLASSIFICATION OF EVIDENCE LEVELS 8

2 UNDERSTANDING AUDIT 9

3 RISK MANAGEMENT FOR MATERNITY AND GYNAECOLOGY 14

4 CONTRACEPTION 20
5 UK MEDICAL ELIGIBILITY CRITERIA FOR: CONTRACEPTIVE USE 35
6 LONG-ACTING REVERSIBLE CONTRACEPTION 44
7 MANAGEMENT OF UNSCHEDULED BLEEDING IN WOMEN USING HORMONAL 51

CONTRACEPTION
8 MALE & FEMALE STERILIZATION 60
9 FEMALE STERILIZATION 62

10 CHRONIC PELVIC PAIN 66

11 PELVIC INFLAMMATORY DISEASE 69

12 ENDOMETRIOSIS 73

13 PREVETION OF INJURIES DURING LAPAROSCOPIC ENTERY 76

14 MANAGEMENT OF PREMENSTRUAL SYNDROME 80

15 LONG TERM CONSEQUANCE OF PCOS 84

16 METFORMIN FOR THE MANAGEMENT OF INFERTILITY IN WOMEN WITH PCOS 85

17 HEAVY MENSTRUAL BLEEDING 91

18 INITIAL MANAGEMENT OF MENORRAHGIA 92

19 MANAGEMENT OF MENORRAHGIA IN SECONDARY CARE 94

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20 MANAGEMENT OF ENDOMETRIAL HYPERPLASIA 101

21 ASYMPTOMATIC ENDOMETRIAL THICKENING 103

22 BEST PRACTICE IN OUTPATIENT HYSTEROSCOPY 105

23 FERTILITY : ASSESSMENT AND TREATMENT 115

24 IMMUNOLOGICAL TESTING AND INTERVENTIONS FOR REPRODUCTIVE FAILURE 119

25 PERINATAL RISKS ASSOCIATED WITH IVF 122

26 OVARIAN HYPERSTIMULATION SYNDROME 128

27 MULTIPLE PREGNANCY 134

28 MANAGEMENT OF MONOCHORIONIC TWIN 137

29 ABORTION 140

30 THE MANAGEMENT OF EARLY PREGNANCY LOSS 146

31 GESTATIONALTROPHOBLASTIC DISEASE (GTD) 150

32 RECURRENT 1ST TRIMESTER AND 2ND TRIMESTER MISCARRIAGE 154

33 CERVICAL CERCLAGE 157

34 THE MANAGEMENT OF TUBAL PREGNANCY 159

35 AMNIOCENTESIS AND CHORIONIC VILLUS SAMPLING 161

36 AMNIOCENTESIS 162

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37 NONINVASIVE PRENATAL DIAGNOSIS USING CFFDNA 164

38 ANTENATAL SCREENING FOR DOWN SYNDROME 165

39 PERICONCEPTIONAL FOLIC ACID AND FOOD FORTIFICATION IN THE PREVENTION OF NEURAL 166
TUBE DEFECTS
40 REVIEW CARDIAC DISEASE IN PREGNANCY . PART 1: CONGENITAL HEART DISEASE 177

41 REVIEW CARDIAC DISEASE IN PREGNANCY . PART 2: ACQUIRED HEART DISEASE 181

42 MANAGEMENT OF SICKLE CELL DISEASE IN PREGNANCY 188

43 MANAGEMENT OF BETA THALASSAEMIA IN PREGNANCY 196

44 DIABETES IN PREGNANCY 203

45 DIAGNOSIS AND TREATMENT OF GESTATIONAL DIABETES 204

46 HYPERTENSION IN PREGNANCY 217

47 THE MANAGEMENT OF SEVERE PRE ECLAMPSIA /ECLAMPSIA 221

48 INVESTIGATION AND MANAGEMENT OF THE SGA 228

49 REDUCED FETAL MOVEMENTS 232

50 LATE INTRAUTERINE FETAL DEATH AND STILLBIRTH 240

51 PREGNANCY IN WOMEN WITH EPILEPSY 243

52 RENAL DISEASE IN PREGNANCY 245

53 MANAGEMENT OF WOMEN WITH OBESITY IN PREGNANCY 250

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54 OBSTETRIC CHOLESTASIS 253

55 ANTENATAL CARE 264

56 ANTENATAL CORTICOSTEROIDS 266

57 ANTI-D IMMUNOGLOBULIN FOR RHESUS D PROPHYLAXIS 270

58 THE MANAGEMENT OF WOMEN WITH RED CELL ANTIBODIES DURING PREGNANCY 279

59 ANTEPARTUM HAEMORRHAGE 280

60 PLACENTA PRAEVIA , PLACENTA ACCRETA AND VASA PRAEVIA 290

61 THE MANAGEMENT OF ANAEMIA IN PREGNANCY AND POSTNATALLY 294

62 BLOOD TRANSFUSION IN OBSTETRICS 298

63 PREGNANCY AND BREAST CANCER 302

64 THE PREVENTION OF MALARIA IN PREGNANCY 310

65 BACTERIAL SEPSIS IN PREGNANCY 313

66 BACTERIAL SEPSIS FOLLOWING PREGNANCY 319

67 PREVENTION OF EARLY ONSET NEONATAL GBS DISEASE 326

68 CHICKEN POX IN PREGNANCY 330

69 MANAGEMENT OF HIV IN PREGNANCY 334

70 MANAGEMENT OF GENITAL HERPES IN PREGNANCY 338

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71 PARVOVIRUS B 19 INFECTION 340

72 EXERCISE IN PREGNANCY 342

73 FEMALE GENITAL MUTILATION 344

74 IMPROVING PATIENT HANDOVER 349

75 THE MANAGEMENT OF BREECH PRESENTATION 351

76 EXTERNAL CEPHALIC VERSION 353

77 HOME BIRTHS 355

78 BIRTH AFTER PREVIOUS CAESAREAN BIRTH 356

79 PRETERM PRELABOUR RUPTURE OF MEMBRANES 359

80 MAGNESIUM SULPHATE TO PREVENT CEREBRAL PALSY FOLLOWING PRETERM BIRTH 362

81 TOCOLYSIS FOR WOMEN IN PRETERM LABOUR 363

82 INDUCTION OF LABOUR 366

83 INTRAPARTUM CARE 371

84 ELECTRONIC FETAL MONITORING 387

85 UMBILICAL CORD PROLAPSE 394

86 OPERATIVE VAGINAL DELIVERY 397

87 CONSENT ADVICE .OPERATIVE VAGINAL DELIVERY 402

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88 SHOULDER DYSTOCIA 404

89 3RD AND 4TH DEGREE PERINEAL TEARS 408

90 SECONDARY SUTURING COMPARED TO NON-SUTURING FOR BROKEN DOWN PERINEAL 412

WOUNDS FOLLOWING CHILDBIRTH
91 CAESAREAN SECTION 413

92 CLAMPING OF UMBILICAL CORD 418

93 PERITONEAL CLOSURE 420

94 PREVENTION AND MANAGEMENT OF PPH 421

95 ELECTIVE INTERVENTIONAL RADIOLOGY IN PPH 430

96 MATERNAL COLLAPSE IN PREGNANCY AND THE PUERPERIUM 431

97 CRITICAL AND MATERNITY CARE 438

98 ANTENATAL AND POSTNATAL MENTAL HEALTH 445

99 OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN 447

100 SUSPECTED OVARIAN MASSES IN PREMENOPAUSAL WOMEN 450

101 TARGETED THERAPIES FOR MANAGEMENT OF OVARIAN CANCER 453

103
POP-Q SYSTEM FOR THE ASSESSMENT OF PELVIC ORGAN PROLAPSE 454

104 POST HYSTERECTOMY VAGINAL VAULT PROLAPSE 460

105 URINARY INCONTINENCE 464

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106 SURGICAL TREATMENT OF URODYNAMIC STRESS INCONTINENCE 470

107 VACCINATION AGAINST CERVICAL CANCER 471

108 REDUCING THE RISK OF THROMBOSIS AND EMBOLISM DURING PREGNANCY AND THE 473
PUERPERIUM
109 THE ACUTE MANAGEMENT OF THROMBOSIS AND EMBOLISM DURING PREGNANCY AND 489
THE PUERPERIUM

110 VENOUS THROMBOEMBOLISM AND HORMONE REPLACEMENT THERAPY 495

111 VTE AND HORMONAL CONTRACEPTION 499

112 THEMANAGEMENT OF VULVAL SKIN DISORDERS 503

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CLASSIFICATION OF EVIDENCE LEVELS

8
UNDERSTANDING AUDIT
Definition
 Clinical audit is a quality improvement process that improve patient care and outcomes
through systematic review of care against explicit criteria and the implementation of
change.
What can be audited?
 Audit may evaluate:
1. the structure of services,
2. the process of care
3. the outcome of care.
Measure of structure or service provision
 For example, research evidence shows that outcome for patients with ovarian cancer is
better if they are operated by trained gynaecologist and managed within multidisciplinary
team.
 An audit of the referral and management of patients with ovarian cancer can provide an
overview of service provision in this area.
Process measure
 Process measures are clinical practices evaluated by research and shown to influence
outcome.
 For example, research evidence shows that the use of antenatal steroids improve
perinatal outcome. Evaluation of this process of care is by measuring the proportion of
appropriate women who received antenatal steroids.
 Process measures may be used to assess the quality of care and have some
advantages over outcome measures:
1. provide more direct measure of the quality of care
2. they occur more frequently, so smaller samples are needed
3. the findings are easier to interpret
4. as smaller audits are needed, they cost less.
Outcome measure
 Outcome measure is the response to an intervention;
 for example, the health status (dead or alive), cure following surgery for stress
incontinence
 Outcomes can be :
1. desirable; improvement in the patient‟s condition or quality of life,
2. undesirable, adverse effects of a treatment.
 the use of outcomes alone in assessing quality of care has limitations:
1. outcomes are not a direct measure of the care provided.
2. not all patients who experience substandard care will have a poor outcome
3. many factors contribute to eventual outcome (e.g. disease severity, health status and
social and health inequalities)
4. outcomes may be delayed
5. research evidence about the impact of some care processes on outcome is limited
6. adverse outcomes occur less frequently so larger samples will be needed.
 Despite all the difficulties with outcome measures, mortality and morbidity measures are
important
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 „Critical incident‟ or „adverse event‟ reporting involves the identification of patients where
an adverse event has occurred, such as the Confidential Enquiries into Maternal Deaths
(CEMD).
The audit cycle
 Steps of Audit (audit cycle):
1. selection of a topic
2. identification of an appropriate standard
3. data collection to assess performance against the prespecified standard
4. implementation of changes to improve care if necessary
5. data collection for a second, time to determine whether care has improved.

Selection of a topic
 In selecting a topic for audit, priority should be given to :
1. common health concerns,
2. areas associated with high rates of mortality, morbidity or disability,
3. where good research evidence is available to inform practice. It is
 important to involve those who will be implementing change at this stage of the audit
process.

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Identification of an appropriate standard
1) Review criteria
 The criterion is the reference point against which current practice is measured.
 High-quality evidence-based guidelines can be used as criteria. Where this is not
possible, criteria should be agreed by a multidisciplinary group including those involved
in providing care and those who use the service.
 Review criteria should be explicit rather than implicit and need to:
1. lead to valid judgements about the quality of care, and therefore should be based on
research evidence
2. relate to aspects of care that are important either to patients or clinical outcome
3. be measurable.

2) Standard and target level of performance

 defined as „the percentage of events that should comply with the criterion‟ (e.g. the
proportion of women undergoing induced abortion who were screened for lower genital
tract organisms, the proportion of women delivered by caesarean section who received
thromboprophylaxis,
 Target levels of performance should be examined periodically.
 setting target levels of performance is by:
1. informal agreement among the group leading the audit or among health professionals.
2. external standards
 Target levels of performance have been most used in screening programmes. For
example, in screening for cervical cancer there are quality criteria to be met, such as the
proportion of cervical smears that have endocervical cells.
3) Benchmarking
 it is the „process of defining a level of care set as a goal to be attained‟.
 benchmarking techniques help participants in audit to avoid setting unnecessarily low or
unrealistically high target levels of performance.
Data collection to assess performance against the pre-specified standard
 the following points need to be considered:
1) What data items to collect?
 Definitions need to be clear so that there is no confusion about what is being collected.
For example, if collecting data on rupture of membranes, it may need to be specified
whether this is spontaneous or artificial.
 Data collectors should be aware of their responsibilities to the Data Protection Act and
any locally agreed guidelines.
 Nationally agreed guidelines, known as the Caldicott Principles:

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 1. Justify the purpose(s).
2. Do not use patient-identifiable information unless it is absolutely necessary.
3. Use the minimum necessary patient-identifiable information.
4. Access to patient-identifiable information should be on a strict need-to-know basis.
Only those individuals who need access to patient-identifiable information should
have access.
5. Everyone should be aware of their responsibilities and obligations to respect patient
confidentiality.
6. Understand and comply with the law.
2) How to collect the data
 Sources of data include:
1. routinely collected data if available (e.g. birth registers);
2. clinical records
3. data collection through direct observation or from questionnaire surveys or patients.
3) Who will collect the data?
 In small audit projects the principal investigators can go through clinical notes for data
abstraction.
 In larger projects, it may be appropriate for those involved in the care of the woman to fill
in standard data collection sheets.
4) Data management
5) Data analysis
 Simple statistics are often all that is required.
 Other useful statistical software packages include Epi Info, SAS, SPSS, STATA and
Minitab.
5.4 Implementation of changes to improve care if necessary
 Data analysis and interpretation will lead to identification of clinical areas that should be
addressed.
 There are many methods by which this can be done. The feedback of audit findings is
most commonly used;
 Simple methods were occasionally effective, for example:
1. feedback of data collected
2. provision of clear data, perhaps using modern information systems, supported by
active teamwork
3. support from the organisation for teamwork
4. use of several methods together within the context of an implementation plan.
 Change does not always occur in audit due to:
1. Resistance to change among local professionals or in the organisational environment
or team
2. Patients themselves may have preferences for care that make change difficult.
Organisation of audit
The following features are associated with successful audit:
1. Good planning with structured programmes with realistic aims and objectives
2. leadership and attitude of senior management
3. nondirective, hands-on approach
4. support of staff, strategy groups and regular discussions
5. emphasis on team working and support
6. environment conducive to conducting audit.

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 7. multidisciplinary approach with the involvement of stakeholders (including consumers
or users of the service provided) and the local audit department
8. resources.
Common reasons why audits fail
1. Failure to participate and attitudes to audit. Involving all stakeholders (including
service users) in the project can encourage participation.
2. Failure to continue and complete the audit cycle.
3. Failure to provide a supportive environment for audit.
4. Lack of resources, especially time.
5. Lack of training in audit methodology and evidence-based skills.
6. Cost.

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RISK MANAGEMENT FOR MATERNITY AND GYNAECOLOGY
Patient safety, risk management and quality of care
 Standards for Better Health, published by the UK Department of Health, outlined
seven domains of health care the first of which is safety.

Managing risk
Definition of risk management: „theculture, processes and structures that are directed
towards realizing potential opportunities whilst managing adverse effects‟.
some misconceptionsregarding risk management:
1. Risk management is not primarily about avoiding or mitigating claims; rather, it is
a tool for improving the quality of care.Risk management is also as much about
learning from claims as it is about mitigating claims.
2. Risk management is not simply the reporting of patient safety incidents. Incident
reporting is only one aspect of the identification of risk.
 incident reporting is on the reactive side of risk management. More
 the proactive side is more effective when resources are used to minimise the
occurrence of patient safety incidents instead of „fire fighting‟ after wrong. fire
drill is one example of proactive risk management.
3. risk management is the business of service managers and of little concern to
working clinicians. Risk management is actually the business of all stakeholders
in the organisation, clinicians and non-clinicians.
Basic questions addressed by risk management

A holistic view of patient safety

 The term „clinical risk management‟ is sometimes used to refer to the application of
risk management in the clinical setting
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  The demarcation between clinical and non-clinical risk is not always clear-cut.
Application of risk management

4. Organisational requirements for risk management

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Integrated framework
 Risk is best managed within a framework that integrates all aspects of clinical
governance including clinical audit, education and training, complaints and claims
handling, health and safety, research and service development.
 The organisation should provide a safety culture which is more likely if there is
strong leadership, teamwork, communication, user involvement and training.
Linked with hospital-wide strategies and initiatives
 Risk management at the specialty or subspecialty level should be linked with
hospital-wide strategies and initiatives.
 Each department should have a written risk management strategy and a
designated risk lead.
 Strategic direction and leadership should be provided by a multidisciplinary risk
management or clinical governance committee. For a maternity unit ( senior
obstetrician, training-grade doctor, a midwife, an anaesthetist, a neonatologist and
the unit manager).
5. The risk management process
1) Risk identification
 either prospectively by checking possible sources of patient safety incidents before
happened or retrospectively by looking back at things that did go wrong.

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1. Incident reporting
 Each unit should have a list of reporting incidents (trigger list) for maternity and
gynaecology
 To optimise the reporting of incidents, staff should be aware and motivated..
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2. Identifying prospective risk
 by using a tool called Failure Mode and Effects Analysis (FMEA).
 this tool has been more extensively used in aviation, aerospace and automobile
industries but is applicable to health care.

3. Looking at what went wrong

 By using system analysis or „root cause analysis‟.
 It is a structured and systematic approach to invistigate clinical incidents.
 The key steps are:
 Identify incident and take decision to investigate.
 Select members of the investigation team.
 Gather data (such as records, interviews, protocols) and relevant physical items.
 Determine the chronology of the incident.
 Identify care delivery problems (unsafe acts; for example, failure to act or
incorrect decision).
 Identify contributory factors (such as inadequate training, lack of supervision).
 Devise an action plan.
 Avoid two fallacies: professionals who try hard enough will not make any errors (the
perfection fallacy) and people will make fewer errors if they get punished for any
error (thepunishment fallacy).
 It is important to distinguish between „active‟ and „latent‟ failures and also between
error and violation, because the aim is not to apportion blame but to reduce the risk
of similar incidents again.
 active failure is the immediate cause of incident while a latent failure is a more
remote but important cause.
 In the evolution of risk management, a unit is more likely to start by looking back at
incidents that have happened („root cause analysis‟) rather than prophylactically
examining processes (FMEA) but either or both approaches can be used.
 Generally, FMEA is more time consuming and should be reserved for high-priority
processes.
2) Risk analysis and evaluation
 risk score matrix helps to identify risks or incidents that require in-depth
investigation or those that require immediate action.

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  The risk score is commonly derived by multiplying the severity of the incident by the
likelihood of its occurrence.
 Levels of severity will be locally defined, taking into account the extent of harm
caused to the patient and the organisation.
 The likelihood rating the probability of occurrence (for
 A risk with a score of 20 or higher is deemed an unacceptable risk.

3) Risk treatment
 Options for dealing with the risk(s) may be elimination, substitution, reduction or
acceptance of the risk, is
 Selection of the appropriate treatment will be influenced by the risk rating and there
may be significant resource implications.
 Lessons learned from the identification and treatment of risk should be shared with
other parts of the hospital/trust and with the wider community through channels
such as multidisciplinary team meetings, ward meetings, safety alerts, newsletters,
intranet and educational meetings.
4) Risk registers
 Each clinical area should have a risk register.
 Risks identified through the processes described above should be entered in the
register.
 A risk register is not a static document.
 Ideally, a risk register should be in electronic format.
6. The national context
 A useful tool produced by the NPSA is the Incident Decision Tree,
 The decision tree helps distinguish between cases requiring disciplinary action and
those attributable to system failure.
 It takes the user through a series of structured questions about the individual‟s
action, motive and behaviour at the time of the incident.
 These questions consider whether deliberate harm was intended, whether illness or
substance misuse was contributory, whether local guidelines were in place and
followed.

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Family Planning: NICE & FSRH Sept 2012
CONTRACEPTION
introdution
 Uptake of contraception in the UK (women aged 16-49 years),Oral contraception 25%
,Male / female sterilisation 24%,Sheath 18%,IUCD 4%
COMBINED ORAL CONTRACEPTIVE PILL
DOSE;
 Oestrogen:
• Contain 35, 30 or 20mcg (Loestrin 20 / Mercilon / Femodette) ethinyl oestradiol (pills
containing 50mcg ethinyl oestradiol are rarely used)
 Progestogen:
 2nd generation ;1\Norethisterone 1mg 2\Levonorgestrel 150mcg
 3rd generation ;1\Desogestrel 150mcg 2\Gestodene 150mcg 3\Norgestimate 250mcg
 Spironolactone derivative ; Drospirenone 3mg
 Failure rate (Pearl index – failure rate per 100 woman year) = 0.1 if correctly taken.
 Mode of action: 1\Suppress ovulation 2\Disrupt endometrium 3\Thicken cervical mucus
RISKS / COMPLICATIONS
 Venous thrombo-embolism (VTE)
 Increased risk of VTE associated with COCP – related to dose of oestrogen and the
type of progestogen.
 10 fold increase in VTE risk in women taking OCP containing over 50mcg ethinyl
oestradiol, 7 fold increase with 50mcg and 4 fold increase with < 50mcg
 Risk of VTE as follows:
1) Healthy woman not taking COCP - 5 / 100,000
2) Second generation COCP user - 15 / 100,000
3) Third generation COCP user (desogestrel or gestodene) - 25 / 100,000
4) Pregnancy - 60 / 100,000
 Women with a family history of VTE, severe varicose veins, immobility or obesity
should not be prescribed third generation COCP.
 COCP use associated with a decrease in antithrombin III and an increase in
fibrinogen, prothrombin, factors VII, IX, X, XII. Low dose COCP (<35mcg ethinyl
oestradiol) tend to increase fibrinolysis and are neutral with respect to their effect on
antithrombin III and protein C but associated with a 10-20% decrease in protein S.
 Individuals at greatest risk of VTE are those with inherited thrombophilias, especially
antithrombin III, protein C and S deficiency and factor V Leiden mutation
 Women with factor V Leiden mutation have an 8 fold higher relative risk of VTE which
is increased to 33 fold if they use the COCP
 WHO does NOT recommend routine screening for thrombophilias before
commencing COCP as the absolute risk of VTE remains small
 MALIGNANT DISEASE

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 I. Breast cancer
 COPC use is associated with an increase in the risk of developing breast cancer
(relative risk 1.24 in current users)
 This risk is independent of duration of use but is related to the age at which COCP
use is discontinued and is not influenced by a family history of breast cancer
 The risk of breast cancer in women who have discontinued COCP for 10 years is not
different from that of never users. Women who develop breast cancer while taking
the COCP tend to have better prognosis tumours
 Use of COCP in older women (aged above 45 years) is not associated with an
increase in the risk of breast cancer
II. Cervical cancer
 Compared with never users of oral contraceptives, the relative risks of cervical
cancer increased with increasing duration of use.
 For durations of approximately less than 5 years, 5-9 years, and 10 or more years,
respectively, the summary relative risks were 1.1 (95% CI 1.1-1.2), 1.6 (1.4-1.7), and
2.2 (1.9-2.4) for all women; and 0.9 (0.7-1.2), 1.3 (1.0-1.9), and 2.5 (1.6-3.9) for HPV
positive women
III. Endometrial and Ovarian cancer
 COCP use for 4 and 8 years associated with a 40% and 51% reduction in risk of
ovarian cancer respectively, and a 54% and 66% reduction in risk of Endometrial
cancer
IV. Colorectal cancer
 COCP associated with a reduction in risk of colorectal cancer
 Myocardial infarction
 Risk related to age, smoking and hypertension
 Risk of MI not significantly increased in women <35 years who smoke
 Risk of MI not significantly increased in non-smokers irrespective of age
 In smokers over the age of 35 years, use of COCP is associated with 450 extra MIs
per 1 million women per year (~30 fold increase in risk)
 Risk of MI also increased in COCP users with a history of hypertension (17 fold
increase)
 Oestrogen increases HDL cholesterol and decreases total and LDL cholesterol while
progesterone decreases HDL but increases LDL cholesterol.
 Stroke
 Stroke is a rare event in women below the age of 45 years. Mortality is however up to
30% with significant morbidity
 Risk factors for ischemic stroke include hypertension (4x), smoking (3x) and focal
migraine. Risk of haemorrhagic stroke particularly increased in hypertensive women
who use COCP
 Hypertension
 Small increase in risk associated with COCP use
 Liver disease

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  Small increase in risk of cholelithiasis / hepatocellular adenomas / focal nodular
hyperplasia / hepatocellular carcinoma
 NON-CONTRACEPTIVE BENEFITS OF COCP
I. Dysmenorrhoea
 COCP reduce menstrual prostaglandin release thereby reducing uterine contractility
and dysmenorrhoea
 Longitudinal studies have shown a significantly lower prevalence and severity of
dysmenorrhoea both at entry and after 5 years of use among women taking low
dose COCP compared to non-users or IUD users
II. Menorrhagia
 Low dose COCP have been shown to reduce menstrual blood loss in women with
menorrhagia by up to 43%
III. Dysfunctional Uterine Bleeding
 Low dose COCP are effective in treating menorrhagia, metrorrhagia,
oligomenorrhoea and polymenorrhoea
 This improvement is associated with a significant improvement in base-line quality-of-
life scores related to physical functioning parameters such as self-care, walking,
lifting and exercise
IV. Anaemia
 Low dose COCP associated with a reduced incidence of iron deficiency anaemia in
menstruating women
V. Functional ovarian cysts
 Evidence that COCP reduce the incidence of functional ovarian cysts is based on
preparations containing over 50mcg ethinyl oestradiol
 Studies on COCP containing 35mcg ethinyl oestradiol or less have NOT shown a
significant reduction in the incidence of functional ovarian cysts
VI. Ectopic pregnancy
 All forms of contraception reduce the incidence of ectopic pregnancy
 Risk of ectopic pregnancy in COCP users is 0.005 per 1000 woman years,
comparable to that associated with vasectomy and lower than the risk associated
with barrier contraception, IUCD or tubal ligation
VII. Fibroadenomas and fibro-cystic breast change
 COCP associated with a reduction in risk of benign breast disease
VIII. Acute PID
 Data on the effect of COCP on the incidence of acute PID are conflicting
 Progesterone effect on cervical mucus – increased viscosity impedes ascent of
pathogens and may confer protective effect. Lower menstrual flow also reduces
bacterial growth
IX. Acne
 Low dose COCP are effective in reducing total lesions, total inflammatory lesions and
papules compared to placebo
 DRUG INTERACTIONS
Hepatic enzyme-inducing drugs
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  Carbamazepine, phenytoin (NOT valproate), griseofulvin, phenobarbital, primidone,
rifampicin (and rifabutin), modafinil – take additional contraceptive precautions during
use and for 7 days after use – start next packet without a break if 7 days runs beyond
the end of a packet
 For rifampicin / rifambutin – use additional contraception for at least 4 weeks after
stopping treatment.
Broad-spectrum antibiotics
 Impair bacterial flora responsible for entero-hepatic circulation of ethinyl-oestradiol –
additional contraception during treatment and for 7 days after treatment as above.
 CONTRA-INDICATIONS
WHO group 4 (conditions for which COCP use is associated with unacceptable health
risks)
1. Previous thrombosis
2. Ischemic heart disease
3. Cardiomyopathies
4. Active Kawasaki disease
5. BMI > 39
6. BP >160/100
7. Severe diabetes mellitus
8. Focal migraine
9. Thrombophilia
10. 4 weeks before major surgery – 2 weeks after full mobility
11. Active liver disease
12. Severe inflammatory bowel disease
13. Undiagnosed genital tract bleeding / pregnancy
14. Acute porphyria / SLE
15. Uncorrected valvular heart disease
16. TIAs / cerebral haemorrhage
17. Altitude > 4500m
18. Trophoblastic disease – until HCG undetectable
19. Hyper-prolactinaemia (seek specialist advice)
 PRESCRIBING COCP
 Detailed history – exclude pregnancy / contra-indications
 Ensure most appropriate method for woman – compliance / life-style
 Weight / BP
 Discuss alternatives
 Discuss benefits (non-contraceptive) and risks
 Outline symptoms to look out for / minor side effects
 Teach pill-taking including missed pill advice
 Provide written information / help-line
 Make appointment for review
COCP is NOT associated with an increased incidence of secondary amenorrhoea.
 Type of progestogen
23
1) NORGESTIMATE
 19-Nortestosterone derivative
 Minimal androgenic activity; associated with a marked increase in SHBG
 Mono-phasic and tri-phasic combinations of EE and norgestimate offer contraceptive
efficacy similar to other COCP with good cycle control.
 There is a favourable lipid profile and no effect on carbohydrate metabolism
2) DESOGESTREL
 19-Nortestosterone derivative with minimal androgenic activity
 Contraceptive efficacy similar to other COCP.
 Favourable effect on lipid profile
 Evidence that COCP containing desogestrel or gestodene associated with an
increased risk of VTE compared to those containing levonorgestrel
3) DROSPIRENONE
 Spironolactone derivative with some anti-androgenic effects
 Effect on VTE risk unknown
 Initial trend towards weight loss in early cycles is offset by a slight weight gain with
long-term use (by cycle 13)
 Contraceptive efficacy is similar to other COCP
 Headache is the most frequently reported side-effect
 Hyperkalaemia is a theoretical possibility and therefore this pill is contra-indicated in
renal and adrenal insufficiency and hepatic dysfunction
 Serum potassium should be checked during the first treatment cycle in women
treated with NSAIDs, potassium sparing diuretics, ACE inhibitors, angiotensin II
receptor antagonists, heparin, aldosterone antagonists and potassium supplements
 Delivery systems
1) INJECTABLE COMBINED CONTRACEPTIVE
 Contains 25mg medroxyprogesterone acetate + 5mg oestradiol cypionate
 Administered once monthly by intra-muscular injection (should be administered every
28-33 days)
 Contraceptive efficacy similar to long-term systemic or intra-uterine progesterone-
only methods or the modern copper IUCD
 Has advantage over 3 monthly progesterone-only regimen as improved bleeding
patterns and swifter return of fertility on discontinuation
 Majority of women (~75%) report satisfactory monthly bleeding patterns
2) CONTRACEPTIVE PATCH
 20 cm squared trans-dermal system
 Contains 6.0mg norelgestromin, the primary active metabolite of norgestimate and
0.75mg ethinyl oestradiol
 Hormones released at a rate of 150mcg norelgestromin and 20mcg EE per day for 7
days during which the patch is worn. The patch is changed every 7 days for 3 weeks
with a drug-free 7 day interval
 Patient compliance is significantly higher with the contraceptive patch compared to
oral contraceptive pills
24
  Pearl Index = 0.88. In comparative trials, efficacy better than COCP
 Side-effects similar to COCP with the addition of application site reaction. Nausea,
headache, breast tenderness and break-through bleeding usually decrease by the
third cycle in most women
PROGESTERONE-ONLY PILLS
 Delivery systems
1. Progeaterone – only pills (POP)
2. Injettables
3. Implants
 Suitable for women with VTE, migraine, older women who smoke, women with
hypertension, valvular heart disease, diabetes mellitus.
 Modes of action
 Suppress ovulation
 Reduce fallopian tube motility
 Reduce endometrial receptiveness
 Thicken cervical mucus and reduce sperm penetrability
 Pearl index - 1.2 / 100 woman year
 Efficacy increases with age and may be reduced if increased weight > 70kg –
consider double dose.
 Main action is on cervical mucus with maximal effect 4 hours after dose
 Suppress ovulation in ~ 40%, this is unpredictable and varies between cycles
resulting in irregular menstruation
 10% - 15% of women have complete inhibition of ovarian activity and are
amenorrhoeic. ~50% have regular ovulatory cycles with a normal luteal phase and a
normal menstrual cycle. 35–40% have inconsistent suppression of ovarian activity
with variable follicular development, and occasional ovulation often characterized by
short or inadequate luteal phases.
 Associated with increased incidence of ovarian follicular cysts and increased risk of
ectopic pregnancy (compared to COCP, but decreased compared to sexually active
non-contraceptive user)
 Efficacy is reduced by hepatic enzyme-inducing drugs. Needs to be taken strictly on
time to maximise efficacy.
 Readily reversible method of contraception – no effect on subsequent fertility, suited
for breast-feeding mothers, older smokers, diabetics, hypertensives and avoids
oestrogenic side-effects of COCP.
 Contra-indications
1. Pregnancy.
2. Undiagnosed vaginal bleeding.
3. Severe arterial disease.
4. Liver adenoma.
5. Porphyria.
6. after evacuation of molar pregnancy until HCG levels return to normal
 Starting routine
25
  One tablet daily taken from day 1 of the cycle and taken continuously
 Should be taken at the same time every day and within 3 hours at the most
 Additional precautions not required when starting treatment
 When switching from COCP, start on the day following completion of COCP without a
break (omit inactive tablets if ED regimen)
 Following delivery – start at any time after 3 weeks post-partum – risk of break-
through bleeding
 If pill missed for more than 3 hours, additional precautions needed for 7 days
 Vomiting within 3 hours of dose or severe diarrhoea – additional precautions for 7
days after recovery
 Formulations
1. Etynodiol diacetate 500mcg
2. Norethisterone 350mcg
3. Levonorgestrel 30mcg
4. Norgestrel 75mcg
 INJECTABLES
 Depo-medroxyprogesterone acetate 150mg (depo-provera, every 84-90 days)
 Norethisterone oenanthate 200mg (Noristerat, every 8 weeks)
 Main effect is inhibition of ovulation
 Endometrial and cervical mucus effects also
 Pearl index0.25 – 0.5 / 100 woman years (depo-provera)0.4 – 2.0 / 100 woman
years (Noristerat)
 Depo-provera commonly used in UK
 Menstrual irregularity is common – amenorrhoea becomes more likely with
repeated doses (30% after 1st dose, 55% after 4th dose).
 Associated with a delay in return to normal fertility of about 8 months after last
injection, may be as long as 24 months.
 Weight gain - ~6lb(35kg) in the first year
 Associated with lower risk of ectopic pregnancy (compared to POP but higher
than COCP), PID, endometrial cancer. Menstrual blood loss is reduced with a
reduction in iron deficiency anaemia and need for hystsrectomy in women with
fibroids
 Heavy bleeding reported in women given depo-provera immediately after delivery
and treatment should be delayed for at least 6 weeks. If the woman is not breast-
feeding and has been counselled, may be administered within 5 days of delivery
 Depo-provera and osteoporosis
 There is evidence that depo-provera causes a significant reduction in bone mineral
density. This effect may be more important in adolescents. This reduction appears to
be partly reversible after discontinuation and resumption of ovarian activity
1) In adolescents, depo-provera should only be used after other methods have
been considered and found to be unsuitable or unacceptable
2) In women with risk factors for osteoporosis, other methods should be
Considered prior to use of depo-provera
3) In all women, careful re-evaluation of risks and benefits of treatment should be
undertaken in those who wish to continue use for longer than 2 years
 IMPLANTS
26
 Implanon (68mg etonorgestrel – ACTIVE METABOLITE OF DESOGESTREL)
 Pearl index 0-1 / 100 woman years
 Ovarian suppression, endometrial effects, cervical mucus thickening
 Lasts 3 years – efficacy may be lower during the third year in overweight women
 Rapid return of fertility – 90% of women ovulate within 30 days
 Associated with irregular bleeding initially, amenorrhoea rate ~ 50%
 Prolonged use of injectables / implants has raised concerns about hypo-
oestrogenaemia in amenorrhoeic women and loss of bone mineral density although
there are no data to substantiate these concerns
 Broad-spectrum antibiotics do not affect the efficacy of injectables / implants. Hepatic
enzyme-inducing drugs may reduce efficacy and in long-term users, the dose interval
of depo-provera should be reduced to 10 weeks
INTRA-UTERINE CONTRACEPTION
 Act by preventing fertilisation and implantation.
 The progesterone releasing intra-uterine system has local progestogenic effects on
the endometrium and cervical mucus.
Disadvantages; are difficulties with insertion, pain and vaginal bleeding, risk of pelvic
Infection, expulsion.
 CONTRAINDICATIONS
Relative (WHO 3)
I. Immunosupression including HIV / AIDS
II. High risk of sexually transmitted disease
III. Menorrhagia (except IUS)
IV. Benign trophoblastic disease
V. Up to 4 weeks post-partum - risk of perforation / expulsion
VI. Ovarian cancer awaiting treatment
Absolute (WHO 4)
1\ Current or recent sexually transmitted infection or PID, including post-partum and
Post-TOP endometritis
2\ Distorted uterine cavity
3\ possible pregnancy
4\ undiagnosed vaginal bleeding
5\ Pelvic tuberculosis
6\ Cervical or endometrial cancer awaiting treatment
7\ Malignant gestational trophoblastic disease
* Women at risk of bacterial endocarditis should have prophylactic antibiotics prior to IUCD
fitting*
 The following conditions are NOT contraindications to the use of IUDs
1) Past history of PID or sexually transmitted disease if the woman is now at low risk
2) Previous ectopic pregnancy
3) Previous expulsion
4) Previous caesarean section
5) Nulliparity
6) Cervical intra-epithelial neoplasia
7) Past or current breast cancer
8) Uterine fibroids without distortion of the endometrial cavity
THE MIRENA INTRA-UTERINE SYSTEM
 Contains 52mg Levonorgestrel released at the rate of 20mcg / day.
 The frame is rendered radio-opaque by impregnation with barium sulphate.
27
  Licensed for contraception for 5 years. Levonorgestrel – induced endometrial
changes are established within three cycles with atrophy of endometrial glands,
decidualisation of the stroma, inactivation of the epithelium, supression of spiral
arterioles and an inflammatory response.
 The endometrium becomes unresponsive to oestrogen.
 After removal, endometrial morphology returns to normal with menstruation within 30
days
 NON-CONTRACEPTIVE USES / BENEFITS
i. Management of menorrhagia - Reduction in menstrual blood loss of up to 97% after
12 months of use with an increase in serum ferritin and Hb concentrations. 35%
amenorrhoea rate at 1 year
ii. Dysmenorrhoea - There is evidence that this may be improved.
iii. Progestogenic opposition for oestrogen replacement therapy / oestrogen therapy for
PMS
iv. Low rate of ectopic pregnancy (0.02/100 woman years compared to 0.25/100 woman
years for the Nova T and 1.2-1.6/100 woman years for sexually active women not
using contraception).
v. Protection against PID – thickening of cervical mucus, inactivation of the
endometrium and reduced bleeding.
vi. Management of endometrial hyperplasia
vii. Some evidence that the incidence of uterine fibroids and their growth is reduced
viii. Cost-effectiveness – compare to cost of hysterectomy / medical treatment for
menorrhagia.
SIDE-EFFECTS / COMPLICATIONS
a) Difficulties with insertion – especially in nulliparous women, cervical dilatation
required under para-cervical block / NSAID.
b) Irregular bleeding – takes 3 months for endometrial atrophy – good counselling
required prior to insertion
c) Increased incidence of functional ovarian cysts compared to copper IUD users
d) Amenorrhoea – unless appropriately counselled, some women may regard this as
abnormal
e) Progestogenic side-effects – oedema / headache / breast tenderness / acne –
subside after a few months
f) Expulsion - commonly occurs during first month following insertion.
 CONTRA-INDICATIONS
1. Pregnancy
2. Undiagnosed genital tract bleeding
3. Severe distortion of the uterine cavity
4. Acute or recurrent PID
5. Leukaemia
6. Valvular heart disease
7. Severe arterial disease
8. Liver disease
9. Sensitivity to levonorgestrel
10. Histories of ovarian cysts / thrombo-embolic disease are relative contra-indications.
 COMPLICATIONS OF IUCD USE
 Expulsion
Most occur in the first year, and especially in the first 3 months.

28
 Increased risk of expulsion in women with heavy painful periods, with
insertion within 6 weeks post-partum, previous expulsion and with
inexperienced operator.
 Perforation
Risk 1.2 / 1000 insertions
 Pregnancy
Remove device gently if possible, as soon as pregnancy is diagnosed -
reduces the risk of spontaneous miscarriage by 50%. Exclude ectopic
pregnancy (risk 1:25 with IUCD).
 Pelvic infection
Six fold increase in risk of developing PID in the first 20 days following
insertion compared with any other time
Thereafter the risk of infection remains constant at 1.4 / 1000 women
 Increased menstrual loss
 Abdominal pain / dysmenorrhoea
PERSONA
 Natural family planning – measures levels of LH and oestron-3-glucuronide in early
morning urine.
 Needs to be programmed for three months (test urine for 16 days in the first month
and 8 days in subsequent months) before device can be relied upon.
 Not suitable for the following groups of women:
1- Cycle length <23 days or > 35 days
2- PCOS
3- Breastfeeding
4- Menopausal symptoms
5- Women taking hormonal medication
 Needs to be re-programmed after post-coital contraception
 Failure rate ~ 6/100 woman years with perfect use. Much higher for „typical‟ user.

FSRH- Emergency Contraception:Updated January 2012

 Methods: CU- IUD (1st line), levonorgestrel (LNG), ulipristal acetate (UPA).
 IUD & UPA: up to 5 days. LNG isn‟t licenced beyond 3 days despite demonstrated
efficacy up to 4 days.
 If woman needs to continue CC after oral EC; offer CHC (excluding co-cyprindiol),
POP or implant + inform to do Preg-Test after 3 wks after UPSI (unprotected sexual
intercource) has occurred. DMPA should be started immediately only if other
methods are not appropriate or acceptable, because it should ideally be offered only
after pregnancy can be excluded.
 Following administration of LNG, women continuing to use a hormonal method of
contraception should be advised to use additional contraceptive precautions for 7
days (2 days for POP, 9 days for Qlaira®).
 Following administration of UPA, women continuing to use a hormonal method of
contraception should be advised to use additional contraceptive precautions for 14
days (9 days for POP, 16 days for Qlaira).

29
  Women taking liver enzyme-inducing drugs (or who have stopped taking this
medication within the last 28 days) should be advised that a Cu-IUD is the only
method of EC not affected by these drugs. They should be advised not to use UPA
during or within 28 days of stopping taking this medication.
 Women taking liver enzyme-inducing drugs, including post-exposure HIV prophylaxis
after sexual exposure (or who have stopped within the last 28 days), and who decline
or are not eligible for a Cu-IUD, should be advised to take a dose of 3 mg LNG (two
Levonelle ® tablets) as soon as possible within 120 hours of UPSI (outside the
product licence). The efficacy of LNG after 96 hours is uncertain.
 Women should be advised not to use UPA if they are currently taking drugs that
increase gastric pH (e.g. antacids, histamine H 2 antagonists and proton pump
inhibitors).
 Women should be advised to seek medical advice if they vomit within 2 hours of
taking LNG or 3 hours of UPA administration. A repeat dose of the same method or a
Cu-IUD may be offered if appropriate.
 LNG can be used more than once in a cycle or for a recent indication even if there
has been an earlier episode of UPSI outside the treatment window (>120 hours).
UPA isn‟t currently supported for such use or concomitantly with LNG.
 The CEU advises that if further UPSI occurs within 12 hours of a dose of
LNG, further EC treatment is not required.
 It is not known if UPA reduces the efficacy of LNG or how long after UPA
administration any such interaction has an effect.
 Women choosing a Cu-IUD for EC may opt to continue using the Cu-IUD for ongoing
contraception. If the woman does not require contraception or prefers another
method, the Cu-IUD can be removed after pregnancy has been excluded and
providing there has been no UPSI in the 7 days prior to removal and guidance for
switching methods is followed.
 No studies have specifically looked at the effect of body weight on the efficacy of oral
EC.
 contraindication :
 LNG: there are no medical contraindications to LNG, including breastfeeding.
 UPA: severe uncontrolled asthma, hepatic dysfunction, hereditary problems
of galactose intolerance, the lactase deficiency or glucose-galactose
malabsorption and peptic ulcer.
Postnatal Sexual and Reproductive Health
 Available evidence suggests that use of progestogen- only contraception while
breastfeeding does not affect breast milk volume. Currently insufficient evidence for
COCS.
 Progestogen-only contraception has been shown to have no effect on infant growth.
 Women may be advised that if they are <6 months postpartum, amenorrhoeic and fully
breastfeeding, the lactational amenorrhoea method (LAM) is over 98% effective in
preventing pregnancy.

31
 Women can be advised that contraception (& EC) is not required before Day 21
postpartum. If starting a hormonal method on or before Day 21 there is no need for
additional contraception.
 If starting a hormonal method after Day 21, exclude preg then use extra protection for
7days [cocs] /2days [pops] unless fully meeting LAM criteria.
 CHC should not be commenced before Day 21 (cat.4) due to the increased risk of
thrombosis. Non-breastfeeding women may start CHC from Day 21 postpartum (cat.1).
Breastfeeding women should avoid CHC in the first 6 weeks postpartum (cat.4) as there
is insufficient evidence to prove the safety.
 Use of CHC between 6 weeks and 6 months should not be recommended in fully
breastfeeding women unless other methods are not acceptable or available(cat.3). In
partially or token breastfeeding women the benefits of CHC use may outweigh the risks
(cat.2).
 Postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time
postpartum (cat.1).
 Non-breastfeeding women can start a progestogen-only injectable method at any time
postpartum (ca.1). Breastfeeding women should not start a progestogen-only injectable
method before Day 21 unless the risk of subsequent pregnancy is high (cat.2).
 For both BF or not; Implanon can be inserted before Day 21, although this is outside the
product licence.
 IUD insertion should be delayed until Day 28 onwards (BF or not) [cat.3<28days. Cat.1
after]. No additional contraception is required.
 IUS can be inserted from Day 28 postpartum (breastfeeding and non-breastfeeding
women). Women should avoid sex or use additional contraception for 7 days after
insertion unless fully meeting LAM criteria.
 Women who choose a diaphragm or cervical cap should be advised to wait at least 6
weeks postpartum before attending for assessment of size requirement.
 Women can be advised that progestogen-only emergency contraception can be used
from Day 21 onwards and the emergency Cu-IUD from Day 28 onwards.

FSRH-Missed pill:May 2011(+Manufacturer’s instructions)

 Cocs Missed pill roles apply if : > 1 pill missed (>48 hrs) OR starting the pack two or
more days late (more than 48 hours late).
 If you have missed one pill, anywhere in the pack:
 Take the last pill you missed now even if it means taking two pills in
one day
 Continue taking the rest of the pack as usual
 No additional contraception needed
 Take your 7-day break as normal.
 If you have missed two or more pills (i.e. more than 48 hours late), anywhere
in the pack:

31
  Take the last pill you missed now even if it means taking two pills in
one day
 Leave any earlier missed pills
 Continue taking the rest of the pack as usual and use an extra
method of contraception for the next 7 days
 EC should be considered if unprotected sex occurred in the pill-free
interval or in the first week of pill-taking.
 OMIT THE PILL-FREE INTERVAl If pills are missed in the third week.

 Qlaira ®: 20 µg estradiol valerate/dienogest containing pill (quadriphasic pill).

-Missed white tablet? (2 tablets at the end of the wallet): you do not need to take it
later.
-If you have forgotten any of the active tablets in a wallet, and you have no bleeding
at the end of a wallet, you may be pregnant. Contact your doctor before you start the
next wallet. (45 days in case of micronor)
 Missed 1 micronor? Take the most recently misse pill [but leave earlier one if > 1] &
take the next one on time. (ie may be 2 pills on same night) + 2days extra protection. If
you lose a pill, just take a pill from a spare strip. Then take all the other pills from your
current strip as usual.
 Marvilon(Desogestrel 150 micrograms +Ethinyl estradiol 30 micrograms):
 Missed pill roles apply if > 12hrs.
 Take the most recently misse pill [but leave earlier one if > 1] & take the next
one on time. (Ie may be 2 pills on same night).

32
  If you start a new strip of pills late, or make your “week off” longer than seven
days EC + 7d extra protection.
 If you lose a pill, either takes one from a spare strip; or take the last pill of the
strip in place of the lost pill & continue. Your cycle will be one day shorter.
 For POP & COCs: If you are sick within the window period, take a spare pill. If sickenss
> window, follow missed pil roles.
 Cerazette: desogestrel (75 microgram)
 < 12hrs, take as soon you remember & no more action needed.
 > 12 hrs: Take a tablet as soon as you remember and take the next one at
the usual time (This may mean taking two in one day) + EC + 7days extra
protection.
 Yasmin: (0.030 milligrams ethinylestradiol and 3 milligrams drospirenone); 21 tablets.
Missed 1 pill (or > 12hrs):
 1st weak: Take the forgotten tablet as soon as you remember + next one on
time +EC + 7 days extra protections.
 2nd wk: as above but NO extra or EC unless > 1pill missed.
 3rd wk: NO extra prec or EC if you do one of the following: either take the
forgotten tablet as soon as you remember & slip pill free period; OR stop the
tablets and go directly to the tablet-free period.
 For COCs: You can also start the pill up to, and including, the fifth day of your period
and you will be protected from pregnancy immediately.

EFFECTS OF CONTRACEPTION ON FUTURE FERTILITY(REVERSE

FERTILITY
 Combined oral contraceptive pill
 Prompt return to ovulation with 70% of women ovulating in the first cycle and 98% by
the third cycle
 Reduced risk of PID due to progestogen
 Reduced risk of ectopic pregnancy
 Higher Hb and ferritin levels may be associated with improved reproductive
outcomes
 No effect on early pregnancy loss, sex ratio or congenital anomalies if inadvertently
taken in early pregnancy
 1% of women would remain amenorrhoeic 6 months after stopping the pill – similar to
rate of secondary amenorrhoea in general population.
 Women who lose weight on the pill are at increased risk. If persists for over 6
months, investigation warranted to exclude PCOS, hyperprolactinaemia, premature
ovarian failure
 Progesterone-only methods
 Prompt return to normal fertility with POP and implants
 POP – less protection from ectopic pregnancy than the combined pill and may be
associated with a slight increase in risk
 Implanon – return to normal ovulation within 6 weeks
 Depo-progestogens: No permanent impact on fertility
 Ovulation returns on average 4-5 months following last injection with a median
conception time of 5-7 months
33
  Women should be warned that conception may be delayed for up to 2 years after the
last injection and alternative methods should be used in women who may wish to get
pregnant sooner
 Thought to be due to delayed metabolism of the drug from micro-crystalline deposits
in muscle tissue
 IUCD
 Risk of PID confined to the first 3 weeks following insertion and thereafter related to
life-style
 Levonorgestrel releasing IUS associated with lower risk of ectopic pregnancy
compared to copper IUCD
 Barrier methods
Associated with lower risk of PID
 No evidence that spermicides are associated with an increased risk of congenital
anomalies

34
CONTRACEPTIVE USE

35
36
37
38
39
41
41
42
43
LONG-ACTING REVERSIBLE CONTRACEPTION
Counselling and provision of information
 Women requiring contraception should be given information and offered all methods
including LARC that will enable them to choose a method and use it effectively. This
information include:
 efficacy
 duration
 risks and side effects
 non-contraceptive benefits
 the procedure for initiation and removal/discontinuation
 when to seek help while using the method.
Training of healthcare professionals in contraceptive care
 Healthcare professionals should be competent to:
 help women to consider and compare the pros and cons of all methods relevant to
their individual needs
 manage common side effects and problems.
 Contraceptive providers who do not provide LARC should have mechanism for referring
women for LARC.
 Healthcare professionals providing intrauterine or subdermal contraceptives should
receive training to develop and maintain the relevant skills to provide these methods.
Cost effectiveness
 LARC methods are more cost effective than the COC even at 1 year of use.
 IUDs, the IUS and the implant are more cost effective than injectable contraceptives.
 Increasing the use of LARC will reduce unwanted pregnancies.
Informed consent for special groups
 Information should take into account the woman‟s needs.
 Be aware of the law on providing contraceptives for young and people with learning
disabilities.
 If a woman is unable to understand and take responsibility for decisions about
contraception, carers and others should meet to agree a care plan.

44
Appendix A: Features of the LARC methods to discuss with women

45
IUD IUS DMPA IMP

46
47
Choice of method for different groups of women
All LARC methods are suitable for:
 nulliparous women
 breastfeeding
 women who have had an abortion – at time of abortion or later
 women with BMI > 30
 women with HIV – encourage safer sex
 women with diabetes
 women with migraine with or without aura – all progestogen-only methods may be
used
 women with contraindication to oestrogen
Choices for adolescents
 IUD, IUS, implants: no specific restrictions to use
 DMPA: care needed; use only if other methods unacceptable or not suitable2
Choices for women more than 40 years old
 IUD, IUS, implants: no specific restrictions to use
48
  DMPA: care needed, but generally benefits outweigh risks
Choices for women post-partum, including breastfeeding
 IUD, IUS: can be inserted from 4 weeks after childbirth (see page 9)
 DMPA, implants: any time after childbirth
Choices for women taking other medication
 IUS, DMPA: no evidence that effectiveness of other medication reduced
 Implants: not recommended for women taking enzyme-inducing drugs
Choices for women with epilepsy
 IUD, IUS, DMPA: no specific contraindications; DMPA use may be associated with
reduced seizure frequency
 Implants: not recommended for women taking enzyme-inducing drugs
Choices for women at risk of sexually transmitted infection (STI)
 IUD, IUS: tests may be needed before insertion
 DMPA, implants: no specific contraindications
 Provide advice on safer sex
Practical details of LARC methods
Copper intrauterine devices and the intrauterine system
Assessing and managing STIs and other infections
 Before inserting an IUD or IUS, test for:
 Chlamydia trachomatis and Neisseria gonorrhoeae in women at risk of STIs
 For woman at increased risk of STIs, give prophylactic antibiotics before inserting an
IUD or IUS if testing has not been completed.
 For women with risks of uterine or systemic infection, arrange investigations and give
appropriate prophylaxis or treatment before inserting an IUD or IUS.
When fitting
 The risk of uterine perforation is related to the skill of the healthcare professional.
 IUDs:the most effective IUDs contain at least 380 mm2 of copper and have banded
copper on arms.
 Provided that the woman is not pregnant, an IUD or IUS may be inserted:
 at any time during the cycle (but, for the IUS, if the woman is amenorrhoeic or it is
> 5 days since her period started, she should use barrier contraception for 7 days
after insertion)
 immediately after first or second trimester abortion
 from 4 weeks post-partum, irrespective of the mode of delivery.
 If the woman has epilepsy, seizure risk increase at the time of fitting an IUD or IUS.
 Women with a history of venous thromboembolism (VTE) may use the IUS.
Managing problems
 For heavier and/or prolonged bleeding associated with use of an IUD:
 Treat with NSAIDs and tranexamic acid
 Suggest changing to the IUS if the woman finds bleeding unacceptable.
 If Actinomyces-like organisms are seen on a cervical smear:
 assess for pelvic infection,
 remove the IUD or IUS if there are signs of infection.
 If a woman becomes pregnant with an IUP, remove the IUD or IUS before 12 weeks‟
gestation.
Injectable contraceptives
When administering
 Given by deep intramuscular injection into the gluteal or deltoid muscle or the lateral
thigh.
 Provided that the woman is not pregnant, use may be started:
 Up to the 5th day of the cycle without the need for additional contraceptives

49
  After the 5th day of the cycle, with barrier contraception for the first 7 days after
injection
 Immediately after first or second trimester abortion.
 At any time post-partum.
Managing problems
 DMPA may be given up to 2 weeks late without the need for additional contraceptives.
 Treat persistent bleeding associated with DMPA with mefenamic acid or
ethinylestradiol.
 When considering DMPA use beyond 2 years, review the woman‟s clinical situation,
discuss the benefits and risks, and support her choice.
 There is no evidence of congenital malformation to the fetus if pregnancy occurs
during DMPA.
Implants
 Inform women that etonogestrel implants [5] have a very low failure rate (less than 1
pregnancy per 1000 implants fitted over 3 years).
 Inform women that vaginal bleeding patterns are likely to change while using an
etonogestrel implant. Vaginal bleeding may stop, become more or less frequent, or
be prolonged during implant use.
 Inform women that dysmenorrhoea may reduce during etonogestrel implant use.
 Inform women that there is no evidence showing a delay in return to fertility after an
etonogestrel implant is removed.
 Inform women that complications with etonogestrel implant insertion and removal are
uncommon. (Possible complications are listed in the summary ofproduct
characteristics.)
When fitting
 Provided that the woman is not pregnant, Implanon may be inserted:
 At any time (but use barrier methods for first 7 days if the woman is amenorrhoeic
or it is more than 5 days since menstrual bleeding started)
 Immediately after abortion in any trimester
 At any time post-partum.
Managing problems
 Treat irregular bleeding with mefenamic acid or ethinylestradiol.
 Remove the implant if a woman becomes pregnant and continues with the pregnancy,
although there is no evidence of a teratogenic effect.

51
MANAGEMENT OF UNSCHEDULED BLEEDING IN WOMEN USING
HORMONAL CONTRACEPTION

51
SUMMARY FOR THE MANAGEMENT OF WOMEN USING
HORMONAL CONTRACEPTION PRESENT WITH UNSCHEDULED
BLEEDINGP
RE-METHOD COUNSELLING
1. advise women Before starting hormonal contraception about the expected bleeding
patterns, both initially and in the longer term.
INITIAL MANAGEMENT
2. A clinical history should be taken from women with unscheduled bleeding to identify the
possibility of an underlying cause.
3. women with unscheduled bleeding who are at risk of STIs (aged <25 years old, or who
have a new sexual partner, or more than one partner in the last year) should be tested
for C. trachomatis as a minimum. Testing for N. gonorrhoeae will depend on sexual risk
and local prevalence.
4. Women who are not participating in a National Cervical Screening Programme should
have a cervical screen.
5. A pregnancy test is indicated if the clinical history identifies the possibility of incorrect
method use, drug interactions or illness, which may lead to malabsorption of oral
hormones.
EXAMINATION AND INVESTIGATION
6. examination may not be required if after taking a clinical history there are no risk factors
for STIs, no concurrent symptoms suggestive of underlying causes, and the woman is
participating in a National Cervical Screening Programme.
7. speculum examination should be performed if they have:
 persistent bleeding or a change in bleeding after at least 3 months use;
 failed medical treatment;
 if they have not participated in a National Cervical Screening Programme.
8. Bimanual examination should be performed for women if they have other symptoms
(such as pain, dyspareunia or heavy bleeding).
9. endometrial biopsy should be considered in women:
 aged ≥45 years (or in
 aged <45 years with risk factors for endometrial cancer (obesity or polycystic ovarian
syndrome)
 persistent unscheduled bleeding after the first 3 months of starting a method or who
present with a change in bleeding pattern.

52
10. The role of uterine polyps, fibroids or ovarian cysts as a cause of unscheduled bleeding
is limited. if such a structural abnormality is suspected TVS and/or hysteroscopy may be
indicated.
THERAPEUTIC MANAGEMENT OPTIONS
11. It is not recommended that a COC is changed within the first 3 months of use as
bleeding disturbances often settle in this time.
12. For women using COCthe lowest dose of ethinylestradiol (EE) to provide good cycle
control should be used. However, the dose of EE can be increased to a maximum of 35

13. Bleeding is common in the initial months of POP use and may settle without treatment. If
treatment may encourage women to continue with the method it may be considered.
14. There is no evidence that changing the type and dose of POP will improve bleeding but
this may help some individuals.
15. For women with unscheduled bleeding using a POI, implant or IUS who wish to continue
with the method and are medically eligible, a COC may be used for up to 3 months (in
the usual cyclic manner or continuously without a pill-free interval).
16. 16 For women using a POI with unscheduled bleeding, mefenamic acid 500 mg twice
daily for 5 days can reduce the length of a bleeding episode but has little effect on
bleeding in the longer term.

53
54
55
MALE AND FEMALE STERILIZATION
Epidemiology
 Rate of female and male sterilisation ~10%
 Between ages 40 to 49 men are more likely than women to have been sterilised
(30% compared with 19% of women aged 40 to 44, and 32% of men compared with
21% of women aged 45 to 49).
COUNSELLING
 If there are any concerns about capacity to provide consent, refer to the courts
 Take extra care if under 30 years of age or nulliparous
 Support verbal counseling with accurate written information
 Provide information on advantages and disadvantages and failure rates of other
methods of long-term reversible contraception – cumulative pregnancy rate after 12
years with CuT380A is 1.9% and after 5 years with LNG-IUS is 1.1%. Intra-uterine
pregnancy rates after reversal of sterilization are 31 – 92% with an ectopic
pregnancy rate of 0 – 7%
 Vasectomy and tubal ligation should be discussed with all men and women
requesting sterilizations
 Sterilization is intended to be permanent. However, provide information on success
rate of reversal and that reversal and treatments like IVF or ICSI may not be
available on the NHS
 Women should be informed that vasectomy carries lower failure rate (1:2000) than
tubal ligation (1:200 life-time, 2-3 :1000 after 10 years; 10 year cumulative life table
probability of failure = 16.6 per 1,000) and carries fewer risks. Risk of failure
significantly higher in women under 28 years
 If tubal ligation fails, there is a risk of ectopic pregnancy – women should seek
medical advice if they think they may be pregnant or have abnormal abdominal pain
or vaginal bleeding. Risk of ectopic pregnancy 4-76% depending on method of
sterilisation. Risk of ectopic pregnancy is however lower in sterilised than non-
sterilised fertile women
 Discuss method of access for tubal ligation – laparoscopy or mini-laparotomy – and
the method to be used if the intended method fails. Outline reasons for preferring a
particular approach. Discuss risks associated with laparoscopy, possibility of
requiring laparotomy particularly if previous abdominal surgery or overweight. Risk of
laparotomy is 1.4 – 3.1 / 1000 with a risk of death of 1:12,000
 Tubal ligation is not associated with increased risk of menorrhaghia if performed after
the age of 30years. There is an association with increased hysterectomy rates.
Limited data on younger women.
 Advise women to use effective contraception until the date of the procedure and
continue until their next period
 No increase in testicular cancer or heart disease associated with vasectomy. Discuss
possibility of chronic testicular pain
 Post-partum or post-TOP tubal ligation is associated with increased regret rate and
possibly increased failure rate. If tubal ligation is to be performed at C/S, counseling
and agreement should have been given at least one week prior to the procedure
 Although not a legal requirement, it is good practice to involve both partners in the
decision making.
PRE-OPERATIVE ASSESSMENT
 Detailed history and clinical examination – ensure that the patient does not have
concurrent conditions which may require additional or alternative procedures or
56
 precautions. Gynaecological history of menorrhagia or significant pelvic pathology
may make options like LNG-IUS or hysterectomy more appropriate
 Ensure that the woman has used effective contraception up until the date of the
procedure. Otherwise defer procedure until the follicular phase and advise the
woman to use effective contraception until her next period
 Perform pregnancy test to exclude pre-existing pregnancy. Negative test does not
exclude luteal phase pregnancy. Routine curettage to prevent luteal phase
pregnancy is not recommended
TUBAL LIGATION
 Tubal occlusion-Types:
 Occlsuion by clips/rings. (laparoscopic or laparotomy)
 Interruption by “endoscopic sutures”  modified Pomeroy technique.
 The Pomeroy technique is the most widely used ligation technique because it is
simple and effective. It involves using absorbable suture material to tie the base
of a loop of fallopian tube near the mid-portion (ampulla) and excising the top of
the loop. The suture material is absorbed rapidly, reducing the chances of
inflammation and the formation of fistulae in the tubes. After the sutures are
absorbed, the ends of the tube pull apart. This procedure destroys 3–4 cm of the
fallopian tube, making reversal of the procedure more difficult.
 The modified Pomeroy technique, often used in the USA (also known as the
Parkland or Pritchard technique) involves separating a small segment of the
fallopian tube from the mesosalpinx. Each end of the tube is ligated and the
portion of the tube between the sutures excised.
 diathermy (either unipolar or bipolar) can be used to destroy a segment of the tube.
Risk of laparotmy after laparoscopy is 2:1000 .Risk of death after laparoscopy is
1:12000(??).
 Any effective surgical or mechanical method of tubal occlusion can be used when a
mini-laparotomy is the method of approach for an interval sterilisation.
 For postpartum sterilisation, both Filshie clips and modified Pomeroy technique are
effective. Filshie clip application is quicker to perform. Should tubal occlusion be
requested either postpartum or post-abortion, women should be made aware of the
increased rate of regret and the possible increased failure rate.
 Mechanical occlusion of the fallopian tubes by Filshie clips should be the method of
choice for laparoscopic tubal occlusion.
 The routine use of more than one Filshie clip is not recommended.
 Approach to the fallopian tubes:
 Culdoscopy should not be used as a method of approach for sterilisation.
 The laparoscopic approach to the fallopian tubes is quicker to perform and results
in less minor morbidity compared to mini-laparotomy.
 Tubal occlusion-Anesthesia:
 Laparoscopic tubal occlusion can be performed using general, regional or local
anaesthesia but general anaesthesia is routinely used in the UK.
 Failure of tubal sterilisation:
 Late failures resulting in a pregnancy can occur any time after tubal occlusion.
 The lifetime risk of laparoscopic tubal occlusion failureis estimated to be 1 in 200.
For Filshie clip, failure rate ≈ 2–3 per 1000 procedures at 10 years.
 Hysteroscopic sterilisation-Procedure:
 usually performed without the need for anaesthesia and involves a hysteroscope
being inserted into the vagina and cervix vaginoscopically or by using a
speculum.
 Flexible micro-inserts (Essure ® ) are then passed through the hysteroscope and
inserted into the proximal section of each fallopian tube. The micro-inserts elicit a
57
 benign tissue response (fibrosis) resulting in the permanent occlusion of each
tube after approximately 3 months.
 There is insufficient evidence to recommend the routine use of oral NSAIDs or
intravenous sedation for hysteroscopic sterilisation.
 local anaesthesia should be used when dilatation of the cervix is necessary & not
for the purpose of alleviation of pain associated with the placement of micro-
inserts.
 associated with a low level of intraoperative complications, results in good long-
term satisfaction in terms of comfort and tolerance of the insert.
 most women able to return to daily activities 1–2 days following the procedure.
 Hysteroscopic sterilisation with micro-inserts is contraindicated if there is
documented proven patch test for nickel allergy.
 Hysteroscopic sterilisation- Insertion of the micro-inserts:
 The incidence of unsuccessful placement following up to two attempts in an
outpatient setting ranges between 0% and 19%.
 The likelihood of successful micro-insert placement is increased if the procedure
is scheduled during the proliferative phase of the menstrual cycle:
 visualisation of the tubal ostia is easier as the endometrium is not thickened.
 Another advantage of insertion during the proliferative phase are that a
negative pregnancy test is likely to rule out pregnancy.
 Hysteroscopic sterilisation- Post-procedure imaging:
 The manufacturer “Bayer” states that pelvic X-ray or TVUSS may be used as the
first-line confirmatory test to confirm placement of micro-inserts but that HSG
should be used in the following circumstances:
 there was concern regarding possible perforation.
 there was difficulty identifying the tubal ostia.
 health professional uncertainty regarding micro-insert placement at insertion.
 procedure time >15 minutes (from insertion to removal of hysteroscope).
 micro-insert placement with 0 (zero) or >8 trailing coils (i.e. coils protruding
inside the uterine cavity).
 unusual post-procedural pain.
 if X-ray or TVUSS is equivocal or unsatisfactory.
 The confirmatory imaging test should be undertaken 3 months after the insertion.
 Women who do not attend for confirmatory testing should be informed that they
need to continue using additional contraception until tubal occlusion is confirmed.
 Hysteroscopic sterilisation-Failure:
 intra-fallopian micro-insert has a low associated failure rate which is
approximately 1 in 500 at 5 years
 Limited available evidence suggests that intra-fallopian micro-insert insertion can
be carried out in combination with endometrial ablation.
 C/I to Hysteroscopic sterilisation (by manuafcturer):
 uncertainty about ending fertility
 pregnancy or suspected pregnancy
 delivery or abortion of a second-trimester pregnancy <6 weeks before micro-
insert insertion
 active or recent pelvic infection
 untreated acute cervicitis
 unexplained or severe vaginal bleeding
 known or suspected gynaecological malignancy
 known abnormal uterine cavity or fallopian tubes that impairs visualisation of
the tubal ostia or that makes cannulation of the proximal fallopian tube
difficult/impossible
 allergy to contrast media used for HSG
58
  women taking corticosteroids.
 Contraceptive advice and excluding pregnancy with tubal occlusion:
 Contraception must be used up to the procedure and most methods need to be
continued for at least 7 days (or until confirmatory imaging in case of hysteroscopic
inserts). CHC a simple, safe approach.
 A pregnancy test must be performed before sterilisation to exclude the possibility of a
pre-existing pregnancy. However, a negative test result does not exclude the
possibility of a luteal-phase pregnancy. Tubal occlusion can be performed at any
time during the menstrual cycle provided that PT is –ve & there was effective CC in
the past 3 wks from the last UPSI.
 During tubal occlusion, curettage should not be performed for the purpose of
preventing luteal-phase pregnancy.
 If the progestogen-only injectable or implant is being used, laparoscopic tubal
occlusion can be carried out at any time during the period of licensed use without
the need for additional contraception.
 The progestogen-only implant can be removed at the time of the procedure or any
time following laparoscopic tubal occlusion.
 If laparoscopic sterilisation is scheduled for the hormone-free interval or Day 1 of a
cycle of CHC, the hormone-free interval should be omitted or CHC should be
restarted, and CHC should be continued for at least 7 days after sterilisation.
 Hysteroscopic sterilisation may be safely and effectively undertaken when
intrauterine contraception is already in situ .This should be retained and removed at
least 1 week after laparoscopic tubal occlusion. In case the intrauterine device
needs to be removed to gain access to the fallopian tubes; Women should be
advised to use additional contraception or abstain from intercourse for 7 days
before the procedure
 Long-term complications of female sterilisation:
 Evidence suggests that the procedure may have a protective effect against
developing ovarian cancer that persists over time.
 There is no available evidence of an association between tubal occlusion and breast
cancer risk.
 Available evidence suggests that there is no association between tubal occlusion and
cervical or endometrial cancer risk.
 There is no evidence that tubal occlusion results in significant changes to hormone
levels.
 Evidence suggests that there is an association between tubal occlusion and an
increased risk of subsequent hysterectomy but there is no evidence of causation.
 Women may report worsening menstrual symptoms following tubal occlusion but
there is no evidence to suggest a causal effect.
 Sterilisation reversal:
 Fallopian tube re-anastomosis involves complex surgery that can result in high
postoperative patency rates, but may not result in pregnancy or a return to fertility.
To date, reversal of sterilisation with micro-inserts cannot be achieved via fallopian
tube re-anastomosis, therefore consideration should be given to in vitro fertilization.

59
Consent Advice No. 3 February 2016
FEMALE STERILISATION
Name of proposed procedure or course of treatment
 Female sterilisation.
The proposed procedure
 Explain the procedure as described in the patient information.
 Should ascertain that the patient does not wish to have any more children in the
future.
 Discuss the potential of not removing intrauterine contraception (IUC) in case a
blastocyst has already passed the site of tubal occlusion.
 Ensure the patient uses other forms of contraception/abstains to prevent pregnancy
Prior to the procedure, and this contraception should continue until the next menses.
 If any other procedures are anticipated, these must be discussed and separate
consents obtained.
Intended and potential benefits
 To prevent pregnancy permanently.
Significant and frequently occurring risks
 Women who are;
 obese,
 women with significant pathology,
 those who have had previous surgery
 who have a pre-existing medical condition
 must understand that the quoted risks for significant or frequent complications may
increase
Significant risks
A. Failure resulting inlaparoscopic tubal occlusion with clips is up to 2–5 in 1000
procedures at 10 years (uncommon)
B. The failure rate of hysteroscopic sterilisation is quoted as 2 in 1000 (uncommon).
C. Sterilisation failure that results in a greater risk of an ectopic pregnancy.
D. Visceral or blood vessel injury at the time of laparoscopy (2 in 1000; uncommon).
E. Death as a result of the procedure (1 in 12 000; very rare).
F. Failure to complete the procedure.
G. Regret is common, and more common if sterilisation is undertaken below 30 years of
age
Frequent risks
 Changes in menstruation may occur following discontinuation of reversible hormonal
contraception, especially with the combined oral contraceptive or levonorgestrel
releasing intrauterine system (LNGIUS).
Any extra procedures which may become necessary during the procedure
 The risk of laparotomy following laparoscopic tubal occlusion is up to 3 in 1000.
Additional procedures are rare after hysteroscopic sterilisation.
What the procedure is likely to involve, the benefits and risks of any
available alternative treatments, including no treatment
Laparoscopic sterilization
 A titanium clipis inserted through a small incision at the umbilicus, is placed across
each fallopian tube to completely obstruct it.
Sterilisation at caesarean section

61
  After delivery of the baby and closure of the uterus, the fallopian tubes are divided
and tied.
 Specimens of fallopian tube are sent for histopathological confirmation.
 Sterilisation at caesarean section is less likely to be amenable to successful future
reversal of female sterilisation.
 Regret and dissatisfaction is increased when sterilisation has been performed
concomitantly with caesarean section.
 Should tubal occlusion be requested postpartum, women should be made aware of
the increased rate of regret and
 the possible increased failure rate.
 Tubal occlusion should ideally be performed at an appropriate interval after
pregnancy wherever possible.
Sterilisation at abortion
 Laparoscopic sterilisation is technically possible at the time of an abortion.
Hysteroscopic sterilization
 A hysteroscope is passed through the vagina and cervix to view the tubal ostia in the
uterine cavity.
 A pellet or nickel/titanium coil is placed within the lumen of each fallopian tube to
completely obstruct it.
 Postoperative imaging is necessary by ultrasound, X-ray or hysterosalpingography to
confirm correct tubal placement or blockage 3 months after this procedure.
 Continued contraception is necessary prior to this confirmatory investigation.
 Reversal of female sterilisation following this procedure cannot be achieved via
fallopian reanastomosis; therefore consideration should be given to in vitro
fertilisation.
Long-acting fertility control
 Long-acting methods of fertility control, such as the LNG-IUS and the progestogen
subdermal implant, offer at least the same degree of protection with lower risks and
disadvantages.
Male sterilization
 Sterilisation by vasectomy has a lower failure rate in the order of 1 in 2000 and less
risk as a procedure. It is often undertaken under local anaesthesia.
Anaesthesia
 The woman must be made aware of the form of anaesthesia planned and be given
an opportunity to discuss this in detail with the anaesthetist before surgery.
 It should be noted that for woman that are obese, there are increased surgical and
anaesthetic risks associated with laparoscopic tubal occlusion which must be
disclosed.
VASECTOMY
 Use a no-scalpel technique: associated with lower rate of early complications. Local
anaesthesia whenever possible
 Division of the vas plus fascial interposition. Division alone associated with high
failure rate. Excised portion of the vas should be sent for histology
 Men should be advised to use contraception until azospermia is confirmed
 Failure rate ~1:2000 after azospermia has been confirmed. The procedure is ment to
be irreversible but information on reversibility and ICSI should be provided
 May be associated with chronic testicular pain. Not associated with increased risk of
testicular cancer or heart disease
 Nearly 75% of men who undergo vasectomy will develop antisperm antibodies

61
THE INITIAL MANAGEMENT OF CHRONIC PELVIC PAIN
Background and introduction
 Chronic pelvic pain defined as intermittent or constant pain in the lower abdomen or
pelvis of a woman of at least 6 months in duration,not occurring exclusively with
menstruation or intercourse and not associated with pregnancy.
 It is a symptom not a diagnosis.
 Affecting 1/6 of the adult female population.
What are the possible aetiological factors in the genesis of chronic pelvic pain?
 There is frequently more than one component to chronic pelvic pain.
 Assessment should aim to identify contributory factors rather than assign causality to a
single pathology.
 Careful scrutiny of the woman‟s history and physical findings will frequently reveal factors
that may be contributing to the pain
 it is necessary to keep an open mind about the cause and consider unusual diagnoses,
such as hernias or retroperitoneal tumours,
 It is important not to leave woman with the feeling that nothing more can be done to help
her.
Central and peripheral nervous system
 Acute pain reflects fresh tissue damage and resolves as the tissues heal.
 In chronic pain pain persist long after original injury or exist in absence of any such
injury.
 Local factors (TNF-alpha) and chemokines, may change peripheral nerve function and/or
stimulate normally quiescent fibres, resulting in altered sensation over a wider area than
that originally affected.
 Alteration in visceral sensation and function, provoked by a variety of neurological
factors, termed „visceral hyperalgesia‟and nerve damage following surgery, trauma,
inflammation, fibrosis or infection may play a part in this process.
 Pain as a result of changes in the nerve itself is termed „neuropathic pain‟ and is
characteristically, burning, aching or shooting in nature.
Endometriosis and adenomyosis
 Pelvic pain which varies markedly over the menstrual cycle is likely to be attributable to a
hormonally driven condition such as endometriosis.
 The cardinal symptoms of dysmenorrhoea, dyspareunia and chronic pelvic pain are said
to be characteristic of endometriosis or adenomyosis.
 No valid diagnostic tests.
 Both progestins and (GnRH) agonists were effectively decrease pain .
 Although many symptom complexes such as IBS, pain perception itself vary a little with
the menstrual cycle and strikingly cyclical pain is likely to be gynaecological in nature.
4.3 Adhesions
 There is no evidence to support division of fine adhesions in women with chronic pelvic
pain.
 Division of dense vascular adhesion should be considered as this is associated with pain
relief.
 Adhesions may be caused by endometriosis, previous surgery or previous infection.
 Two distinct forms of adhesive disease are recognised:
1. residual ovary syndrome (a small amount of ovarian tissue left behind following
oophorectomy which may become buried in adhesions)

62
 2. trapped ovary syndrome (in which a retained ovary becomes buried in dense
adhesions post-hysterectomy).
 Removal of all ovarian tissue or suppression using a GnRH analogue may relieve
pain.
IBS and interstitial cystitis
 Symptoms suggestive of IBS or interstitial cystitis are often present in women with
chronic pelvic pain.
 These conditions may be a primary cause of chronic pelvic pain, a component of chronic
pelvic pain or a secondary effect caused by efferent neurological dysfunction in the
presence of chronic pain

Musculoskeletal
 Musculoskeletal pain may be a primary source of pelvic pain or an additional component
resulting from postural changes.
 Pelvic organ prolapse may also be a source of pain.
 Spasm of the muscles of the pelvic floor is proposed as a cause of pelvic pain which can
be reduced by botulinum toxin injections.
Nerve entrapment
 Nerve entrapment in scar tissue, fascia or a narrow foramen may result in pain and
dysfunction in the distribution of that nerve.
 The incidence of nerve entrapment after one Pfannenstiel incision is 3.7%.35,36
Psychological and social issues
 Enquiry should be made regarding psychological and social issues which commonly
occur in association with chronic pelvic pain; addressing these issues may be important
in resolving symptoms.
 Depression and sleep disorders are common in women with chronic pain. This may be a
consequence rather than a cause of their pain,
 women with chronic pelvic pain tend to suppress their unwanted thoughts and feelings
either as a cause or consequence of their pain.
 The relationship between chronic pelvic pain and sexual or physical abuse is complex.
Women with chronic pelvic pain are more likely to report sexual abuse than women with
another chronic pain complaint.
 In summary, it may be that, child sexual abuse may initiate a cascade of events or
reactions which make an individual more vulnerable to development of chronic pelvic
pain as an adult.
What should underline the initial assessment of chronic pelvic pain?
 Adequate time should be allowed for the initial assessment
 They need to feel able to tell their story and listened to and believed.
 Many women present with theory or a concern about the origin of the pain which should
ideally be discussed
 The multifactorial nature of chronic pelvic pain should be discussed from the start.

63
 Partnership should be developed between clinician and woman to plan a management
programme.
1) History
 questions about the pattern of the pain and its association such as psychological,
bladder and bowel symptoms, and the effect of movement and posture.
 special note should be taken of any „red flag‟ symptoms which may need further
investigation and referral to a specialist.
 it is helpful to ask directly about past or present sexual assault, particularly intimate
partner violence.
 Completing a daily pain diary for two to three menstrual cycles is helpfull
 Asking which drugs have been used previously,
 Symptom-based diagnostic criteria can be used with confidence to make the diagnosis of
IBS
 If history suggests that there is a specific non-gynaecological component to the pain,
referral to the relevant healthcare professional should be considered.

Examination
 The examination is most usefully undertaken when there is time to explore the woman‟s
fears and anxieties.
 The examiner should be prepared for new information to be revealed at this point.
 The assessment should include abdominal and pelvic examination, looking for focal
tenderness, enlargement, distortion or tethering, or prolapse.
 Highly localised trigger points may be identified in the abdominal wall and/or pelvic floor.
 The sacroiliac joints or symphysis pubis may also be tender, suggestive of a
musculoskeletal origin to pain.
What investigations should be undertaken?
Screening for infection
 screening for infection, particularly Chlamydia trachomatis and gonorrhoea, should be
taken if there is any suspicion of pelvic inflammatory disease (PID).
 All sexually active women with chronic pelvic pain should be offered screening for STIs.
Transvaginal scanning (TVS) and MRI
 TVS is appropriate to identify and assess adnexal masses.
 TVS and MRI are useful tests to diagnose adenomyosis.
 The role of MRI in diagnosing small deposits of endometriosis is uncertain.
Diagnostic laparoscopy
 laparoscopy has been regarded in past as the „gold standard‟ in diagnosis of chronic
pelvic pain.
 It is better seen as a second-line investigation if other therapeutic interventions fail.
 laparoscopy may have a role in developing the woman‟s beliefs about her pain.
 laparoscopy carries significant risks: risk of death1 /10 000, injury to bowel-bladder-blood
vessel 2.4/1000, of whom 2/3 require laparotomy.

64
 conditions such as IBS and adenomyosis are not visible at laparoscopy also some forms
of endometriosis will be missed.
 1/3-1/2 of diagnostic laparoscopies will be negative and much of the pathology identified
is not necessarily the cause of pain.
CA125
 Women reporting any of the following symptoms persistently or frequently (more than 12
times per month): bloating, early satiety, pelvic pain or urinary urgency or frequency
should have a serum CA125 Particularly in women over the age of 50 years.
What therapeutic options are available?
 Women with cyclical pain should be offered a trial using hormonal treatment (COC
progestogens, Mirena, danazol or GnRH analogues)for a period of 3–6 months before
having a diagnostic laparoscopy.
 Women with IBS should be offered:
 trial with antispasmodics.
 encouraged to amend their diet to attempt to control symptoms.
 Women should be offered appropriate analgesia to control their pain
 If pain is not adequately controlled, consider referral to a pain management team or a
specialist pelvic pain clinic.

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MANAGEMENT OF ACUTE PID
Purpose and scope
 PID is usually the result of infection ascending from the endocervix causing endometritis,
salpingitis, parametritis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis.
 While sexually transmitted infections (STIs) such as Chlamydia trachomatis and
Neisseria gonorrhoeae have been identified, other STIs including Mycoplasma
genitalium, anaerobes and other organisms are implicated.
 Delays of only a few days in receiving appropriate treatment especially in chlamydia
infections markedly increase the risk of sequelae, which include:
 infertility,
 ectopic pregnancy.
 chronic pelvic pain.
Diagnosis of acute PID
1) Clinical
 A low threshold for empiric treatment of PID is recommended because of the lack
diagnostic criteria and because significant sequelae if PID not treated.
 The following clinical features are suggestive of a diagnosis of PID:
 bilateral lower abdominal tenderness (sometimes radiating to the legs)
 abnormal vaginal or cervical discharge
 fever > 38°C
 abnormal vaginal bleeding (intermenstrual, postcoital)
 deep dyspareunia
 positive cervical excitation
 adnexal tenderness with or without a palpable mass.
 laparoscopy may also lack sensitivity, but enables:
 sampling from the fallopian tubes and the pouch of Douglas
 provide information on the severity of the condition
 exclude alternative pathologies.
 Transvaginal ultrasound scanning may be helpful
 When supported by power Doppler, it can identify inflamed and dilated tubes and
tubo-ovarian masses.
 May differentiate PID from acute appendicitis.
 There is insufficient evidence to support its routine use.
 CT and MRI can assist in diagnosis but the evidence is limited.
 Blood leucocytosis, elevated ESR or C-reactive protein support the diagnosis and
severity of the disease.
 leucocytosis on a wet-mount vaginal smear lack sensitivity as it is also found in isolated
lower genital infection.
 There is insufficient evidence to support endometrial biopsy as a routine diagnostic test.
2) Microbiological
 Women with suspected PID should be tested for gonorrhoea and chlamydia.
 A positive result support the clinical diagnosis of PID.
 Gonorrhea and chlamydia should be tested with an endocervical specimen for:
1. Culture (direct inoculation on to a culture plate)
2. Nucleic acid amplification test (NAAT).
 women at high risk of gonorrhea:
1. the woman‟s partner has gonorrhoea,
2. clinically severe disease,
3. sexual contact abroad.
66
 Additional sample from the urethra is recommended if NAAT is not available to enforce
the diagnosis.
 Screening is not yet justified for other organisms, including M. genitalium because of
limited information on prevalence, natural history, treatment and cost effectiveness.
Starting treatment
1) Management in the outpatient setting for mild or moderate PID
 Interactions between antibiotic and hormonal contraception and other medications
should be assessed.
 Antibiotic should be commenced as soon as the diagnosis is suspected.
 Outpatient antibiotic regimens:
1. oral ofloxacin 400 mg twice daily + oral metronidazole 400 mg twice daily
for 14 days.
2. intramuscular ceftriaxone 250 mg single dose + oral doxycycline 100
mg twice daily + metronidazole 400 mg twice daily for 14 days.
 Cefoxitin is better for the treatment of PID than ceftriaxone but is not easily
available in the UK.
 Metronidazole may be discontinued with mild or moderate PID if not tolerate.

 Alternative treatments with less strong evidence than above:

1. intramuscular ceftriaxone 250 mg immediately, followed by azithromycin 1
g/week for 2 weeks.
 Women should be counseled verbally and written informations provided their condition
and the long-term implications for their health and their partner(s) including:
 Treatment and its possible adverse effects
 Repeat episodes of PID are associated with high increase in the risk of infertility
 Future use of barrier contraception will significantly reduce the risk of PID
 The need for tracing of sexual partners
 Clinically more severe disease is associated with a greater risk of sequelae
 the earlier treatment is given the lower the risk of future fertility problems.
2) Management in the hospital setting for severePID
 Indication for admission:
 Surgical emergency cannot be excluded
 Clinically severe disease
 Tubo-ovarian abscess
 PID in pregnancy
 Incompliance or lack of response to oral therapy
 Hospital antibiotic regimens based on IV therapy which should be continued until 24
hours after clinical improvement and followed by oral therapy:
1. ceftriaxone 2 g by IV daily + doxycycline 100 mg IV twice daily, followed by oral
doxycycline 100 mg twice daily + oral metronidazole 400 mg twice daily for a total of
14 days.
2. clindamycin 900 mg IV three times daily + gentamicin IV followed by either:
 oral clindamycin 450 mg four times daily to complete 14 days
OR
 oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice
daily to complete 14 days.
Gentamicin should be given as a 2 mg/kg loading dose followed by 1.5 mg/kg
three times daily or a single daily dose of 7 mg/kg/day.
3. Ofloxacin 400 mg IV twice daily + metronidazole 500 mg IV three times daily for 14
days.
3) Treatment in pregnancy and in young women
 A pregnancy test should be done in all women suspected of having PID to exclude an
ectopic pregnancy.

67
 When the risk of EP clinically is high, repeat pregnancy test 21 days after the last
unprotected intercourse.
 The risk of giving any of the antibiotic regimens in early pregnancy(before a positive
pregnancy test) is low.
 PID is rare in women with an intrauterine pregnancy except in the case of septic
abortion.
 Drugs known to be toxic in pregnancy, such as tetracyclines, should be avoided.
 A combination of cefotaxime, azithromycin and metronidazole for 14 days may be used.
 Ofloxacin should be avoided, in young women, when bone development is still occurring.
 Doxycycline can be safely used over the age of 12 years.
4) Treatment in a woman with an intrauterine contraceptive device
 Remove IUD in women presenting with PID, especially if symptoms not resolved within
72 hrs.
5) Other modes of treatment
 Surgical treatment in severe cases or where there is clear evidence of a pelvic abscess.
 Identify the origin of the abscess, as the abscess may have arisen from the appendix or
colon.
 Ultrasound-guided aspiration of pelvic fluid collections is less invasive and equally
effective.
Management of sexual partner(s) of women with PID
 Referral woman and her partner to a genitourinary medicine/sexual health clinic to
facilitate contact tracing and infection screening.
 With STIs, the sexual partner(s) should be contacted and offered advice and screening.
 Tracing of sexual partners should be within a 6- month period of the onset of
symptoms.
 The risk of STIs in the partners of women with PID is high.
 Women should avoid intercourse until they and their partner complete treatment
course.
Review of women with PID
 In the outpatient setting, review at 72 hours, particularly those with a moderate or severe
presentation.
 Further review 4–6 weeks after therapy may be useful to ensure:
 Adequate response to treatment
 Compliance with oral antibiotics
 Screening and treatment of sexual contacts
 Awareness of the significance of PID and its sequelae
 Negative pregnancy test, if clinically indicated.
 Repeat testing for chlamydia and gonorrhoea in:
 persisting symptoms,
 tracing of sexual contacts indicate the persisting or recurrent infection.
Women who are infected with HIV
 Women with PID who are also infected with HIV should be treated with same antibiotic
regimens
 Women with HIV should be managed in conjunction with their HIV physician.
Contraception options and PID
 Women on hormonal contraception presenting with breakthrough bleeding should be
screened for genital tract infection, especially C. trachomatis.
 COC pill is protective against symptomatic PID.
 IUD only increases the risk of developing PID in the first few weeks after insertion.
 If a woman is at risk of future PID and requests an IUD for contraception, the LNG-
IUS is appropriate.

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ENDOMETRIOSIS
Purpose and scope
 Endometriosis is defined as the presence of endometrial-like tissue outside the uterus,
which induces a chronic, inflammatory reaction.
 The condition is predominantly found in women of reproductive age.
 The associated symptoms can impact on general physical, mental and social wellbeing.
 Some women have no symptoms at all and finding endometriosis in them may be
coincidental.
 Pain persist despite adequate medical and/or surgical treatment of the disease may
suggest another source of pain, such as adenomyosis, interstitial cystitis or
musculoskeletal (pelvic floor muscle spasm).
 In such conditions, a multidisciplinary approach involving pain clinic and counselling
should be considered.
Localisation and appearance of endometriosis
 The most commonly affected sites are pelvic organs and peritoneum, bowel or lungs are
occasionally affected.
 The extent of the disease varies from a few, small lesions to large, ovarian endometriotic
cysts.
 There can be extensive fibrosis in structures such as the uterosacral ligaments and
adhesion causing marked distortion of pelvic anatomy.
 Disease severity is assessed by describing the findings at surgery or quantitatively by a
classification system.
 Endometriosis typically appears as:
1. superficial „powder-burn‟ or „gunshot‟ lesions on the ovaries, serosal surfaces and
peritoneum:
2. black, dark-brown or bluish lesions, nodules or small cysts containing old
haemorrhage surrounded by a variable extent of fibrosis.
3. Atypical or „subtle‟ lesions, including red implants (petechial, vesicular, , red
flame-like) and serous or clear vesicles.
4. white plaques or scarring and yellow-brown peritoneal discoloration of the
peritoneum.
5. Endometriomas containing thick chocolate fluid often adherent to the peritoneum
of the ovarian fossa and the surrounding fibrosis may involve the tubes and
bowel.
 Deep infiltrating nodules extend more than 5 mm beneath the peritoneum and may
involve the uterosacral ligaments, vagina, bowel, bladder or ureters. The depth of
infiltration is related to the type and severity of symptoms.
 Severe cases of endometriosis should be referred to units with multi-disciplinary context
including advanced laparoscopic surgery.
Diagnosis
1) History and clinical examination:
 Endometriosis can cause the following symptoms:
 Severe dysmenorrhoea
 Deep dyspareunia
 Chronic pelvic pain
 Ovulation pain
 Cyclical or perimenstrual symptoms, such as bowel or bladder, with or without
abnormal bleeding
 Infertility
69
  Chronic fatigue
 Diagnosis on the basis of symptoms alone is difficult because there is overlap with other
conditions such as IBS and PID. So there is often a delay up to 12 yrs between symptom
onset and a definitive diagnosis.
 Deeply infiltrating nodules are most reliably detected when examination is performed
during menstruation.
 Finding pelvic tenderness, fixed retroverted uterus, tender uterosacral ligaments or
enlarged ovaries is suggestive of endometriosis.
 Palpable nodules on the uterosacral ligaments or in the pouch of Douglas or visible
lesions seen in the vagina or on the cervix is more certain for diagnosis.
2) Laparoscopy
 Visual inspection of the pelvis at laparoscopy is the gold standard investigation.
 Ideal practice is to record the findings on video or DVD.
 At laparoscopy, deeply infiltrating endometriosis may appear as minimal disease,.
3) Histological examination
 Visual inspection is usually adequate but histological confirmation of at least one lesion
is ideal.
 Positive histology confirms the diagnosis of endometriosis; negative histology does not
exclude it.
 In cases of ovarian endometrioma > 3 cm in diameter and deeply infiltrating disease,
histology should be obtained to to exclude rare instances of malignancy.
4) Imaging
 TVS has limited value in diagnosing peritoneal endometriosis but it is a useful for ovarian
endometrioma.
5) Serum CA125
 Serum CA125 levels may be elevated in endometriosis.
 Compared with laparoscopy, serum CA125 has no value as a diagnostic tool, sensitivity
28-47% .
Empirical treatment of pain symptoms without a definitive diagnosis
 Empirical treatment for pain presumed to be caused by endometriosis without a definitive
diagnosis includes: counselling, adequate analgesia, progestogens or COC.
Medical treatment of endometriosis-associated pain
1) NSAIDs: no conclusive evidence to show whether NSAIDs(specifically naproxen)are
effective for pain
2) Hormonal treatment:
 Suppression of ovarian function for 6 months reduces endometriosis-associated pain.
 COC, danazol, gestrinone, Depo-Provera and GnRH are equally effective but adverse
effect and cost differ.
 medical treatment does not always provide complete pain relief and Symptom
recurrence is common.
 Pilot data suggesting that the aromatase inhibitor, letrozole, may be effective although it
is associated with significant bone density loss.
3) LNG-IUS: appears to reduce endometriosis-associated pain with symptom control over 3
years.
How long should treatment be continued?
 Duration of therapy should be determined by the choice of drug, response to treatment
and adverse effect.
 The combined oral contraceptive and Depo-Provera can be used long term but the
use of danazol and GnRH agonists is usually restricted to 6 months.
 GnRH associated with loss of up to 6% of bone density in 6 months which not
entirely reversible.
 Conversely, danazol produces an increase in bone mineral density.
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 The use of a GnRH with „add-back‟ therapy(HRT or tibolone)protects against bone
mineral density loss.
Preoperative assessment
What investigations are recommended to assess disease extent?
 If there is clinical evidence of deeply infiltrating endometriosis Consider performing
MRI or ultrasound (transrectal and/or TVS and/or renal), with or without IVP and
barium enema, to map the extent of disease.
How should suspected severe/deeply infiltrating disease be managed?
 The management of severe/deeply infiltrating endometriosis is complex.
 If multiple organs are suspected or diagnosed referral to a centre with a multidisciplinary
context, including advanced laparoscopic surgery and laparotomy, is strongly
recommended.
Surgical treatment of endometriosis-associated pain
1) Ablation of endometriotic lesions reduces endometriosis-associated pain compared with
diagnostic laparoscopy.
2) Laparoscopic uterine nerve ablation by itself does not reduce endometriosis-associated
pain.
3) Radical surgery removing the entire lesions in severe and deeply infiltrating disease
reduces pain.
 If a hysterectomy is performed, all visible endometriotic tissue should be removed
at the same time.
 Bilateral salpingo-oophorectomy may result in improved pain and a reduced
chance of future surgery.
4) There is insufficient evidence to justify the use of preoperative or postoperative hormonal
treatment.
5) The ideal HRT regimen after bilateral oophorectomy is unclear and should be discussed
on an individual basis.
 HRT has small risk of recurrent disease. Adding progestogen is unnecessary but
may protect against the unopposed action of oestrogen on any residual disease.
Treatment of endometriosis-associated infertility
1) Suppression of ovarian function to improve fertility in minimal–mild endometriosis is not
effective and There is no evidence of its effectiveness for moderate-severe disease.
2) Ablation of endometriotic lesions plus adhesiolysis to improve fertility in minimal–mild
endometriosis is effective and the role of surgery in improving pregnancy rates for
moderate-severe disease is uncertain.
3) Laparoscopic cystectomy for ovarian endometriomas is better than drainage and
coagulation.
 Subsequent spontaneous pregnancy rates in women who were previously
subfertile are also improved.
4) Postoperative hormonal treatment has no beneficial effect on pregnancy rates after
surgery.
5) Tubal flushing with oil-soluble media improve pregnancy rates in endometriosis-
associated infertility.
Assisted reproduction in endometriosis
1) IUI plus gonadotrophins improves fertility in minimal to mild endometriosis.
2) IVF is appropriate, if tubal function is compromised, male factor infertility, and/or other
treatments failed.
3) Laparoscopic ovarian cystectomy before IVF is recommended for endometriomas ≥ 4 cm
in diameter.
 to confirm the diagnosis histologically; reduce the risk of infection; improve access
to follicles, and improve ovarian response and prevent endometriosis progression.

71
4) GnRH agonist for 3–6 months before IVF in endometriosis increases the rate of clinical
pregnancy.
Coping with disease
complementary therapies
 The role of complementary therapies in relieving endometriosis-associated pain is
unclear.
 There is evidence from two systematic reviews suggesting that high frequency
TENS, acupuncture, vitamin B1 vitamin E and magnesium may help to relieve
dysmenorrhoea.
What is the role for patient support groups
 Patient self-help groups can provide invaluable counselling, support and advice.

72
PREVENTING ENTRY LAPAROSCOPIC INJURIES
Purpose and scope
 serious complications occur in about 1/ 500 cases.
 Laparoscopic injuries frequently occur during the blind insertion of needles, trocars and
cannulae.
Background
 One of the difficulties of bowel damage with laparoscopic surgery is that it may not be
immediately recognized and present some time later or after discharge from hospital.
Incidence of complications
 The rate of major complications is 1.4/1000 procedures: intestinal injuries 0.6/1000,
urological injuries 0.3/1000 and vascular injuries 0.1/1000.
Assessment, counselling and consent
 Women must be informed of the risks and potential complications associated with
laparoscopy.
 The risks of the entry technique used:
 injury to the bowel,
 urinary tract
 major blood vessels,
Frequent risks include
 wound bruising
 shoulder-tip pain
 wound gaping
 wound infection
 later complications associated with the entry ports:
 hernia formation.
 Women at increased risks are:
 obese or significantly underweight
 previous midline abdominal incisions, peritonitis or inflammatory bowel disease.
Safe surgical techniques and training
 Surgeons undertaking laparoscopic surgery :
 should have appropriate training, supervision and experience.
 should be familiar with the equipment, instrumentation and energy sources they
intend to use.
 should ensure that nursing staff and surgical assistants are appropriately trained for
their roles.
Laparoscopic entry techniques
 The effective way to reduce entry complications is to optimize insertion of the primary
trocar and cannula.
 Gynaecologists favour the closed or Veress needle entry technique.
 The RCS of England recommends the open (Hasson) approach in all circumstances.
1) Veress needle (closed) laparoscopic entry technique
 the primary incision for laparoscopy should be vertical from the base of the umbilicus.
 Care should be taken not to enter the peritoneal cavity.
 The Veress needle should be sharp, with a good and tested spring action. A disposable
needle is recommended.
 The operating table should be horizontal at the start of the procedure.
 The abdomen is palpated to check for any masses and for the position of the aorta
before insertion.

73
  The lower abdominal wall should be stabilised to allow right angles insertion of the
Veress needle.
 Two audible clicks are usually heard as the fascia and the peritoneum are penetrated.
 Excessive lateral movement of the needle should be avoided, as this may convert a
small needlepoint injury into a more complex tear.
 An intra-abdominal pressure of 20–25 mmHg should be used before inserting the
primary trocar.
 Pressure should be reduced to 12–15 mmHg once the insertion of the trocars is
complete.
 This gives adequate distension for operation and allows the anaesthetist to ventilate
the patient effectively.
Where should the primary trocar be inserted ?
 The primary trocar should be inserted in a controlled manner at 90 degrees in the base
of the umbilicus.
 Once the laparoscope has been introduced it should be rotated 360degrees to check
for any adherent bowel, haemorrhage, damage or retroperitoneal haematoma.
 If there is concern that the bowel may be adherent to umbilicus, the primary trocar site
should be visualised from a secondary port site.
 After completion, use the laparoscope to check that there are no injury by visual control
during removal.
2) Hasson (open) entry technique
 Confirm the peritoneum is opened by visualising bowel or omentum before inserting the
blunt tipped cannula.
 After the initial skin incision.
 Fascial edges are incised and held by a lateral stay suture on either side.
 The peritoneum is opened,
 The fascial sutures are then pulled into the suture holders on the cannula to produce
an airtight seal.
 Gas is insufflated directly through the cannula to produce the pneumoperitoneum.
 The blunt trocar is withdrawn only after the abdomen is partially distended.
 At the end, the fascial defect should be closed using the stay sutures to minimize
herniation.
Alternative entry techniques
1) Direct trocar insertion
 Direct trocar insertion is an acceptable alternative method.
 This technique overcome difficulty associated with grasping distended abdominal
wall by gas.
 with experienced hands it is the most rapid method of entry and can be safely used
with selected cases.
2) Alternative entry devices
 Several ingenious devices introduced to minimize the risk during primary trocar
insertion.
 These include visual access systems, radially expanding trocars and 2nd generation
Endotip systems.
3) Alternative sites for primary trocar or Veress needle insertion
 Palmer‟s point is the preferred alternative site, except in previous surgery in this area or
splenomegaly.
 It is 3 cm below the left costal margin in the mid-clavicular line .
 Adhesion at umbilicus is 50% after midline laparotomy and 23% after low transverse
incision.
 2–5 mm endoscope is used through Palmer‟s point to inspect the undersurface of
umbilicus.
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  If this is free of adhesions, trocar and cannulae can be inserted under direct
laparoscopic vision.
 If there are adhesions, it can be dissected via secondary ports in the lower left
abdomen or an alternative entry site can be selected visually.
 Other sites have been tried but, are to be avoided(Suprapubic insertion of the Veress
needle, Instillation of gas through the uterine fundus with the Veress needle, entry
through the posterior fornix).
Secondary ports
How should secondary ports be inserted?
 Should be inserted under direct vision perpendicular to skin, with 20–25 mmHg
pneumoperitoneum.
 Inferior epigastric vessels should be visualized laparoscopically to enter away from the
vessels.
 The deep epigastric arteries and the venae comitantes running beside them can be
visualised just lateral to the lateral umbilical ligaments (the obliterated hypogastric
arteries)
 Once the tip of the trocar has pierced the peritoneum it should be angled towards the
anterior pelvis under careful visual control until the sharp tip has been removed.
 Secondary ports must be removed under direct vision.
 Any non-midline port over 7 mm and any midline port greater than 10 mm requires
formal sheath closure to avoid the occurrence of port site hernia.
The woman who is obese
 Hasson technique or entry at Palmer‟s point are recommended for the primary entry.
 If Veress needle is used, care must taken to ensure that the incision is made at the
base of the umbilicus.
The woman who is very thin
 Hasson technique or entry at Palmer‟s point are recommended for the primary entry.
 Women at highest risk of vascular injury are: the young, thin, nulliparous women with
well developed abdominal musculature.
 The aorta may lie less than 2.5 cm below the skin in these women.

75
MANAGEMENT OF PREMENSTRUAL SYNDROME
Introduction
 5% of women experience severe premenstrual symptoms including:
1) Psychological symptoms:
 mood swings,
 depression,
 anxiety,
 irritability,
 loss of confidence,
 feeling out of control,
2) physical symptoms:
 headaches,
 bloating ,
 mastalgia.
3) behavioural symptoms:
 reduced visuospatial,
 cognitive ability,
 increase in accidents
Definition of PMS
 distressing physical, behavioural and psychological symptoms, in the absence of organic
or psychiatric disease, regularly recurs during the luteal phase of cycle and disappears
or regresses by the end of menstruation‟.

Aetiology and prevalence

 unknown but cyclical ovarian activity and the effect of estradiol and progesterone on the
neurotransmitters serotonin and gamma-aminobutyric acid (GABA) appear to be key
factors.
 Absence of PMS before puberty, in pregnancy and after the menopause supports this
theory.
 The prevalence of severe PMS is between 3% to 30%.
 PMS more prevalent in women who are obese, perform less exercise and are of lower
academic achievement.
 PMS lower prevalent in women using hormonal contraception.
Diagnosis of PMS
 symptoms should be recorded prospectively, over two cycles using a symptom diary.
Management of severe PMS
1) general advice about: exercise, diet and stress reduction before starting treatment.
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 2) women with marked underlying psychopathology should be referred to a psychiatrist.
3) symptom diaries (DRSP) should be used to assess the effect of treatment.
4) Referral to a gynaecologist should be considered when :
 Simple measures have been explored and failed .
 when the severity of the PMS justifies gynaecological intervention.
5) Complementary therapies
6) cognitive behavioural therapy
7) SSRIs and selective serotonin and noradrenaline reuptake inhibitors (SNRIs)

1) Complementary therapies
 Complementary medicines may be of benefit, but clinicians need to consider that:
 data from clinical studies are insufficient
 clinician has legal responsibility for the patient‟s wellbeing when refering to
complementary therapists
 Interactions with conventional medicines should be considered.
 Example for Complementary therapies:
 Lifestyle changes (reduction in alcohol, caffeine and refined carbohydrates
 Reflexology
 Vitamin B6
 Magnesium
 Nutritional supplements
 Calcium/vitamin
 Pollen extract
 Evening primrose oil
 Light therapy (bright light therapy has the possibility of retinopathy).
2) Managing severe PMS with cognitive behavioural therapy(CBT)
 Cognitive behavioral therapy should be provided routinely through a clinical psychology
service for severe PMS.
 Ten sessions of CBT is associated with better maintenance of treatment
compared with fluoxetine.
 No additional benefit of combining the treatments.
3) Management of PMS with SSRIs and SNRIs
 Physical and psychological symptoms of PMS improve with SSRIs.
 SSRIs are effective in treatment of depression and anxiety and their benefits outweigh
their risks. risks include: nausea, insomnia, reduction in libido and few suicides in young
people being treated for depression
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 Should be considered one of the first line treatment in severe PMS.
 Should only prescribed by health professionals (gynaecologists, psychiatrists or GPs)
who have expertise.
 Either luteal phase or continuous dosing with SSRIs can be recommended for PMS.
 SSRI therapy should be withdrawn gradually to avoid withdrawal symptoms, if given on a
continuous basis.
 withdrawal symptoms:
 GIT disturbances,
 Headache
 Anxiety
 Dizziness
 Paraesthesia
 Sleep disturbances
 Fatigue
 Influenza like symptoms,
 Efficacy and adverse effects of SSRIs can be optimised by the use of luteal-phase
regimens with the newer agents.
 The use of newer SSRIs, such as citalopram, may produce resolution where
other SSRIs have failed.
4) Management of PMS with cycle-modifying hormonal agents
1. The combined oral contraceptive pill
 New contraceptive pill (Yasmin) contains an anti-mineralocorticoid and anti-androgenic
progestogen may be effective treatment for PMS and should be considered as one of the
first-line pharmaceutical interventions.
 data suggest that the contraceptive pill should be given continuously rather than
cyclically.
 Percutaneous estradiol, implant(100- microgram implant) or patch(200 micrograms),
combined with cyclical progestogen, is effective for the management of physical and
psychological symptoms of severe PMS.
 Alternative barrier or intrauterine methods of contraception should be used when
estradiol (patches and implant) are used for PMS.
 The lowest possible dose of progestogen is recommended to minimise adverse effects.
 Women should be informed that low systemic levels of levonorgestrel released by (LNG-
IUS) can initially produce PMS-type adverse effects.
 There are insufficient data on the long-term effects of estradiol on endometrial or breast
carcinoma.
2. Danazol
 although treatment with low-dose danazol (200 mg twice daily) is effective, it has
irreversible virilising effects.
 Women treated with danazol for PMS should be advised to use contraception during
treatment.
5) Gonadotrophin-releasing analogues
 GnRH analogue therapy results in profound ovarian suppression and elimination of PMS.
 Lack of efficacy suggests a questionable diagnosis rather than a limitation of therapy.
 GnRH analogue therapy should be recommended as second- or even third-line
treatment
 therapy should not be used as a first-line treatment, except for women with the most
severe PMS
 add-back therapy with continuous combined HRT or tibolone is recommended, as it
reduces menopausal symptoms without reappearance of PMS-like progestogenic effects
 low-dose therapy is not recommended and showed no benefit.
 Treatment should only be continued for 6 months when used alone.
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 Treatment should be stopped if bone density declines significantly in scans performed 1
year apart.
 General advice about how exercise, diet and smoking affect bone mineral density should
be given.
6) Progesterone and progestogens
 There is insufficient evidence to recommend the routine use of progesterone or
progestogens for PMS.
7) Surgical approach (hysterectomy and bilateral salpingo-oophorectomy)
 Hysterectomy and bilateral salpingo-oophorectomy has been shown to be of benefit with
severe PMS.
 Surgery should not be done without preoperative GnRH analogues test of cure.
 Such therapy should be reserved for extremely severe PMS sufferers in whom other
treatment has failed.
How vital is the role of continuing hormone therapy?
 HRT should be considered in women undergoing surgical oophorectomy before the age
of 50 years.
 Without adequate hormone therapy, PMS symptoms are replaced by those of the
menopause.
 Consideration should also be given to replacing testosterone, as the ovaries are a major
production source (50%) and deficiency could result in distressing low libido.
Summary
 The aetiology and management of premenstrual syndrome continues to be poorly
understood and in many cases inadequately managed.
 It is important that appropriate multidisciplinary services are provided in an appropriate
setting throughout the country.

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LONG-TERM CONSEQUENCES OF PCOS
Introduction
 PCOS is a common disorder, complicated by:
 chronic anovulatory infertility and hyperandrogenism.With the clinical manifestation of
oligomenorrhoea, hirsutism and acne.
 obesity and a higher prevalence of impaired glucose tolerance, type 2 diabetes and
sleep apnoea than is observed in the general population.
 cardiometabolic syndrome:
 hypertension,
 dyslipidaemia,
 visceral obesity,
 Insulin resistance and hyperinsulinaemia.
Prevalence of PCOS
 Prior to the new Rotterdam diagnostic criteria. Prevalence is 6–7% of the population.
 The prevalence of PCOS may differ according to ethnic background; in women of South
Asian origin, PCOS presents at a younger age, have more severe symptoms and a
higher prevalence.
Diagnosis
How is PCOS diagnosed?
 Diagnosis of PCOS can only be made when other aetiologies have been excluded
(thyroid dysfunction, congenital adrenal hyperplasia, hyperprolactinaemia, androgen-
secreting tumours and Cushing syndrome).
 Rotterdam diagnostic criteria has suggested a broader definition for PCOS, with two of
the three following criteria :
 polycystic ovaries (either 12 or more peripheral follicles each one of(2-9mm)or
increased ovarian volume > 10 cm3)
 oligo- or anovulation(cycle42days)
 Clinical and/or biochemical signs of hyperandrogenism; alopecia, hirsutism and acne.
 A raised LH/FSH ratio is no longer a diagnostic criterion for PCOS.
 Baseline screening tests: Thyroid function tests, serum prolactin and free androgen
index (total testosterone x 100 / SHBG to give a calculated free testosterone level)
 If clinical evidence of hyperandrogenism and total testosterone > 5nmol/l →do 17-
hydroxyprogesterone role out androgen-secreting tumors
 AMH; a special protein released by cells that are involved in the growth of the ovum
every month. Its levels correlate with the number of antral follicles found on the ovary
every month. The higher the antral follicle count, the higher the serum AMH levels.
Women with PCOS typically have higher antral follicle and therefore higher AMH levels.
AMH is now used in many clinics as a potential diagnostic marker for PCOS and an
indicator of ovarian reserve in older women

Counselling
 Women with PCOS should be informed of the possible long-term risks to health.
 They should be advised regarding weight control and exercise.
Long-term consequences
1) Metabolic consequences of PCOS
 the risk of developing type II diabetes in women with PCOS:
 obesity (BMI>25),

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  strong family history of type 2 diabetes
 age of 40 years,
 women should be offered a 2-hour post 75 g glucose tolerance test
 In women with impaired fasting glucose (fasting plasma glucose level from 6.1 mmol/l to
6.9 mmol/l) or impaired glucose tolerance (plasma glucose of 7.8 mmol/l or more but less
than 11.1 mmol/l after a 2-hour oral glucose tolerance test), an oral glucose
tolerance test should be performed annually.
2) Obstructive sleep apnoea
 More common in PCOS.
 The risk of developing sleep apnoea in women with PCOS:
 Snoring.
 Daytime fatigue/somnolence.
 The strongest predictors for sleep apnoea were fasting plasma insulin levels and
glucose-to-insulin ratios.
3) Cardiovascular risk
 The conventional cardiovascular risk calculators are not valid in women with PCOS.
 They have increased cardiovascular risk factors such as( obesity,lack of physical
activity, cigarette smoking, family history of type II diabetes,
dyslipidaemia,hypertension, impaired glucose tolerance, type II diabetes)
 They are at increased risk of developing accelerated atherosclerosis resulting in MI.
 Hypertension should be treated but lipid-lowering treatment is not recommended
routinely.
PCOS and pregnancy
 Women with PCOS before pregnancy should be screened for GDM,for pregnant women
should be performed at 24–28 weeks of gestation (13% vs. 5% in normal individuals),
with referral to a specialist obstetric diabetic service if abnormalities are detected
 pregnancy-induced hypertension
 Increased risk of miscarriage (30–40%)
 Metformin is not licensed for use in pregnancy in the UK.
 A meta-analysis provided reassurance that metformin is safe, and may reduce
incidence of recurrent miscarriage if taken in the first trimester, but the methodology
of this studies was poor
 Metformin is excreted in breast milk in a very low level.
Cancer and PCOS
 Oligo or amenorrhoea in PCOS may predispose to endometrial hyperplasia and later
carcinoma.
 It is good practice to offer progestogens to induce a withdrawal bleed at least every 3–4
months.
 Transvaginal ultrasound should be considered in the absence of withdrawal bleeds or
abnormal uterine bleeding, In PCOS, an endometrial thickness of less than 7 mm is
unlikely to be hyperplasia.
 PCOS is not association with breast or ovarian cancer and no additional surveillance is
required.
Strategies for reduction of risk
1) Exercise and weight control
 Loss of significant weight has been reported to result in:
1. spontaneous resumption of ovulation and improvement in fertility
2. increased SHBG
3. Reduced basal level of insulin and normalisation in glucose metabolism.
2) Drug therapy
 Insulin-sensitising agents are not licensed in the UK for use in women who are not
diabetic.
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 Although there is evidence about the safety of these drugs, there is no evidence of a
long-term benefit for the use of insulin-sensitising agents.
 Metformin and troglitazone have short-term effects on insulin resistance in non-
diabetic women with PCOS
 Metformin reduce androgen levels by 11% in women with PCOS and modest
reductions in body weight.
 Women with BMI > 37 may not respond well to metformin.
 Metformin is not superior to lifestyle intervention in improving cardiometabolic risk
and progression to type 2 diabetes.
 Letrozole
 Is aromatase inhibitor effective in stimulating ovulation in women with polycystic
ovaries and anovulation, and/or for those with unexplained infertility
 Used in women with PCOS that do not respond to ovulate with Clomid will respond
well to letrozole.
 Also for controlled ovarian stimulation to women with unexplained infertility.
 The most common dose of Femara is 2.5 upto 7.5mg per day on days five (orally)
through nine of the menstrual cycle.
 Use of weight-reduction drugs may be helpful in reducing insulin resistance through
weight loss.
 Orlistat and Sibutramine have been shown to significantly reduce body weight and
hyperandrogenism in women with PCOS; Sibutramine is Not recommended in patients
with systolic hypertension
 Rimonabant – may have benefit in weight reduction and improvement in
cardiometabolic profile
 Bariatric surgery may be indicated in selected women with morbid obesity

3) Surgery prognosis
Role of laparoscopic ovarian drilling

 clomiphene-resistant PCOS
 as effective as gonadotrophin therapy
 ovulation occurs in 80% of the patients while 40–69% get pregnant
 serum LH, androgens and sex hormone binding globulin (SHBG) normalise in
more than 60%
 has a low miscarriage rate (14%)
 no risk of multiple pregnancy or ovarian hyperstimulation syndrome (OHSS)
 no need for intensive monitoring

 short-lasting effect of treatment (6–12 months)

 expensive procedure
 operative and anaesthetic complications
 Important note: ovarian surgery / drilling may affect the reproductive capacity of the
ovaries in the future

Image-related issues
How should women with hirsutism and acne be advised?
 There is insufficient evidence to support metformin or oral contraceptive pill in treating
hirsutism or acne.
 Licensed treatments for hirsutism include :
 oral contraceptive pills, dianette (oestrogen and cyproterone acetate),

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  Cosmetic measures (laser, electrolysis, bleaching, waxing and shaving) and topical
facial eflornithine (vaniqua).
 Usually a combination of methods is often required to achieve an acceptable
cosmetic result

 Non-licensed treatments include:

 spironolactone,
 Antiandrogens, such as flutamide, finasteride and high-dose cyproterone acetate.
 Metformin has modest effect on hirsutism associated with 11% reduction in
testosterone levels

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METFORMIN FOR THE MANAGEMENT OF INFERTILITY
IN WOMEN WITH PCOS
Introduction
 Only 40–50% of women with PCOS are overweight.
 Ovarian hyperandrogenism is driven primarily by LH in slim women; while in the
overweight insulin may augment the effects of LH.
 Women with PCO are more insulin resistant than weight-matched women with no PCO.
 Insulin resistance is seen in 10–15% of slim and 20–40% of obese women with PCOS
Insulin resistance
 In the ovary, high levels of insulin results into excess androgen production and to
anovulation.
 (OGTT) is conducted in those at high risk (BMI > 30 kg/m2 in white women or > 25
kg/m2 in women from South Asia, who have a greater degree of insulin resistance at a
lower body weight).
Metformin therapy for PCOS
 Metformin:
 inhibits the production of hepatic glucose,
 enhances insulin sensitivity at the cellular level
 and have direct effects on ovarian function:
o lowering serum androgen levels
o restoring menstrual cyclicity
 Most of studies are observational and showed that metformin is effective in achieving
ovulation either alone or with clomifene .
 Metformin is less effective if BMI >37 kg/m2)
 There is no agreement about the dose and whether should be adjusted for body weight
or other factors.
 The most common dose regimens are 500 mg three times daily or 850 mg twice a day.
 Metformin appears to be safe in pregnancy, although usual advice is to discontinue if
preg. occurs.
 more recent large randomised controlled trials like US study, showed that:
 Metformin alone was significantly less effective than clomifene citrate alone
and the addition of metformin to clomifene citrate produced no significant
benefit.
 metformin for only 4 weeks during an IVF cycle in women with PCO and a
mean BMI of 28 is associated with: increase in continuing pregnancy rates and
significant decrease in the incidence of severe OHSS
Opinion
 While initial studies appeared to be promising, more recent large randomised controlled
trials have not observed beneficial effects of metformin either as first-line therapy or
combined with clomifene citrate for the treatment of the anovulatory woman with PCOS.
The European Society for Human Reproduction and Embryology and American Society for
Reproductive Medicine consensus on infertility treatment for PCOS concluded that there is
no clear role for insulin sensitising and insulin lowering drugs in the management of PCOS,
and should be restricted to those patients with glucose intolerance or type 2 diabetes.

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HEAVY MENSTRUAL BLEEDING
Impact of HMB on women
 HMB defined as excessive menstrual blood loss which interferes with the woman‟s
physical, emotional, social and material quality of life, occurring alone or with other
symptoms.
History, examination and investigations for HMB
1) History
 Identify the nature of the bleeding, related symptoms, comorbidity and impact on quality
of life.
 Discuss range and natural variability in menstrual cycles with the woman..
 If the history suggests HMB without structural or histological abnormality, medical
treatment can be started without examination or investigations in primary care
 If history suggests structural or histological abnormality(intermenstrual or postcoital
bleeding, pelvic pain, pressure symptoms); examination and/or investigations should be
performed.
 Measuring blood loss directly(alkaline haematin)or indirectly(Pictorial chart) is not
routinely recommended for HMB.
 Whether menstrual blood loss is a problem should be determined not by measuring
blood loss but by the woman herself.
2) Examination
 physical examination should be carried out before:
 LNG-IUS fitting
 investigations for structural or histological abnormalities
 immediate referral to a specialist if there are abdominally palpable fibroids, intracavity
fibroids and/or uterine length >12 cm by ultrasound or hysteroscopy.
3) Laboratory tests
 FBC.
 Coagulation profile for women with HMB since menarche or personal or family history
of coagulopathy.
 Serum ferritin not routinely recommended with HMB.
 Female hormone testing is not recommended with HMB.
 TFT should be carried out only when other signs and symptoms of thyroid disease.
4) Structural and histological investigations
 Biopsy to exclude endometrial cancer or atypical hyperplasia Indicated for:
 Persistent intermenstrual bleeding
 Women aged >45
 Treatment failure or ineffective.
 Imaging indicated for:
 Palpable uterus abdominally.
 A pelvic mass of uncertain origin on vaginal examination.
 Medical Treatment failure.
 Ultrasound is the first-line diagnostic tool for structural abnormalities.
 The followings should not be used as first-line diagnostic tool:
 Hysteroscopy unless ultrasound results are inconclusive.
 Saline infusion sonography.
 MRI.
 Dilatation and curettage alone should not be used as a diagnostic tool.

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Education and information provision
 Women should be made aware of the impact of treatment options on fertility and
potentially unwanted outcomes.
 Women should be given the following information on potentially unwanted outcomes.

Potential unwanted outcomes experienced by some women (Common: 1 in 100 chance; Treatment
less common: 1 in 1000 chance; rare: 1 in 10,000 chance; very rare: 1 in 100,000 chance)
Common:irregular bleeding may last over 6 months; breast tenderness, acne or headaches Levonorgestrel-
Less common: amenorrhoea releasing
intrauterine
Rare: uterine perforation at the time of insertion
system
Less common: GIT symptoms; headaches Tranexamic acid
Common: GIT symptoms Non-steroidal
Rare: worsening of asthma; peptic ulcers anti-inflammatory
drugs
Common: mood changes; headaches; nausea; fluid retention; breast tender Combined oral
Very rare: DVT; stroke; IHD contraceptives
Common: weight gain; bloating; breast tenderness; headaches; acne Oral progestogen
Rare: depression (norethisterone)
Common: weight gain; irregular bleeding; amenorrhoea; premenstrual-like syndrome Injected
Less common: loss of bone density progestogen

Common: menopausal-like symptoms GRHA

Less common: osteoporosis, with longer than 6-months‟ use
Common: vaginal discharge; increased period pain or cramping; need for additional surgery Endometrial
Less common: infection ablation
Rare: perforation (but very rare with second generation techniques)
Common: vaginal discharge; post-embolisation syndrome(pain, nausea, vomiting and fever) Uterine artery
Less common: need for additional surgery; premature ovarian failure; haematoma embolisation
Rare: haemorrhage; tissue necrosis; infection causing septicaemia
Less common: adhesions; need for additional surgery; recurrent fibroids; perforation; infection Myomectomy
Rare: haemorrhage
Common: infection Hysterectomy
Less common: haemorrhage; damage to other abdominal organs,; urinary dysfunction
Rare: thrombosis
Very rare: death
(Complications are more likely when hysterectomy is performed in the presence of fibroids.)
Common: menopausal-like symptoms Oophorectomy at
time of
hysterectomy
Choice
 A woman with HMB should have adequate time and support in decision-making process.
 A woman should have a 2nd opinion if no agreement on treatment options is reached.
Medical treatments for HMB
 Medical treatments are Considered if:
1. No structural or histological abnormality is present
2. For fibroids less than 3 cm in diameter with no distortion of the uterine cavity.

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 Determine whether hormonal contraception is accepted to the woman(may wish to
conceive)
 If medical treatment is appropriate and hormonal treatments are acceptable, consider the
following order:
1. LNG-IUS if long-term (at least 12 months) use is anticipated
2. Tranexamic acid or NSAIDs or combined oral contraceptives (COCs)
3. Norethisterone 15 mg daily from days 5 to 26 of the cycle, or injected
progestogens.
 If hormonal treatments are not accepted, either tranexamic acid or NSAIDs can be used.
 Women with LNG-IUS should be advised :
 About changes in the bleeding patternwhich may lasting longer than 6 months.
 To persevere for at least 6 cycles to see the benefits of the treatment.
 tranexamic acid or NSAIDs should be used If required while investigations and definitive
treatment are being organised.
 NSAIDs are preferred when HMB coexists with dysmenorrhoea.
 NSAIDs and/or tranexamic acid can be used as long as it is beneficial by the woman.
 Stop NSAIDs and/or tranexamic acid if it does not improve symptoms within 3 cycles.
 When 1st medical treatment is ineffective, 2nd medical treatment can be considered
before referral to surgery.
 GRHA can be used:
1. prior to surgery
2. when all other treatment options for uterine fibroids are contraindicated.
 Danazol should not be used routinely for the treatment of HMB.
 Oral progestogens given during the luteal phase only should not be used for HMB.
 Etamsylate should not be used for the treatment of HMB.
Non-hysterectomy surgery for HMB
1) Endometrial ablation
 Endometrial ablation should be considered if woman does not want to conceive in future.
 Endometrial ablation may be offered as an initial treatment for HMB after discussion with
the woman of the risks and benefits and of other treatment options.
 Endometrial ablation considered in women with HMB who have a normal uterus(<10-
week) or small uterine fibroids < 3 cm.
 women considering endometrial ablation should have a 2ndgeneration ablation
technique.
 The second-generation techniques include:
 radiofrequency ablation
 thermal balloon endometrial ablation (TBEA)
 Microwave endometrial ablation (MEA)
 Free fluid thermal endometrial ablation
 First-generation ablation techniques (rollerball endometrial ablation) are appropriate if
hysteroscopic myomectomy is to be included in the procedure.
2) Dilatation and curettage
 Dilatation and curettage should not be used as a therapeutic treatment.
Other interventions for uterine fibroids with HMB
 Indications For surgery:
1. Large fibroids greater than 3 cm with HMB,
2. significant symptoms such as dysmenorrhoea with severe impact on quality of life
3. pressure symptoms.
 Women should be informed that UAE or myomectomy may potentially retain their fertility.
 Myomectomy is recommended when women want to retain their uterus.

87
 UAE is recommended for women with uterine fibroids and want to retain their uterus
and/or avoid surgery.
 before UAE or myomectomy, the uterus and fibroid(s) should be assessed by ultrasound.
 MRI If further information about fibroid position, size, number and vascularity is required.
 GRHA for 3 to 4 months before hysterectomy and myomectomy should be considered if
uterine fibroids are causing an enlarged or distorted uterus.
 GRHA should be stopped as soon as UAE has been scheduled.
Hysterectomy
 Hysterectomy should not be used as a first-line treatment for HMB. Hysterectomy should
be considered only when:
 Other treatment options failed, are contraindicated or are declined by the woman
 there is a wish for amenorrhoea
 the woman requests it
 the woman no longer wishes to retain her uterus and fertility.
 Women offered hysterectomy should have a full discussion include:
1. sexual feelings,
2. fertility impact,
3. bladder function,
4. need for further treatment,
5. alternative surgery
6. psychological impact.
7. Serious complications
8. possible loss of ovarian function, even if their ovaries are retained.
 The following factors need to be taken when deciding the route of hysterectomy:
1. presence of other gynaecological conditions or disease
2. uterine size
3. presence and size of uterine fibroids
4. mobility and descent of the uterus
5. size and shape of the vagina
6. history of previous surgery.
 the route of hysterectomy should be considered in the order of vaginal then abdominal.
 Under circumstances such as morbid obesity or the need for oophorectomy during
vaginal hysterectomy, LAVHshould be considered.
Removal of ovaries (oophorectomy) with hysterectomy
 Removal of healthy ovaries at the time of hysterectomy should not be undertaken
 Removal of ovaries should only be undertaken with the consent of the womanafter
disscution of the impact on the woman‟s wellbeing and the possible need for HRT.
 Refer women with a significant family history of breast or ovarian cancer for genetic
counselling prior to a decision for oophorectomy.
 In women with symptoms related to ovarian dysfunction (PMS), a trial of medical ovarian
suppression for at least 3 months should be used to assess the need for oophorectomy.
 If removal of ovaries is being considered, should be discussed.

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THE INITIAL MANAGEMENT OF MENORRHAGIA
INTRODUCTION
 Menorrhagia is defined as a complaint of heavy cyclical menstrual bleeding over several
consecutive cycles.
 Menorrhagia can be defined objectively or subjectively
 Objective menorrhagia is taken to be a total menstrual blood loss >80ml per
menstruation.
 Subjectively, menorrhagia is defined as a complaint of excessive menstrual blood
loss occurring over several consecutive cycles in a woman of reproductive years.
 1/ 20 women aged 30-49 years consults her GP each year with menorrhagia.
 Once referred to a Gynaecologist, surgical intervention is highly likely.
 1/5 women in the UK will have a hysterectomy before the age of 60 years, 50% due to
menorrhagia
 50%women who have a hysterectomy for menorrhagia have a normal uterus removed.
RECOMMENDATIONS
1. A history of heavy cyclical menstrual blood loss over several consecutive cycles
without any intermenstrual or postcoital bleeding should be obtained
2. An abdominal and pelvic examination should be performed in all women complaining
of menorrhagia.
3. full blood count should be obtained in all women complaining of menorrhagia
4. Thyroid function tests do not need to be routinely performed in the initial evaluation of
menorrhagia unless the woman has symptoms or signs of hypothyroidism.
5. No other endocrine investigations are necessary in the investigation of menorrhagia.
6. An endometrial biopsy is not required in the initial assessment of menorrhagia.
7. Tranexamic acid and mefenamic acid are effective treatments for reducing heavy
menstrual blood loss.
8. Antifibrinolytic drugs and NSAIDs are both effective in reducing heavy menstrual
blood loss in women with IUDs.
9. COC can be used to reduce menstrual blood loss.
10. A progestogen-releasing IUD is an effective treatment for menorrhagia .
11. Continued use of long-acting progestogens renders most women amenorrhoeic and
therefore could be considered for use in menorrhagia.
12. Low dose, luteal phase administration of norethisterone is not an effective treatment
for menorrhagia.
13. Ethamsylate, at currently recommended doses, is not an effective treatment for
menorrhagia

CLINICAL EVALUATION OF THE COMPLAINT OF MENORRHAGIA

89
91
MEDICAL MANAGEMENT OF THE COMPLAINT OF MENORRHAGIA

91
THE MANAGEMENT OF MENORRHAGIA IN SECONDARY CARE

92
RECOMMENDATIONS
Indications
 If a woman continues to complain of heavy menstrual bleeding, despite having drug
treatment recommended in the first guideline, her menstrual history should be re-
evaluated and an abdominal, bimanual and speculum examination performed.
Investigations
1. FBC should be performed.
2. Tests for thyroid function and bleeding disorders should only be performed if there
are suggestive features present in the history or on examination.
3. No other endocrine investigations are necessary in the investigation of menorrhagia .
4. The uterine cavity should initially be investigated using TVS.
5. An endometrial biopsy should be considered for all women with persistent
menorrhagia.
6. A D&C does not give additional diagnostic information over and above a
hysteroscopy with endometrial biopsy.
7. When hysteroscopy is indicated, it allows direct visualisation and endometrial biopsy
without the need for a general anaesthetic.
8. consider performing an objective or semi-objective measurement of menstrual blood
loss before deciding upon definitive surgical treatment.
Treatment
Patient Issues
 Patients must be involved in the decision making process regarding their treatment and
be provided with appropriate information.
 If definitive surgical treatment is intended, the likely outcomes and complications should
be discussed with the woman beforehand.
 Quality of life issues are important and must be addressed during the decision making
process .
Drug Treatments
1. Second line drugs such as danazol, gestrinone, and gonadotrophin releasing
hormone analogues are effective in reducing heavy menstrual blood loss but side
effects limit their long-term use.
2. A progestogen releasing IUD is an effective treatment and should be considered as
an alternative to surgical treatment .
Surgical Treatments
1. A D&C is not therapeutic in cases of heavy menstrual bleeding
2. If intrauterine pathology such as sub-mucous fibroids or polyps are found during
ultrasonic or hysteroscopic investigation should be removed hysteroscopically
3. Endometrial ablative procedures are effective in treating menorrhagia.
4. Hysterectomy is an established, effective treatment for menorrhagia.
5. hysterectomy as a treatment for menorrhagia should be balanced against its potential
mortality and morbidity.
6. Prophylactic antibiotics should be given to all women undergoing major surgical
treatment for menorrhagia.
7. Risk factors for venous thromboembolism should be assessed before hysterectomy.

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Green-top Guideline No. 67 RCOG/BSGE Joint Guideline | February 2016
MANAGEMENT OF ENDOMETRIAL HYPERPLASIA
Introduction and background epidemiology
 Endometrial hyperplasia is defined as irregular proliferation of the endometrial glands
with an increase in the gland to stroma ratio when compared with proliferative
endometrium.
 The incidence of endometrial hyperplasia is estimated to be at least three times higher
than endometrial cancer and if left untreated it can progress to cancer.
 The most common presentation of endometrial hyperplasia is abnormal uterine
bleeding. This include; heavy menstrual bleeding, intermenstrual bleeding, irregular
bleeding, unscheduled bleeding on hormone replacement therapy (HRT) and
postmenopausal bleeding.
What are the risk factors for endometrial hyperplasia?
 Endometrial hyperplasia is often associated with multiple identifiable risk factors and
assessment should aim to identify and monitor these factors.
 unopposed by progesterone.
 increased body mass index (BMI).
 anovulation associated with the perimenopause or polycystic ovary syndrome(PCOS).
 estrogen-secreting ovarian tumours, e.g. granulosa cell tumours (with up to 40%
prevalence of endometrial hyperplasia)
 drug-induced endometrial stimulation, e.g. the use of systemic estrogen replacement
therapy or long-term tamoxifen.
 Other risk factors;
 Immunosuppression
 Infection
 renal graft recipients
How should endometrial hyperplasia be classified?
 The revised 2014 World Health Organization (WHO) classification is recommended.
This separates endometrial hyperplasia into two groups based upon the presence of
cytological atypia:
(i) hyperplasia without atypia and (ii) atypical hyperplasia.
 Classification systems for endometrial hyperplasia were developed based upon
histological characteristics and oncogenic potential.
What diagnostic and surveillance methods are available for endometrial
hyperplasia?
 Diagnosis of endometrial hyperplasia requires histological examination of the
endometrial tissue.
 Endometrial surveillance should include endometrial sampling by outpatient
endometrial biopsy.
 Obtained by using outpatient suction devices designed to blindly abrade
 aspirate endometrial tissue from the uterine cavity or by inpatient endometrial
sampling, such as dilatation and curettage performed under general
anaesthesia.
 Endometrial sampling is also fundamental in monitoring regression, persistence
or progression.
 Diagnostic hysteroscopy should be considered to facilitate or obtain an endometrial
sample, especially where outpatient sampling fails or is nondiagnostic.
 Transvaginal ultrasound may have a role in diagnosing endometrial hyperplasia in pre-
and post menopausal women;
 that detects an irregularity of the endometrial profile
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  An abnormal double layer endometrial thickness measurement would give
further reason to perform an endometrial biopsy in women with postmenopausal
bleeding
 the endometrial thickness cut-off of 3 mm or 4 mm for ruling out endometrial
cancer is reduced to less than 1%.
 Direct visualisation and biopsy of the uterine cavity using hysteroscopy should be
undertaken where endometrial hyperplasia has been diagnosed within a polyp or other
discrete focal lesion.
 There is insufficient evidence evaluating computerised tomography (CT), diffusion-
weighted magnetic resonance imaging (MRI) or biomarkers as aids in the management
of endometrial hyperplasia and their use is not routinely recommended.
How should endometrial hyperplasia without atypia be managed?
What should the initial management of hyperplasia without atypia be?
 Women should be informed that the risk of endometrial hyperplasia without atypia
progressing to endometrial cancer is less than 5% over 20 years and that the majority
of cases of endometrial hyperplasia without atypia will regress spontaneously during
follow-up.
 Reversible risk factors such as obesity and the use of HRT should be identified and
addressed if possible.
 Advising obese women to lose weight is recommended, but there is no
evidence on weight loss strategies and their impact on progression or relapse
outcomes during follow-up.
 Observation alone with follow-up endometrial biopsies to ensure disease regression
can be considered, especially when identifiable risk factors can be reversed. However,
women should be informed that treatment with progestogens has a higher disease
regression rate compared with observation alone.
 Progestogen treatment is indicated in women who fail to regress following observation
alone and in symptomatic women with abnormal uterine bleeding.
What should the first-line medical treatment of hyperplasia without atypia
be?
 Both continuous oral and local intrauterine [LNG-IUS] progestogens are effective in
achieving regression of endometrial hyperplasia without atypia.
 The LNG-IUS should be the first-line medical treatment because compared with oral
progestogens it has a higher disease regression rate with a more favourable bleeding
profile and it is associated with fewer adverse effects.
 Continuous progestogens should be used (medroxyprogesterone 10–20 mg/day or
norethisterone10–15 mg/day) for women who decline the LNG-IUS.
 Cyclical progestogens should not be used because they are less effective in inducing
regression of endometrial hyperplasia without atypia compared with continuous oral
progestogens or the LNG-IUS.
What should the duration of treatment and follow-up of hyperplasia without
atypia be?
 Treatment with oral progestogens or the LNG-IUS should be for a minimum of 6
months in order to induce histological regression of endometrial hyperplasia without
atypia.
 Change from 3 to 6 months the regression rates improved for the LNG-IUS from
84% to 100% and for oral medroxyprogesterone from 50% to 64%.
 If adverse effects are tolerable and fertility is not desired, women should be
encouraged to retain the LNG-IUS for up to 5 years as this reduces the risk of
relapse, especially if it alleviates abnormal uterine bleeding symptoms.

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  Endometrial surveillance incorporating outpatient endometrial biopsy is
recommended after a diagnosis of hyperplasia without atypia.
 Endometrial surveillance should be arranged at a minimum of 6-monthly intervals,
although review schedules should be individualised and responsive to changes in a
woman‟s clinical condition.
 At least two consecutive 6-monthly negative biopsies should be obtained prior to
discharge.
 Women should be advised to seek a further referral if abnormal vaginal bleeding
recurs after completion of treatment because this may indicate disease relapse.
 In women at higher risk of relapse, such as women with a BMI of 35 or greater or
those treated with oral progestogens, 6-monthly endometrial biopsies are
recommended. Once two consecutive negative endometrial biopsies have been
obtained then long-term follow-up should be considered with annual endometrial
biopsies.
When is surgical management appropriate for women with endometrial
hyperplasia without atypia?
 Hysterectomy should not be considered as a first-line treatment for hyperplasia
without atypia because progestogen therapy induces histological and symptomatic
remission in the majority of women and avoids the morbidity associated with major
surgery.
 Hysterectomy is indicated in women not wanting to preserve their fertility when;
I. progression to atypical hyperplasia occurs during follow-up,
II. there is no histological regression of hyperplasia despite 12 months of
treatment.
III. there is relapse of endometrial hyperplasia after completing progestogen
treatment.
IV. there is persistence of bleeding symptoms.
V. the woman declines to undergo endometrial surveillance or comply with
medical treatment.
 Postmenopausal women requiring surgical management for endometrial hyperplasia
without atypia should be offered a bilateral salpingo-oophorectomy together with the
total hysterectomy.
 For premenopausal women, the decision to remove the ovaries should be
individualised; however,bilateral salpingectomy should be considered as this may
reduce the risk of a future ovarian malignancy.
 A laparoscopic approach to total hysterectomy is preferable to an abdominal
approach as it is associated with a shorter hospital stay, less postoperative pain and
quicker recovery.
 Endometrial ablation is not recommended for the treatment of endometrial
hyperplasia because complete and persistent endometrial destruction cannot be
ensured and intrauterine adhesion formation may preclude future endometrial
histological surveillance.
What should the initial management of atypical hyperplasia be?
 Women with atypical hyperplasia should undergo a total hysterectomy because of
the risk of underlying malignancy or progression to cancer.
 A laparoscopic approach to total hysterectomy is preferable to an abdominal
approach as it is associated with a shorter hospital stay, less postoperative pain and
quicker recovery.
 There is no benefit from intraoperative frozen section analysis of the endometrium or
routine lymph adenectomy.
 Postmenopausal women with atypical hyperplasia should be offered bilateral
salpingo-oophorectomy together with the total hysterectomy.
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  For premenopausal women, the decision to remove the ovaries should be
individualised; however, bilateral salpingectomy should be considered as this may
reduce the risk of a future ovarian malignancy.
 Endometrial ablation is not recommended because complete and persistent
endometrial destruction cannot be ensured and intrauterine adhesion formation may
preclude endometrial histological surveillance.
How should women with atypical hyperplasia who wish to preserve their
fertility or who are not suitable for surgery be managed?
 Women wishing to retain their fertility should be counselled about the risks of
underlying malignancy and subsequent progression to endometrial cancer.
 Pretreatment investigations should aim to rule out invasive endometrial cancer or co-
existing ovarian cancer and invasive endometrial cancer, these include (tumour
markers such as CA125 and imaging with TVS and/or MRI scan).
 Histology, imaging and tumour marker results should be reviewed in a
multidisciplinary meeting and a plan for management and ongoing endometrial
surveillance formulated.
 First-line treatment with the LNG-IUS should be recommended, with oral progestogens
as a second-best alternative (see section 7.2).
 Once fertility is no longer required, hysterectomy should be offered in view of the high
risk of disease relapse.
How should women with atypical hyperplasia not undergoing hysterectomy be
followed up?
 Routine endometrial surveillance should include endometrial biopsy.
 Review schedules should be individualised and be responsive to changes in a
woman‟s clinical condition.
 Review intervals should be every 3 months until two consecutive negative biopsies
are obtained.
 In asymptomatic women with a uterus and evidence of histological disease
regression, based upon a minimum of two consecutive negative endometrial
biopsies, long-term follow-up with endometrial biopsy every 6–12 months is
recommended until a hysterectomy is performed.
How should endometrial hyperplasia be managed in women wishing to
conceive?
 Disease regression should be achieved on at least one endometrial sample before
women attempt toconceive.
 Women with endometrial hyperplasia who wish to conceive should be referred to a
fertility specialist to discuss the options for attempting conception, further assessment
and appropriate treatment.
 Assisted reproduction may be considered as the live birth rate is higher and it may
prevent relapse compared with women who attempt natural conception.
 Prior to assisted reproduction, regression of endometrial hyperplasia should be
achieved as this is associated with higher implantation and clinical pregnancy rates.
HRT and endometrial hyperplasia
 Systemic estrogen-only HRT should not be used in women with a uterus.
 All women taking HRT should be encouraged to report any unscheduled vaginal
bleeding promptly,should be referred for further investigation.
 Women with endometrial hyperplasia taking a sequential HRT preparation who wish
to continue HRT should be advised to change to continuous progestogen intake
using the LNG-IUS or a continuous combined HRT preparation.
 Subsequent management should be as described in the preceding sections

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 of the guideline.
 Women with endometrial hyperplasia taking a continuous combined preparation who
wish to continue HRT should have their need to continue HRT reviewed. Discuss the
limitations of the available evidence regarding the optimal progestogen regimen in
this context. Consider using the LNG-IUS as a source of progestogen replacement.
Subsequent management should be as described in the preceding sections of the
guideline.
How should endometrial hyperplasia be managed in women on adjuvant
treatment for breast cancer
How should endometrial hyperplasia confined to an endometrial polyp
be managed?
 Women taking tamoxifen should be informed about the increased risks of developing
endometrial hyperplasia and cancer.
 They should be encouraged to report any abnormal vaginal bleeding or discharge
promptly.
 Women taking aromatase inhibitors (such as anastrozole, exemestane and letrozole)
should be informed that these medications are not known to increase the risk of
endometrial hyperplasia and cancer.
Should women on tamoxifen be treated with prophylactic progestogen
therapy?
 There is evidence that the LNG-IUS prevents polyp formation and that it reduces the
incidence of endometrial hyperplasia in women on tamoxifen.
 The effect of the LNG-IUS on breast cancer recurrence risk remains uncertain so its
routine use cannot be recommended.
How should women who develop endometrial hyperplasia while on tamoxifen
treatment for breast cancer be managed?
 The need for tamoxifen should be reassessed and management should be according
to the histological classification of endometrial hyperplasia and in conjunction with the
woman‟s oncologist.
How should endometrial hyperplasia confined to an endometrial polyp
be managed?
 Complete removal of the uterine polyp(s) is recommended and an endometrial biopsy
should be obtained to sample the background endometrium.
 Subsequent management should be according to the histological classification of
endometrial hyperplasia.

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99
ASYMPTOMATIC ENDOMETRIAL THICKENING
Recommendations
1. TVS or endometrial biopsy should not be used as screening for endometrial cancer. (II-
1E)
2. Endometrial sampling in a postmenopausal woman without bleeding should not be
routinely performed. (II-1E)
3. further investigations in asymptomatic women with increased endometrial thickening
should be made on a case-by-case basis taking in mind:
 risk factors for endometrial cancer. (II-1B)
 positive findings on ultrasound, such as increased vascularity, inhomogeneity of
endometrium, particulate fluid, or thickened endometrium over 11 mm
4. Women with asymptomatic polyps on ultrasound should be triaged for intervention
according to size of the polyp, age, and other risk factors. (II-1A)

INTRODUCTION
 postmenopausal asymptomatic endometrial thickening is defined as an endometrium of
> 5 mm with no bleeding.
 The endometrium is measured at its maximal thickness on a midline sagittal image
by transvaginal ultrasound. It is a bilayer measurement
 An endometrium 2 mm thicker in women on sequential hormonal therapy may be
normal.
 The endometrium may normally be thicker in the first year of menopause due to
some residual hormonal activity.
 The incidence 3% to 17%, while the incidence of endometrial cancer in
postmenopausal population is 1.3 to 1.7/1000.
 Current literature suggests that asymptomatic endometrial thickness of 8 to 11 mm in a
postmenopausal women is not abnormal .
ENDOMETRIAL CANCER AND RISK FACTORS
 Endometrial cancer is the 2nd most common gynaecologic malignancy.
 80% of endometrial cancers occur in postmenopausal women.
 90% present with bleeding.
 75% have stage I cancer when diagnosis is made,
 Survival rate depends on stage, grade, and type of cancer, the overall 5-year survival
rate is 86%.
 Duration of postmenopausal bleeding was correlated with increasing tumour stage and
reduced survival time.
 Individual risk factors are:
 obesity,
 high-fat diet,
 reproductive factors such as nulliparity and PCOS, early menarche, and late
menopause.
 Tamoxifen the risk increase if women were previously taking estrogen replacement
therapy or having initial endometrial lesions .
 Hypertension and antihypertensive medications.
 Diabetes mellitus
 Hereditary nonpolyposis colorectal cancer syndrome have incidence from 20% to
60%. The mean age of developing cancer is 47. No benefit of screening for
endometrial cancer in this group.
 White ethnicity. However, the mortality due to the disease is higher among blacks.

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  postmenopausal bleeding , the risk is 10%. If the woman is on hormone therapy, the
risk is 1%.
SIGNIFICANCE OF ASYMPTOMATIC ENDOMETRIAL THICKENING
 In a menstruating woman the endometrium ranges from 3 mm after menses to a
thickness of 15 mm in the luteal phase.
 Descriptions of the endometrium on ultrasound examination include:
 global thickening,
 heterogeneity,
 thickening,
 focal areas of thickening,
 fluid collections,
 increased vascularity,
 myometrial findings such as myometrial cysts, and submucosal fibroids.
 Aftermenopause, endometrial thickening may reflect:
 proliferative endometrium,
 cystic hyperplasia,
 complex hyperplasia,
 atypical hyperplasia, or
 carcinoma of the endometrium.
ENDOMETRIAL THICKENING IN WOMEN ON HT
 Tibolone is not significantly associated with endometrium thickness and could be
considered as an alternative to HT.
 Hysteroscopy and biopsy are recommended for women with bleeding on HT if
endometrial thickness is > 8 mm.
STUDIES IN WOMEN WITH ENDOMETRIAL POLYPS
 The prevalence of polyps in women with postmenopausal bleeding 13% to 50%.
 Most are benign, some are pre-malignant or malignant(0.5% to 4.8%).
 The authors concluded that hysteroscopic resection of both symptomatic and
asymptomatic polyps should be performed since the natural course of malignant polyps
is still unknown.
 Advanced age and postmenopausal status are the most risk factors for cancer (over 60
years have 3.28times risk, over 60 with postmenopausal bleeding have 5.31 times risk )
 Other risk factors such as diabetes mellitus, HT, tamoxifen were not significantly different
between the benign and cancerous polyp groups.
IMPLICATIONS OF TAMOXIFEN FOR ENDOMETRIAL THICKENING
 A routine ultrasound or endometrial biopsy in asymptomatic women on tamoxifen for
endometrial thickening should not be performed.
 endometrial thicken with tamoxifen at a rate of 0.75 mm/yr. The mean endometrial
thickness after 5 years of tamoxifen use was 12 mm. After discontinuation of tamoxifen
the endometrium decreased by 1.27 mm/yr.
COMPLICATIONS OF INVESTIGATION
 Endometrial biopsy may result in pain, bleeding, infection, and uterine perforation, and
office-based endometrial biopsy has false negative rates of 5% to 15%.
 Dilatation and curettage has false negative rates of 2% to 6%.
 Endometrial sampling may be limited or impossible because of virginal status, cervical
stenosis, small introitus, pain, or anatomical abnormalities such as fibroids .
 Investigations for asymptomatic endometrial thickening are not risk free, and serious
complications such as bowel injury and uterine perforation have been reported in the
literature.

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BEST PRACTICE IN OUTPATIENT HYSTEROSCOPY
Service provision
 All gynaecology units should provide a outpatient hysteroscopy service to aid
management of women with abnormal uterine bleeding.
 There are clinical and economic benefits associated with this type of service.
 Outpatient hysteroscopy should be performed in an appropriately sized and equipped
room.
 The clinitian should have the necessary skills and expertise to carry out
hysteroscopy.
 Written patient information should be provided and consent for the procedure should
be taken.
Analgesia
 Routine use of opiate analgesia before outpatient hysteroscopy should be avoided as
it may cause adverse effects.
 NSAIDs around 1 hour before outpatient hysteroscopy is recommended with the aim
of reducing pain in the immediate postoperative period.
Cervical preparation
 Routine cervical preparation before outpatient hysteroscopy should not be used in
the absence of any evidence of benefit in terms of reduction of pain, rates of failure
or uterine trauma.
Type of hysteroscope
 Miniature hysteroscopes (2.7mm with a 3–3.5mm sheath) should be used for
diagnostic outpatient hysteroscopy as they significantly reduce the pain.
 There is insufficient evidence to recommend 0° or fore-oblique lenses for
hysteroscopy.
 Flexible hysteroscopes are associated with less pain compared with rigid one.
 rigid hysteroscopes have: better images, fewer failed rate, quicker and reduced cost.
 There is insufficient evidence to favour use of rigid or flexible outpatient
hysteroscopes.
Distension medium
 For outpatient hysteroscopy, nither carbon dioxide or normal saline is superior in
reducing pain.
 Uterine distension with normal saline: reduce the incidence of vasovagal episodes,
improve image quality and quicker compared with carbon dioxide.
 Operative outpatient hysteroscopy, using bipolar electrosurgery, requires the use of
normal saline as conducting medium.
Local anaesthesia and cervical dilatation
 Blind cervical dilatation to facilitate insertion of the miniature outpatient hysteroscope
is unnecessary in the majority of procedures.
 Cervical dilatation generally requires administration of local cervical anaesthesia.
 Instillation of local anaesthetic into the cervical canal does not reduce pain but may
reduce the incidence of vasovagal reactions.
 Application of intracervical or paracervical local anaesthetic is associated with
reduction of pain
 Miniaturisation of hysteroscopes and increasing use of the vaginoscopic technique
may diminish the need for anaesthesia.
 Routine administration local anaesthetic should be used where larger hysteroscopes
are being used (outer diameter greater than 5mm), where the need for cervical

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 dilatation is anticipated (cervical stenosis) and with application of a cervical
tenaculum.
Conscious sedation
 Conscious sedation should not be routinely used it confers no advantage in terms of
pain control over local anaesthesia.
 Life-threatening complications can result from the use of conscious sedation.
Vaginoscopy
Vaginoscopy should be the standard technique for outpatient hysteroscopy, especially where
successful insertion of a vaginal speculum is anticipated to be difficult and where blind
endometrial biopsy is not required.

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FERTILITY: ASSESSMENT AND TREATMENT
Initial advice to people concerned about delays in conception
Natural conception
 about 84% of couples of general population will conceive in the 1st year and 92% in the
2nd year if they have regular unprotected sexual intercourse.
 female fertility declines with age, but that the effect of age on male fertility is less clear.
 94% of fertile women aged 35 years, and 77% aged 38 years, will conceive within 3
years.
Frequency and timing of sexual intercourse
 Sexual intercourse every 2 to 3 days optimises the chance of pregnancy.
 Timing intercourse with ovulation causes stress and is not recommended.
Alcohol
 Women drinking 1-2 units of alcohol once or twice per week reduces the risk of harming
fetus.
 Men drinking 3-4 units per day will not fertility. excessive alcohol will affect semen
quality.
Smoking
 Active and passive smoking is likely to reduce Women fertility.
 smoking will reduced semen quality.
Caffeinated beverages(tea, coffee and colas)
 there is insufficient evidence of an association between caffeinated beverages and
fertility problems.
Body weight
 Women of body mass index > 29 assocciated with delayed conception and losing weight
increase the chance of conception.
 Men of body mass index > 29 should have reduced fertility.
 Women of body mass index <19 with irregular or not menstruating, increasing body
weight improve fertility.
Tight underwear for men
 there is an association between elevated scrotal temperature and reduced semen
quality, but it is uncertain whether wearing loose underwear improves fertility.
Occupation
 Some occupations involve exposure to hazards that can reduce male or female fertility
 There is an association between work-related stress and a lower conception rate in
women
Prescribed, over-the-counter and recreational drug use
 There is evidence that NSAIDs drugs inhibit ovulation.
 Immunosuppressive and anti-inflammatory drugs for rheumatic diseases may affect
conception.
 Thyroid replacement hormones, antidepressants, tranquilisers and asthma medication
have elevated risks of anovulation.
 cytotoxic drugs can induce ovarian failure
 cimetidine, sulphasalazine, long acting some antibiotics and androgen injections can
cause oligozoospermia.
 beta-blockers and psychotropic drugs may cause impotence.
 Recreational drugs and drugs abuse adversely affect ovulatory and tubal function.
 anabolic steroids and cocaine adversely affect semen quality.
Complementary therapy
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 effectiveness of complementary therapies for fertility problems has not been properly
evaluated.
Folic acid supplementation
 folic acid before conception and up to 12 weeks‟ gestation reduces the risk of neural tube
defects.
 The dose is 0.4 mg/day and 5 mg /day For women with previous NTD or receiving anti-
epileptic.
Susceptibility to rubella
 Offer rubella vaccination to susceptible women and to avoid conception for at least 1
month.
Cervical cancer screening
 Abnormal cervical cytology lead to increased delay in fertility treatment because
treatment of cervical intraepithelial neoplasia is more complicated during pregnancy.
 Cervical screening should be offered according to the national programme.
Defining infertility
 Infertility : defined as failure to conceive after regular unprotected sexual intercourse for
2 years in the absence of known reproductive pathology.
 Offere investigations (semen analysis and/or assessment of ovulation)for People failed
to conceived after 1 year of regular unprotected sex.
 Offere investigations earlier if :
 there is predisposing factors (amenorrhoea, oligomenorrhoea, PID or
undescended testes)
 woman age > 35 years.
 Where there is a known reason for infertility early specialist referral should be offered.
 People who are known to have chronic viral infections such as hepatitis B, hepatitis C or
HIV should be referred to specialized centres providlng safe investigation and risk-
reduction treatment.
Principles of care
Information given to couple
 Couples with fertility problems should be seen together because both are affected by any
decision.
 Provide evidence-based information regarding care and treatment.
 Verbal information should be supplemented with written information or audio-visual
media.
Psychological effects of fertility problems
 Stress can affect libido and frequency of intercourse which can contribute to fertility
problems
 Offer counselling because fertility problems, investigation and treatment can cause
psychological stress.
 Counselling should be offered before, during and after investigation and treatment,
 Counselling should be provided by someone who is not directly involved in the
management.
Specialist and generalist care
 Treatment by a specialist team will improve the effectiveness of treatment and patient
satisfaction.
Investigation of fertility problems and management strategies
1) Semen analysis

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 Don‟t offer Screening for antisperm antibodies because there is no evidence of effective
treatment.
 If the initial result is abnormal, repeat test after 3 months.
 If a gross deficiency (azoospermia or severe oligozoospermia) detected repeat the test
sooner.
2) Assessing ovulation
 Asked about the frequency and regularity of menstrual cycles. Women with regular
menstrual cycles are likely to be ovulating.
 Measure serum progesterone in the mid-luteal phase to confirm ovulation in women with
regular cycles.
 measure serum progesterone later in the cycle and repeated weekly until the next cycle
in women with prolonged irregular menstrual cycles.
 Don‟t use basal body temperature charts to confirm ovulation.
 measure serum FSH & LH in women with irregular cycles.
 Ovulation disorders cause 21% of female infertility.
 WHO classification of ovulation disorders:
1. Group 1 Hypothalamic pituitary failure (hypogonadotrophic hypogonadism)
 10% of ovulatory disorders.
 Characterized by :
o low gonadotrophins
o low oestrogen and hypo-oestrogenic amenorrhoea
o normal prolactin
2. Group 2 ovulation disorders
 %85of ovulatory disorders .
 Characterized by :
o normal gonadotrophin LH increase in 60% of PCO pt.
o normal oestrogen
o anovulatory oligo/amenorrhea,
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  predominately involve women with polycystic ovaries.
o PCO present in 80–90% of women with oligomenorrhoea and 30% of
women with amenorrhoea.
o 30% of the PCOS population is of normal weight.
o the diagnosis of PCOS requires the presence at least two of the following
three:
a. oligo- and/or anovulation
b. clinical and/or biochemical hyperandrogenism
c. polycystic ovaries:the presence of at least 12 follicles measuring 2–9
mm in diameter and/or an ovarian volume in excess of 10 cm3.
3. Group 3 Ovarian failure(hypergonadotrophic hypogonadism)
 4–5% of ovulatory disorders.
 Characterized by :
o High gonadotrophins
o low oestrogen,
 prolactin test offered only to women with ovulatory disorder associated with
galactorrhoea or a pituitary tumour.
 Tests of ovarian reserve have limited sensitivity and specificity in predicting fertility.
However, women with high gonadotrophins are likely to have reduced fertility.
 Inhibin B for assessing ovarian reserve using is uncertain and not recommended.
 TSH offered only to women with symptoms of thyroid disease.
 Endometrial biopsy to evaluate the luteal phase is not recommended because there is no
evidence that treatment of luteal phase defect improves pregnancy rates.
3) Screening for Chlamydia trachomatis
 uterine instrumentation during infertility investigation may disseminate endocervical
chlamydial infectionto pelvic inflammatory disease.
 PID following HSG is up to 4% of cases.
 Offered screening for Chlamydia trachomatis before uterine instrumentation .
 Refer women with positive test and their partners for management and contact tracing.
 Consider Prophylactic antibiotics if screening has not been performed.
 Both doxycycline and azithromycin are effective prophylaxis and treatment for chlamydia.
4) Assessing tubal damage
 semen analysis and assessment of ovulation should be known before testing for tubal
patency.
 Offered HSG to Women with no co-morbidities (PID, previous ectopic pregnancy or
endometriosis) because it is a reliable test, less invasive and cost effective than
laparoscopy.
 hysterosalpingo-contrastultrasonography is an effective alternative to HSG.
 Offered laparoscopy and dye to Women with co-morbidities.
5) Assessing uterine abnormalities
 Don‟t offer hysteroscopy unless clinically indicated because the effectiveness of surgery
for uterine abnormalities to improve pregnancy rates is uncertain.
6) Post-coital testing of cervical mucus
 post-coital testing of cervical mucus in has no predictive value on pregnancy rate.
Medical and surgical management of male factor fertility problems
1) Medical management
 offer gonadotrophin to Men with hypogonadotrophic hypogonadism.
 anti-oestrogens, gonadotrophins, androgens, bromocriptine or kinin-enhancing drugs are
not effective with idiopathic semen abnormalities.
 The effectiveness of corticosteroids for antisperm antibodies is uncertain.
 Don‟t offer antibiotic for leukocytes in the semen unless there is evidence for infection.

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 2) Surgical management
 offere surgical correction of epididymal blockage because it is likely to improve fertility.
 Is an alternative to surgical sperm recovery and IVF.
 Don‟t offer surgery for varicoceles because it does not improve pregnancy rates.
3) Management of ejaculatory failure
 Treatment of ejaculatory failure can restore fertility without the need for invasive
methods.
Ovulation induction
1) Anti-oestrogens
 Offer clomifene citrate (or tamoxifen) as the first line of treatment for Group II ovulation
disorders up to 12 months.
 Inform women about the risk of multiple pregnancies associated with clomifene and
tamoxifen.
 Clomifene citrate increases the chance of pregnancy with unexplained fertility.
 Offer ultrasound monitoring for at least the first cycle of clomifene citrate treatment to
optimize the dose with minimum risk of multiple pregnancy.
2) Metformin
 Metformin is not licensed for the treatment of ovulatory disorders in the UK.
 Offer metformin with clomifene to women with PCO and BMI>25 who didn‟t respond to
clomifene alone.
 Inform women about the side effects of metformin (GIT disturbances).
3) Ovarian drilling
 Offer laparoscopic ovarian drilling toWomen with PCO who didn‟t respond to clomifene
 Is as effective as gonadotrophin treatment and is not associated with risk of multiple
pregnancy.
4) Gonadotrophin for ovulation induction
 Offer gonadotrophins to Women with Group II ovulation disorders who didn’t respond
to clomifene or tamoxifen.
 informed women about the risk of multiple pregnancy and ovarian hyperstimulation.
 Human menopausal gonadotrophin, urinary follicle-stimulating hormone and
recombinant follicle-stimulating hormone are equally effective.
 Offer clomifene citrate-stimulated IUI to Women with Group II ovulation disorders who
ovulate with clomifene citrate but have not become pregnant after 6 months of
treatment.
5) Gonadotrophin with IVF
 Gonadotrophin are used following pituitary down-regulation as part of in IVF.
6) Gonadotrophin-releasing hormone analogues in ovulation induction therapy
 GRHA should not be used adjunct to gonadotrophins in Group II ovulation disorders
because it does not improve pregnancy rates, and increase the risk of ovarian
hyperstimulation.
7) GRHA during IVF
 pituitary down-regulation using GRHA followed by gonadotrophin stimulation results in
higher pregnancy rates than the use of gonadotrophins alone in IVF.
8) Growth hormone as an adjunct to ovulation induction therapy
 Adjuvant growth hormone during ovulation induction in women who do not respond to
clomifene does not improve pregnancy rates.
9) Pulsatile gonadotrophin-releasing hormone
 Offer pulsatile GRH or gonadotrophins with LH activity for Group I ovulation disorders.
 The effectiveness of pulsatile GRH in women with clomifene -resistant PCO is uncertain.
10) Dopamine agonists
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 Offer dopamine agonists to women with ovulatory disorders due to hyperprolactinaemia.
Monitoring ovulation induction during gonadotrophin therapy
 OHSS is a fatal condition, leading to ascites, pleural and pericardial effusion,
haemoconcentration and coagulopathy.
 Available data suggest an incidence of 3% of cycles when hMG is used, and in 0.2% to
1.0% of all assisted reproduction cycles.
 Offer Ovarian ultrasound monitoring to measure follicular size and number during
gonadotrophin therapy to reduce the risk of multiple pregnancy and ovarian
hyperstimulation.
Other risks and side effects associated with ovulation induction agents
 the possible association between ovulation induction therapy and ovarian cancer
uncertain.
 Practitioners should use induction agents with the lowest effective dose and duration.
Tubal and uterine surgery
11) Tubal microsurgery and laparoscopic tubal surgery
 Tubal surgery may be more effective with mild tubal disease.
12) Tubal catheterisation or cannulation
 Salpingography plus tubal catheterisation, or hysteroscopic tubal cannulation for
proximal tubal obstruction may improve the chance of pregnancy.
13) Uterine surgery
 hysteroscopic adhesiolysis for intra-uterine adhesions improve the chance of pregnancy.
Medical and surgical management of endometriosis
Medical management (ovarian suppression)
 Medical treatment of minimal and mild endometriosis does not improve fertility.
Surgical ablation
 Surgical ablation or resection of endometriosis plus laparoscopic adhesiolysis for
minimal, mild, moderate or severe endometriosis improves the chance of pregnancy.
 Laparoscopic cystectomy for ovarian endometriomas improves the chance of pregnancy.
 Post-operative medical treatment does not improve pregnancy rates and is not
recommended.
Intra-uterine insemination
 Up to six cycles of IUI increases the chance of pregnancy for:
 mild male factor fertility
 unexplained fertility.
 minimal to mild endometriosis should be because this.
 Don‟t offer ovarian stimulation with IUI for male factor fertility because it is not more
effective and increase the risk of multiple pregnancy.
 Don‟t offer stimulated IUI for unexplained fertility, even though it is associated with higher
pregnancy rates than unstimulated IUI, because it carries a risk of multiple pregnancy.
 offer stimulated IUI for minimal or mild endometriosis it is associated with higher
pregnancy rates than unstimulated IUI.
 Single rather than double insemination should be offered.
 fallopian sperm perfusion (a large-volume solution, 4 ml) for unexplained fertility
improves pregnancy rates compared with standard insemination techniques.
Factors affecting the outcome of in vitro fertilisation treatment
1) Laparoscopic salpingectomy, before IVF improves the chance of a live birth.
2) the optimal female age range for IVF is 23–39 years. Chances of a live birth per cycle
are:
 > 20% for women aged 23–35 years
 15% for women aged 36–38 years
 10% for women aged 39 years
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  6% for women aged 40 years or older.
3) To balance the chance of a live birth and the risk of multiple pregnancy, no more than
two embryos should be transferred per cycle of IVF.
4) the effectiveness and the chance of a live birth after three cycles of IVF is less certain.
5) IVF is more effective in women who have previous pregnancy and/or a live birth.
6) consumption of more than one unit of alcohol per day reduces the effectiveness of IVF.
7) maternal and paternal smoking reduces the effectiveness of IVF.
8) caffeine consumption reduces the effectiveness of IVF.
9) A female body mass index outside 19–30 reduce the effectiveness of IVF.
10) IVF should offered for:
1. Couples in which the woman is aged 23–39 years with identified cause for
fertility (azoospermia or bilateral tubal occlusion)
2. Couples who have infertility of at least 3 years‟.
11) Embryos not transferred during IVF cycle can be freezed and transferred later.
12) There is insufficient evidence to support the use of gamete intrafallopian transfer or
zygote intrafallopian transfer over IVF in couples with unexplained or male factor
fertility.
Procedures used during in vitro fertilization treatment
Medical assessment and screening
 Offer screening for HIV, hepatitis B virus and hepatitis C virus.
 the implications of HIV, hepatitis B or hepatitis C infections on children should be taken
into account before providing fertility treatment.
Ovulation induction during IVF
 Natural cycle IVF has lower pregnancy rates per cycle than stimulated IVF.
Oocyte maturation using hCG
 Both recombinant hCG and urinary hCG have similar pregnancy rates and incidence of
OHSS.
Monitoring of stimulated cycles
 Ultrasound monitoring of ovarian response should form an integral part of the IVF cycle.
 Monitoring oestrogen levels during ovulation induction during IVF is not recommended
Ovarian hyperstimulation syndrome
 Women with high risk of developing OHSS should not be offered hCG for oocyte
maturation.
Oocyte retrieval
 Conscious sedation for Women undergoing transvaginal retrieval of oocytes is safe.
 Don‟t offer follicle flushing if Women developed > three follicles before oocyte retrieval
because this will not increase the numbers of oocytes retrieved or pregnancy rates.
Assisted hatching
 Assisted hatching doesn‟t improve pregnancy rates.
Embryo transfer techniques
 Ultrasound-guided embryo transfer improves pregnancy rates.
 Embryo transfers on day 2 or 3 and day 5 or 6 are equally effective.
 Replacement of embryos into a uterine cavity with an endometrium < 5 mm thickness is
unlikely to result in a pregnancy.
 bed rest > 20 minutes‟ after embryo transfer does not improve the outcome of IVF.
Luteal support
 luteal support using hCG or progesterone after IVF using GRHA for pituitary down-
regulation improves pregnancy rates.
 Routine luteal support with hCG is not recommended because of the increased risk of
OHSS.
Intracytoplasmic sperm injection
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Indications
1. severe deficits in semen quality
2. obstructive azoospermia
3. non-obstructive azoospermia.
4. When previous IVF cycle has resulted in failed or very poor fertilisation.
Genetic issues and counselling
 couples should undergo appropriate investigations, both to establish a diagnosis and to
enable informed discussion about the implications of treatment.
 If known or suspected genetic defect associated with male infertility, offer appropriate
genetic counselling and testing for.
 Offer man‟s karyotype if there is severe deficit of semen quality or non-obstructive
azoospermia.
 Don‟t offer routine testing for Y chromosome microdeletions before intracytoplasmic
sperm injection.
Intracytoplasmic sperm injection versus in vitro fertilisation
 intracytoplasmic sperm injection improves fertilisation rates compared to IVF alone, but
once fertilisation is achieved the pregnancy rate is the same.
Sperm recovery
 Surgical sperm recovery may be performed before intracytoplasmic sperm injection
 cryopreservation of spermatozoa should be available.
Donor insemination
Oocyte donation
Applications of cryopreservation in cancer treatment
 offer semen cryostorage to men and adolescent boys undergoing treatment that is likely
to make them infertile.
 Offer oocyte or embryo cryostorage to women undergoing treatment that is likely to
make them infertile, provided that this will not worsen their condition and there is
sufficient time.
 oocyte cryostorage has very limited success, and cryostorage is still under development.
Follow-up of children born as a result of assisted reproduction
 Current research is broadly reassuring about the health and welfare of children born as a
result of assisted reproduction.

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113
IMMUNOLOGICAL TESTING AND INTERVENTIONS FOR
REPRODUCTIVE FAILURE
Background
 Reproductive failure is defined as the inability to conceive or to carry a pregnancy to
term.
 Recurrent miscarriage and infertility are the two major categories of reproductive failure.
 It has been suggestedthat some cases of human reproductive failure may be the
consequence of immunological abnormalities.
Investigations
1) Antiphospholipid antibodies
 Antiphospholipid antibodies are a family of approximately 20 antibodies. However, only
the lupus anticoagulant and anticardiolipin antibodies (immunoglobulin G and
immunoglobulin M subclass, but not immunoglobulin A) have been shown to be of
clinical significance.
 Testing for antiphospholipid antibodies other than lupus anticoagulant or anticardiolipin
antibodies is uninformative.
 There is a considerable inter- and intra-laboratory variation in the detection of aPL and
the laboratory assays.
Recurrent miscarriage
 The antiphospholipid syndrome is an established and treatable cause for recurrent
miscarriage.
 The mechanism of aPL is related to the effect of these antibodies on embryonic
implantation, trophoblast function and differentiation, and later in pregnancy, on placental
thrombosis.
 Women with aPL have a poor livebirth rate in future untreated pregnancies
 combination treatment with aspirin and heparin significantly improves the live birth rate in
these women.
Infertility
 Most studies have reported an increased prevalence of aPL among women with infertility
undergoing IVF.
 One meta-analysis concluded that the presence of aPL did not reduce IVF success as
estimated by the clinical pregnancy rate or livebirth rate
 Hence, routine testing for aPL in women with infertility is uninformative.
2) Thyroid antibodies
 It has been suggested that thyroid antibodies may serve as a peripheral marker for
abnormal T-cell function and thus be responsible for implantation failure after IVF in
women with infertility and in women with recurrent miscarriage.
 current evidence suggests that routine screening for thyroid antibodies is of no practical
benefit in the investigation of reproductive failure.
Recurrent miscarriage
 Pregnancy outcome is not affected by the presence of thyroid antibodies in euthyroid
women with a history of recurrent miscarriage.10
Infertility
 Prevalence of thyroid antibodies is similar in women with unexplained infertility or women
undergoing IVF compared with fertile controls.
 Thyroid antibodies do not affect pregnancy outcome in women undergoing IVF.11
3) Ovarian antibodies
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 heterogenous group of autoantibodies directed against various ovarian structures.
 Ovarian antibodies are associated with premature ovarian failure and unexplained
infertility but not recurrent miscarriage.
 Autoimmune gonaditis and hypogonadism occurs as a component part of autoimmune
polyglandular syndrome which characterised by the presence of autoantibodies reactive
with all steroid hormone-secreting cells.
 it is unclear whether ovarian antibodies are a cause of infertility.
 repeated IVF may induce ovarian antibodies by trauma during oocyte retrieval, in which
case they may be the consequence, rather than cause of infertility.
Antinuclear antibodies
 ANA form a group of antibodies that react with various components of the cell nucleus.
The ANA is also reported in a proportion of the normal population.
 specific subsets of ANA test are used to help to pinpoint the specific immune disease
including anti-dsDNA, anti-Sm, anti-Ro (SS-A), anti-La (SS-B) and anti-RNP.
 The role of ANA in reproduction is unclear.
Recurrent miscarriage
 ANA varies from similar to increased among women with recurrent miscarriage
compared with normal parous women
 ANA has no effect on pregnancy outcome.
Infertility
 ANA varies from similar to increased in women with infertility and IVF failure.
 However, there are no data to suggest that they influence future reproductive outcome.
4) Antisperm antibodies
 ASA may be detected in the serum of both sexes, in local secretions (seminal, cervical or
vaginal fluids) and attached to the surface of spermatozoa.
 Data on the role of ASA in reproduction are conflicting.
 Studies examining the role of ASA in women with recurrent miscarriage have reported no
association.
 excluding assisted conception treatment, the presence of ASA in either partner is a poor
predictor of conception.
 male partners with more than 50% of the sperm surface coated with ASA have reduced
fertility.
 the use of condoms and IUI does not improve pregnancy rates and the role of systemic
steroids remains controversial.
 ASA do not appear to influence reproductive outcome following IVF.25
5) Cytokines and Th1/Th2 response
 CD4 T-helper (Th) lymphocytes differentiate into two subsets with different functions and
pattern of cytokine release
 the balance between Th1 and Th2 cytokine responses is important in pregnancy;
successful pregnancy resulting when there is systemic shift to a Th2 cytokine, whereas
unsuccessful pregnancies are associated with a predominantly Th1
 recurrent implantation failure after IVF has been reported to be associated with a
predominantly Th1 response.
 These data suggest that increased Th1 cytokine may be the immune aetiology for some
cases of reproductive failure.
6) Natural killer cells
 Increased peripheral blood NK cell cytotoxic activity has been reported in women with a
history of both recurrent miscarriage and failed IVF cycles.
 Similarly, increased numbers of uterine NK cell subsets have been reported in
nonconception cycles of women with a history of recurrent miscarriage.

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 there is no evidence of a correlation between peripheral blood and uterine NK cell
populations
 This lack of data needs to be appreciated by both clinicians and women before they
embark upon extensive peripheral blood tests and endometrial biopsy analyses.
7) Shared parental human leucocyte antigens
 It was suggested that couples who are histocompatible are more likely to miscarry
because they mount an inappropriate immune response also suggested that a fetus that
is HLA-incompatible with mother has a survival advantage over an HLA-compatible
fetus.
Recurrent miscarriage
 Evidence for the role of parental HLA sharing in recurrent miscarriage is controversial.
Infertility
 The role of parental HLA sharing in couples with unexplained infertility is conflicting
Treatment
1) Lymphocyte immune therapy
 LIT was used to improve maternal immunotolerance towards her fetus, who carries
dissimilar paternal antigens.
 The US Food and Drug Administration agency advise that such treatment should only be
performed as part of a clinical research project.
2) Intravenous immune globulin
 Passive immunisation with intravenous immune globulin has been advocated for the
treatment of women with recurrent miscarriage and recurrent IVF failure.
 The therapeutic effect include downregulation of peripheral blood NK cell activity,
counteracting NK cell activity at implantation site, and downregulation of autoantibody
production.
Recurrent miscarriage
 A meta-analysis concluded that IVIG had no benefit among women with unexplained
recurrent miscarriage.
Infertility
 A randomised controlled trial has shown that IVIG had no benefit in unexplained
recurrent IVF failure.
3) Steroids
Recurrent miscarriage
 steroid therapy in women with recurrent miscarriage associated with aPL did not improve
the livebirth rate when compared with aspirin or aspirin plus heparin, but is associated
with significant maternal and fetal morbidity.
Infertility
 the routine use of steroids was of no benefit to women undergoing IVF treatment.
 A small uncontrolled study reported that prednisolone plus aspirin may be of benefit to
those who are ANA positive.
4) Aspirin
Recurrent miscarriage
 Some cases of recurrent miscarriage are associated with hereditary or acquired
thrombophilias and the use of low-dose aspirin improve pregnancy outcome.
 the empirical use aspirin is of no benefit in unselected women with recurrent miscarriage.
Infertility
 The role of aspirin in women with infertility is controversial, some studies shows
Improved implantation and pregnancy rates in women undergoing IVF with asperin and
others doesn't show.
5) Heparin

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 The therapeutic benefits of heparin are based on its ability to bind to aPL thereby
improving trophoblast invasion and differentiation, resulting in successful implantation
and in later pregnancy reduces the risk of placental thrombosis and infarction.
Recurrent miscarriage
 combination treatment with aspirin and heparin significantly improves the live birth rate of
women with antiphospholipid syndrome.
Infertility
 aspirin and heparin therapy was of no benefit in aPL positive women undergoing IVF.
6) Anti-tumour necrosis factor
 The presumed rationale behind anti-timour necrosis factor (TNF) therapy is to counteract
the Th1 cytokine response.
 there are no published data on the use of anti- TNF drugs in women undergoing IVF or
among those with a history of recurrent miscarriage.

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PERINATAL RISKS ASSOCIATED WITH IVF
Introduction
 Infertility affects 1/7 couples in the UK at some stage in their reproductive life.
 Births following IVF account for over 1% of all births in the UK.
Multiple conceptions and multiple births
 number of fetuses and chorionicity are the most important predictors of outcome for
multiple gestations.
Genetic risks
 abnormalities can result from transmission of genetic factors from parents or from the
technique.
 Chromosome anomalies
1. 13.7% of azoospermic males and 4.6% of oligozoospermic males have an
abnormal karyotype.In the first group, sex chromosome abnormalities predominate
(mainly 47,XXY), whereas in the latter group autosome anomalies (such as
Robertsonian and reciprocal translocations) predominate.
2. Cystic fibrosis transmembrane regulator (CFTR) gene defect with congenital
absence of vas deferens
 CF carrier should be checked in the male with azoospermia or severe oligospermia
but not with vasectomyor frozen sperm post-chemotherapy when a couple is
undergoing ICSI.
 Microdeletions and ICSI
 Microdeletions of the long arm of the Y chromosome are associated with
spermatogenic failure and have been used to define three azoospermia factor
regions (AZFa, AZFb and AZFc)
 10–15% of men with azoospermia and 5–10% with severe oligozoospermia have Yq
microdeletions.
 ICSI with testicular sperm retrieval can be used in these circumstances, but there is
potential for transmission of genetic causes of male infertility.
 Cystic fibrosis and ICSI
 CF is one of the most common autosomal recessive diseases with Over 800 CFTR
mutations
 the three base pair deletion, _F508, accounts for 75% of carriers of CF.
 99% of adult males with CF have CBAVD.
 CBAVD is also found in 1–2% of men without CF who are infertile.
 A multiple mutations assay will detect approximately 90% of carriers of the CFTR
mutation.
 Imprinting
 Genomic imprinting is phenomenon by which the expression of a gene is determined
by its parental origin and only one allele of the imprinted gene is expressed.
 Imprinted genes cause rare genetic defects including: Beckwith-Wiedemann
syndrome, Angelman syndrome, Prader-Willi syndrome and Albright hereditary
osteodystrophy.
 up to a six-fold increase in the risk of Beckwith-Wiedemann syndrome with IVF
Maternal morbidity
 requiring IVF to conceive are increased with advancing maternal age.
 Advanced maternal age is associated with:
 Higher rate of CS, preeclampsia, PIH and GDM.
 Unfavorable perinatal outcomes: preterm delivery, low birth weight and admission to
NICU.

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 pregnancies resulting from donor oocytes are at increased risk of maternal and perinatal
morbidity
Low birth weight
 Low birth weight (< 2500 g)and very low birth weight (< 1500 g).
 Risk of low birth weight for IVF singletons is 1.7-1.8 higher than the naturally conceived
singletons.
 The risk of being a very low birth weight singleton is 2.7-3.0 times higher.
 Much of increased risk may be attributed to the increased risk of prematurity associated
with IVF
 Risk of low birth weight is influenced by the original number of fetal hearts detected on
early scan.
 The risk for singletons is 12.6% with a single early fetal heart and 50% with 4 fetal
hearts.
 The risk for twins with two fetal hearts present in early pregnancy is 53% compared
with 90% with > 6 fetal hearts present originally.
Preterm birth
 There is two-fold increased risk for IVF singletons compared with naturally conceived
singletons
 The risk for very preterm birth (less than 32 weeks) is over three-fold
 Gestational age is influenced by the original number of fetal hearts and the No. of
gestational sacs.
 IVF Twins are not at increased risk of preterm or very preterm delivery compared with
spontaneous one .
Small for gestational age
 There is a 40–60% excess risk of SGA in IVF singletons compared with spontaneous
singletons
 The evidence for twins is less clear, ranging from no increase in the risk of SGA for IVF
twins to a nearly 30% increase
Perinatal mortality
 There is 70% increase in risk of perinatal death for IVF singletons compared with
spontaneous one.
 The results for twins are similarly inconsistent. If adjusted for confounders, there is a
decrease in the risk of perinatal death in IVF twins of between 16% and 42%.
 There is > 3fold increased risk of perinatal death in singletons conceived spontaneously
following a prolonged time compared with singletons spontaneously conceived without
prolonged time to conception.
Congenital anomalies
 There is 30% increased risk of congenital anomalies with IVF compared with
spontaneous conception.
 The excess risk is not only due to the increased risk of congenital anomalies associated
with multiple birth
Specific IVF and related procedures
 Preimplantation genetic diagnosis
 The purpose is to provide information that allows unaffected embryos to be selected
for transfer.
 Current opinion is that there is no increased risk of adverse perinatal outcomes
following the procedure.
 Blastocyst culture
 The extended culture of embryos in vitro from the traditional day 2 transfer date to
day 5 (blastocyst stage) was thought to improve embryo selection and pregnancy
rates.

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  However, there is increase in monozygous twinning rate following blastocyst transfer,
with the associated poorer perinatal outcomes.
 A recent Cochrane review concluded that embryo transfer on day 2 or 3 and day 5 or
6 appears to be equally effective in terms of pregnancy rate and live birth rate/cycle
started.
 Assisted hatching
 Assisted hatching has been developed as a method to disrupt the zona pellucida,
which has been suggested as facilitating and enhancing implantation and pregnancy
rates, especially in older women.
 Studies suggested no increase in the rate of major congenital malformations,
although monoamniotic multiple gestation may be increased in zona-manipulated
cycles.
 The current UK recommendation is that assisted hatching is not performed, as it has
not been shown to improve pregnancy rates.
Conclusions
 It is as yet unclear what are all the factors that place IVF pregnancies at an increased
risk of perinatal mortality and other adverse perinatal outcomes.
 Factors may be related to aspects of the treatment or the underlying features that the
couple brings to the pregnancy or a mixture of both.
 In the meantime, we must ensure that, while IVF is now an established routine medical
procedure, prospective recipients do not equate routine with being completely safe and
the outcomes being completely risk-free for the infants.

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OVARIAN HYPERSTIMULATION SYNDROME
Background
 OHSS is a systemic disease resulting from vasoactive agents released by
hyperstimulated ovaries.
 The pathophysiology of OHSS is characterised by:
 Increased capillary permeability.
 Tendency to develop thrombosis, renal and liver dysfunction and acute ARDS,
 the true incidence of mortality from OHSS is unknown, generally it is rare.
Incidence of OHSS
 33%of IVF cycles are complicated by mild OHSS.
 3–8% of IVF cycles are complicated by moderate or severe OHSS.
 OHSS can occur after any form of ovarian stimulation, including clomifene and
gonadotrophin.
Diagnosis of OHSS
 the diagnosis of OHSS is based on clinical criteria.
1. History of ovarian stimulation, followed by abdominal distension and pain, nausea and
vomiting.
2. Differential diagnoses include: ovarian cyst accident, PID, EP and other acute
abdomen.
Table 1. Relevant history from a woman suspected to be suffering from OHSS
History
 Time of onset of symptoms relative to trigger
 Medication used for trigger (hCG or GnRH agonist)
 Number of follicles on final monitoring scan
 Number of eggs collected
 Were embryos replaced and how many?
 Polycystic ovary syndrome diagnosis?
Symptoms
 Abdominal bloating
 Abdominal discomfort/pain, need for analgesia
 Nausea and vomiting
 Breathlessness, inability to lie flat or talk in full sentences
 Reduced urine output
 Leg swelling
 Vulval swelling
 Associated comorbidities such as thrombosis

Table 2. Examination and investigation of women with suspected OHSS

Examination
 General: assess for dehydration, oedema (pedal, vulval and sacral); record heart
rate, respiratory rate, blood pressure, body weight
 Abdominal: assess for ascites, palpable mass, peritonism; measure girth
 Respiratory: assess for pleural effusion, pneumonia, pulmonary oedema
Investigations

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  Full blood count
 Haematocrit (haemoconcentration)
 C-reactive protein (severity)
 Urea and electrolytes (hyponatraemia and hyperkalaemia)
 Serum osmolality (hypo-osmolality)
 Liver function tests (elevated enzymes and reduced albumin)
 Coagulation profile (elevated fibrinogen and reduced antithrombin)
 hCG (to determine outcome of treatment cycle) if appropriate
 Ultrasound scan: ovarian size, pelvic and abdominal free fluid. Consider ovarian
Doppler if torsion suspected
Other tests that may be indicated
 Arterial blood gases
 D-dimers
 Electrocardiogram (ECG)/echocardiogram
 Chest X-ray
 Computerised tomography pulmonary angiogram (CTPA) or ventilation/perfusion
(V/Q) scan

Assessing severity and reporting adverse outcome

 The severity of OHSS should be graded according to a standardised classification
scheme.
 Remember that severity could worsen over time
 Early OHSS – presenting within 9 days after the ovulatory dose of hCG; reflects
excessive ovarian response and the precipitating effect of exogenous hCG administered
for final follicular maturation
 Late OHSS – presenting 9 days after ovulatory dose of hCG; reflects endogenous hCG
stimulation from an early pregnancy; more likely to be severe and to last longer than
early OHSS
 Any death related to OHSS must be reported to the Confidential Enquiries into Maternal
Deaths, irrespective of whether the woman was pregnant. All units should follow HFEA
guidelines for reporting severe untoward incidents
Table 3. Proposed RCOG classification of severity of OHSS
Category Features
Mild OHSS Abdominal bloating
Mild abdominal pain
Ovarian size usually < 8 cma
Moderate OHSS Moderate abdominal pain
Nausea ± vomiting
Ultrasound evidence of ascites
Ovarian size usually 8–12 cma
Severe OHSS Clinical ascites (± hydrothorax)
Oliguria (< 300 ml/day or < 30 ml/hour)
Haematocrit > 0.45
Hyponatraemia (sodium < 135 mmol/l)
Hypo-osmolality (osmolality < 282 mOsm/kg)
Hyperkalaemia (potassium > 5 mmol/l)
Hypoproteinaemia (serum albumin < 35 g/l)
Ovarian size usually > 12 cma

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 Critical OHSS Tense ascites/large hydrothorax
Haematocrit > 0.55
White cell count > 25 000/ml
Oliguria/anuria
Thromboembolism
Acute respiratory distress syndrome

 An Ovarian size may not correlate with severity of OHSS in cases of assisted reproduction
because of the effect of follicular aspiration. Women demonstrating any feature of severe or
critical OHSS should be classified in that category.
Women at risk of OHSS
 Assisted conception units should provide women with written information about OHSS
including:
1. Risks
2. Symptoms of OHSS,
3. What action to take
4. 24-hour contact number with prompt access to a clinician
 Risk of developing OHSS include those with:
1. PCO
2. women under 30 years of age,
3. use of GnRH agonists,
4. development of multiple follicles during treatment,
5. exposure to LH/hCG,
6. previous episodes of OHSS.
7. in cycles where conception occurs, particularly multiple pregnancies.
8. increased antral follicle count (AFC) or high levels of anti-Müllerian hormone (AMH)
are at an increased risk of OHSS.
Outpatient management
What management is appropriate in the outpatient setting for patients with OHSS?
 women with mild OHSS and many with moderate OHSS can be managed on an
outpatient basis and in selected cases with severe OHSS.
1. Analgesia using paracetamol or codeine is appropriate.
2. NSAIDs should not be used because they may compromise renal function in patients
with OHSS.
3. Women should be encouraged to drink to thirst, rather than to excess;
 Fluid intake of at least 1 litre a day should be advised.
 Outpatient management may be aided if patients are able to maintain fluid input
output charts.
 Urine output of less than 1000 ml per 24 hours or a positive fluid balance of greater
than 1000 ml over 24 hours should prompt medical review to assess severity.
4. Strenuous exercise and intercourse should be avoided for fear of accidents of
hyperstimulated ovaries.
5. Continue progesterone luteal support but hCG luteal support is inappropriate.
6. Women with severe OHSS being managed on an outpatient basis should receive
thromboprophylaxis with LMWH. The duration of treatment should be individualised,
taking into account risk factors and whether or not conception occurs.
7. Paracentesis of ascitic fluid may be carried out on an outpatient basis by the
abdominal or transvaginal route under ultrasound guidance.
8. There is insufficient evidence to support the use of GnRH antagonists or dopamine
agonists in treating established OHSS.
How should women with OHSS managed on an outpatient basis be monitored?
 Urgent review is necessary if:
 increasing abdominal distension and pain
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  shortness of breath
 tachycardia or hypotension
 reduced urine output (less than 1000 ml/24 hours) or positive fluid balance
(more than1000 ml/24 hours)
 weight gain and increased abdominal girth
 increasing haematocrit (greater than 0.45).
 Investigations to assess severity of OHSS: 1\Hb,2\haematocrit,3\serum creatinine and
electrolytes and 4\LFT.
 In the absence of these, review every 2–3 days is likely to be adequate.

Inpatient Management
When should women with OHSS be admitted?
1) Hospital admission should be considered for women who:
 are unable to achieve satisfactory pain control
 are unable to maintain adequate fluid intake due to nausea
 show signs of worsening OHSS despite outpatient intervention
 are unable to attend for regular outpatient follow-up
 Have critical OHSS.
2) Care of women with OHSS
 Multidisciplinary assistance for all women with critical or severe OHSS who have
persistent hemoconcentration and dehydration (anesthesia and medical colleagues)
 features of critical OHSS (ARDS, renal failure and thromboembolism) should prompt
consideration of the need for intensive care
 Doctor experienced in managing OHSS should remain in overall charge to provide
information concerning OHSS to other personnel, who may not have experience in
managing this condition
1) Relief of symptoms of OHSS
 management is essentially supportive until condition resolves spontaneously
 Pain relief is best provided with paracetamol and if necessary oral or parenteral
opiates
 NSAIDs are not recommended – they may compromise renal function in patients with
OHSS
 antiemetic drugs used should be appropriate for the possibility of early pregnancy (
prochlorperazine, metoclopramide and cyclizine)
 measures to reduce abdominal distention to relieve nausea
 counseling support for woman and her partner to allay anxiety
1) Monitoring of women with OHSS
 daily fluid intake and output monitoring (Note: urine output <1000 ml/day or persistent
(+) fluid balance is cause for concern)
 hemoconcentration: measure Hb and Hct; increase in WBC count may indicate
ongoing systemic stress response
 hyponatremia (observed in 56% cases of severe OHSS) may be dilutional as a result
of ADH hypersecretion; reduced renal perfusion 2ndry to hypovolemia or tense
ascites
 abnormal LFTs can be found in 25-40% of severe OHSS cases and usually normalize
with resolution of the disease
2) Management of fluid balance
 Allow women to drink according to their thirst – the most physiological approach to
replacing volume, avoiding the risk of hypervolemia and worsening ascites
 Antiemetics and analgesics to enable to tolerate oral fuid intake satisfactorily

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  IV crystalloids such as Normal saline if oral intake not tolerated; 2-3 liters in 24 hours
guided by strict fluid balance chart
 Women with severe OHSS with persistent oliguria and hemoconcentration despite
initial colloid volume expansion may need invasive monitoring (CVP monitoring) and
should be discussed with anesthetist
 Women with Hb > 14g/dl, Hct > 45% need intensive initial rehydration : 1 liter
physiological saline over 1 hour
 If persistent hemoconcentration and/or urine output < 0.5 ml/kg/hour will benefit from
colloids like Human albumin, 6% Hydroxyethylstarch (HES), dextran, mannitol and
Hemaccel
 Persistent hemoconcentration and oliguria despite fluids consider paracentesis
 Diuretics should not be used in oliguria 2ndry to reduced blood volume and decreased
renal perfusion – may worsen intravascular dehydration
 If oliguria persists despite adequate rehydration, rarely there may be a role for
judicious use of diuretics with senior multidisciplinary involvement and usually after
paracentesis
3) Management of Ascites and effusion
Indications for paracentesis include the following:
 Severe abdominal distension and abdominal pain secondary to ascites
 shortness of breath and respiratory compromise secondary to ascites and
increased intra-abdominal pressure
 oliguria despite adequate volume replacement, secondary to increased
abdominal pressure causingreduced renal perfusion.
 paracentesis to relieve intraabdominal pressure may promote renal perfusion and
improve urine output
 intraabdominal pressure > 20mmHg suggests need for decompression
 the rate of ascitic fluid drainage should be controlled, IV colloid should be
administered and BP and pulse should be monitored
 Paracentesis should be performed under US guidance to avoid inadvertent puncture
of vascular ovaries distended by large luteal cysts. Transabdominal aspiration is
better tolerated than vaginal approach
 Repeated paracentesis may be avoided by the use of pigtail or suprapubic catheter
left in place
 Drainage of ascites alone may suffice to resolve hydrothorax, but symptomatic
hydrothorax that persists despite paracentesis may be drained directly
4) Management of Thrombosis
How should the risk of thrombosis be managed?
 Routine screening for thrombophilia in all women undergoing assisted conception is
not warranted, although testing may be helpful for those with a personal or family
history of thrombosis
 Women with severe or critical OHSS and those admitted with OHSS should receive
LMWH prophylaxis.
 The duration of LMWH prophylaxis should be individualised according to patient risk
factors and outcome of treatment.
 Women with moderate OHSS should be evaluated for predisposing risk factors for
thrombosis and prescribed either antiembolism stockings or LMWH if indicated.
 In addition to the usual symptoms and signs of venous thromboembolism (VTE),
thromboembolism should be suspected in women with OHSS who present with
unusual neurological symptoms, even if they present several weeks after apparent
improvement in OHSS. Unusual neurological symptomatology following ovarian
stimulation → possibility of thrombotic episode in uncommon location, prompt referral
for expert opinion
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 
Incidence of thrombosis wit OHSS is 0.7%-10%; with preponderance for upper body
sites and frequent involvement of the arterial system
 Mechanism of thrombosis : hemoconcentration, altered coagulation system and
reduced venous return 2ndry to enlarged ovaries, ascites and immobility
 Risk of thrombosis appears to persist into the 1st TM of pregnancy and consideration
should be given to risks and benefits of heparin prophylaxis until the end of 1 st TM or
longer depending in other risk factors and the course of OHSS
 If thromboembolism is suspected → therapeutic anticoagulation should be
commenced + diagnostic measures (ABGs and V/Q scan)
5) Surgical Management
When is surgical management indicated?
 Pelvic surgery should be restricted to cases with adnexal torsion or co-incident
problems requiring surgery and only undertaken by an experienced surgeon following
careful assessment
 OHSS with pregnancy is risk factor for ovarian torsion
 Suspect torsion in presence of further ovarian enlargement, worsening particularly
unilateral pain, nausea, leucocytosis and anemia
 Color Doppler assessment may help in diagnosis
 Untwisting of the twisted adnexa followed by observation of improved color at
laparoscopy or laparotomy is associated with favorable prognosis for ovarian function
 The presence of ovarian enlargement and ascites should be kept in mind when
considering a diagnosis of ectopic pregnancy.
OHSS and pregnancy
 Women should be reassured that pregnancy may continue normally despite OHSS, and
there is no evidence of an increased risk of congenital abnormalities.
 High rates pre-eclampsia and premature birth.

Summary of Inpatient management

 Indicated for women with severe OHSS and moderate OHSS who can't achieve control with
oraltreatment.
 Women should be kept under review until resolution.
 Multidisciplinary assistance for all women with critical or severe OHSS with
persistenthaemoconcentration and dehydration.
 Consider intensive care for critical OHSS.
 Pain relief with paracetamol and if necessary oral or parenteral opiates. NSAIDs are
notrecommended.
 Antiemetic drugs appropriate for early pregnancy(prochlorperazine, metoclopramide
andcyclizine).
 Review at least daily and more frequent assessment for critical OHSS.
 Women should be encouraged to drink to thirst, rather than to excess.
 Persistent oliguria and haemoconcentration despite initial colloid volume expansion may
needinvasive monitoring discussed with an anaesthetist.
 Diuretics should be avoided as they deplete intravascular volume.
 Consider paracentesis in distressed women or when oliguria persists despite adequate
volumereplacement.
 Perform paracentesis under scan guidance to avoid puncture of distended vascular ovaries.
 Consider IV colloid replacement for women who have large volumes of ascetic fluid drained.
 Provide thromboprophylaxis for hospitalized women at least until discharge or longer.
 Unusual neurological symptoms raise possibility of a thrombotic episode in an
uncommonlocation.
 Pelvic surgery should be restricted to cases with adnexal torsion or co-incident problems.

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MULTIPLE PREGNANCY
 The incidence of multiple births is rising, due to increasing of assisted reproduction
techniques
Determining gestational age and chorionicity
 Offer ultrasound at 11+0 to13+6 weeks (crown–rump length 45-84 mm)to:
1) Estimate gestational age,
2) Determine chorionicity when multiple pregnancy is detected using:
o the number of placental masses, 3% of MC have two placental masses
(bipartite)
o the lambda or T-sign and/or
o intermembrane thickness.
 For women presenting after 14 weeks 0 days, use all of the above + discordant
fetal sex.
 Do not use three-dimensional ultrasound scans to determine chorionicity.
3) Screen for Down‟s syndrome.
 Use the largest baby to measure gestational age.
 Assign nomenclature to babies (upper and lower, or left and right) and document it
clearly.
 Problems determining chorionicity:
 If transabdominal views are poor ( retroverted uterus or high BMI), use TVS.
 If it is not possible to determine chorionicity when detecting the multiple
pregnancy,seek a second opinion from a senior ultrasonographer.
 If it is still difficult, manage as monochorionic until proved otherwise.

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Specialist care
 Clinical care should be provided by a nominated multidisciplinary team consisting of:
1) a core team:
 specialist obstetricians,
 specialist midwives
 ultrasonographers, all have experience and knowledge of managing twin and
triplet
2) an enhanced team for referrals:
 a perinatal mental health professional
 a women‟s health physiotherapist
 an infant feeding specialist
 a dietitian.
 Do not refer women routinely to the enhanced team
 The core team should offer information and emotional support and advice including:
 Antenatal and postnatal mental health and wellbeing
 Antenatal nutrition
 Risks, symptoms and signs of preterm labour and the potential need for
corticosteroids
 Timing and possible modes of delivery
 Breastfeeding
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  Parenting.
Monitoring for FGR
 Estimate fetal weight discordance using two or more biometric parameters from 20
weeks.
 Scans at intervals of less than 28 days.
 Consider a 25% or greater difference in size between twins as indicator of FGR and offer
referral to a tertiary level fetal medicine centre.
 Do not use:
 abdominal palpation or symphysis–fundal height measurements umbilical artery
 Doppler ultrasound to monitor for FGR or birthweight differences.
Indications for referral to a tertiary level fetal medicine centre
1. monochorionic monoamniotic twin pregnancies
2. monochorionic monoamniotic triplet pregnancies
3. monochorionic diamniotic triplet pregnancies
4. dichorionic diamniotic triplet pregnancies
5. pregnancies complicated by any of the following:
 discordant fetal growth
 fetal anomaly
 discordant fetal death
 feto-fetal transfusion syndrome.
Timing of birth
 Offer women with uncomplicated:
 monochorionic twin elective birth from 36 weeks 0 days, after a course of
corticosteroids
 dichorionic twin pregnancies elective birth from 37 weeks 0 days
 triplet pregnancies elective birth from 35 weeks 0 days, after a course of
corticosteroids.
Nutritional supplements and diet and lifestyle advice
 Give the same advice about lifestyle and nutritional supplements as routine antenatal
care.
 Be aware of the higher incidence of anaemia in women with twin and triplet pregnancies.
 Perform a FBC at 20–24 weeks, and repeat at 28 weeks as in routine antenatal
care.
Maternal complications
Hypertension
 Measure blood pressure and test urine for proteinuria at each appointment.
 75 mg of aspirin daily from 12 weeks until birth if they have one or more of the following
risks:
1. first pregnancy
2. age 40 years or older
3. pregnancy interval of more than 10 years
4. BMI of 35 kg/m2 or more at first visit
5. family history of pre-eclampsia.

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Screening and management of fetal complications
Screening for Down s syndrome

Structural abnormalities (such as cardiac abnormalities)

 Offer screening as in routine antenatal care.
 Consider scheduling scans slightly later and be aware that they will take longer.
Feto-fetal transfusion syndrome for monochorionic pregnancies only
 Do not monitor for feto-fetal transfusion syndrome (FFTS) in the first trimester.
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 Monitor with ultrasound for FFTS from 16 weeks.
 Repeat fortnightly until 24 weeks.
 If signs: intermembrane infolding and amniotic fluid discordance are found, monitor
weekly.
Preterm birth
Predicting the risk of preterm birth
 women with twin pregnancies have a higher risk of spontaneous preterm birth if they
have had a spontaneous preterm birth in a previous singleton pregnancy.
 Do not use the following routinely to predict the risk of preterm birth:
 cervical length with or without fetal fibronectin.
 fetal fibronectin testing alone
 home uterine activity monitoring.
Preventing preterm birth
 Do not use the following routinely to prevent spontaneous preterm birth:
 bed rest at home or in hospital
 intramuscular or vaginal progesterone
 cervical cerclage
 oral tocolytics.
Untargeted corticosteroids
 Do not use single or multiple untargeted (routine) courses of corticosteroids.
Timing of birth

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132
MANAGEMENT OF MONOCHORIONIC TWIN
Introduction
 one-third of twin pregnancies have monochorionic placentas.
 Monochorionic placentationcan also occur in higher-order multiples.
 Monochorionic (MC) and dichorionic (DC) twin pregnancies share increased risks of:
 preterm birth, FGR, pre-eclampsia, increased maternal pregnancy symptoms and
PPH.
 The challenges of monochorionic pregnancies arise from:
 TTTS complicates 10–15% of MC pregnancies
 Management of discordant malformations.
 A very high risk of cord entanglement in monochorionic, monoamniotic
pregnancies.
 TTTS:
 Fetal survival is better with bidirectional artery–artery anastomoses.
 is more common in MCDA than MCMA, due to more protective artery–artery
anastomoses in the latter.
 Rarely (5%), the transfusion may reverse during pregnancy or following laser
surgery to the placenta.
 Unequal placental sharing and peripheral, „velamentous‟ cord insertions are
common.
 In 10% of MC twins ,size discordance occurs in in the absence of TTTS.
 Discordant FGR can be differentiated from TTTS by the absence of polyhydramnios in
one of the amniotic sacs, although the small twin may have oligohydramnios owing to
placental insufficiency.
Diagnosis of twin twin transfusion syndrome
 The diagnosis of TTTS is based on ultrasound criteria:
 The presence of a single placental mass
 Concordant gender
 Oligohydramnios in one sac and polyhydramnios in other sac .
 Discordant bladder appearances – severe TTTS
 Haemodynamic and cardiac compromise – severe TTTS.
What is the outcome of MC compared to DC twin pregnancies?
 MC twin pregnancies have:
 higher fetal loss rates than DC twin pregnancies, mainly due to second trimester
loss
 excess neurodevelopmental morbidity.
Ultrasound scanning
What is the place of nuchal translucency measurement in monochorionic twin
pregnancies?
 Offer Nuchal translucency to women with MC pregnancy who wish to have fetal
aneuploidy screening.
 The place of nuchal translucency measurements in predicting TTTS is unclear.
 DNA testing was used to assess zygosity after delivery.
 TTTS was diagnosed in 23% of MC pregnancies.
Is fetal echocardiography useful in monochorionic twin pregnancy?
 All monochorionic twins should have a detailed scan with extended views of the fetal
heart.
 A fetal echocardiographic assessment should be considered in the assessment of
severe TTTS.
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 11% of fetuses with laser ablation for TTTS, had secondary structural heart disease,
primarily right-sided and pulmonary stenosis.
What is the optimum ultrasound regimen for monochorionic twin pregnancies?
 Fetal scan every 2–3 weeks in uncomplicated MC pregnancies from 16 weeks should
include:
1. abdominal circumference
2. imaging of the fetal brains with or without head circumference
3. amniotic fluid measurement
4. umbilical artery Doppler studies (after 24 weeks)
 Ultrasound examinations between 16 and 24 weeks focus primarily on detection of
TTTS.
 After 24 weeks, when TTTS is uncommon, the main purpose is to detect FGR(
concordant or discordant).
 Umbilical artery Doppler in MC twins may show cyclical absent or reversed end diastolic
flow:
1. In 45% of discordant FGR
2. In 5% uncomplicated
3. In 2% severe TTTS pregnancies.
Grading/staging system for severity of TTTS
 Sudden increases in abdominal size or breathlessness may indicate TTTS.

 amnioreduction or selective laser ablation are assocciated with at least one neonatal
survivor in 91% stage I, 88% stage II, 67% stage III and 50% stage IV.
The optimal treatment(s) of TTTS and their outcomes
 Twin–twin transfusion syndrome should be managed in fetal medicine centres.
 Severe TTTS before 26 weeks should be treated by laser ablation rather than by
amnioreduction or septostomy.
 TTTS can recur later in up to 14% of pregnancies treated by laser ablation.
 Selective termination of pregnancy using bipolar diathermy of one of the umbilical
cords if there is severe hydrops fetalis in the recipient or evidence of cerebral
damage.
 Little information is available about maternal morbidity after laser ablation.
The optimal timing and method of delivery for uncomplicated MC pregnancies
 vaginal birth for MC twins is appropriate unless there are accepted, specific indications
for CS.

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 Delivery should be planned at 36–37 weeks, unless there is an indication to deliver
earlier.
Management for the surviving twin after fetal death of the co-twin in a MC pregnancy
 After discordant death in a MC pregnancy, the risk to the surviving twin of death or
neurological abnormality is of the order of 12% and 18%, respectively.
 These risks are not restricted to MC pregnancies with a prior diagnosis of TTTS.
 the risks are much higher in MC than DC pregnancies.
 Discordant death in a MC pregnancy should be referred and assessed in a regional fetal
medicine centre.
 Damage to the surviving twin caused by acute haemodynamic changes and
shifting part of its circulating volume into the circulation of the dying twin. This may
cause transient or persistent hypotension and low perfusion, leading ischaemic
organ damage, notably to the brain.
 Fetal anaemia in the surviving twin can be measured by the fetal middle cerebral artery
peak systolic velocity.
Specific problems of MC, monoamniotic pregnancies
 60% of MC, monoamniotic twins have cord entanglement and are best delivered at 32
weeks, by caesarean section, after corticosteroids.
Higher order multiple pregnancies
 Triplet pregnancies that include a MC pair have higher fetal loss rates than trichorionic
triplet pregnancies.
 They may be complicated by twin–twin transfusion syndrome.
 Therefore, increased ultrasound surveillance is warranted.
Management for discordant abnormalities in MC pregnancies, including TRAP
sequence
 Refer at an early gestation for assessment and counselling in a regional fetal medicine
centre.
 Selective feticide by intracardiac injection of KCL is not an option in MC because
of the anastomoses.
 Cord coagulation by bipolar diathermy or intrafetal laser ablation can be used in
severe discordant abnormalities, TRAP sequence or severe TTTS with overall,
74% of co-twins survived
 The decision for invasive treatment for TRAP sequence depends on:
1. The relative size of the „acardiac‟ twin to the pump twin.
2. The presence of any cardiovascular impairment in the „pump‟ twin.
How are conjoined twins diagnosed and what are the outcomes?
 Very rare, one in 90 000–100 000 pregnancies worldwide.
 Prenatal diagnosis of conjoined twins is now well-reported in first-trimester, using B-
mode ultrasound, Doppler, colour Doppler and three-dimensional imaging techniques,
 detailed assessment of cardiovascular anatomy important for determining prognosis and
planning management.

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ABORTION
 Unwanted pregnancies occur because women are unable to regulate their fertility by
contraception alone.
 The causes of unwanted pregnancies and the reasons why legal abortion remains a
healthcare need were clearly summarised by Abortion Provision in Britain, the 1967
Abortion Act.
Summary of recommendations
Organisation of services
 Abortion services should have protocol in place for providing information to both women
and healthcare professionals on the choices available and on routes of access to the
service.
 It is helpful if the referring doctor is able to provide the first signature on Certificate A. If a
woman refers herself, or if the referring doctor is not willing to support the abortion, it
must be possible for the woman to be assessed by a second doctor within the abortion
service.
 Any woman considering induced abortion should have access to clinical assessment.
 The earlier in pregnancy an abortion is performed, the lower the risk of complications.
Services should therefore offer arrangements that minimise delay (for example, a
telephone referral system and a formal care pathway with arrangements for access from
a wide range of referral sources, not just general practitioners).
 There should be Service arrangements to minimise delay (a telephone referral system
and a formal care pathway):
 ideally, all women requesting abortion are offered an assessment appointment within
5 days of referral. And as a minimum standard, within 2 weeks of referral.
 ideally, all women can undergo the abortion within 7 days of the decision. And as a
minimum standard, within 2 weeks of the decision.
 as a minimum standard, no woman need wait longer than 3 weeks from her initial
referral to the time of her abortion.
 women should be seen as soon as possible if require termination for urgent medical
reasons.
 The assessment appointment should be within clinic time
 In the absence of contraindications, induced abortion may be managed on a day case
basis.
 An adequate number of staffed inpatient beds must be available for those women who
are unsuitable for day case care(5%).
 women admitted for abortion should be cared separated from other gynae patients.
 Women having second-trimester abortions by medical means must be cared for by
experienced midwife or nurse. Ideally, in a single room.
Information for women
 Verbal advice should be supported by accurate, impartial printed patient information
including:
 The risk of haemorrhage is low 1 in 1000 (0.88 in 1000 at less than 13 weeks; 4.0 in
1000 at more than 20 weeks).
 The risk of uterine perforation is moderate 1–4 in 1000. The risk is lower in early
pregnancy and those performed by experienced clinicians.
 Uterine rupture in mid-trimester medical abortion is very low, under 1 in 1000.
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 Cervical trauma: the risk of damage to the external cervical os is moderate (no greater
than 1 in 100). The risk is lower in early pregnancy and when it is performed by an
experienced clinician.
 Failed abortion and continuing pregnancy:The risk for surgical abortion is around 2.3 in
1000 and for medical abortion between 1 and 14 in 1000
 Post-abortion infection: including pelvic inflammatory disease of varying degrees of
severity, occurs in up to 10% of cases. The risk is reduced when prophylactic antibiotics
are given or infection has been excluded by bacteriological screening.
 Breast cancer: no increased risk.
 Future reproductive outcome: no increased risk for subsequent ectopic pregnancy,
placenta praevia or infertility. a small increased risk of subsequent miscarriage or
preterm delivery.
 Psychological sequelae: psychiatric illness or self-harm are higher among women who
have had an abortion compared with women give birth and to non pregnant women of
similar age.
Pre-abortion management
The abortion decision
 Clinicians should try to identify those who require more support in decision making
 Care pathways for additional support, including access to social services, should be
available.
Blood tests
 measurement of haemoglobin concentration
 determination of ABO and rhesus blood groups and atypical antibodies
 testing for other conditions such as HIV, hepatitis B and C if indicated
 It is not cost effective routinely to crossmatch women undergoing abortion.
Cervical cytology
 Women who missed her recommended cervical smear may be offered one.
Ultrasound scanning
 All services must have access to scanning. However, ultrasound scanning is not
considered to be an essential prerequisite of abortion in all cases.
Prevention of infective complications
 offer testing for lower genital tract organisms with treatment of positive cases.
 offer antibiotic prophylaxis:
 metronidazole 1 g rectally at the time of abortion plus doxycycline 100 mg orally twice
daily for 7 days, on the day of abortion OR
 metronidazole 1 g rectally at the time of abortion plus azithromycin 1 g orally on the
day of abortion.
Abortion procedures
Surgical methods
 Conventional suction termination should be avoided at gestations below 7 weeks
because failure rate is higher than for medical abortion.
 Conventional suction termination is an appropriate method at gestations of 7–15 weeks,
 During suction termination, The procedure should not be completed by sharp curettage,
blunt forceps (if required) only.
 local anaesthesia is safer than general anaesthesia.
 If conscious sedation is used in place of general anaesthesia, it should be undertaken
only by trained practitioners.
 Operating times are shorter with electric aspiration than manual aspiration.
 Cervical preparation is beneficial prior to surgical abortion and should be routine if the
woman less than 18 years or gestation of more than 10 weeks.
 the following regimen appears to be optimal for cervical preparation:
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  misoprostol 400 microgms (2 x 200-microgm tablets) vaginally, 3 hours prior to
surgery.
 gemeprost 1 mg vaginally, 3 hours prior to surgery
 mifepristone 600mg orally 36–48 hours prior to surgery.
Medical methods
 is the most effective method of abortion at gestations of less than 7 weeks. And
appropriate method for 7–9 week gestation band.
 Misoprostol is a cost-effective alternative for all abortion procedures
 the following regimen appears to be optimal for medical abortion up to 9 weeks (63
days):
 mifepristone 200 mg orally, 36–48 hours later misoprostol 800 micro vaginally.
 for 7–9 week gestation if abortion has not occurred after 4 hours, a second dose of
misoprostol 400 micro is administered vaginally or orally
OR
 mifepristone 600 mg orally ,36–48 hours later gemeprost 1 mg vaginally.
 between 9 and 13 weeks of gestation:
 mifepristone 200mg orally ,36–48 hours later misoprostol 800 micro vaginally. A
maximum of 4 further doses of misoprostol 400 micro may be given at 3-hourly
intervals, vaginally or orally
 between 13–24 weeks of gestation:
 mifepristone200 mg ,36–48 hours later misoprostol 800 micro vaginally, then
misoprostol 400 micrograms orally, 3-hourly, to a maximum of four oral doses.
OR
 mifepristone 600 mg orally, 36–48 hours later gemeprost 1 mg vaginally every 3
hours, to a maximum of five pessaries.
 Surgical evacuation of the uterus is not required routinely following mid-trimester medical
abortion Unless abortion is incomplete.
 Some women will require analgesia after surgical abortion or during and after medical
abortion.
 Routine histopathological examination of tissue obtained is unnecessary.
Aftercare
Rhesus prophylaxis
 Anti-D (250 iu before 20 weeks and 500 iu thereafter) into the deltoid muscle, to all
nonsensitised RhD negative within 72 hours following all abortions.
Post-abortion information and followup
 A follow-up appointment within 2 weeks of the abortion.
 On discharge, each woman should be given a letter that includes information about the
procedure, symptoms they may experience and a list of those would make an urgent
medical consultation necessary.
 Referral for further counselling for those who experience long-term post-abortion
distress. Risk factors are:
 lack of a supportive partner
 a psychiatric history
 membership of a cultural group that considers abortion to be wrong.
Contraception following abortion
 Intrauterine contraception can be inserted immediately following a abortion.
 Sterilisation can be safely performed at the time of abortion, but with higher failure rates
B

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THE MANAGEMENT OF EARLY PREGNANCY LOSS
Purpose and scope
 early pregnancy loss, defined as a loss within the first 12 completed weeks of pregnancy.
 Miscarriage occurs in 10–20% of clinical pregnancies.
Appropriate terminology

Service provision
What is the ideal setting for assessment of women with early pregnancy loss?
 All units should provide a dedicated outpatient early pregnancy assessment service
(EPAU).
 There are clinical and economic benefits associated with this type of service.

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 Admission to hospital can be avoided in 40% of women, with a further 20% requiring
shorter hospital stay.
What are the requirements for running an effective EPAU?
 EPAU should be:
1. generally available and easily accessible.
2. Ideally sited in a dedicated area with appropriate staffing.
3. Direct access for GPs and selected patient groups.
 Efficient appointments system,
 Appropriate setting,
 Ultrasound equipment (including transvaginal probes)
 Laboratory facilities for rhesus antibody and selective serum hCG and progesterone
estimation.
 The service should be available on a daily basis during the normal working week,
 Standardised information leaflets, referral and discharge letters should be available.
 Certain groups(women with previous ectopic pregnancy and those with recurrent
miscarriage),are offered future access to the service by direct self-referral via the
appointments system.
Diagnosis and investigation
1) TVS
 EPAUs should have TVS with trained staff.
 Ultrasound has 98% positive predictive value in confirming the diagnosis of complete
miscarriage
 TAS and TVS are complementary.
 EPAUs should develop diagnostic and therapeutic algorithms specially for the
suspected:
1. Ectopic pregnancy,
2. Intrauterine pregnancy of uncertain viability: Intrauterine sac <20mm with no obvious
yolk sac or Fetal echo or fetus <6mm crown–rump length with no obvious fetal heart
activity. Incidence is 10%.
 In order to confirm, a repeat scan at a minimal interval of 1 week is necessary.
3. pregnancy of unknown location:No signs of either intra- or extrauterine pregnancy or
retained products of conception in a woman with a positive pregnancy test. Incidence
is as low as 8–10%.
2) Serial hCG assessment
 Serial serum hCG is particularly useful in the diagnosis of asymptomatic ectopic
pregnancy.
 The majority of women attending an EPAU can be managed using urine-based hCG
tests.
 Modern monoclonal antibody based kits detect hCG at 25 iu/l, 9 days postconception.
 Discriminatory zones for serum hCG should be defined to help exclude possible EP.
 Rarer diagnoses, such as gestational trophoblastic disease or cranial germ cell
tumour,must be considered although, in these cases, serum hCG levels are likely to be
greater than 1000 iu/l.
 Serial hCG assessment revealed ectopic pregnancy is 5.9% of women with a history and
TVS findings suggestive of complete miscarriage.
 Serum hCG need caution in interpretation in cases of twin pregnancy or heterotopic
pregnancy, a suboptimal rise may be misleading.
3) Serum progesterone assay
 TVS, serial serum hCG levels and progesterone may all be required in order to establish
a diagnosis.

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 In the presence of pregnancy of unknown location, a serum progesterone < 20 nmol/l
predicts spontaneous pregnancy resolution with a sensitivity of 93% and specificity of
94%.
 Levels >25nmol/l are „likely‟ and >60 nmol/l are „strongly associated with‟ pregnancies
subsequently shown to be normal.
Should all women with early pregnancy loss receive anti-D immunoglobulin?
 Non-sensitised rhesus negative women should receive anti-D immunoglobulin in the
following situations:
 ectopic pregnancy,
 all miscarriages over 12 weeks of gestation (including threatened) and all
miscarriages where the uterus is evacuated (whether medically or surgically).
 Threatened miscarriage under 12 weeks only when bleeding is heavy or associated
with pain.
 Discharge documentation from the EPAU should clearly state whether or not anti-D was
required/ given.

Treatment
1) Screening for genital tract infection
 Consider Screening for infection, including Chlamydia, in women undergoing surgical
evacuation.
 Consider vaginal swabs to exclude bacterial vaginosis if clinically indicated.
 Women with C. trachomatis, Neisseria gonorrhoea or bacterial vaginosis in the lower
genital tract at the time of induced abortion are at an increased risk of PID.
2) prophylactic antibiotics prior to surgical evacuation

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 There is insufficient evidence to recommend routine antibiotic prophylaxis prior to
surgical evacuation.
 Antibiotic prophylaxis should be given based on individual clinical indications.
3) Evacuation
surgical uterine evacuation
1. When women who prefer that option.
2. When there are Clinical indications including:
 persistent excessive bleeding,
 haemodynamic instability,
 evidence of infected retained tissue.
 suspected gestational trophoblastic disease.
 Surgical evacuation should be performed using suction curettage because it is
associated with:
1. Decreased blood loss
2. Less pain
3. Shorter duration of procedure
 Routine use of a metal curette after suction curettage is not required.
 Use of oxytocin is associated with significant difference in median blood loss.
 Delay surgical intervention for 12 hours Where infection is suspected to allow IV
antibiotic administration.
 Offer surgical evacuation techniques under local anaesthesia or sedation for those
women who prefer that.
 Prostaglandin administration prior to surgical abortion is assocciated with significant
reductions in:
1. dilatation force,
2. haemorrhage
3. uterine/cervical trauma.
Medical evacuation
 Medical methods are effective alternative in 1st trimester miscarriage but doesn't replace
surgical evacuation.
 women should be informed that bleeding may continue for up to 3 weeks after medical
uterine evacuation.
 Efficacy rates vary widely from 13% to 96%,influenced by many factors:
1. the type of miscarriage,
2. sac size
3. and whether follow-up is clinical or involves ultrasound.
4. Total dose, duration of use and route of administration of prostaglandin.
 success rates 70–96% were associated with incomplete miscarriage, high-dose
misoprostol, prostaglandins administered vaginally and clinical follow-up without
routine ultrasound.
 The absence of a gestational sac in TVS 12 hrs. after medical evacuation for missed
miscarriage is the main criterion to predict successful outcome 86% and no further
treatment is needed.
 Incomplete miscarriage is usually managed with prostaglandin alone.
 No difference in efficacy between surgical and medical evacuation for incomplete
miscarriage and early fetal demise at gestations < 71 days or sac diameter < 24mm.
 Medical evacuation is associated with reduced clinical pelvic infection.
 Medical methods may be undertaken successfully on an outpatient basis, depending
on the clinical situation and patient choice
Misoprostol doses according to GA;
 Upto 12wks =600mg/dose QTS
 13-17wks=400mg/dose QTS

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  18-26wks=200mg/dose QTS
 >26wks=25-50ug/dose QTS
 Misoprostol is contraindicated in women with a known allergy.
Mifepristone;
 200mg orally 36-48hrs prior to misoprostol.
 contraindicated in the following conditions:
• porphyrias
• smokers >35 years of age
• known allergy to mifepristone
• anaemia
• women on long-term glucocorticoid therapy
• women with known major haemoglobinopathies
• women on anticoagulant therapy
• adrenal insufficiency
• suspected ectopic pregnancy
 The relative contraindications include hypertension and severe asthma.
Expectant management as another effective method for selected cases.
 Counseling is particularly important for those women with intact sac who wish expectant
approach
 They should be aware that complete resolution may take several weeks and efficacy is
lower.
 Expectant management for incomplete miscarriage is highly effective.
 Similar factors like medical evacuation affect the success rates.
 low serum progesterone can be used to predict pregnancies which most likely to resolve
spontaneously.
 published data suggest a reduction in pelvic infection and no adverse affects on future
fertility.
 Future work aims to predict which miscarriage most likely to resolve spontaneously using
of novel serum markers including: insulin growth factor-binding protein 1 (IGFBP-1),
inhibin A and inhibin pro a-C R1.
 Medical and expectant management should only be offered in units where women can
access 24-hour telephone advice and emergency admission if required.
 Tissue obtained at the time of miscarriage should be examined histologically to confirm
pregnancy and to exclude ectopic pregnancy or unsuspected gestational trophoblastic
disease.
Psychological aspects of early pregnancy loss
Is there potential benefit from support and follow-up after pregnancy loss?
 All professionals should be aware of the psychological sequelae associated with
pregnancy loss and hould provide support, follow-up and access to formal counselling
when necessary.
 Plans for follow-up should be clearly recorded in the discharge letter from the EPAU or
ward.
 In terms of therapeutic intervention, patient choice should be encouraged, as it is
associated with positive quality-of-life outcomes.

 The aim of this advice is to ensure that all women are given consistent and adequate
information for consent; it is intended to be used together with dedicated patient
information.
 After discharge women should have clear direction to obtaining help if there are
unforeseen problems.
CONSENT FORM
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1. Name of proposed procedure or course of treatment
 Surgical evacuation of the uterus for early pregnancy loss.
2. The proposed procedure
 Describe the nature of the procedure: removal of early pregnancy tissue from the uterus.
 Note: if other procedures are anticipated, such as diagnostic laparoscopy to exclude EP
if there is no pregnancy tissue in uterus, then these must be discussed and a separate
consent obtained.
3. Intended benefits
 The aim of procedure is to treat an incomplete or missed miscarriage, or retained
placental tissue,
4. Serious and frequently occurring risks2,4 7
 Risks for serious or frequent complications increased for women with obesity, significant
pathology, previous surgery or pre-existing medical conditions
Serious risks
1. Uterine perforation, 5/ 1000 women (uncommon)
 Mostly anteriorly
Suction canula 51.3%
Higer dilator 24.4%
Currate 16.2%
2. Significant trauma to the cervix (rare)
3. There is no evidence in the literature of any impact on future fertility.
Frequent risks
1. Bleeding that lasts for up to 2 weeks is very common but blood transfusion is
uncommon 1–2/1000 women
2. Need for repeat surgical evacuation, 5/ 100 women (common)
3. Localized pelvic infection, 3/100 women (common).
5. Any extra procedures which may become necessary during the procedure
1. Laparoscopy or laparotomy to diagnose and/or repair organ injury or uterine
perforation.
6. What the procedure is likely to involve, alternative treatments, including no
treatment
 The cervix may need to be dilated to allow emptying of the uterine contents.
 If tissue is sent for histology, the reasons (to exclude ectopic or molar pregnancy) should
be explained.
The alternatives are:
1. Medical management (with mifepristone, prostaglandins)
2. Expectant management, particularly for women without an intact sac.
 Non-surgical methods are associated with :
1. longer, heavier bleeding and a 15–50% needing surgical evacuation for clinical need
or woman‟s preference.
2. lower risk of infection compared with surgery.
7. Statement of patient: procedures which should not be carried without discussion
 Other procedures, which may be appropriate but not essential at the time, should be
discussed and the woman‟s wishes recorded.
8. Preoperative Information
 A record should be made of any sources of information given to the woman prior to
surgery.
9. Anaesthesia; General or local anaesthesia can be used. woman must be aware and
discuss this in detail with anaesthetist

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GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Background and introduction
 GTD forms a group of disorders :
1. Complete and partial molar pregnancies
2. The malignant conditions of:
 Invasive mole,
 Choriocarcinoma
 The very rare placental site trophoblastic tumour (PSTT).
 Gestational trophoblastic neoplasia (GTN) is a persistence of GTD, most commonly
defined as a persistent elevation of beta hCG.
 Incidence of GTD is 1/714 live births
 There is ethnic variation with women from Asia having a higher incidence compared
with non-Asian.
 GTN may develop after molar pregnancy, a non-molar pregnancy or a live birth. The
incidence after a live birth is 1/50 000.
 Complete moles are
 Diploid and androgenic in origin.
 No fetal tissue.
 75–80% due to duplication of a single sperm following fertilization of an „empty‟
ovum.
 20–25% due to dispermic fertilisation of an „empty‟ ovum.
 Partial moles are
 90% triploid in origin, with two sets of paternal haploid genes and one set of
maternal haploid genes.
 In almost all cases, following dispermic fertilisation of an ovum.
 10% represent tetraploid or mosaic conceptions.
 There is evidence of a fetus or fetal red blood cells.
How do molar pregnancies present to the clinician?
 The classic features of molar pregnancy are:
1. irregular vaginal bleeding,
2. hyperemesis,
3. excessive uterine enlargement .
4. early failed pregnancy.
5. Rarer presentations include:
 Hyperthyroidism
 Early onset pre-eclampsia.
 Abdominal distension due to theca lutein cysts.
6. Very rare presentation with:
 Acute respiratory failure
 neurological symptoms such as seizures due to metastatic disease
 Clinicians should check a urine pregnancy test in women presenting with such
symptoms.
How are molar pregnancies diagnosed?
 Scan examination is helpful but definitive diagnosis is made by histological
examination products.
 The accuracy of pre-evacuation diagnosis is 35–40 % before 14 weeks and 60% after
14 weeks.
 The ultrasound diagnosis of a partial molar pregnancy is more complex; the following
may help :
1. The finding of multiple soft markers, including cystic spaces in the placenta.
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 2. ratio of transverse to anterioposterior dimension of the gestation sac of greater
than 1.5.
 hCG levels greater than two multiples of the median may help in diagnosing molar
pregnancies:.
Evacuation of a molar pregnancy
 Suction curettage is the method of choice of evacuation for complete and partial mole.
 when fetal parts in partial mole detects use of suction curettage, medical evacuation
can be used.
 Perform urinary pregnancy test 3 weeks after medical management of failed
pregnancy if products not sent for histological examination..
 Medical evacuation of complete molar pregnancies should be avoided if possible.
because of the potential to embolise and disseminate trophoblastic tissue through the
venous system.
 Because of poor vascularization of the chorionic villi and absence of the anti-D
antigen in complete moles, anti-D prophylaxis is not required. It is however, required
for partial moles.
 Preparation of the cervix immediately prior to evacuation is safe.
 Prolonged cervical preparation, particularly with prostaglandins, should be avoided
where possible to reduce the risk of embolisation of trophoblastic cells.
 The use of oxytocic infusion prior to completion of the evacuation is not
recommended.
 If the woman is experiencing significant haemorrhage prior to evacuation, surgical
evacuation should be expedited and the need for oxytocin infusion weighed up
against the risk of tumour embolisation.
Histological examination of the products of conception in the diagnosis of GTD
 Histological assessment of evacuation products of all failed pregnancies is
recommended to exclude GTN.
 There is no routine histological examination following therapeutic termination of
pregnancy, provided that fetal parts have been identified on prior scan examination.
Management of persisting symptoms after an evacuation for molar pregnancy
 Consultation with the trophoblastic screening centre is recommended prior to second
evacuation.
1. evaluation of the patient with hCG estimation and ultrasound examination is
advised.
2. 2nd evacuation in selected cases when the hCG is less than 5000 units/litre.
Which women should be investigated for persistent GTN after a non-molar pregnancy?
1. Any woman who develops persistent or irregular vaginal bleeding after a pregnancy
event.
 A urine pregnancy test should be performed in these cases.
2. Symptoms indicate metastatic disease, such as dyspnoea or abnormal neurology,
can occur very rarely.
 The prognosis of GTN after non-molar pregnancies may be worse, due to delay in
diagnosis or advanced disease at presentation.
How is twin pregnancy of a fetus and coexistent molar pregnancy managed?
 When there is doubt about the possibility of a combined molar pregnancy with a viable
fetus, advice should be sought from the fetal medicine unit and the trophoblastic
screening centre.
 In the situation of a twin pregnancy where there is one viable fetus and the other
pregnancy is molar, the woman should be counselled about:
1. Outcome of 25% chance of achieving a live birth
2. Increased risk of perinatal morbidity: early fetal loss (40%) and premature delivery
(36%).
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  Consider prenatal invasive testing for fetal karyotype:
1. if it is unclear if pregnancy is a complete mole with a coexisting normal twin or a
partial mole.
2. in cases of abnormal placenta, such as suspected mesenchymal hyperplasia of the
placenta.
Which women should be registered at GTD screening centres?
 Registration of women with GTD represents a minimum standard of care.
 Women with following diagnoses should be registered and follow-up by GTD
screening centre:
1. complete hydatidiform mole
2. partial hydatidiform mole
3. twin pregnancy with complete or partial hydatidiform mole
4. limited macroscopic or microscopic molar change suggesting partial or early
complete mole
5. choriocarcinoma
6. placental-site trophoblastic tumour
7. atypical placental site nodules: consist of nuclear atypia of trophoblast, areas of
necrosis, calcification and increased proliferation.
 After registration, follow-up consists of serial hCG levels, either in blood or urine
specimens.
What is the optimum follow-up following a diagnosis of GTD?
 If hCG has reverted to normal within 56 days of the pregnancy then follow up will be
for 6 months from the date of uterine evacuation.
 If hCG has not reverted to normal within 56 days of the pregnancy then follow-up will
be for 6 months from normalisation of the hCG level.
 All women should notify the screening centre at the end of any future pregnancy,
whatever the outcome and hCG levels are measured 6-8 weeks after the end of the
pregnancy to exclude disease recurrence.
What is the optimum treatment for GTN?
 Women with GTN may be treated either with single-agent or multi-agent
chemotherapy.
 The need for chemotherapy following a complete mole is 15% and 0.5 % after a
partial mole and 1/50000 after birth.
 Women are assessed before chemotherapy using the FIGO 2000 scoring system.
 Women with scores ≤6 are at low risk and are treated with single-agent IM
methotrexate alternating daily with folinic acid for 1 week followed by 6 rest days.
 Women with scores ≥7 are at high risk and are treated with IV multi-agent
chemotherapy, which includes combinations of methotrexate, dactinomycin,
etoposide, cyclophosphamide and vincristine.
 Treatment is continued, in all cases, until the hCG level has returned to normal for
6 consecutive weeks.
 Cure rate for women with a score ≤6 is almost 100%; rate for women with a score
≥7 is 95%.
 Placental site trophoblastic tumour is treated with surgery because it is less
sensitive to chemotherapy.
When can women whose last pregnancy was a complete or partial hydatidiform molar
pregnancy try to conceive in the future and what is the outcome of pregnancies?
 Women should be advised not to conceive until their follow-up is complete.
 Women undergo chemotherapy are advised not to conceive for 1 year after
completion of treatment.
 The risk of a further molar pregnancy is low 1/80.
If a further molar pregnancy occur, in 68–80% of cases it will be of the same
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  histological type.
 women who conceived within 12 months of completing chemotherapy, there was
an increased risk of miscarriage and higher rate of termination in women who
received multi-agent chemotherapy.
 The rate of congenital abnormality was low 1.8% irrespective of the type of
chemotherapy.
 The rate of stillbirth was elevated compared with the normal population
What is the long-term outcome of women treated for GTN?
 Women who receive chemotherapy for GTN are likely to have an earlier menopause.
 in single-agent chemotherapy is advanced by 1 year and by 3 years in multi-agent
chemotherapy.
 Women with high-risk GTN who require multi-agent chemotherapy may be at
increased risk of developing secondary cancers(leukaemia, melanoma, breast
cancer).
 If combination chemotherapy is limited to less than 6 months there appears to be
no increased risk.
What is safe contraception following a diagnosis of GTD?
 Advise Women with GTD to use barrier methods of contraception until hCG levels
revert to normal.
 Once hCG level have normalised, the combined oral contraceptive pill may be used.
 There is no evidence as to whether single-agent progestogens have any effect on
GTN.
 If oral contraception has been started before the diagnosis of GT, the woman can be
advised to remain on oral contraception but there is a potential but low increased risk
of developing GTN.
 IUDs should not be used until hCG levels are normal to reduce the risk of uterine
perforation.
Is HRT safe for women to use after GTD?
 HRT may be used safely once hCG levels have returned to normal.
 There is no evidence that the use of HRT affects the outcome of GTN.

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RECURRENT 1ST TRIMESTER AND 2ND TRIMESTER MISCARRIAGE
Background and introduction
 advances in neonatal care have resulted in a small number of babies surviving birth
before 24 weeks.
 Recurrent miscarriage,defined as the loss of three or more consecutive pregnancies,
 affects 1% of couples trying to conceive.
 1–2% of second-trimester pregnancies miscarry before 24 weeks.
Risk factors for recurrent miscarriage
1) Epidemiological factors
1. Maternal age and number of previous miscarriages are two independent risk factors.
 Advancing maternal age is associated with a decline in both the number and quality
of the oocytes.
 Advanced paternal age has also been identified as a risk factor for miscarriage.
 The risk of miscarriage is higher among couples where woman is 35 yrs. of age and
man 40 yrs. of age.
 The risk of a further miscarriage approximately 40% after three consecutive
pregnancy losses.
 A previous live birth does not preclude a woman developing recurrent miscarriage.
2. Maternal smoking and caffeine have increased risk of spontaneous miscarriage in
dose-dependent manner.
3. Heavy alcohol consumption is toxic to the embryo and the fetus with increased risk of
sporadic miscarriage.
4. The evidence on the effect of anaesthetic gases for theatre workers is conflicting.
5. obesity increases the risk of both sporadic and recurrent miscarriage.
2) Antiphospholipid syndrome
 Antiphospholipid antibodies are present in 15% of women with recurrent miscarriage.
 the prevalence of antiphospholipid antibodies in women with a low-risk obstetric history
is less than 2%.
 Antiphospholipid syndrome is the most important treatable cause of recurrent
miscarriage.
 Antiphospholipid syndrome refers to the association between:
1. antiphospholipid antibodies: lupus anticoagulant, anticardiolipin and anti-B2
glycoprotein-I antibodies
2. adverse pregnancy outcome or vascular thrombosis.
 three or more consecutive miscarriages before 10 weeks
 one or more morphologically normal fetal losses after the 10th week of gestation
 one or more preterm births before the 34th week of gestation owing to placental
disease.
 The mechanisms by which antiphospholipid antibodies cause pregnancy morbidity
include:
 Inhibition of trophoblastic function and differentiation,
 Activation of complement pathways at the maternal–fetal interface resulting in a local
inflammation
 in later pregnancy, thrombosis of the uteroplacental vasculature.
 Live birth rate in recurrent miscarriage associated with antiphospholipid antibodies
without intervention< 10%.
3) Genetic factors
1. Parental chromosomal rearrangements

149
 2–5% of couples with recurrent miscarriage, one of the partners carries a balanced
structural chromosomal anomaly: most commonly a balanced reciprocal or Robertsonian
translocation.
 Risk of miscarriage is influenced by the size and genetic content of the rearranged
chromosomal segments.
2. Embryonic chromosomal abnormalities
 In recurrent miscarriage, chromosomal abnormalities of embryo account for 30–57% of
further miscarriages.
 Risk of miscarriage resulting from chromosomal abnormalities of the embryo increases
with maternal age.
 As the number of miscarriages increases, the risk of euploid pregnancy loss increases.
4) Anatomical factors
1. Congenital uterine malformations
 The prevalence of uterine anomalies in recurrent miscarriage between 1.8% and 37.6%.
 The prevalence of uterine malformations is higher in 2nd trimester miscarriages
compared 1st trimester, this may be related to the cervical weakness that is frequently
associated with uterine malformation.
 Arcuate uteri more associated with 2nd trimester while septate uteri are more associated
with 1st trimester.
2. Cervical weakness
 a recognised cause of second-trimester miscarriage, but the true incidence is unknown.
 There is no satisfactory objective test to identify women with cervical weakness in the
non-pregnant state.
 Diagnosis is usually by history of 2nd trimester miscarriage preceded by SROM or
painless cervical dilatation.
5) Endocrine factors
 Endocrine disorders such as diabetes mellitus and thyroid disease have been associated
with miscarriage.
 Women with diabetes and high haemoglobin A1c levels in 1st trimester are at risk of
miscarriage.
 Well-controlled diabetes and treated thyroid dysfunction are not a risk factor for recurrent
miscarriage.
 The presence of thyroid antibodies in euthyroid women with a history of recurrent
miscarriage does not affect future pregnancy outcome.
 PCOS has been linked to an increased risk of miscarriage but the exact mechanism
remains unclear.
 The mechanism recently attributed to insulin resistance, hyperinsulinaemia and
hyperandrogenaemia.
6) Immune factors
 There is insufficient evidence to support the hypothesis of HLA incompatibility between
couples, the absence of maternal leucocytotoxic antibodies or the absence of maternal
blocking antibodies.
 Natural killer NK cells are found in peripheral blood and the uterine mucosa.
 There is no clear evidence that altered peripheral blood NK cells are related to
recurrent miscarriage..
 Raised uNK numbers in women with recurrent miscarriage is associated with
increased risk of miscarriage.
 A meta-analysis concluded the modest associations between cytokine polymorphisms
and recurrent miscarriage.
7) Infective agents
 Any severe infection that leads to bacteraemia or viraemia can cause sporadic
miscarriage.
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 The role of infection in recurrent miscarriage is unclear.
 For an infective agent to be a cause of repeated pregnancy loss, it must be persisting in
the genital tract, avoiding detection or must cause insufficient symptoms. TORCH do not
fulfill these criteria and routine TORCH screening should be abandoned.
 Bacterial vaginosis in the 1st trimester of pregnancy is a risk factor for 2nd trimester
miscarriage and preterm delivery, but the evidence for an association with 1st trimester
miscarriage is inconsistent.
 There is insufficient data to assess role of antibiotic in women with a previous 2nd
trimester miscarriage.
8) Inherited thrombophilic defects
 Inherited thrombophilias is a possible cause of recurrent miscarriage and late pregnancy
complications.
 fetal loss varies according to type of thrombophilia.
 Association between thrombophilia and late pregnancy loss is stronger than with
early pregnancy loss.
Recommended investigations of recurrent 1st and 2nd trimester miscarriage
 Women with recurrent 1st and 2nd trimester miscarriage should be looked after by
expertise health professional Where available, within a recurrent miscarriage clinic.
1) Antiphospholipid antibodies
 Women with adverse pregnancy outcome should be screened for antiphospholipid
antibodies.
 2 positive tests at least 12 weeks apart for either lupus anticoagulant or
anticardiolipin antibodies of IgG or IgM in a medium or high titre considered as
positive test.
2) Karyotyping
 Perform Cytogenetic analysis on products of conception of the third and subsequent
miscarriage(s).
 Perform Parental peripheral blood karyotyping of both partners in couples with recurrent
miscarriage when testing of products of conception reports an unbalanced structural
chromosomal abnormality.
 sporadic fetal chromosome abnormality is the most common cause of any single
miscarriage,
 the risk of miscarriage as a result of fetal aneuploidy decreases with an increasing
number of losses.
 If the karyotype of miscarried pregnancy is abnormal, there is a better prognosis for
next pregnancy.
 couples with balanced translocations have a low risk 0.8% of pregnancies with an
unbalanced karyotype surviving into the second trimester and that their chance of
having a healthy child is 83%.
3) Anatomical factors
 Women with adverse pregnancy outcome should have pelvic scan to assess uterine
anatomy
 Advise for hysteroscopy, laparoscopy or 3dimensional pelvic ultrasound if Suspected
uterine anomalies.
4) Thrombophilias
 Women with 2nd trimester miscarriage should be screened for inherited thrombophilias.

Treatment options for recurrent miscarriage

 Women with recurrent miscarriage should be offered referral to a specialist recurrent
miscarriage clinic.
1) Antiphospholipid syndrome
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 Consider low-dose aspirin plus heparin to prevent further miscarriage by 54%.
 Pregnancies associated with antiphospholipid antibodies treated with aspirin and
heparin remain at high risk of complications including repeated miscarriage, pre-
eclampsia, FGR and preterm birth.
 Corticosteroids and immunoglobulin therapy doesn‟t improve the live birth rate for
antiphospholipid syndrome
2) Genetic factors
 The finding of an abnormal parental karyotype should prompt referral to a clinical
geneticist.
 Genetic counselling offers the couple a prognosis for the risk of future pregnancies
and familial chromosome studies.
 Preimplantation genetic screening with IVF in women with unexplained recurrent
miscarriage does not improve live birth rates.
3) Anatomical factors
1. Congenital uterine malformations
 There is insufficient evidence to assess the effect of uterine septum resection to prevent
further miscarriage.
2. Cervical weakness and cervical cerclage
 History-indicated cerclage may be offered.
 History of one second-trimester miscarriage attributable to cervical factors, an
ultrasound-indicated cerclage should be offered if a cervical length of 25mmor less is
detected by TVS before 24 weeks.
4) Endocrine factors
 There is insufficient evidence to evaluate the effect of progesterone to prevent
miscarriage.
 There is insufficient evidence to evaluate the effect of hCG to prevent miscarriage.
 Suppression of high LH in recurrent miscarriage and PCO does not improve the live birth
rate.
 There is insufficient evidence to evaluate the effect of metformin to prevent a
miscarriage.
5) Immunotherapy
 Paternal cell immunisation, third-party donor leucocytes, trophoblast membranes and
intravenous immunoglobulin in women with previous unexplained recurrent miscarriage
does not improve live birth rate.
6) Inherited thrombophilias
 There is insufficient evidence to evaluate the effect of heparin to prevent miscarriage in
women with recurrent first-trimestermiscarriage associated with inherited thrombophilia.
 Heparin therapy during pregnancy may improve the live birth rate of women with second-
trimester miscarriage associated with inherited thrombophilias.
7) Unexplained recurrent miscarriage
 Women with unexplained recurrent miscarriage have an excellent prognosis(in the
region of 75%) for future pregnancy outcome without pharmacological intervention if
offered supportive care alone.

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CERVICAL CERCLAGE
 Prematurity is the leading cause of perinatal death and disability
 Preterm birth accounted for 7.6% of all live births in England and Wales.
 Mortality increases from about 2% for infants born at 32 weeks to > 90% at 23 weeks.
 cerclage :
1. provide structural support to a „weak‟ cervix,
2. maintain cervical length and the endocervical mucus plug as a mechanical barrier
to ascending infection.

History-indicated cerclage:
 performed as a prophylactic in asymptomatic women
 inserted electively at 12–14 weeks of gestation.
 Indication: >2 previous preterm births and/or second-trimester losses.
 The followings are not helpful in the decision for a history-indicated cerclage:
 painless dilatation of the cervix
 rupture of the membranes before the onset of contractions
 cervical surgery
 prepregnancy diagnostic tests: cervical resistance index, hysterography or insertion
of cervical dilators.

Ultrasound-indicated cerclage:
 Indication :previous one or more spontaneous mid-trimester loss or preterm birth and
cervix is 25 mm or less before 24 weeks of gestation.
 An ultrasound-indicated cerclage is not recommended for funneling of the cervix in the
absence of cervical shortening to 25 mm or less.
 cerclage is not indicated in women who have an incidentally identified cervix of 25 mm or
less withno history of spontaneous mid-trimester loss or preterm birth.
Who should be offered serial scan surveillance ultrasound-indicated cerclage?
 Offer serial sonographic surveillance to women with one or more second-trimester loss
or preterm delivery :
 those who experience cervical shortening are at an increased risk of subsequent
second-trimester loss/preterm birth and may benefit from ultrasound-indicated cerclage.
 those whose cervix remains long have a low risk of second-trimester loss/premature
delivery.
 Because the majority of women with a history of second-trimester loss/preterm delivery
will deliver after 33 weeks of gestation, no evidence to support serial sonographic
surveillance over expectant management.
cervical cerclage in other groups considered at increased risk of preterm delivery
 History- or ultrasound-indicated cerclage is not Recommended in:
 multiple pregnancies.
 high-risk groups müllerian anomalies, previous cervical surgery or multiple dilatation
and evacuation.
 A concomitant cerclage at radical trachelectomy should be individualized, there are
successful outcomes.
Transabdominal cerclage:
 Indication: previous failed transvaginal cerclage.
 Associated with increased maternal morbidity.
 Can be performed before or in early pregnancy.

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 There is no evidence to support a laparoscopic approach over laparotomy abdominal
cerclage.
 Management of a delayed miscarriage or fetal death with an abdominal cerclage
 Senior involvement.
 Suction curettage or by dilatation and evacuation through the stitch by up to 18
weeks of gestation.
 alternatively, cut the suture usually via a posterior colpotomy.
 Failing this, a hysterotomy may or caesarean section may be required.
Rescue cerclage:
 Even with rescue cerclage the risks of sevre preterm delivery and neonatal mortality and
morbidity remain high.
 Delay delivery by 5 weeks on average compared with expectant management(bed rest)
alone.
 Associated with a two-fold reduction in the chance of delivery before 34 weeks of
gestation.
 Conditions associated with high failure:
 Advanced dilatation of the cervix (more than 4 cm)
 membrane prolapse beyond the external os.
Contraindications to cerclage insertion
 active preterm labour
 clinical chorioamnionitis
 continuing vaginal bleeding
 PPROM
 Fetal compromise
 Lethal fetal defect
 Fetal death.
What information should be given to women before cerclage insertion?
 Cerclage insertion is associated with:
 doubling in risk of maternal pyrexia increase in chorioamnionitis.
 small risk of intraoperative bladder damage, cervical trauma, membrane rupture and
bleeding
 Increased risk of an additional anaesthetic for Shirodkar cerclage removal.
 Increased risk of cervical trauma if there is spontaneous labour with the suture in
place.
 Cerclage insertion is not associated with:
 Increased risk of PPROM, induction of labour or caesarean section.
 Increased risk of preterm delivery or second trimester loss.

Pre operative management:

 Investigations :
 ultrasound scan for viability and major fetal abnormality before history-indicated
cerclage.
 Anomaly scan before ultrasound-indicated or rescue cerclage.
 The followings are not recommended:
o white cell count and C-reactive protein to detect subclinical chorioamnionitis before
rescue cerclage.
o routine amniocentesis before rescue or ultrasound indicated cerclage.
o genital tract screening for infection before cerclage insertion.
 Amniocentesis in selected cases if there is suspicion of intra-amniotic infection.
 in positive culture from a genital swab, antimicrobial before cerclage insertion is
recommended.

154
 There is an absence of data to either refute or support the amnioreduction before rescue
cerclage.
 There is absence of data to support immediate versus delayed cerclage in rescue or
ultrasound-indicated cerclage to see if infection manifests clinically or not.
Operative issues:
 There is no evidence to support the use of routine perioperative tocolysis.
 antibiotic prophylaxis should be at the discretion of the operating team.
 There are no studies comparing general with regional anaesthesia for insertion of
cervical cerclage.
 Elective transvaginal cerclage can safely be performed as a day-case procedure.
 Women with ultrasound-indicated or rescue cerclage, with higher risk of complications
such as PPROM, early preterm delivery, miscarriage and infection, may benefit from at
least a 24-hour observation in hospital.
 stay of at least 48 hours is recommended In women with laparotomy for transabdominal
cerclage.
 The choice of Shirodkar versus McDonald should be at the discretion of the surgeon.
 No evidence to support the placement of two purse-string sutures over a single suture.
 No evidence to support the placement of a cervical occlusion suture in addition to the
primary cerclage.

Adjuvant management:
Bed rest:
 Bed rest should not be routinely recommended and should dependon the clinical
circumstances.
 Abstinence from sexual intercourse following cerclage insertion should not be routinely
recommended.
 routine serial sonographic measurement of the cervix is not recommended.
 Offer timely administration of steroids or in utero transfer following ultrasound-indicated
cerclage.
 following ultrasound-indicated cerclage, upper cervical length (closed cervix above the
cerclage) of less than 10 mm before 28 weeks is the best prediction of subsequent
preterm delivery before 36 weeks.
 The decision to place a rescue cerclage following an elective or ultrasound-indicated
cerclage should be made on an individual basis.
 Routine fetal fibronectin testing is not recommended post-cerclage.
 Routine use of progesterone supplementation following cerclage is not recommended.
Removal of cerclage
 between 36+1 and 37+0 weeks of gestation, unless delivery is by elective caesarean
section, in which removal can be delayed until this time.
 established preterm labour.
 A Shirodkar suture usually require anaesthesia for removal.
 women with a transabdominal cerclage require delivery by caesarean section, and the
abdominal suture may be left in place following delivery.
Removal following PPROM(24-34 weeks)?
 without evidence of infection or preterm labour, delayed removal of the cerclage for
48 hours can be considered, for a course of prophylactic steroids and/or in utero
transfer.
 Delayed suture removal until labour is associated with an increased risk of
maternal/fetal sepsis and is not recommended.
 the cerclage should be removed immedietly following PPROM before 23 weeks ad
after 34 weeks.

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THE MANAGEMENT OF TUBAL PREGNANCY
Background
 Tubal pregnancy can be managed by laparotomy, operative laparoscopy, medically and
occasionally by observation alone.
Surgical management of tubal pregnancy
1) laparoscopic approach to manage tubal pregnancy, in haemodynamically stable patient,
is preferable.
 There was no difference in overall between laparoscopic and open approach regarding
to:
1. tubal patency rates.
2. The subsequent intrauterine pregnancy rates
 There is a lower repeat ectopic pregnancy rates if a laparoscopic approach is used
 Laparoscopic salpingotomy is associated with higher rates of persistent trophoblast
2) In the presence of haemodynamic instability management should be by the most
expedient method. In most cases this will be laparotomy.
3) In the presence of a healthy contralateral tube, no clear evidence to favour salpingotomy
over salpingectomy.
 intrauterine pregnancy rates is similar in the two groups with higher subsequent EP in
salpingotomy arm
 The cumulative pregnancy rates at one year were 72.4% after conservative and 56.3%
after radical surgery.
4) In the presence of contralateral tubal disease, Laparoscopic salpingotomy should be
considered as the primary treatment if there is desire for future fertility.
 IU pregnancy following laparoscopic salpingotomy compared with laparoscopic
salpingectomy 49% vs. 27%
 Because of postoperative follow-up and the treatment of persistent trophoblast, the
short-term costs of salpingotomy are greater than salpingectomy.
Medical management of tubal pregnancy
 The use of laparoscopy for diagnosis of ectopic pregnancy is often the main reason for
surgical interventions.
 In stable patients a variety of medical treatments are as effective as surgery.
 methotrexate given as a single dose calculated from patient body surface area
(50 mg/m2).
 Serum hCG levels are checked on days four and seven and a further dose is
given if hCG levels have failed to fall by more than 15% between day four and
day seven.
 14% will require more than one dose of methotrexate and less than 10% require
surgical intervention.
 women should be given clear information (preferably written) about the possible need for
further treatment and adverse effects following treatment.
 Women most suitable for methotrexate therapy are those with a serum hCG below 3000
iu/l, minimal symptoms and able to return easily for assessment at any time during
follow-up.
 Outpatient medical therapy with single-dose methotrexate is cost effective.
Expectant management of pregnancy of unknown location
1) Expectant management is an option for clinically stable women with minimal symptoms
and PUL.

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  When serum hCG levels are below the discriminatory zone (<1000 iu) and there
is no pregnancy (intra- or extrauterine) visible on TVS, the pregnancy can be
described as being of unknown location.
 44–69% of pregnancies of unknown location resolve spontaneously with
expectant management.
 23–29% of cases requires intervention.
 EP diagnosed in 14–28% of cases of PUL .
 In pregnancy at risk of ectopic pregnancy should be managed expectantly with
48–72 hours of follow-up and should be considered for active intervention if:
1. symptoms of ectopic pregnancy occur,
2. serum hCG levels rise above the discriminatory level (1000 iu/l) or levels start
to plateau.
 In women managed expectantly, serial serum hCG performed until hCG levels
are less than 20 iu/l.
2) Expectant management is an option for ultrasound diagnosis ectopic pregnancy with the
following criteria
1. The patient clinically stable,
2. Minimal symptoms.
3. Initial serum hCG < 1000 iu/l
4. an adnexal mass of less than 4 cm or less than 5 cm
5. less than 50 ml or 100 ml of free fluid.
6. A fall in initial hCG of greater than 15% in 24 hours
Persistent trophoblast
 When salpingotomy is used, protocols should be in place to identify and treat persistent
trophoblast.
 Risks for developing persistent trophoblast include :
1. Higher preoperative serum hCG levels >3000 iu/l
2. Rapid preoperative rise in serum hCG
3. The presence of active tubal bleeding.
 There is insufficient data to support one method of diagnosing and treating persistent
trophoblast over another
 Methotrexate 50 mg/m2 has been widely used as a single dose instead of a repeat
surgical procedure.
 Prophylactic methotrexate at the time of laparoscopic salpingotomy compared with
simple salpingotomy alone associated with significant reduction in persistent trophoblast
(1.9% versus 14%).
Service provision and training
 Available facilities for the management of suspected ectopic pregnancy should include:
1. diagnostic and therapeutic algorithms
2. transvaginal ultrasound
3. serum hCG estimations.
Anti-D immunoglobulin
 Nonsensitised women who are rhesus negative with a confirmed or suspected ectopic
pregnancy should receive anti-D immunoglobulin. A dose of 250 iu (50 microgrammes)
be given.

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AMNIOCENTESIS AND CHORIONIC VILLUS SAMPLING
Aim
 around 5% of the pregnant women are offered invasive prenatal diagnostic tests.
 The type of diagnostic test vary depending upon the timing of screening test performed.
Background and introduction
 Amniocentesis is the most common invasive prenatal diagnostic test in the UK.
 Amniocentesis should be performed after (15+0) weeks of gestation.
 Amniocentesis performed before (15+0) weeks is referred to as „early amniocentesis‟.
 Chorionic villus sampling (CVS) is usually performed between (11+0 ) and (13+6 )
weeks
Rates of miscarriage
 the additional risk of miscarriage following amniocentesis is around 1%.
 the additional risk of miscarriage following CVS may be slightly higher than of
amniocentesis after 15 weeks.
 Early amniocentesis has a higher fetal loss(7.6% compared with 5.9%) rate and
increased incidence of fetal talipes and respiratory morbidity compared with other
procedures.
 CVS should not be performed before 10 (10+0) completed weeks of gestation (increase
risk of oromandibular limb hypogenesis syndrome and technically difficult, a smaller
uterus and thinner placenta).
Consent prior to performing amniocentesis or CVS
 Written consent should be obtained.
 Written or oral information should include
o the indication of invasive procedure,
o the type of cytogenetic results which will become available,
o processes for any long-term sample storage.
o national and locally estimated risks for pregnancy loss
o accuracy and limitations of the laboratory test(s) being performed.
o method of communication of results
o indications for seeking medical advice following the test
o the need for anti-D.
 A record of the counselling process, should be clearly recorded in the patient notes.
Technique to perform amniocentesis or CVS
 Needle insertion during amniocentesis and transabdominal CVS should be carried out
under ultrasound guidance.
 Transplacental passage of the amniocentesis needle should be avoided unless it
provides the only safe access. It is also important to avoid cord insertion.
 Maximum outer needle gauge size of 0.9 mm (20-gauge) should be used.
 CVS can be performed transabdominal or transcervical, using local anaesthesia for
transabdominal CVS.
Amniocentesis or CVS for multiple pregnancy
 It is recommended to be performed by a specialist who has the expertise to perform a
selective termination of pregnancy if required.
o This is essential to ensure that separate samples are taken for each fetus and
labelled
o separate puncture sites or a single-entry can be used.
o Either way, the miscarriage rate is higher than in singleton pregnancies.
o Two separate needles are used to minimise crosscontamination of chorionic
tissue in CVS in dichorionic pregnancies .
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What information should women be given about third-trimester amniocentesis?
 third-trimester amniocentesis is not associated with significant risk of emergency
delivery.
 complications including multiple attempts and bloodstained fluid are more common in
third-trimester procedures.
What are the risks of transmission of infection?
 The ultrasound probe should be enclosed in a sterile bag.
 Separate sterile gel should be used.
 Viral screening should be considered before Invasive prenatal procedures.
 Where women decline screening, inform and document the potential risk of vertical
transmission of infection to the fetus.
 Review viral load and treatment regimens in women with HIV
o If on treatement consider delaying the procedure until there is no detectable viral
load.
o Consider antiretroviral therapy if not yet on treatment for HIV.
 There is limitations of available data about safety of Invasive prenatal testing in women
who carry hepatitis B or C.

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AMNIOCENTESIS
 All patients should be given adequate information for valid consent.
 clinicians should discuss the following with the patient and to document in the record:
1. Name of procedure
 Amniocentesis.
2. The details of procedure
 The procedure will involve obtaining a sample of amniotic fluid from the pregnancy sac
using a needle inserted through the woman‟s abdomen.
3. Intended benefits
 The procedure intends to provide the woman with information regarding the karyotype of
her fetus(es). Less commonly, it is carried out with the intention of obtaining biochemical,
metabolic or genetic information.
4. Serious or frequently occurring risks
 Women who are obese must be aware that the procedure may be technically difficult and
that this could lead to an increased rate of complications.
4.1 Serious risks include:
 failure to obtain a sample.
 failure of cell culture in the laboratory.
 blood stained samples in approximately 0.8% of procedures.
 miscarriage.A rate of 1% over the norm.
 fetal injury is rare and be minimized by the standard use of continuous ultrasound
guidance.
 maternal bowel injury is rare and is minimised by the use of continuous ultrasound
guidance.
 amniotic fluid leakage – temporary or prolonged and with the added risk of preterm
delivery
 chorioamnionitis. severe sepsis is less than 1/1000 procedures.
4.2 Frequent risks include:
 mild discomfort at needle insertion site.
5. benefits and risks of any available alternative treatments, including no treatment
 The procedure will be carried out or supervised by an operator who is deemed to be
experienced by national standards.
 Rhesus prophylaxis with anti-D immunoglobulin must be offered following the procedure
to all women who are rhesus negative, in line with national recommendations.
6. Information
 record the information given to the woman prior to the procedure, which should include:
o the method of communicating results,
o the reporting time and
o the indications for seeking medical advice after the test.
o storage and eventual disposal of the sample.
7. Anaesthesia
 The woman should be made aware if any form of local anaesthesia is to be used.

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NONINVASIVE PRENATAL DIAGNOSIS USING CFFDNA
Background and Introduction
 Current prenatal diagnosis of fetal genetic status or aneuploidy depends on the use of
invasive diagnostic tests which carry a small but significant risk of miscarriage.
 cell-free fetal DNA (cffDNA) in the maternal circulation can be detected from 4 weeks of
gestation and is rapidly cleared from the maternal circulation after delivery
 the vast majority of cell-free DNA in the circulation is maternal in origin, with the fetal
component contributing around 3% in early pregnancy, rising to 6% towards term.
 Current methodologies do not allow complete separation of fetal from maternal cell-free
DNA and current applications focus on the detection or exclusion of genes not present in
the mother, such as Y chromosome or rhesus D (RHD) in RhD-negative women.
 Following extraction of total cffDNA, highly sensitive PCR method called real-time PCR is
used
Fetal RHD typing
 fetal RHD typing using cffDNA has been used to direct management in RhD-women at
increased risk of haemolytic disease of the newborn (HDN). This has almost completely
replaced amniocentesis or chorionic villus sampling in the UK.
 Determination of other fetal RhC, c, E and Kell blood groups using cffDNA has also been
reported using this methodology.
 If this technique performs well in early pregnancy, then there is the potential to decrease
the use of anti-D in RhD-negative women who are found to be carrying an RhD-negative
baby.
Fetal sex determination
 Fetal sex can be determined using cffDNA and the identification of genes (DYS14 or
SRY) on the Y chromosome.
 It is being used to determine fetal sex in women at risk of X-linked disorders, where early
identification of a male fetus indicates a need for an invasive diagnostic test to determine
whether the affected X chromosome has been inherited.
 It is used in pregnancies at risk of congenital adrenal hyperplasia (CAH) where early
treatment of pregnancies with an affected female fetus has been shown to reduce the
degree of virilisation of the external genitalia.
 Testing before 7 weeks was less accurate,
Single gene disorder diagnosis
 Occasional diagnoses of a single gene disorder have been reported by detecting or
excluding the paternal allele inherited from an affected father with an autosomal
dominant condition, such as Huntingdon‟s disease.
 currently available techniques are unsuitable for the diagnosis of X-linked and most
recessive disorders, as the fetal genes inherited from the mother are swamped by the
excess of the mother‟s own cell-free DNA.
Aneuploidy diagnosis
 NIPD of Down syndrome is not feasible using the methods described above as these are
not sensitive to detect the small increase of fetal chromosome 21 (less than 3%) derived
from a trisomy 21 fetus in the high background of maternal chromosome 21 found in cell-
free DNA
 By extracting cell-free RNA (cfRNA) rather than cell-free DNA from maternal plasma and
testing a single nucleotide polymorphism located in fetal mRNA, the maternal : paternal
chromosome 21 ratio can be determined. A ratio of 1:1 indicates that the fetus has 2
copies of chromosome 21 (normal) and a ratio of 2:1 indicates that the fetus has 3
copies of chromosome 21 (Down synd).

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 ANTENATAL SCREENING FOR DOWN SYNDROME JULY 2003
 The results show that screening performance in the first trimester of pregnancy
wasvirtually the same as that in the second trimester and in either it was much less
effective than integrating screening measurements from both trimesters into a
single test.Applying
 the most effective and safe method of screening:
1) Overall: integrated test
2) If NT is not available: serum integrated test
3) For women who do not attend for antenatal care until the second trimester of
pregnancy: quadruple test
4) For women who choose to have a screening test in the first trimester: combined
test.

 The cost-effectiveness of these four tests is broadly similar.

 The evidence presented in this report indicates that the double test, the triple test or
NT measurements on their own (with or without maternal age) would lead to many
more women having invasive diagnostic tests without increasing the proportion of
Down syndrome pregnancies detected.
 the integrated approach is superior, but it is important to remember that it says
nothing about patient acceptability or the challenges of implementation.

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PERICONCEPTIONAL FOLIC ACID AND FOOD FORTIFICATION IN THE PREVENTION
OF NEURAL TUBE DEFECTS
Background
 Neural tube defects (NTDs), which comprise open spina bifida, anencephaly and
encephalocele, complicate 1.5/1000 pregnancies
 represent the first congenital malformations to be preventable through public health
measures.
 The effect of periconceptional folic acid on reducing the incidence of both
occurrence and recurrence of NTDs by about 75% has been confirmed in
randomised controlled
 Prophylaxis commenced after pregnancy has been diagnosed is unlikely to prevent
these serious handicapping malformations.
 Because only 1/3 women take folic acid supplements preconceptionally, the
reasonable approach to maintain adequate periconceptional folic acid isthrough
food fortification. In the USA all cereal-based products have been fortified since
1998.
Public health measures
 Relationship between maternal red cell (and plasma) folate and NTD risk : occurred
in 6.6/1000 women with values below 150 g/l, falling to 0.8/1000 with booking red
cell folate levels 400 g/l.
 an intervention which raised the periconceptional red cell folate level of all pregnant
women above 400 g/l would be responsible for a reduction of about 50-60% in
NTD risk.
 A randomised study compared five regimes:
 folic acid 400 g/day
 folic acid fortified foods contributing an extra 400 g/day
 foods containing natural folates equivalent to an additional 400 g/day
 dietary advice to improve natural folate intake and
 controls.
and results suggested that only folic acid supplementation or food fortification was likely
to be effective in achieving therapeutically beneficial levels of red cell folate.
Biological plausibility of folic acid prevention of NTD
 677 cytosine thymine (677 C T) mutation of the 5, 10-methylene-
tetrahydrofolate reductase gene (MTHFR) results in 50% decreased activity and
increased thermolability of the enzyme with about a 25% increase in homocysteine
concentrations, even when folate intakes are adequate.
 This mutation is common, and has been implicated in the aetiology of NTDs.
 this enzyme defect, can be overcome by folic acid supplementation leading to
reduced plasma homocysteine levels
 because it is found in only a small minority of affected individuals, so screening for
677C T is only likely to have a marginal effect on NTD reduction.
 The evidence confirmed the likely role of MTHFR, but was unable to find evidence
of similar effects for polymorphisms of methionine synthase or cystathionine
synthase.20
 number of mechanisms for folate-induced reduction in NTDs.

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 1. Hyperhomocysteinaemia, either of dietary or metabolic origin ( MTHFR
homozygosity), act as an N-methyl-D-aspartate receptor (NMDA) blocker in early
embryonic neural ectoderm,
2. folate deficiency could have a direct effect on neural epithelium, which unlike
most embryonic cells, express very high levels of folate receptor
Food fortification benefits, risks and optimal dosage
 benefits:
 After fortification of wheat flour in the USA, red cell folate levels rose from an
average of 181ng/ml to 315ng/ml and 19% decline in the birth prevalence of
NTDs
 Hyperhomocystinaemia has implication in adult cardiovascular disease.
fortification of wheat flour in the USA result in fall in US adults with raised plasma
homocysteine levels from 18.7 mmol/l to 9.8 mmol/l.
 6 Meta-analysis suggests that a 25% reduction in plasma homocysteine levels
result in a 11% lower risk of ischaemic heart disease and a 19% lower risk of
stroke.
 Objections to food fortification can be addressed as follows:
 The universal fortification removes freedom of choice.
 The risk of masking Vitamin B12 deficiency in the elderly, leading to irreversible
neurological damage in the form of sub-acute combined degeneration of the
cord.
 Millions of members of the public would be taking compulsory treatment from
which only a few might benefit.
 there may be a relationship between folic acid intake and twinning
Folic acid supplementation and twinning
 It is thus theoretically possible that hyperhomocysteinaemia associated with the
MTHFR 677C T mutation reduces twin births and that folic acid supplementation
might lead to an increase in twinning.
 The resultant increase in perinatal mortality and morbidity secondary to increased
twinning as a result of widespread folic acid fortification might outweigh benefit from
reduced NTD incidence.
 In conclusion, there is no consistent effect of periconceptional folic acid
supplementation or fortification on twinning in the available studies. The evidence
suggesting twinning is not strong
 Until now, there is no evidence of harm from folic acid fortification, and the evidence
of likely benefit is strong.

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REVIEW CARDIAC DISEASE IN PREGNANCY. PART 1:
CONGENITAL HEART DISEASE
Congenital heart disease
 congenital heart disease is now more common in pregnant women than acquired heart
disease.
 has risen in two decades from 5% to almost 80%.4 This reflects advances in cardiac
surgery and medication.
Physiological changes in normal pregnancy
 fall in systemic vascular resistance to 30–70% of its preconception value by 8 weeks due
to estrogens, vasodilatory peptides or factors such as nitric oxide and calcitonin-gene
related peptide (CGRP)
 fluid retention and an increased blood volume.
 expansion in plasma volume this results in a fall in haematocrit and plasma osmolality.
 cardiac output rises to a peak between 20–24 weeks
 Arterial blood pressure falls until mid pregnancy, gradually returning to prepregnancy
levels late in the second trimester.
 Prolonged volume overload results in progressive physiological left ventricular
hypertrophy.
 Labour, particularly the second stage, is associated with a further increase in cardiac
output.
 Following delivery the return of uterine blood into the systemic circulation results in a
further increase in cardiac output.
 Stroke volume, heart rate and cardiac output remain high for 24 hours post delivery,with
rapid intravascular volume shifts in the first 2 weeks postpartum. Thus, the later stages
of labour and early postpartum period are periods of high risk of pulmonary oedema.
Management principles
 Women with congenital heart disease should have a planned pregnancy managed by a
multidisciplinary team (obstetricians, cardiologists, anaesthetists, neonatologists and
midwives).
 Effective management involves:
1. prepregnancy counselling
2. risk assessment,
3. close fetal and maternal monitoring during pregnancy
4. detailed management plan for labour and delivery
5. close surveillance in the immediate postpartum period.
Prepregnancy counselling
 Allow women to make informed choices.
 The risks to the mother and fetus should be discussed and the likelihood of congenital
heart disease in the fetus outlined.
 Any medical, interventional or surgical treatments that can improve pregnancy outcome
should be considered.

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Antepartum
 a risk assessment of any woman with a heart murmur or a history of any cardiac defect
should be carried out early in pregnancy in a joint clinic
 Women at low risk can be identified and returned to routine care.
 Women at significant risk of adverse events during pregnancy should be seen
regularly whenever possible by the same consultant obstetrician
 at every antenatal clinic the following should be carried out:
 Cardiovascular assessment.
 Blood pressure should be measured manually with a sphygmomanometer
 Measurement of pulse rate and rhythm is also mandatory
 Auscultation to assess any change in murmur or any lung changes associated
with pulmonary oedema
 Women with cyanotic heart disease should have their oxygen saturations checked
periodically
 All women with structural congenital heart disease should be offered a fetal
echocardiogram during the second trimester.
 A further multidisciplinary meeting should take place at 32–34 weeks of gestation to
establish:
1. plan of management for delivery including:
 who involved in supervising the labour,
 whether a caesarean section is appropriate,
 whether bearing down is advisable
 prophylaxis against postpartum haemorrhage
2. postpartum management plan including:
 prophylaxis against thrombosis
 length of postpartum stay in hospital
 timing of cardiac and obstetric review.
 Appropriate advice about contraception should also be given.

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Labour and delivery
 The appropriate timing is by balance maternal and neonatal morbidity and mortality.
 A clear plan for labour and delivery should be established in advance, clearly
documented.
 vaginal delivery with low dose epidural anaesthesia is the mode of choice.
 Indication for CS:
1. Aortopathy with aortic root_4cm
2. Aortic dissection or aneurysm
3. Warfarin treatment within 2 weeks
4. Obstetric indication
 Labour requires careful monitoring of both mother and fetus.
 Preload and blood pressure should be monitored carefully and blood loss minimised.
 Women should be nursed in the left lateral position.
 Forceps or ventouse delivery can be used to shorten maternal expulsive effort in the
second stage.
 Antibiotic prophylaxis should be given during labour and delivery except those with:
repaired patent ductus arteriosus (PDA), isolated ostium secundum atrial septal defects
and mitral valve prolapse without regurgitation.
 In the third stage, bolus doses of oxytocin should be avoided as they can cause severe
hypotension. Low dose oxytocin infusions are safer.
 Ergometrine should be avoided in most cases as it can cause acute hypertension.
 Uterine compression sutures can be helpful in the management of uterine atony at CS.
 The safety of misoprostol is yet to be determined.
 Careful haemodynamic monitoring postpartum is typically required for 24–72 hours
extended to 10–14 days in women with pulmonary hypertension.
 Multidisciplinary followup should take place 6 weeks after delivery.

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168
Specific lesions and maternal and fetal risk
 Different congenital cardiac lesions carry specific mortality risks:
1. dependent on current haemodynamic status,
2. previous operations
3. anatomical features.
 Pregnancy poses the risk of serious maternal morbidity:
1. Pulmonary oedema
2. cardiac arrhythmia
3. thromboembolism,
4. angina,
5. hypoxaemia
6. infective endocarditis .
Low risk lesions
1) Small left-to-right shunts

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 Due to decrease in peripheral vascular resistance in pregnancyLeft-to-right shunting in
women with ASDs, VSDs, PDA is reduced.
 In the absence of pulmonary hypertension, pregnancy, labour and delivery are well
tolerated.
 Women with ASDs are at risk of atrial arrhythmias and paradoxical emboli so, there is a
low threshold for heparin prophylaxis.
 Acute blood loss or vasodilatation (from regional anaesthesia) can affect the degree and
direction of shunting acutely, reducing left ventricular output.
2) Coarctation of the aorta
 6–8% of patients with congenital heart disease.
 Women with repaired coarctation of the aorta are expected to reach childbearing age.
 regnancy is usually well tolerated in women with adequately repaired coarctation
 assess cardiac status before conception to exclude and appropriately managing
complications:
1. re-coarctation,
2. aneurysm at the site of repair,
3. associated bicuspid aortic valve
4. systemic hypertension.
 Risks during pregnancy include:
1. aortic dissection and rupture
2. resistant hypertension.
3. Poorly controlled hypertension can lead to adverse neonatal outcomes (FGR,
placental abruption and premature delivery) and maternal outcomes
(preeclampsia, hypertensive crisis and rupture of an intracranial aneurysm).
3) Tetralogy of Fallot
 is the most common form of cyanotic congenital heart disease.
 pregnancy in women with repaired ToF is well tolerated
 complications such as arrhythmias and right ventricular failure do occur, particularly in
the presence of:
1. residual shunts,
2. right ventricular outflow obstruction
3. pulmonary hypertension.
 Many women with ToF will have significant pulmonary regurgitation and become
symptomatic during pregnancy, occasionally needing diuretic treatment or admission for
bed rest.
Moderate risk lesions
1) Transposition of the great arteries
 Post repair in which the Rt. ventricle become the systemic one, a number of potential
long term complications: systemic right ventricle failure, tricuspid regurgitation, sinus
node dysfunction, arrhythmias and baffle obstruction (venous pathway obstruction).
 Pregnancy is well tolerated following uncomplicated repair; right ventricular dysfunction
and/or atrial arrhythmia, may still occur.
 In long term complications, pregnancy is poorly tolerated with an increased risk of
cardiac complications.
2) Cyanotic heart disease without pulmonary hypertension
 is caused by uncorrected transposition of the great arteries, truncus arteriosus,
uncorrected ToF with, tricuspid atresia and Ebstein‟s anomaly with ASD.
 During pregnancy the fall in systemic vascular resistance and rise in cardiac output
exacerbates any right-toleft shunting,worsening pre-existing cyanosis and hypoxia.
 Maternal complications include haemorrhage, paradoxical embolism and heart failure.

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 The effects on the fetus are marked: high incidence of miscarriage and a 30–50% risk of
premature delivery and low birthweight.
 The degree of maternal hypoxaemia is the most important predictor of neonatal
outcome.
 Admission for bed rest and oxygen therapy is an effective for mother and fetus.
3) Fontan procedure
 Is the definitive palliative procedure for cyanotic heart defects characterised by a single
functional ventricle.
 Atrial separation divides the systemic and pulmonary circulations and with the
construction of atriopulmonary connections blood enters the pulmonary circulation
without pulsatile ventricle
 The main concern regarding pregnancy is the ability to augment, maintain and adjust
cardiac output and heart rate.
 maternal risks of pregnancy are low in NYHA class I–II women, provided ventricular
function is good.
High risk lesions
1) Marfan syndrome
 is an inherited disorder of connective tissue.
 thoracic aortic aneurysm leading to aortic dissection, rupture or both is increased in
pregnancy.
 With an aortic root < 4 cm, the overall maternal mortality during pregnancy is 1%. This
increases to 25% when > 4 cm,
 In this situation, pregnancy should be postponed until aortic arch replacement
and In unplanned pregnancy the option of termination should be discussed.
 Aortic root diameter should be monitored throughout pregnancy with serial
echocardiograms and if aortic root dilatation occurs, prophylactic beta blockade is
advised and HTN treated aggressively.
 Systolic hypertension is factor in most of the deaths from aortic dissection,
2) Pulmonary vascular disease
 Pregnancy with pulmonary hypertension of any cause remains high risk.
 Pregnancy is poorly tolerated,with a risk of worsening cyanosis and hypoxia,
arrhythmias, heart failure and death.
 The majority of complications occur at term or during the first postpartum week.
 Maternal mortality depends on the underlying cause: 36% in Eisenmenger syndrome,
30% in primary pulmonary hypertension and 56% in secondary pulmonary hypertension.
 In unplanned pregnancy a termination should be offered.
 Those who elect to continue require close cardiovascular monitoring and bed rest from
the third trimester with monitoring for up to 14 days postpartum.
 premature delivery and FGR occurring in 50% and only 15–25% of pregnancies reaching
term.
 Anticoagulation, oxygen therapy and pulmonary vasodilators may improve outcome.
Neonatal outcome
 neonatal complications is significantly increased in women with heart disease:
 preterm birth,
 SGA,
 RDS,
 intraventricular haemorrhage
 death.
 Maternal predictors of adverse neonatal outcome are:
 obstetric risk factors,
 multiple gestation,
 smoking
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  anticoagulation.
 The children are also at increased risk of inheriting a congenital heart disease 3–
5%,compared with a 1% risk in the general population
 3% in common conditions such as ToF and as high as 10% with ASD, coarctation
of the aorta and aortic stenosis.
 Marfan syndrome is an autosomal dominant therefore has a 50% recurrence rate
in offspring.
Contraception in women with heart disease
 By planning ahead you will avoid having to deal with the crisis of an unexpected
pregnancy.
 women with very high risk will need contraception that is very effective. Women at lower
risk may be willing to accept a contraceptive method with a higher failure rate.
 No contraceptive is 100% reliable (even sterilisation).
Natural methods
 These methods are not very reliable and depend very much on how carefully they are
used.
Barrier methods (condoms, diaphragm)
 barrier contraception has few adverse effects but again has a high failure rate even when
used with spermicidal creams. condoms have the additional benefit of protecting against
STDs.
Coils (intrauterine contraceptive devices, IUCDs)
 are much more reliable, with as few as 1/ 100 getting pregnant over five years. The
Mirena coil has the advantage of causing less bleeding and less infection than copper
coils, and can be used more safely nulliparous whose wombs are more at risk of
infection.
 1/ 1000 women have a fainting reaction at the time the coil is inserted. This can be
dangerous for women with severe heart disease. So, it should be inserted in hospital,
with cardiac anaesthetic on standby
 rare complication of all coils is ectopic pregnancy,
 the risk of pregnancy is extremely low with the Mirena coil even lower than after
sterilisation.
 Mirena coils are effective for up to five years.
Oral contraceptive pills
 failure rates of COC < 1/ 300 women per year
 The most important complication is that it can cause thrombosis (3-4fold increased risk).
 Certain heart conditions are associated with an increased risk of clotting and therefore
this form of contraception is not suitable.
 progestogen-only pill (Micronor) does not cause thrombosis. However, it has a higher
failure rate than the combined pill.
 As a result, Micronor is replaced by a new version, Cerazette, containing desogestrel, a
newer progestogen-only pill which stops ovulation. There is also a longer window of time
for the woman to remember to take her pill, so missed pill is less likely to result in
pregnancy.
 1/5women discontinue Cerazette because of irregular bleeding.
Progestogen-only injectable (depot) injections of hormone (Depo-Provera)
 Periods will often disappear, although they may be irregular or heavy for a while when
stop the injections.
 The failure rate is low: 1/ 300 women per year.
Implant of progestogen (or Nexplanon )
 It delivers a continuous dose of the hormone etonogestrel. In 1/5 women, periods stop
completely.

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 Implanon is one of the safest and most effective forms of contraception available.
 The implant is effective for three years.
 Failure rate is < 1/ 1000 per year.
Caution: The drug bosentan, sometimes used for heart disease, can reduce the effectiveness of most
hormonal contraception, including Cerazette and Nexplanon, so additional contraception should be used if
you need to take bosentan.
Sterilisation
 Vasectomy is more reliable and safer.
 sterilisations of tubes can be done by laparoscopy or mini-laparotomy under a
 regional anaesthetic not asleep may be safer for some women with heart problems
 gas of laparoscopy can affect the heart.
 Failure rate of clips 1/ 500
 The tubes can be cut and tied at caesarean section, but the risk of the tubes joining up
again is 1/200.
Essure: A technique that recently available involves putting tiny implants into the fallopian
tubes to
block them via a hysteroscope.
Emergency contraception, including the morning after pill
 Emergency contraception can be used up to five days after unprotected sex, a burst
condom or missed pills.
1) The copper IUCD (coil) is the most effective method of emergency contraception and
will prevent over 99% of pregnancies. It can be used later than five days after sex, if it
is no more than five days since ovulation.
 offer an antibiotic to prevent pelvic infection.
 You can keep using the IUCD for contraception, or it can be easily removed when
next period comes.
2) Oral emergency contraception can be used up to five days after sex.
 The sooner it is taken, the more effective it is likely to be.
 There are two types of pill available.
a. contains progestogen hormone (levonorgestrel) (Levonelle). can be used
up to 72 hours after sex. It may upset warfarin control.
b. ulipristal acetate (ellaOne), which can be used up to five days (120 hours)
after sex. It should not be used by women with severe asthma or liver
disease.
 adverse effects of emergency oral contraceptive pills are mild (nausea, breast
tenderness, disruption to periods).
what to look out for in the symptomatic woman

 Many pregnant women will experience deterioration of one class as pregnancy

progresses, and they should be warned about this.
 They may need to take more rest than usual during pregnancy
 A useful tactic is to call a woman to your consulting room yourself and watch how quickly
she can walk from the waiting area to your consulting room, how short of breath this
makes her, and what her pulse rate and rhythm is when she first sits down
 A rising pulse rate can be one of the first signs of cardiac decompensation. The pulse
rate is best measured using a stethoscope.
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 Heart murmurs are graded from one (extremely soft) to six (the loudest one has ever
heard). It is usual for a murmur to increase by one grade as pregnancy progresses
because of the increase in cardiac output. A sudden increase in the loudness suggest
endocarditis and the appearance of a new murmur is significant.
 The lung bases posteriorly should be auscultated at each visit to check for crackles,
which can indicate pulmonary oedema. Sometimes women develop crackles as a result
of poor lung expansion late in pregnancy, when the diaphragm is splinted by the
enlarging uterus. Asking the woman to take several deep breaths and cough several
times will usually cause such crackles to disappear.
 Any woman complains of feeling suddenly less well, who develops „funny turns‟ , a
sudden increase in shortness of breath or new palpitations should always be assessed
carefully by a cardiologist.
 If the woman complains of chest pain, it is useful to take blood immediately for
measurement of troponin I levels and repeat the test 24 hours later
 A myocardial perfusion scan or coronary angiography can be considered if symptoms
continue or worsen despite treatment.
 Doppler examination of the leg vessels should be performed to identify any deep vein
thrombosis.
 Management of a woman who develops new symptoms is dependent on the nature of
the underlying lesion and the results of urgent investigations of cardiac function.
The typical patient journey
1. All women with heart disease should be assessed at the time of puberty by clinicians
with expertise in the management of pregnancy complicated by heart disease.
2. They should be given an estimate of their risks which should be reassessed every
five years
3. they should be advised to see the appropriate high-risk pregnancy team as soon as a
pregnancy is confirmed
4. At the initial assessment by the high-risk multidisciplinary team, a full clinical
examination should be carried out and all recent investigations reviewed.
5. Usually, an echocardiogram will be ordered to assess cardiac function. An ECG
should be taken and kept in the notes for future reference
6. The special antenatal notes should be started.
7. The woman should be asked to carry her notes with her at all times, in case of any
emergencies.
8. offer the woman a fetal nuchal translucency scan, as this is a significant indicator of
recurrent cardiac disease in the fetus.
9. standard fetal anomaly scan at approximately 20 weeks, and a fetal cardiac scan at
approximately 22 weeks, should be organised.
10. the woman should be seen by an experienced consultant obstetrician every two to
four weeks until 20 weeks, then every two weeks until 24 weeks, and then weekly
thereafter.
11. If the woman had threatens labour before 34 weeks, immediate assessment by the
multidisciplinary team is important for management.
12. In pregnancies progressing satisfactorily, a multidisciplinary team assessment at 32–
34 weeks is important to plan care around the time of delivery
13. The woman should be given clear instructions about how to recognise the onset of
labour. Once labour begins, she should ring the labour ward to alert them that she is
coming.
14. On arrival at the labour ward, the woman should make herself known immediately to
the labour ward staff.
15. They should inspect the delivery plan and take action accordingly.
16. The majority of women with significant lesions will have epidural anaesthesia during
labour, and a significant number will have an assisted vaginal delivery.
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17. Following delivery, the woman should be transferred to a high-dependency area
where she can be monitored closely for anything between 12 and 48 hours.
18. She should not be transferred to a normal labour ward until she has been reviewed
by senior staff
19. Plans for discharge from the maternity unit should have been made antenatally.
20. Before discharge, a check should be made that the woman has appropriate
appointments for obstetric and cardiac follow-up and that she is aware of her
contraceptive options.
21. At the postnatal check-up:
 the woman should be assessed for her recovery from giving birth.
 The woman‟s contraceptive plans should be reviewed in detail.
 Her cardiac function should be checked by a cardiologist,
 arrangements made for cardiological follow-up.

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REVIEW CARDIAC DISEASE IN PREGNANCY. PART 2:
ACQUIRED HEART DISEASE
Introduction
 The incidence of heart disease during pregnancy in the United Kingdom remained
constant 0.9%.However, the severity and the risk of it during pregnancy is increasing.
 Heart disease is one of the leading causes of maternal mortality and is now the most
common cause of indirect maternal death in the UK
 Pregnancy poses a risk of maternal mortality and serious morbidity ( heart failure, stroke
and cardiac arrhythmia).
 neonatal morbidity and mortality from FGR and prematurity markedly increased.
 CEMACH shown increase in mortality from cardiac disease mainly due to acquired heart
disease,
 1/3 are a result of myocardial infarction/ischaemic heart disease, 1/3 of late deaths are
associated with peripartum cardiomyopathy, 5–10% each for rheumatic heart disease,
congenital heart disease and pulmonary hypertension.
Causes of acquired heart disease
 With increasing immigration from countries with rheumatic fever, valvular heart disease
become a significant problem in UK
 valvular heart disease is often first recognised during pregnancy, due to increased
demands.
 Ischaemic heart disease is increasing in pregnancy due to increasing incidence of
diabetes, obesity and smoking, and increasing maternal age at first pregnancy.
 cardiomyopathy occurs predominantly around the time of delivery in women with multiple
pregnancy and/or preeclampsia.
 Cardiac arrhythmias are also an important cause of maternal morbidity.
Valvular heart disease
 Regurgitant abnormalities are better tolerated in pregnancy than stenosis.
Mitral stenosis
 Rheumatic mitral stenosis is the most common in pregnancy.
 The rise in cardiac output increases the pressure gradient across the narrowed mitral
valve. This leads to an increase in left atrial pressure and the development or worsening
of symptoms, pulmonary oedema and atrial fibrillation which can lead to heart failure.
 The risk of deterioration persists into the puerperium.
 Mortality among pregnant women:
 with minimal symptoms is less than 1%, with a neonatal mortality rate of 12–31%.
 Women with severe symptoms (NYHA class III or IV) or severe stenosis (valve area <1
cm) should delay conception until after surgical correction.
 medical therapy is directed to :
1. reduce volume overload through bed rest and diuretics
2. optimising ventricular filling with beta blockade.
3. Atrial fibrillation requires prompt treatment with DC cardioversion, beta-blockers
or digoxin.
4. Balloon mitral valvuloplasty is indicated with refractory symptoms to medical
therapy and is safe and effective during pregnancy.
Mitral valve prolapse
 Affecting 12–17% of women of childbearing age.

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 Mitral valve prolapse without regurgitation does not affect cardiovascular response to
pregnancy.
Mitral regurgitation
 Mitral regurgitation during pregnancy is due to rheumatic valvular disease or mitral valve
prolapse.
 Because of the fall in systemic vascular resistance and reduced left ventricular afterload,
mitral regurgitation is usually well tolerated during pregnancy.
 Asymptomatic women do not require therapy during pregnancy.
 Symptomatic heart failure can be treated with nitrates, hydralazine, diuretics and digoxin.
Aortic stenosis
 In young women aortic stenosis is usually congenital in origin.
 Pregnancy outcome is dependent on the degree of stenosis.
 results in an abnormal elevation of left ventricular systolic and filling pressures.
 The hypertrophied ventricle is at a risk of angina, hypertension, heart failure and
arrhythmia
 Women who are symptomatic or have severe stenosis (peak outflow gradient >80
mmHg) or left ventricular dysfunction are advised to delay conception until after surgical
correction.
 If a pregnant woman becomes symptomatic, bed rest should be advised and valve
replacement considered.Wherever possible,
 Open heart surgery and CABAG should be avoided as it carries a 1.5–5% maternal
mortality and a 16–33% fetal mortality,with no relation to gestational age.
 Aortic balloon valvuloplasty may be used as a palliative procedure, allowing deferral of
valve replacement until after delivery.
Prosthetic heart valves
 Bioprosthetic valves are not associated with increased risk and do not degenerate more
rapidly during pregnancy.
 Pregnancy in women with mechanical valve replacement is associated with :
 45% incidence of thrombotic episodes,
 maternal mortality rate of 1–4%.
 Effective anticoagulation is critical with mechanical valve and the risks to the mother and
fetus need to be balanced;

 the most effective option is to take warfarin for the duration of the pregnancy, stopping at
38 weeks for elective caesarean delivery,with intravenous heparin perioperatively.
 Associated with low rate of maternal thromboembolism 4% but fetal abnormality
is high 6%.
 substituting LMWH for warfarin during the period of organogenesis 6–12 weeks
abolishes the risk of warfarin embryopathy but doubles the maternal thromboembolism
rate to 9%.
 LMWH throughout pregnancy abolishes the risk of warfarin embryopathy but is
associated with a 25% risk of thrombosis.
 Low dose aspirin has been used as an adjunct to heparin with successful outcomes.
 Monthly anti-factor Xa levels to monitor the therapeutic effect of LMWH, maintained
within the high therapeutic range.
 Regardless of whether heparin or warfarin is used, the risk of fetal loss is up to 30%.
Endocarditis prophylaxis
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 Antibiotic prophylaxis should be given during labour and delivery for all women with
valvular lesions except mitral valve prolapse without regurgitation.
Ischaemic heart disease
 Acute MI is rare during pregnancy and the puerperium, 1/10 000 pregnancies.
 Maternal mortality rates 37–50%
 Pregnancy itself is not risk factor for acute myocardial infarction.
 Pregnancy raises the risk of acute myocardial infarction by three- to four-fold, with 30
times higher for women > 40 years compared with women < 20 years.
 Other risk factors include chronic hypertension, pre-eclampsia, diabetes, smoking,
obesity and hyperlipidaemia.
 1/13 women with a myocardial infarction in pregnancy will die.
 most women affected will be asymptomatic before pregnancy, with no history of heart
disease.
 All women with chest pain in pregnancy should have an ECG and if the pain is severe,
they should have CT or MRI of the chest. A serum troponin I measurement can also be
useful.Treatment of myocardial infarction during pregnancy is the same as that outside
pregnancy, with heparin, beta-blockers and nitrates.
 Coronary angiography is safe in pregnancy
 Thrombolysis can cause bleeding from the placental site but is still indicated in the
management of acute myocardial infarction.
Cardiac arrhythmias
 Pregnancy increases the incidence of cardiac arrhythmia.
 This is the result of hormonal changes, alterations in autonomic tone and mild
hypokalemia.
 The risk is highest during labour and delivery.
 Atrial and ventricular premature beats are frequently present during pregnancy.They
have no adverse effects and require no investigation.
 The risk SVT is increased during pregnancy.
 Atrial fibrillation and atrial flutter are rare and can be caused by preexisting congenital or
valvular disease thyrotoxicosis or electrolyte imbalance.
 Because of the risk of thromboembolism early treatment, either with conversion to sinus
rhythm or ventricular rate control, is important.
 Initial treatment in the haemodynamically stable woman to terminate an SVT should
involve the vagal manoeuvre. If this fails, intravenous adenosine can be used safely.
Second-line treatments include digoxin, beta-blockers and calcium channel blockers.
 Ventricular tachycardia is uncommon in pregnancy. It is usually associated with
underlying heart disease
 Initial therapy is lidocaine or procainamide in haemodynamically stable women.
 Amiodarone is contraindicated, as it is associated with fetal hypothyroidism, FGR
and prematurity.
 Electrical cardioversion is safe in pregnancy for tachyarrhythmias who are
haemodynamically unstable.
Cardiomyopathy
Dilated
 Pregnancy is poorly tolerated in women with dilated cardiomyopathy.
 7% mortality rate with NYHA class III or IV and a risk of heart failure, irreversible left
ventricular dysfunction and fetal loss.
 In unplanned pregnancy a termination of pregnancy should be offered.
Hypertrophic
 Pregnancy in asymptomatic women is usually well tolerated.

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 in women with heart failure or severe symptoms before pregnancy, there is a risk of
symptomatic progression, atrial fibrillation, syncope and maternal death.
Peripartum
 Defined as left ventricular systolic dysfunction and heart failure present in the last month
of pregnancy and the first 5-6 months post delivery.
 incidence is 1 / 2 289 live births.
 Women present with signs and symptoms of left ventricular failure.
 Peripartum cardiomyopathy is a diagnosis of exclusion.
 Adequate treatment with beta-blockers, diuretics, hydralazine and digoxin reduce
mortality rates and improve overall prognosis.
 ACE inhibitors replace hydralazine post partum.
 20% of women with the disorder either die or survive only because they receive cardiac
transplantation. The remainder of women recover partially or completely.
 Subsequent pregnancy carries a higher risk of relapse if left ventricular systolic function
is not fully recovered, even with full recovery, some additional risk of remains.
 There is no consensus regarding recommendations for future pregnancies .
 As 25% of affected women will be hypertensive, it can be confused with pre-eclampsia.
Conclusion
 Effective management of valvular heart lesions is based on the treatment of symptoms,
with the option of balloon valvuloplasty and valve replacement.

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MANAGEMENT OF SICKLE CELL DISEASE IN PREGNANCY
Background and introduction
 SCD is a group of disorders inherited as a single-gene autosomal recessive disease.
 SCD has its origins in sub-Saharan Africa and the Middle East.
 The term SCD includes:
1. sickle cell anaemia (HbSS)
2. heterozygous of haemoglobin S and other abnormal haemoglobins such as
haemoglobin C (giving HbSC), beta thalassaemia (giving HbSB
thalassaemia) and haemoglobin D, E or O-Arab.
 The term sickle trait (AS) means Haemoglobin S combined with normal haemoglobin (A):
 Asymptomatic
 has increased risk of urinary tract infections and microscopic haematuria.
 SCD is the most common inherited condition. 300 000 children with SCD are born each
year; 2/3 in Africa.
 There are 100–200 pregnancies in women with SCD per year in the UK.
 The pathophysiology of SCD is a consequence of polymerisation of the abnormal
haemoglobin in low-oxygen conditions, which leads to the formation of rigid and fragile
sickle-shaped red cells. These cells are prone to increased breakdown, which causes
the haemolytic anaemia, and to vaso-occlusion in the small blood vessels, which causes
most of the other clinical features, including acute painful crises.
 Other complications of SCD include:
 Crises
 stroke
 pulmonary hypertension,
 renal dysfunction,
 retinal disease
 leg ulcers,
 cholelithiasis,
 avascular necrosis (which commonly affects the femoral head).
 SCD was previously associated with a high early mortality rate, but now live to
reproductive age and average life expectancy is at least the mid-50s.
Preconception care
 From adolescence, the intentions of women with SCD regarding pregnancy and
contraception should be documented at each contact with sickle care team.
 Preconceptually women should receive information about how SCD affects pregnancy
and vice versa, and how to improve outcomes for mother and baby.informations should
include:
1. SCD in pregnancy is associated with an increased incidence of:
 perinatal mortality,
 premature labour,
 FGR, which increases the likelihood of fetal distress, induction of labour and CS
 acute painful crises and other crises during pregnancy.
 miscarriage,
 antenatal hospitalisation,
 maternal mortality,
 infection, especially urinary tract infection
 thromboembolic events,
 antepartum haemorrhage.
 pre-eclampsia and pregnancy-induced hypertension.
 worsening anaemia,
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  acute chest syndrome (ACS)
2. The role of dehydration, cold, hypoxia, exertion and stress in the frequency of sickle
cell crises
3. The role of nausea and vomiting in pregnancy causing dehydration and precipitation
of crises
4. The chance of their baby being affected by SCD
 Optimization of management and screening for end organ damage including:
1. Screening for pulmonary hypertension with echocardiography.
2. Blood pressure and urinalysis to identify hypertension and/or proteinuria.
3. Renal and liver function tests should be performed annually.
4. Retinal screening: Proliferative retinopathy is common in patients with SCD,
especially HbSC.
5. Screening for iron overload by cardiac MRI In women with multiple transfusion
or a high ferritin. Aggressive iron chelation before conception is advisable in
women iron loaded.
6. Screening for red cell antibodies.
 Women with SCD should receive additional advice about vaccinations, medications and
crisis avoidance.
 Advise women to have a low threshold for seeking medical help.
The importance of genetic screening
 Women and men with SCD should have the haemoglobinopathy status of their partner
before pregnancy.
 If identified as an „at risk couple‟, they should receive counselling and advice about
reproductive options.
The importance of antibiotic prophylaxis and immunisation
 Penicillin prophylaxis should be prescribed.
 Vaccination status should be determined and updated.
 Patients with SCD at risk of infection, in particular from encapsulated bacteria.
 women should receive H. influenza type b and the conjugated meningococcal C
vaccine as a single dose.
 The pneumococcal vaccine should be given every 5 years.
 Hepatitis B vaccination is recommended.
 the influenza and „swine flu‟ vaccine is recommended annually.
Vitamin supplements
 Folic acid (5 mg) once daily both preconceptually and throughout pregnancy.
What medications should be reviewed preconceptually?
 Hydroxycarbamide (hydroxyurea) which used to decrease the incidence of acute painful
crises should be stopped at least 3 months before conception, because it is teratatogenic
 If women become pregnant while taking hydroxyurea, stop it and perform
ultrasound to look for structural abnormality, but termination is not indicated.
 ACE inhibitors and ARB should be stopped before conception.
Antenatal care
General aspects
 Multidisciplinary approach (obstetrician, specialist midwife, anaesthetists and a
haematologist).
 Screen for end organ damage (if not been undertaken preconceptually).
 Avoid precipitating factors of sickle cell crises.
 Women with Persistent vomiting should seek medical advice early to avoid dehydration
and sickle cell crisis.
 Influenza vaccine should be recommended if not administered in the previous year.
Antenatal haemoglobinopathy screening
 If the woman has not been seen preconceptually, she should be offered partner testing.
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 If the partner is a carrier, offer counselling early to allow the option of termination if the
woman wish.
What medication should be given during pregnancy?
 Daily folic acid and prophylactic antibiotics.
 Drugs that are unsafe in pregnancy should be stopped immediately.
 Iron supplementation only if there is laboratory evidence of iron deficiency.
 Low-dose aspirin 75 mg daily from 12 weeks to reduce the risk of pre-eclampsia.
 Prophylactic LMW heparin and TED stocking during antenatal hospital admissions.
 NSAIDs should be prescribed only between 12 and 28 weeks because of adverse effects
on fetal development.
What additional care should be provided during the antenatal appointment?
 Blood pressure and urinalysis should be performed each visit, and midstream urine for
culture monthly.
What is the recommended schedule of ultrasound scanning during pregnancy?
1. Viability scan at 7–9 weeks.
2. Routine first-trimester scan (11–14 weeks)
3. Detailed anomaly scan at 20 weeks of gestation.
4. In addition, serial growth scans every 4 weeks from 24 weeks of gestation.
What is the role of blood transfusion during pregnancy?
 Routine prophylactic transfusion is not recommended in pregnancy for SCD except for
twins pregnancy.
 Blood should be matched for full rhesus typing (C, D and E) as well as Kell typing.
 Alloimmunisation is common in SCD, occurring in 18–36% of patients .
 Blood used for transfusion in pregnancy should be cytomegalovirus negative.
Specific antenatal care for women with SCD
No absolute level for transfusion and the decision must be made in conjunction with:
1. Clinical findings,
2. Haemoglobin under 6 g/dl
3. Fall of over 2 g/dl from baseline.
 Exchange transfusion for ACS is accepted as best practice.
 Exchange transfusion is also indicated for acute stroke.
The optimal management of acute painful crisis during pregnancy
 Sickle cell crises should be excluded urgently in Women with SCD who become unwell.
 Pregnant women should be rapidly assessed by the multidisciplinary team and
appropriate analgesia given.
 Pethidine should not be used because of the associated risk of seizures.
 fluids and oxygen administered if required.
 Thromboprophylaxis should be given to women admitted to hospital with acute painful
crisis.

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Indications for blood transfusion in pregnancy complicated by SCD

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 Painful crisis is the most frequent complication of SCD in pregnancy, and the most
frequent cause of admission.
 Indication for referral referred to hospital in women with painful crisis:
 Pain does not settle with simple analgesia,
 Fever
 Atypical pain or chest pain or shortness of breath.
 Initial investigations: FBC, retic count and RFT. Other investigations depend on the
clinical scenario.
 Initial analgesia should be given within 30 minutes of arriving to hospital.
 paracetamol for mild pain;
 NSAIDs for mild to moderate pain.
 Weak opioids such as co-dydramol, or dihydrocodeine for moderate pain,
 stronger opiates such as morphine severe pain. if a mother received opiates in
late pregnancy for log time, the neonate should be observed for signs of opioid
withdrawal
 Every 20-minute monitor pain severity, respiratory rate, Oxygen saturations and
sedation.
 Women whose pain settles following oral analgesia can be discharged home.
 If the women need strong opiate, they need admission to hospital: to a medical ward in
early pregnancy, or to antenatal ward in later pregnancy, under the joint care of
obstetricians and haematologists.
Outline of management of acute pain

 Fluid intake of at least 60ml/kg/24 hours.

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 Oxygen saturation falls below the woman‟s baseline or below 95%.
 Assess for infection.
 Offer antibiotics if the woman is febrile or there is a high clinical suspicion of
infection.
 WBCs often raised in SCD and do not necessarily indicate infection.
 Thromboprophylaxis to women with SCD who are admitted to hospital with painful crises.
Management for the other acute complications of SCD
 ACS(7–20% of pregnancies), acute stroke and acute anaemia.
 The signs and symptoms of ACS are the same as those of pneumonia.
 There is an increased risk of pulmonary embolism in women with SCD. In women
presenting with acute hypoxia, there should be a low threshold for considering
pulmonary embolism.
 In acute stroke, rapid-exchange blood transfusion can decrease long-term
neurological damage. Thrombolysis is not indicated in acute stroke secondary to
SCD.
 Acute anaemia in women with SCD may be due to erythrovirus infection. causes
aplastic crisis.
 With erythrovirus infection, there is a risk of vertical transmission to the fetus,
which can result in hydrops fetalis.
 Rare causes of anaemia in SCD include malaria and, occasionally, splenic
sequestration.
Intrapartum care
What is the optimal timing and mode of delivery?
 Offer elective birth by IOL, or by elective CS if indicated, after 38+0 weeks for women
with SCD with no FGR.
 SCD in itself is not a contraindication for vaginal delivery or VBAC.
 Blood should be cross-matched for delivery if there are atypical antibodies present
otherwise a „group and save‟.
 In women who have hip replacements, discuss the suitable positions for delivery.
 The risks of abruption, pre-eclampsia, peripartum cardiomyopathy and crisis are
increased and unpredictable.
What is the optimum care and place of birth for a woman with SCD?
 Advise women to deliver in hospitals that are able to manage complications of SCD and
high-risk pregnancies.
 The multidisciplinary team should be informed as soon as labour is confirmed.
 Women should be kept warm and given adequate fluid during labour.
 Continuous intrapartum electronic fetal monitoring is recommended.
 pulse oximetry to detect hypoxia in the mother and arterial blood gas should be
performed saturation < 94%.
 Routine antibiotic prophylaxis in labour is currently not supported by evidence.
 hourly observations of vital signs should be performed.
What is the optimal mode of analgesia and anaesthesia?
 Offer anaesthetic assessment in the third trimester of pregnancy.
 Regional analgesia is recommended for caesarean section.
 General anaesthesia carries additional risks beyond the normal obstetric case and
should be avoided if possible.
Postpartum care
 In pregnant women where the baby is at high risk of SCD, early testing for SCD should
be offered.
 Maintain maternal oxygen saturation above 94% and adequate hydration until discharge.

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 LMW heparin while in hospital and 7 days post-discharge after vaginal delivery or for 6
weeks after CS.
 Same care level as described for antenatal care, since crisis and complications of SCD
remain a risk in puerperium.
What postpartum contraceptive advice should women be given?
 Progesterone only pill, Depo-Provera and Mirena are safe and effective in SCD.
 Estrogen-containing contraceptives should be used as second-line agents.
 women taking depo-medroxyprogesterone acetate (DMPA) were less to have a painful
episode.
 WHO define the COC and copper IUD as category 2, indicating that the advantages
outweigh the disadvantages. Other methods of contraception(progestogen only pill,
Depo-Provera, Mirena and emergency contraception as category 1, indicating there is no
restriction on their use.

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Green-top Guideline No. 66 March 2014
MANAGEMENT OF BETA THALASSAEMIA IN PREGNANCY
Introduction and background
 More than 70 000 babies are born with thalassaemia worldwide each year and there
are 100 million individuals who are asymptomatic thalassaemia carriers.
 The basic defect in the thalassaemia syndromes is reduced globin chain synthesis with
the resultant red cells having inadequate haemoglobin content.
 Thalassaemia major;(homozygous β thalassaemia) results from the inheritance of a
defective β globin gene from each parent. This results in a severe transfusion-
dependent anaemia.
 thalassaemia minor; The heterozygous state, β thalassaemia trait causes mild to
moderate microcytic anaemia with no significant detrimental effect on overall health.
 Thalassaemia intermedia; is defined as a group of patients with β thalassaemia
whose disease severity varies. usually diagnosed between the ages of two and six
years
Preconception care
What are the additional risks to the woman and baby?
 Cardiomyopathy in the mother due to iron overload and the increased risk of fetal
growth restriction (FGR).
 In addition, with around 9 months of little or no chelation, women with thalassaemia
major may develop new endocrinopathies: in particular, diabetes mellitus,
hypothyroidism and hypoparathyroidism due to the increasing iron burden.
What is the optimum preconceptual care for women with thalassaemia?
 Women with thalassaemia are best cared for in a multidisciplinary team setting,
including an obstetrician, haematologist.
 This team should provide prepregnancy counselling so that the woman is fully informed
about how thalassaemia affects pregnancy and vice versa.
 The preconception evaluation involves a review of transfusion requirements,
compliance with chelation therapy and assessment of the body iron burden.
 The assessment should include optimisation of management and screening for end-
organ damage and optimisation of complications prior to embarking on any pregnancy.
 At each visit with the thalassaemia team, there should be a discussion and
documentation of intentions regarding pregnancy.
 Haemoglobinopathy Centre should have a guideline for the management of pregnant
women with thalassaemia.
 Women should be advised to use contraception despite the reduced fertility associated
with thalassaemia.
 Fertility may be reduced in transfusion-dependent individuals where chelation
has been suboptimal and iron overload has occurred resulting in damage to the
anterior pituitary.
 They may require ovulation induction using injectable gonadotrophins to
conceive.
 There is no contraindication to the use of hormonal methods of contraception such as
the combined oral contraceptive pill, the progestogen-only pill, the Nexplanon® implant
and the Mirena® intrauterine system in women with thalassaemia.
Are there any interventions which are beneficial at the preconceptual
stage?
 Aggressive chelation in the preconception stage can reduce and optimise body iron
burden and reduce end-organ damage.
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  All chelation therapy should be regarded as potentially teratogenic in the first
trimester.
 Desferrioxamine is the only chelation agent with a body of evidence for use in the
second and third trimester.
 The optimisation of iron burden is therefore critical as the ongoing iron
accumulation from transfusion in the absence of chelation may expose the
pregnant woman to a high risk of new complications related to iron overload,
particularly diabetes and cardiomyopathy.
1. Pancreas;
 Diabetes is common in women with thalassaemia. Women with diabetes should be
referred to a diabetologist. Good glycaemic control is essential prepregnancy.
 Women with established diabetes mellitus should ideally have serum fructosamine
concentrations < 300 nmol/l for at least 3 months prior to conception. This is equivalent
to an HbA1c of 43 mmol/mol.
 An HbA1c of less than 43 mmol/mol is associated with a reduced risk of
congenital abnormalities.
 HbA1c is not a reliable marker of glycaemic control as this is diluted by
transfused blood and results in underestimation, so serum fructosamine is
preferred for monitoring.
2. Thyroid;
 Thyroid function should be determined. The woman should be euthyroid
prepregnancy
 Hypothyroidism is frequently found in patients with thalassaemia.
 Untreated hypothyroidism can result in maternal morbidity, as well as perinatal
morbidity and mortality. Patients should be assessed for thyroid function as part of
the preconceptual planning and, if known to be hypothyroid, treatment initiated to
ensure that they are clinically euthyroid.
3. Heart;
 All women should be assessed by a cardiologist with expertise in thalassaemia
and/or iron overload prior to embarking on a pregnancy.
 It is important to determine how well the cardiac status of the woman will
support a pregnancy as well as the severity of any iron-related
cardiomyopathy.
 Cardiac arrhythmias are more likely in older patients who have previously had
severe myocardial iron overload and are now clear of cardiac iron.
 An echocardiogram and an electrocardiogram (ECG) should be performed as well as
T2* cardiac MRI.
 Aim for cardiac T2* > 20 ms wherever possible as this reflects minimal iron in
the heart.
 However, pregnancies with successful maternal and fetal outcomes have
occurred with lower cardiac T2* values.
 A T2* < 10 ms is associated with an increased risk of cardiac failure.
4. Liver;
 Women should be assessed for liver iron concentration using a FerriScan® or liver
T2*. Ideally the liver iron should be < 7 mg/g (dry weight) (dw).
 A target liver iron of less than 7 mg/g (dw) is recommended because iron
chelation is discontinued during pregnancy and therefore transfusional iron
burden and the risk of iron overload-related complications increases.
 Anecdotally, ovulation induction is more likely to be successful when iron
burden is well controlled
 If liver iron exceeds 15 mg/g (dw) prior to conception, the risk of myocardial
iron loading increases so iron chelation with low-dose desferrioxamine should
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 be commenced between 20 and 28 weeks under guidance from the
haemoglobinopathy team.
 Liver and gall bladder (and spleen if present) ultrasound should be used to detect
cholelithiasis and evidence of liver cirrhosis due to iron overload or transfusion-
related viral hepatitis.
 Cholelithiasis is common in women with thalassaemia due to the underlying
haemolytic anaemia and they may develop cholecystitis in pregnancy.
 Liver cirrhosis and active hepatitis C (HCV) may run a more complex clinical
course during pregnancy.
 Women who are HCV RNA-positive should be reviewed by their hepatologist
preconceptually.
 Women who have any evidence of cirrhosis, either due to previous hepatitis or as
a consequence of severe hepatic iron loading, should be reviewed by a
hepatologist
5. Bone density scan;
 All women should be offered a bone density scan to document pre-existing
osteoporosis.
 Osteoporosis is a common finding in adults with thalassaemia.
 Serum vitamin D concentrations should be optimised with supplements if necessary.
 The pathology is complex, but thought to be due to a variety of factors
including underlying thalassaemic bone disease, chelation of calcium by
chelation drugs, hypogonadism and vitamin D deficiency.
 Most women with thalassaemia syndromes are vitamin D deficient and often
osteoporotic as well.
 All women should have vitamin D levels optimised before pregnancy and
thereafter maintained in the normal range.
6. Red cell antibodies;
 ABO and full blood group genotype and antibody titres should be measured.
 Alloimmunity occurs in 16.5% of individuals with thalassaemia.
 Red cell antibodies may indicate a risk of haemolytic disease of the fetus and
newborn.
 If antibodies are present there may be challenges in obtaining suitable blood
for transfusion.
What medications should be reviewed preconceptually?
 Iron chelators should be reviewed and deferasirox and deferiprone ideally
discontinued 3 months before conception.
 All bisphosphonates are contraindicated in pregnancy and should ideally be
discontinued 3 months prior to conception in accordance with the product safety
information sheet.
What is the importance of genetic screening and what procedure(s) are
involved for women with thalassaemia?
 If the partner is a carrier of a haemoglobinopathy that may adversely interact with the
woman‟s genotype then genetic counselling should be offered.
 In vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) with a pre-implantation
genetic diagnosis (PGD) should be considered in the presence of
haemoglobinopathies in both partners so that a homozygous or compound
heterozygous pregnancy can be avoided.
 Egg and sperm donors considering IVF should be screened for
haemoglobinopathies.

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 Table 1:
Conditions requiring counselling where the mother is affected by thalassaemia

 Carrier or sufferer condition in partner  Affected offspring

 Beta thalassaemia HbS  Risk of serious haemoglobinopathy
 HbE applies to all
 Delta beta thalassaemia
 Hb Lepore
 HbO Arab
 Hb Constant Spring
 HbC  Risk of a mild to moderate disorder
 Other variant haemoglobin

What is the importance of immunisation and antibiotic prophylaxis in

women who are at risk of transfusion-related viral infections or have had a
previous splenectomy?
 Hepatitis B vaccination is recommended in HBsAg negative women who are
transfused or may be transfused.
 The majority of women with thalassaemia major will have been immunised
against hepatitis B but some women with thalassaemia intermedia may not.
 Hepatitis C status should be determined.
 All women who have undergone a splenectomy should take penicillin prophylaxis or
equivalent.
 All women who have undergone a splenectomy should be vaccinated for
pneumococcus and Haemophilus influenzae type b if this has not been done before.
 In addition, women should be given Haemophilus influenzae type b and the
conjugated meningococcal C vaccine as a single dose if they have not
received it as part of primary vaccination.
 The pneumococcal vaccine (such as Pneumovax®II, Sanofi Pasteur MSD
Limited,Maidenhead, UK) should be given every 5 years.
What vitamin supplements should be recommended?
 Folic acid (5 mg) is recommended preconceptually to all women to prevent neural
tube defects.
Antenatal care
How is specialist input delivered for women with thalassaemia?
 Women with thalassaemia should be reviewed monthly until 28 weeks of gestation
and fortnightly thereafter.
 The multidisciplinary team should include an obstetrician, a midwife and a
haematologist. A diabetologist and cardiologist may also provide additional specialist
input.should provide routine as well as specialist antenatal care.
 Women with both thalassaemia and diabetes should have monthly assessment of
serum fructosamine concentrations and review in the specialist diabetic pregnancy
clinic.
 All women with thalassaemia major should undergo specialist cardiac assessment at
28 weeks of gestation and thereafter as appropriate.
 Thyroid function should be monitored during pregnancy in hypothyroid patients.
What is the recommended schedule of ultrasound scanning during
pregnancy?
 Women should be offered an early scan at 7–9 weeks of gestation.

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  In addition to the routine first trimester scan (11–14 weeks of gestation) and a
detailed anomaly scan at 18–20+6 weeks of gestation, women should be offered
serial fetal biometry scans every 4 weeks from 24 weeks of gestation.
 Women with both thalassaemia and diabetes have a higher risk of early
pregnancy loss.
 Fertility treatment with ovulation induction is often required to achieve
pregnancy so an early scan is indicated to determine viability as well as the
presence of a multiple pregnancy.
 Severe maternal anaemia predisposes to FGR in women with thalassaemia.
How should the transfusion regimen be managed during pregnancy in
women with thalassaemia major?
 All women with thalassaemia major should be receiving blood transfusions on a
regular basis aiming for a pretransfusion haemoglobin of 100 g/l.
How should the transfusion regimen be managed during pregnancy in
women with thalassaemia intermedia?
 If there is worsening maternal anaemia or evidence of FGR, regular transfusions
should be considered. Aiming for maintenance of pretransfusion haemoglobin
concentration above 100 g/l. Initially a 2–3 unit transfusion should be administered
with additional top-up transfusion if necessary the following week until the
haemoglobin reaches 120 g/l.
 If a woman with thalassaemia intermedia starts transfusion, haemoglobin targets are
managed as for thalassaemia major.
 Women with thalassaemia intermedia who are asymptomatic with normal fetal growth
and low haemoglobin should have a formal plan outlined in the notes with regard to
blood transfusion in late pregnancy.
 Generally, in nontransfused patients, if the haemoglobin is above 80 g/l at 36 weeks
of gestation, transfusion can be avoided prior to delivery. Postnatal transfusion can
be provided as necessary.
 If the haemoglobin is less than 80 g/l then aim for a top-up transfusion of 2 units at
37–38 weeks of gestation.
What antenatal thromboprophylaxis is recommended?
 Women with thalassaemia who have undergone splenectomy or have a platelet
count greater than 600 x 109/l should commence or continue taking low-dose aspirin
(75 mg/day).
 Women with thalassaemia who have undergone splenectomy and have a platelet
count above 600 x 109/l should be offered low-molecular-weight heparin
thromboprophylaxis as well as low-dose aspirin (75 mg/day).
 Women with thalassaemia who are not already using prophylactic low-molecular-
weight heparin should be advised to use it during antenatal hospital admissions.
What is the optimum antenatal management of iron chelation therapy?
 Iron chelation therapy is complex and should be tailored to the needs of the individual
woman.
 The chelation should be managed by a haematologist with experience in iron
chelation therapy particularly during pregnancy.

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Management of women with myocardial iron;
 Women with myocardial iron loading should undergo regular cardiology review with
careful monitoring of ejection fraction during the pregnancy as signs of cardiac
decompensation are the primary indications for intervention with chelation therapy.
 Those women at highest risk of cardiac decompensation should commence low-dose
subcutaneous desferrioxamine (20 mg/kg/day) on a minimum of 4–5 days a week
under joint haematology and cardiology guidance from 20–24 weeks of gestation.
 Cardiac MRI is safe in pregnancy and should be undertaken in women who have not
received preconceptual assessment or where there is concern about cardiac
function. As the cardiac T2*value falls below 20 ms there is an increasing risk of
cardiac decompensation.
 Those women at highest risk are those where the value is below 10 ms.
 Women with myocardial iron loading and T2* > 20 ms do not require desferrioxamine
chelation during pregnancy unless there is severe hepatic iron overload.
 Women with thalassaemia major and myocardial iron loading with T2* of < 10 ms
are at high risk of cardiac decompensation which may present as increasing
breathlessness, paroxysmal nocturnal dyspnoea,orthopnoea, syncope, palpitations
or peripheral oedema.
 If a woman describes symptoms of palpitations then a cardiac assessment is
appropriate a detailed history, ECG and 24 hour ECG monitor assessment are
needed to confirm a pathological cause. A falling ejection fraction or increasing
ventricular volumes on echocardiography will suggest increasing risk of developing
heart failure.
 Presentation in the first trimester is associated with adverse clinical outcome.
 In either circumstance desferrioxamine infusions may be indicated if there are
concerns.
Management of women with liver iron;
 Women with severe hepatic iron loading should be carefully reviewed and
consideration given to low dose desferrioxamine iron chelation from 20 weeks.
Intrapartum care
What is the best intrapartum management for women with thalassaemia
major or intermedia?
 Timing of delivery should be in line with national guidance.
 Senior midwifery, obstetric, anaesthetic and haematology staff should be informed as
soon as the woman is admitted to the delivery suite.
 In the presence of red cell antibodies, blood should be cross-matched for delivery
since this may delay the availability of blood. Otherwise a group and save will suffice.
 In women with thalassaemia major intravenous desferrioxamine 2 g over 24 hours
should be administered for the duration of labour.
 Continuous intrapartum electronic fetal monitoring should be instituted.
 Thalassaemia in itself is not an indication for caesarean section.
 Active management of the third stage of labour is recommended to minimise blood
loss.
 If there are medical complications such as cardiomyopathy, a detailed
management plan formulated during the pregnancy should be in the woman‟s
notes.
 If the haemoglobin is less than 100 g/l, cross-match 2 units on admission to
the labour ward.
 Women who are transfusion-dependent and not on a chelating agent will
have high serum concentrations of a toxic iron species known as non-
transferrin bound iron. These may cause free radical damage and cardiac
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 dysrhythmia when the woman is subjected to the stress of labour. Peripartum
chelation therapy is therefore recommended.
Postpartum care
What should be the optimum care post delivery?
 Women with thalassaemia should be considered at high risk for venous
thromboembolism.
 Breastfeeding is safe and should be encouraged
 Women with thalassaemia major who plan to breastfeed should restart
desferrioxamine as soon as the initial 24-hour infusion of intravenous
desferrioxamine finishes after delivery.
 Desferrioxamine is secreted in breast milk but is not orally absorbed and therefore
not harmful to the newborn. There is minimal safety data on other iron chelators.
 If a woman decides not to breastfeed, intravenous or subcutaneous desferrioxamine
infusions are continued until discharge from hospital or until resumption of her
previous iron chelation regimen under haematology supervision, whichever is
sooner?

Booking appointment
Offer information, advice and support in relation to optimising general health.
Discuss information, education and advice about how thalassaemia will affect
pregnancy.
Primary care or hospital appointment – offer partner testing if not already done,
review partner results if available and discuss prenatal diagnosis (chorionic villus
sampling, amniocentesis or cell-free fetal DNA) if appropriate.
Take a clinical history to establish the extent of thalassaemia complications. Women
with diabetes to be referred to joint diabetes pregnancy clinic with haematology input.
Review medications e.g. chelators such as deferiprone or deferasirox.
Women should be taking 5 mg folic acid.
Women who have had a splenectomy should receive antibiotic prophylaxis.
Discuss vaccinations with those women who have had a splenectomy.
Offer MRI heart and liver (T2* and FerriScan®) if these have not been performed in
the previous year for thalassaemia major patients only.
Determine presence of any red cell antibodies.
Document blood pressure.
Send midstream specimen of urine for culture.
Confirm viability with ultrasound.

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Schedule of antenatal appointments
11–14 weeks
 Midwife with high-risk obstetric experience.
 Review partner results and discuss prenatal diagnosis if appropriate.
 Confirm that all actions from first visit are complete.
 Continue folic acid 5 mg.
16 weeks
 Midwife and multidisciplinary review (haematologist, obstetrician and diabetologist if
diabetic).
20 weeks
 Midwife and multidisciplinary review.
20–24 weeks
 Women assessed with risks of cardiac decompensation should start on low-dose
subcutaneous desferrioxamine (20 mg/kg/day) on a minimum of 4 to 5 days a week under
guidance of a haematologist with experience in iron chelation.
 Women with T2* > 10 but < 20 ms should be assessed for risks and consideration given
to starting desferrioxamine infusions if there are concerns.
 Women with T2* > 20 ms (optimal preconception result) should not be given any
desferrioxamine chelation during pregnancy unless there is severe hepatic iron overload.
24 weeks
 Midwife and multidisciplinary review.
 Ultrasound for fetal biometry.
28 weeks
 Midwife and multidisciplinary review.
 Ultrasound for fetal biometry.
 Specialist cardiology review and formulation of delivery plan based on cardiac function.
30 weeks
 Midwife for routine assessment.
32 weeks
 Midwife and multidisciplinary review.
 Ultrasound for biometry.
34 weeks
 Midwife for routine assessment.
36 weeks
 Midwife and multidisciplinary review.
 A care plan regarding the delivery should be formulated by the team and documented in
the notes.
 Ultrasound for fetal biometry.
 Offer information and advice about:
 Timing, mode and management of the birth
 Analgesia and anaesthesia; arrange anaesthetic assessment if cardiac dysfunction
 Care of baby after birth.
38 weeks
 Midwife and obstetrician for routine assessment.
 Offer induction of labour if the woman has diabetes.
39 weeks
 Midwife for routine assessment.
40 weeks
 Obstetrician for routine assessment.
41 weeks
 Obstetrician for routine assessment.
 For a non diabetic woman with normal fetal growth and no complications, offer induction
of labour in accordance with the NICE guideline for

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DIABETES IN PREGNANCY
Introduction
 Diabetes involves 2–5% of pregnancies.
 87.5% is due to GDM the incidence is increasing due to obesity and in older
women.
 7.5% is due to type 1 diabetes and 5% is due to type 2 diabetes.
 Diabetes in pregnancy is associated with risks to the woman and to the fetus which are
more common in women with pre-existing diabetes:
 Miscarriage,
 congenital malformations,
 macrosomia,
 preterm labour
 Stillbirth,
 birth injury,
 perinatal mortality
 postnatal adaptation problems (such as hypoglycaemia)
 pre-eclampsia
 diabetic retinopathy can worsen rapidly during pregnancy.
Pre-conception care ( women with Diabetes)
1) Outcomes and risks for the woman and baby
 Diabetic women who are planning for pregnancy should be offered pre-conception care
and advice before discontinuing contraception.
 Pre-conception care should be given in a supportive environment and the woman‟s
partner should be encouraged to attend.
 diabetic women who are planning for pregnancy should be:
 informed that good glycaemic control before conception and during pregnancy will
reduce the risk of miscarriage, congenital malformation, stillbirth and neonatal death.
 offered information about how diabetes affects pregnancy and vise versa including:
o the role of diet, body weight and exercise
o the risks of hypoglycaemia
o how nausea and vomiting can affect glycaemic control
o the increased risk of having a baby large for gestational age,
o the need for assessment of diabetic retinopathy before and during pregnancy
o the need for assessment of diabetic nephropathy before pregnancy
o the importance of maternal glycaemic control during labour and birth
o the importance of early feeding in order to reduce the risk of neonatal hypoglycaemia
o the possibility of transient morbidity in baby, which may require admission to NICU
o the risk of the baby developing obesity and/or diabetes in later life.
2) The importance of planning pregnancy and the role of contraception
 The importance of avoiding unplanned pregnancy for women with diabetes.
 Diabetic women who are planning for pregnancy should be advised:
 That the complications of diabetes in pregnancy increase with the duration of
diabetes
 To use contraception until good glycaemic control, their choice of contraception
should be based on their own preferences and any risk factors (as indicated
by [UKMEC])
Prefer an oral contraceptives ( no contraindications to their use).

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  That glycaemic targets, glucose monitoring, medications for diabetes and
medications for complications of diabetes will need to be reviewed before and during
pregnancy
 That additional time and effort is required to manage diabetes during pregnancy
3) Diet, dietary supplements, body weight and exercise
 Diabetic women who are planning for pregnancy and have BMI>27 kg/m2 should be
adviced to lose weight
 Diabetic women who are planning for pregnancy should be advised to take folic acid (5
mg/day) until 12 weeks to reduce the risk of NTD.
4) Target ranges for blood glucose in the pre-conception period
 HbA1c level below 48 mmol/mol (6.5%), 
 Strongly against pregnancy if HbA1c level is above 86 mmol/mol (10%) 

5) Monitoring blood glucose and ketones in the pre-conception period

 Diabetic women who are planning for pregnancy should be offered:
 Monthly measurement of HbA1c.
 HbA1c level target the same capillary plasma glucose as for all people with type 1
diabetes
 Meter for self-monitoring of blood glucose.
 Advise to increase the frequency of self-monitoring of blood glucose to include fasting
and a mixture of pre- and postprandial levels.
 Ketone strips and advised to test for ketonuria if become hyperglycaemic or unwell.
6) The safety of medications for diabetes before and during pregnancy
 Diabetic women can use metformin as an adjunct or alternative to insulin in the pre-
conception and during pregnancy.
 All other oral hypoglycaemic agents should be discontinued before pregnancy.
 The rapid-acting insulin analogues (aspart and lispro) are safe to use during pregnancy.
 There is insufficient evidence about the use of long-acting insulin analogues in
pregnancy. isophane insulin(NPH)remains the first choice for long-acting insulin in
pregnancy.
7) The safety of medications for diabetic complications
 ACE and ARB and Statins should be discontinued before or as soon as pregnancy is
confirmed.
8) Retinal assessment in the pre-conception period
 At their first appointment (unless they have had an annual retinal assessment in the
last 6 months) and
 then annually if no diabetic retinopathy is found.
9) Renal assessment in the pre-conception period
 Measure of low-level albuminuria (microalbuminuria), before discontinuing contraception.
Refer to nephrologist if:
 S. creatinine is abnormal (120 micromol/litre or more),
 urinary albumin:creatinine ratio is greater than 30 mg/mmol or
 estimated glomerular filtration rate (eGFR) is less than 45 ml/minute/1.73m2,
Gestational diabetes
1) Risk factors for GDM
 BMI > 30 kg/m2
 Previous macrosomic baby >4.5 kg
 Previous GDM
 Family history of diabetes (first-degree relative)
 Family origin with a high prevalence of diabetes:
o South Asian
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 o Black Caribbean
o Middle Eastern specifically gulf area, Jordan, Syria, Lebanon or Egypt
2) Screening, diagnosis and treatment for GDM
 Screening for gestational diabetes using risk factors is recommended.
 If any of the 5 risk factors for gestational diabetes:
 2-hour 75 g oral glucose tolerance test (OGTT) at 24 to 28 weeks
 further testing to exclude gestational diabetes if glycosuria:
 2+ or above on 1 occasion or
 1+ or above on 2 or more occasions detected by reagent strip
 If previous GDM
 early self-monitoring of blood glucose or
 75 g 2-hour OGTT at booking
 If at booking OGTT normal, - 75 g 2-hour OGTT at 24–28 weeks
Diagnosed if:
 fasting plasma glucose level of 5.6 mmol/litre or above or
 2-hour plasma glucose level of 7.8 mmol/litre or above
Interventions
 fasting plasma glucose level below 7 mmol/litre
 Trial of diet and exercise
 Metformin - if no target level within 1–2 weeks with diet, exercise
 insulin – if metformin is contraindicated or unacceptable to the woman
 fasting plasma glucose level of 7.0 mmol/litre or above
 immediate treatment with insulin
Antenatal care
1) Target ranges for blood glucose during pregnancy
 Type 1 diabetes – daily
 Fasting
 Pre meal
 1 hr post meal
 Bed time
 HbA1c should not used routinely for assessing glycaemic control in the 2nd and 3rd trim
 Type 2 DM / GDM & multi inj of insulin - daily
 Fasting
 Pre meal
 1 hr post meal
 Bed time
2) Management of diabetes during pregnancy
 On diet and exercise or
 Oral therapy or
 Rapid-acting insulin analogues(aspart and lispro) have advantages over soluble human
insulin during pregnancy.
 Women on insulin should be:
 advised of the risks of hypoglycaemia.
 provided with a concentrated glucose solution and glucagon if type 1 diabetes.
 offered continuous S.C insulin infusion if uncontrol by multiple daily injections.
 Women with type 1 diabetes who become unwell should have DKA excluded.
 Women who are suspected of having DKA should be admitted to level 2 critical care
 then daily
 Fasting

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 1 hr post meal
Maintain their capillary plasma glucose
 fasting: <5.3 mmol/litre and
 1 hour after meals: < 7.8 mmol/litre or 2 hours after meals: < 6.4 mmol/litre.
 If on insulin or glibenclamide : > 4 mmol/litre

3) Retinal assessment during pregnancy

 Pregnant women with pre-existing diabetes should be offered retinal assessment
following their first antenatal clinic appointment and again:
 At 28 weeks if the first assessment is normal.
 At 16–20 weeks If any diabetic retinopathy is present.
 Diabetic retinopathy should not be considered a contraindication to rapid optimisation of
glycaemic control in women who present with a high HbA1c in early pregnancy.
 Women who have preproliferative diabetic retinopathy during pregnancy should have
ophthalmological follow-up for at least 6 months following the birth.
 Diabetic retinopathy should not be considered a contraindication to vaginal birth.
4) Renal assessment during pregnancy
Refer to Nephrologist if:

5) Screening for congenital malformations

 Offer examination of the 4-chamber of the fetal heart and outflow tracts at 18–20 weeks.
6) Monitoring fetal growth and well-being
 ultrasound scan for fetal structural abnormalities,
 fetal heart (4 chambers, outflow tracts and 3 vessels), at 20 weeks.
 USG – FG & AF volume - every 4 weeks from 28 to 36 weeks
 If risk of FGR - umbilical artery doppler & fetal well being b/f 38 wks
7) Timetable of antenatal appointments
 offered immediate contact with a joint diabetes and antenatal clinic.
 contact with the diabetes care team for assessment of glycaemic control every 1–2
weeks throughout pregnancy.
8) Preterm labour in women with diabetes
 Diabetes should not be considered a contraindication to antenatal steroids or tocolysis.
 Women with insulin-treated diabetes who are receiving steroids for fetal lung maturation
should have additional insulin and should be closely monitored.
 Betamimetic drugs should not be used for tocolysis in women with diabetes.

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Appointment Care for women with diabetes during pregnancy

Booking Discuss information, education and advice about how diabetes will affect the
appointment pregnancy, birth and early parenting (such as breastfeeding and initial care of
(joint diabetes the baby). If the woman has been attending for preconception care and
and antenatal advice, continue to provide information, education and advice in relation to
care) – ideally by achieving optimal blood glucose control (including dietary advice). If the
10 weeks woman has not attended for preconception care and advice, give information,
education and advice for the first time, take a clinical history to establish the
extent of diabetes-related complications (including neuropathy and vascular
disease), and review medicines for diabetes and its complications. Offer
retinal assessment for women with pre-existing diabetes unless the woman
has been assessed in the last 3 months.Offer renal assessment for women
with pre-existing diabetes if this has not been performed in the last 3
months.Arrange contact with the joint diabetes and antenatal clinic every 1–2
weeks throughout pregnancy for all women with diabetes. Measure HbA1c
levels for women with pre-existing diabetes to determine the level of risk for
the pregnancy.
Offer self-monitoring of blood glucose or a 75 g 2-hour OGTT as soon
aspossible for women with a history of gestational diabetes who book in the
first trimester. Confirm viability of pregnancy and gestational age at 7–9
weeks.
16 weeks Offer retinal assessment at 16–20 weeks to women with pre-existing diabetes
if diabetic retinopathy was present at their first antenatal clinic visit.Offer self-
monitoring of blood glucose or a 75 g 2-hour OGTT as soon as possible for
women with a history of gestational diabetes who book in the second
trimester.
20 weeks Offer an ultrasound scan for detecting fetal structural abnormalities, including
examination of the fetal heart (4 chambers, outflow tracts and 3 vessels).
28 weeks Offer ultrasound monitoring of fetal growth and amniotic fluid volume. Offer
retinal assessment to all women with pre-existing diabetes. Women
diagnosed with gestational diabetes as a result of routine antenatal testing at
24–28 weeks enter the care pathway.
32 weeks Offer ultrasound monitoring of fetal growth and amniotic fluid volume. Offer
nulliparous women all routine investigations normally scheduled for 31 weeks
in routine antenatal care.
34 weeks No additional or different care for women with diabetes.

36 weeks Offer ultrasound monitoring of fetal growth and amniotic fluid volume.
Provide information and advice about:
 timing, mode and management of birth
 analgesia and anaesthesia
 changes to blood glucose-lowering therapy during and after birth
 care of the baby after birth
 initiation of breastfeeding and the effect of breastfeeding on blood
glucose control
 contraception and follow-up.
37+0 weeks to Offer induction of labour, or caesarean section if indicated, to women with
38+6 weeks type 1 or type 2 diabetes; otherwise await spontaneous labour.

38 weeks Offer tests of fetal wellbeing.

39 weeks Offer tests of fetal wellbeing. Advise women with uncomplicated gestational
diabetes to give birth no later than 40+6 weeks.

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* Women with diabetes should also receive routine care according to the schedule of appointments in
the NICE guideline on antenatal care, including appointments at 25 weeks (for nulliparous women)
and 34 weeks, but with the exception of the appointment for nulliparous women at 31 weeks.
OGTT = oral glucose tolerance test.

Intrapartum care
1) Timing and mode of birth
 Type 1 or type 2 diabetes –
 induction of labour, or elective CS between 37+0 weeks and 38+6 weeks
 Consider elective birth before 37+0 weeks , if metabolic or any other maternal or fetal
complications
 GDM -
 birth no later than 40+6 weeks, by induction or CS
 Consider elective birth before 40+6 weeks – if not delivered by 40+6 weeks
 Consider elective birth before 40+6 weeks - if metabolic or any other maternal or fetal
complications
 Diabetes is not a contraindication for VBAC.
 Diabetic women with ultrasound macrosomic fetus should be informed of the risks and
benefits of vaginal birth, IOL and CS.
2) Analgesia and anaesthesia
 Offer anaesthetic assessment in the 3rd trimester if there is comorbidities such as
obesity or autonomic neuropathy.
 If GA is used, blood glucose should be monitored every 30 minutes from induction of
general anaesthesia until after birth and the woman is fully conscious.
3) Glycaemic control during labour and birth
 During labour and birth, capillary blood glucose should be monitored hourly and
maintained between 4-7 mmol/litre.
 If not maintained between 4-7 mmol/litre start IV dextrose and insulin infusion.
 Women with type 1 diabetes should receive IV dextrose and insulin infusion from the
onset of labour.
Neonatal care
 Carry out blood glucose 2–4 hours after birth
 Pre-feed capillary plasma glucose levels at a minimum of 2.0 mmol/litre.
 tube feeding or intravenous dextrose – if glucose values are below 2.0 mmol/litre on
2 consecutive readings
Postnatal care
1) glycaemic control
 Insulin-treated pre-existing diabetes should reduce their insulin
 GDM - discontinue blood glucose-lowering therapy immediately after birth
 Pre-existing type 2 diabetes resume or continue to take metformin and glibenclamide
immediately after birth
2) follow-up after birth
 GDM –
 Offer a fasting plasma glucose test 6–13 weeks after birth
 after the birth glucose test has not been performed by 13 weeks,
 offer a fasting plasma glucose test, or
 An HbA1c test if a fasting plasma glucose test is not possible, after 13 weeks.
Fasting plasma glucose test
1. Level below 6.0 mmol
 low probability of having diabetes at present
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  they have a moderate risk of developing type 2 diabetes
2. Level between 6.0 and 6.9 mmol/litre
 at high risk of developing type 2 diabetes,
3. Level of 7.0 mmol/litre or above
 likely to have type 2 diabetes, and offer them a diagnostic test to confirm diabetes
HbA1c test
1. Level below 39 mmol/mol (5.7%)
 low probability of having diabetes at present
 they have a moderate risk of developing type 2 diabetes
2. Level between 39 and 47 mmol/mol (5.7% and 6.4%)
 at high risk of developing type 2 diabetes
3. Level of 48 mmol/mol (6.5%) or above
 likely to have type 2 diabetes, and offer them a diagnostic test to confirm diabetes
fasting plasma glucose test / HbA1c test - negative
 HbA1c test annualy

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DIAGNOSIS AND TREATMENT OF GESTATIONAL DIABETES
New evidence the relationship of maternal glucose to fetal growth
 There is a linear relationship between maternal fasting plasma glucose and oral glucose
tolerance test at 1 hour and 2 hours with birthweight above the 90th percentile.3 infant
adiposity estimated by sum of skin-fold thickness exhibited a strong linear relationship
with
New evidence efficacy of screening, diagnosing and treating gestational diabetes
 treatment of gestational diabetes with insulin improved pregnancy outcomes.11
Specifically, birthweight, macrosomia and serious perinatal outcomes: death, shoulder
dystocia, bone fracture and nerve palsy were significantly reduced from 4% to 1%and
decrease CS.
 treatment of gestational diabetes reduce maternal weight gain resulting in a small but
significant difference in body mass index of 1 kg/m2 at delivery.
New evidence treatment
 Lifestyle advice including dietary modification is the primary intervention
 In 7–20% of women oral hypoglycaemic agents or insulin will be required to control
GDM.
 Both glibenclamide and metformin are effective treatments for GDM.
 starting with glibenclamideor metformin is associated with similar birth outcomes to a
strategy involving initial treatment with insulin.
 Need for insulin in about 20–30% of patients who were initially started on glibenclamide
and metformin, with those requiring insulin having a higher fasting glucose.
 Metformin treatment was also associated with lower maternal weight gain.
 Metformin and glibenclamide cross the placenta and, while no immediate safety
concerns for the fetus have been demonstrated, potential long-term effects remain under
investigation.
Screening and diagnosis of gestational diabetes

Diabetes is diagnosed where one or more threshold value is exceeded

 Application of this criteria result in a pregnancy incidence of gestational diabetes > 16%
a major change in terms of obstetric practice from current levels of 3.5%.

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HYPERTENSION IN PREGNANCY
Introduction
 Most hypertensive disorders in pregnancy develop for the first time in the second half of
pregnancy.
 New hypertension can occur without significant proteinuria (gestational hypertension) or
with significant proteinuria (pre-eclampsia).
 Hypertensive disorders during pregnancy can occur in women with chronic hypertension
(pre-existing hypertension).
 Hypertensive disorders during pregnancy are among the leading causes of maternal
death in the UK.
 Hypertensive disorders also carry a risk for the baby in terms of higher perinatal
mortality, preterm birth and low birth weight.
Reducing the risk of hypertensive disorders in pregnancy
 Advise women at high risk of pre-eclampsia to take 75 mg of aspirin daily from 12 weeks
until the birth of the baby. Women at high risk are those with any of the following:
1. hypertensive disease during a previous pregnancy
2. chronic kidney disease
3. autoimmune disease such as systemic lupus erythematosis or antiphospholipid
syndrome
4. type 1 or type 2 diabetes
5. chronic hypertension.
Management of pregnancy with chronic hypertension
 Tell women who take ACE inhibitors or ARBs:
1. that there is an increased risk of congenital abnormalities
2. to discuss other antihypertensive treatment with the healthcare professional
responsible if they are planning pregnancy.
 In pregnant women with uncomplicated chronic hypertension aim to keep blood pressure
lower than 150/100 mmHg.
Assessment of proteinuria in hypertensive disorders of pregnancy
 Use an automated reagent-strip reading device or a spot urinary protein:creatinine ratio.
Definitions
 Chronic hypertension Hypertension present at booking or before 20 weeks, or that is
being. Can be primary or secondary in aetiology.
 Degrees of hypertension
1. Mild Diastolic blood pressure 90–99 mmHg, systolic blood pressure 140–149 mmHg.
2. Moderate Diastolic blood pressure 100–109 mmHg, systolic blood pressure 150–159
mmHg.
3. Severe Diastolic blood pressure ≥ 110 mmHg, systolic blood pressure ≥ 160 mmHg.
 Eclampsia Convulsive condition associated with pre-eclampsia.
 Gestational hypertension New hypertension presenting after 20 weeks without significant
proteinuria.
 Pre-eclampsia New hypertension presenting after 20 weeks with significant proteinuria.
 Severe pre-eclampsia Pre-eclampsia with severe hypertension and/or with symptoms,
and/or biochemical and/or haematological impairment.
Reducing the risk of hypertensive disorders in pregnancy
Symptoms of pre-eclampsia
 Tell women to seek advice immediately if they experience any of:
 severe headache
 severe pain just below ribs
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  problems with vision such as blurring
 vomiting
 flashing before eyes
 sudden swelling of face, hands or feet.
Lifestyle interventions
 Offer advice on rest, exercise and work
Pharmacological interventions
 Do not use the following to prevent hypertensive disorders in pregnancy:
 nitric oxide donors – diuretics
 progesterone – low molecular weight heparin.
Nutritional supplements and diet
 Do not recommend the following solely with the aim of preventing hypertensive disorders
 during pregnancy:
 taking supplements of magnesium, folic
 restricting salt intake.
 acid, antioxidants (vitamins C and E), fish or algal oils, or garlic
Assessment of proteinuria
 Use an automated reagent-strip reading device or a spot urinary protein:creatinine ratio.
 Diagnose significant proteinuria if urinary protein:creatinine ratio > 30 mg/mmol or a
validated 24-hour urine collection result shows > 300 mg protein.
 Where 24-hour urine collection is used to quantify proteinuria, there should be a
recognized method of evaluating completeness of the sample.

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Advice for women, their community midwives and primary care physicians
Breastfeeding
 Tell women that the following drugs have no known adverse effects on babies receiving
breast milk:
 labetalol
 nifedipine
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  enalapril
 captopril
 atenolol
 metoprolol.
 Tell women that there is insufficient evidence on the safety of the following drugs in
babies receiving breast milk:
 ARBs
 amlodipine
 ACE inhibitors other than enalapril† and captopril†.
Weight management
 Advise women who have had pre-eclampsia to achieve and keep BMI 18.5–24.9 kg/m2
before next pregnancy.

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THE MANAGEMENT OF SEVERE PRE ECLAMPSIA/ECLAMPSIA
Purpose and scope
 5/1000 maternities suffering severe pre-eclampsia and 5/10 000 maternities suffering
eclampsia.
 In eclampsia, case fatality is 1.8% and a further 35% of women experience a major
complication.
Introduction and background
 Eclampsia is defined as one or more convulsions superimposed on pre-eclampsia.
 Preeclampsia is PIH in association with proteinuria (> 0.3 g in 24 hours) ± oedema.
 Clinical features of severe pre-eclampsia (in addition to hypertension and proteinuria)
are:
1. severe hypertension with a diastolic blood pressure ≥ 110 mmHg on two
occasions or systolic blood pressure ≥ 170 mmHg on two occasions together with
significant proteinuria (at least 1 g/litre),
2. diastolic blood pressure ≥ 100 mmHg on two occasions and significant proteinuria
with at least two signs or symptoms of imminent eclampsia
3. HELLP syndrome
4. platelet count falling to below 100 x 106/l
5. abnormal liver enzymes (ALT or AST rising to above 70 iu/l)
6. signs of clonus
7. papilloedema
Management of severe pre-eclampsia
 The management of severe pre-eclampsia is based on:
1. careful assessment,
2. stabilisation,
3. continued monitoring
4. delivery at the optimal time for the mother and her baby.
5. Follow-up and final diagnosis
1) Assessment and diagnosis
1. Assessment of the woman
 Although the classification of severity is primarily based on the level of blood pressure
and the presence of proteinuria, be aware of involvement of other organs when
assessing maternal risk, including placental disease with fetal manifestations.
 Senior obstetric and anaesthetic staff and experienced midwives should be involved in
the assessment and management of women with severe pre-eclampsia and eclampsia.
 preeclampsia should be considered in women present with convulsions, abdominal pain
or general malaise.
 Maternal tendon reflexes are not of value in assessing the risk of convulsion, although
the presence of clonus may be.
 oxygen saturation monitoring with pulse oximeter give early signs of pulmonary oedema.
How should the blood pressure be taken?
 the woman should be rested and sitting at a 45-degree angle.
 The blood pressure cuff should be of the appropriate size at the level of the heart.
 Multiple readings should be used.
 Use Korotkoff phase 5.
 The method used should be documented.
 Automated methods need to be used with caution.
How should proteinuria be measured?
 The usual screening test is dipstick.
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 A two + dipstick an be taken as evidence of proteinuria but ideally a more accurate test
(spot protein creatinine ratio or ideally 24-hour urine collection) is required.
 urine dipstick testing: 1+ = 0.3 g/l, 2+ = 1 g/l and 3+ = 3 g/l.
 protein/creatinine ratios :0.03 g/mmol = 0.3 g/24 hours.
 24-hr urine collection, is recommended unless clinical urgency indicate immediate
delivery.
How should the woman be monitored?
 Check BP each 15 min until the woman is stabilised and then every 30 min.
 Check BP 4-hourly if conservative management planed and woman is stable and
asymptomatic.
 FBC, LFT and RFT at least daily when the results are normal but more often if other.
 Clotting studies are not required if the platelet count is over 100 x 106/l.
 Close fluid balance with charting of input and output is essential.
 Catheter with hourly urometer is advisable in the acute situation, especially in immediate
postpartum period.
 rise in uric acid confers an increased risk to the mother and baby but the levels, in
themselves, should not be used for clinical decision-making.
 Renal function is generally maintained in preeclampsia until the late stage unless
HELLP syndrome develops. If creatinine is elevated early renal disease should be
suspected.
 renal failure is uncommon in pre-eclampsia but it is usually associated with
haemorrhage, HELLP syndrome or sepsis.
 platelet count of less than 100 should be a consideration for delivery.
 An AST>75 iu/l is significant and>150 iu/l is associated with increased morbidity to
mother.
1) How should the fetus be assessed?
 In the acute setting, an initial assessment with CTG should be undertaken.
 Women in labour with severe pre-eclampsia should have continuous EFM.
 If conservative management is planned consider Serial ultrasound measurements of
fetal size, umbilical artery Doppler and liquor volume.
 FGR occurs in around 30% of pre-eclamptic.
 FGR is usually asymmetrical so measurement of the AC is the best method.
How should we control the blood pressure?
 Antihypertensive treatment should be started in women with a systolic blood pressure
>160 mmHg or a diastolic blood pressure >110 mmHg. or at a lower levels with other
markers of potentially severe disease
 Labetalol, given orally or intravenously, nifedipine given orally or intravenous hydralazine
can be used for the acute management of severe hypertension.
 In moderate hypertension, treatment may assist prolongation of the pregnancy.
 Atenolol, ACE inhibitors, ARB and diuretics should be avoided.
 Nifedipine should be given orally not sublingually.
 Labetalol should be avoided in women with known asthma.
2) Stabilization and treatment
How should seizures be prevented?
 Magnesium sulphate should be considered for women with :
1. pre-eclampsia if there is concern about eclampsia.
2. severe pre-eclampsia once a delivery decision has been made and in the
immediate postpartum period.
 In women with less severe disease decision is less clear and depend on individual
assessment.
How should seizures be controlled?
 Apply ABC.
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  Do not leave the woman alone but call for help.
 Ensure that it is safe to approach woman and aim to prevent maternal injury during
convulsion.
 Place the woman in the left lateral position and administer oxygen.
 Once stabilised, plans should be made to deliver the woman a delay of several hours
is acceptable, assuming there is no acute fetal concern.
 The woman‟s condition will always take priority over the fetal condition.
 Magnesium sulphate loading dose of 4 g given by infusion pump over 5–10 minutes,
followed by 1 g/hour maintained for 24 hours after the last seizure.
 Magnesium toxicity is unlikely with these regimens and levels do not need to be
routinely measured.
 Magnesium sulphate is mostly excreted in the urine.
 Give Calcium gluconate 1g (10ml) over 10 minutes if there is respiratory depression.
 Treat recurrent seizures with either a further bolus of 2 g magnesium sulphate or an
increase in the infusion rate to 1.5 g or 2.0 g/hour.
 prolonged use of diazepam is associated with an increase in maternal death.
 If convulsions persist, intubation is likely to be necessary to protect the airway and
maintain oxygenation. Transfer to ICU.
How should fluid balance be managed?
 In usual circumstances, total fluids should be limited to 80 ml/hour or 1 ml/kg/hour.
3) Planning delivery
When and how should the baby be delivered?
 The decision to deliver should be made once the woman is stable.
 If the fetus is less than 34 weeks of gestation and delivery can be deferred,
corticosteroids should be given, and after 24 hours reassess the benefits of conservative
management.
 Conservative management at very early gestations must be carefully balanced with
maternal wellbeing.
 Determine the mode of delivery according to the presentation of the fetus and the fetal
condition, together with the likelihood of success of induction of labour after cervical
assessment.
 Vaginal delivery is preferable but if gestation < 32 weeks, CS is more likely as the
success of induction is reduced.
 After 34 weeks with a cephalic presentation, vaginal delivery should be considered.
 The consultant obstetrician should discuss the mode of delivery with the mother.
 Vaginal prostaglandins will increase the chance of success.
 Anti-hypertensive treatment should be continued throughout assessment and labour.
 The third stage should be managed with 5 units intramuscular or intravenous
Syntocinon. Ergometrine or Syntometrine should not be given.
How should the woman be managed following delivery?
 be aware of the risk of late seizures and careful review before discharge from hospital.
 Continue Anti-hypertensive medication after delivery as dictated by the blood pressure.
 It may be necessary to maintain treatment for up to 3 months andmost women can have
treatment stopped before this.
 Women with persisting hypertension and proteinuria at 6 weeks may have renal disease
and should be investigated.
 44% of eclampsia occurs postpartum, especially at term, so women with signs or
symptoms compatible with pre-eclampsia should be carefully assessed.
 As eclampsia reported up to 4 weeks postnatally, the optimum length of inpatient
postnatal stay is unclear but the incidence of eclampsia falls after 4th postpartum
day.
 A reduction in anti-hypertensive therapy should be made in a stepwise fashion.
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  woman can go home on treatment, to be weaned off therapy as an outpatient.
 avoid the use of alpha methyldopa in the postnatal period because of its adverse
effect particularly depression.
 Corticosteroids have been used in HELLP syndrome. The evidence suggests they
lead to rapid resolution of the biochemical and haematological abnormalities but
there is no evidence that they reduce morbidity.
4) Follow-up and final diagnosis
 An assessment of blood pressure and proteinuria by the general practitioner at the 6
weeks postnatal check is recommended.
 If hypertension or proteinuria persists then further investigation is recommended.
 13% of women with pre-eclampsia have underlying chronic or essential hypertension.
 Women whose pregnancies have been complicated by severe pre-eclampsia or
eclampsia should be offered a formal postnatal review to discuss the events of the
pregnancy.
Preconceptional counselling should be offered in subsequent pregnancies

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INVESTIGATION AND MANAGEMENT OF THE SGA
Introduction and background
 SGA birth is defined as an estimated fetal weight (EFW) or abdominal circumference
(AC) less than the 10th centile and severe SGA as an EFW or AC less than the 3rd
centile.
 SGA fetuses are a heterogeneous group comprising:
1. fetuses that have failed to achieve their growth potential (fetal growth restriction,
FGR)
2. Fetuses that are constitutionally small. 50–70% of SGA are constitutionally small.
 Fetus with growth restriction may not be SGA.
 SGA fetuses are at greater risk of stillbirth, birth hypoxia, neonatal complications
impaired neurodevelopment, and possibly type 2 diabetes and hypertension in adult life.
 The poor perinatal outcome associated with SGA is likely due to high incidence of FGR
in this group. However, the vast majority of term SGA infants have no appreciable
morbidity or mortality.
Diagnosis
 Methods employed to detect SGA fetuses include:
1. abdominal palpation,
2. measurement of symphyseal fundal height,
3. ultrasound biometry,
4. ultrasound estimated fetal weight
5. ultrasound Doppler flow velocimetry.
 Four important issues need to be considered with the use of these tests:
1. most measurements require an accurate estimation of GA as a prerequisite
2. most tests attempt to diagnose SGA fetuses rather than FGR.
3. most studies use a one-off measurement (size) to predict SGA while there is
evidence that it is the trend (growth) that is of more value in predicting FGR and
poor fetal outcome.
4. in most situations no allowance is made for important prognostic factors for SGA,
such as maternal height, weight, ethnicity, parity and fetal gender.
 Biometric tests - tests to measure size / growth
 Biophysical tests - tests to assess fetal wellbeing
 Abnormal results such as small fetus with reduced liquor or abnormal Doppler may
indicate pathology.
 the diagnosis of SGA is by biometric tests while abnormal biophysical tests indicate
FGR.
1) Abdominal palpation
 Abdominal palpation has limited diagnostic accuracy 30%to predict SGA fetus.
2) Symphyseal fundal height(SFH)
 Has limited diagnostic accuracy to predict SGA fetus. Sensitivity 27%and specificity88%.
 Significant intra- and inter-observer variation; supplement with ultrasound biometric
tests
 Customized fundal height chart improves accuracy to predict an SGA fetus.
3) Ultrasound biometry
 Abdominal circumference and estimated fetal weight to diagnose SGA has sensitivities
of 72.9–94.5% and specificities of 50.6–83.8%.so are the most accurate diagnostic
measurements to predict SGA.

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 FORMULAE FOR ESTIMATION OF FETAL WEIGHT:
1. Shepard‟s formula:
 EFW = BPD + AC
2. Aoki‟s formula:43
 EFW = BPD + FAA + FL
3. Hadlock‟s formula:45
 EFW = AC + FL + HC + BPD
 The tenth centile for both EFW and AC had better sensitivities and specificities than
other centiles.
 Customized ultrasound charts; that are adjusted for important independent physiological
variables, such as maternal weight, maternal height, ethnic group and parity, have better
sensitivities for identifying SGA and FGR.
 Use growth velocity in addition to size. Serial measurements of AC and EFW (growth
velocities) are superior to single estimates in the prediction of FGR (abnormal neonatal
ponderal index and skinfold thickness) and predicting poor perinatal outcome.
4) Biophysical tests to diagnose SGA/FGR
 All biophysical tests , AFV, Doppler, CTG and BPPs are poor at diagnosing SGA/FGR
i. AFV has minimal value in diagnosing FGR
ii. Uterine artery Doppler has limited use in predicting FGR- aortic to middle cerebral
artery pulsatility index ratio are used to predict FGR fetuses but needs to be evaluated
further.
Investigations that are indicated in SGA fetuses
 Offer referral for a detailed fetal anatomical survey and uterine artery Doppler by a fetal
medicine specialist if severe SGA is identified at 18–20 week scan.
 Karyotyping should be offered in severely SGA fetuses with structural anomalies and in
those detected before 23 weeks of gestation, especially if uterine artery Doppler is
normal.
 Serological screening for congenital cytomegalovirus (CMV) and toxoplasmosis infection
should be offered in severely SGA fetuses.
 Testing for syphilis and malaria should be considered in high risk populations.
 Uterine artery Doppler has limited accuracy to predict adverse outcome in SGA fetuses
diagnosed during the 3rd trimester.
Management
1) Assess for risk of chromosomal defects.
 19% of fetuses with an AC and EFW < 5th centile may have chromosomal defects.
 The risk is higher when growth restriction is associated with: structural
abnormalities, normal AFV or a normal uterine or umbilical artery Doppler.
 Therefore, all growth-restricted fetuses need: ultrasound anatomical survey as a
minimum. It may also be appropriate to offer karyotyping.
2) Surveillance of the small fetus
1. Use umbilical artery Doppler as the primary surveillance tool.
 Only umbilical artery Doppler had value in predicting poor perinatal outcomes in
SGA fetuses.
 There is evidence that Use of Doppler:
1. Doesn't lead to increased interventions as the rates of positive test are low .
2. reduces the use of resources compared with cardiotocography.
3. In a low-risk or unselected population does not reduce perinatal mortality or
morbidity.
 A variety of indices of umbilical arterial Doppler waveform is used, such as:
1. Resistance index,
2. Systolic/diastolic ratio,
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 3. Pulsatility index
4. Diastolic average ratio,
 Resistance index had the best ability to predict abnormal outcomes such
associated with SGA.
 When anomaly scan and umbilical artery Doppler are normal, the small fetus is
likely to be a „normal small fetus‟
 Monitoring in SGA with normal Doppler need not generally be more than once
every fortnight.
2. Measure liquor volume using either AFI or pocket depth as both have similar
diagnostic accuracy.
 Reduced liquor volume is associated with increased perinatal mortality compared
with normal.
3. Use biophysical profile and cardiotocography infrequently.
 Biophysical profile doesn't improve perinatal outcome but no sufficient data to rule
out its value.
 So, it not recommended for primary surveillance in SGA fetuses.
 There is evidence that BPP in high-risk women has good negative predictive
value(fetal death is rare in women with a normal BPP).
 Use of cardiotocography (CTG) antepartum is not associated with better perinatal
outcome.
3) Delivery
1. There is wide variation in practice in the timing of delivery of FGR.
2. When end diastolic flow is present (PED), delay delivery until at least 37 weeks,
provided other surveillance findings are normal.
 Absent or reversed end diastolic flow is associated with:
1. increased perinatal mortality and morbidity.
2. No lncrease in RDS and necrotising enterocolitis .
3. Increase in cerebral haemorrhage, anaemia and hypoglycaemia.
3. When end diastolic flow is absent or reversed, admission, close surveillance and
steroids are required. Then do;
 daily CTG/BPP and/or venous Doppler
 Delivery is indicated If :
1. When the CTG becomes pathological (decelerations with reduced
variability).
2. The BPP becomes abnormal (≤ 4).
3. There is reversal of Doppler velocities in ductus venosus during atrial
contraction.
4. There are umbilical vein pulsations.
5. If gestation is over 34 weeks, even if other results are normal.

4. Use gestation- and customized birth weight charts to determine the likelihood of
survival if early delivery is required.
5. Administer steroids if gestation is below 36 weeks.
6. Delivery by emergent cs
7. Deliver in a unit with optimal neonatal expertise and facilities.
8. A skilled newborn resuscitator should be present at delivery. A neonatologist should
be present if there is extremely preterm or severe growth restriction.
9. Intrapartum monitoring with continuous CTG is recommended.
4) Evidence summary for other interventions that have been tried
 Most prenatal interventions do not show any significant effects on perinatal outcome.

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 Smoking cessation can be effective for a small minority of smokers in increasing birth
weight but there are no data to suggest that this intervention improves perinatal
outcome.
 meta-analysis found that aspirin reduces the incidence of FGR, but few studies have
used aspirin in the treatment of FGR, these trials are small and with conflicting results.
 There is insufficient evidence to support oxygen therapy, nutrient therapy, hospitalisation
and bed rest, betamimetics, calcium blockers, hormonal therapy and plasma expansion
in treating growth restriction.

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226
REDUCED FETAL MOVEMENTS
Background:
 There is no agreed definition of RFM because of different fetal activity patterns and
maternal perception of fetal activity.
 Fetal movements have been defined as any discrete kick, flutter, swish or roll.
 A significant reduction or sudden alteration in fetal movement is important clinical sign.
 reduced or absent fetal movements may be a warning sign of impending fetal death.
 55% of women with a stillbirth perceived a RFM prior to diagnosis.
 Inappropriate response by clinicians to RFM was a common contributory factor in
stillbirth.
Normal fetal movements during pregnancy
 Most women are aware of fetal movements by 18–20 weeks of gestation.
 The frequency of spontaneous movements increase until the 32nd week of pregnancy
then plateaus until the onset of labour; and.
 The type of fetal movement may change in the third trimester but there is no reduction
in the frequency.
 By term, the number of movements per hour range 16–45 and the longest period
between 50-75 minutes.
 From 20 weeks, fetal movements show diurnal changes with afternoon and evening
peak.
 fetal „sleep‟cycles, last for 20–40 minutes and rarely exceed 90 minutes in the normal
fetus .
factors which influence a woman s perception of fetal movements
 posture: most fetal movements percieved when lying down, fewer when sitting and
fewest while standing.
 Busy women often report a misperception of a reduction of fetal movements.
 Maternal perception of fetal movement increase during evening.
 anteriorly positioned placenta Prior to 28+0 weeks, decrease perception of fetal
movements.
 Sedating drugs such as alcohol, benzodiazepines, and opioids can reduce fetal
movements.
 Elevated maternal blood glucose is associated with increase in fetal movements.
 smoking is associated with RFM from 30 weeks of gestation onwards.
 corticosteroids decrease fetal movements and fetal heart rate variability over the 2
days.
 Fetal anomalies are associated with RFM.
 Anencephalic fetuses may be associated with normal or excessive fetal activity.
 Fetal presentation has no effect on perception of movement.
 Fetal position might influence maternal perception.
Assessment of fetal movements
 Fetal movements should be assessed by subjective maternal perception.
 mean time to perceive 10 movements varied between 21 min for focused counting to
162 min with unfocused.
 Women should be advised to be aware of pattern of movements after 28+0weeks, if
changed or reduced they should contact their maternity unit.
 Women with RFM should not wait until the next day for assessment of fetal wellbeing.

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  Women unsure about RFM, advise them to lie on their left side and count fetal
movements for 2 hours, If they do not feel 10 or more discrete movements in 2 hours,
they should contact their maternity unit immediately.
the optimal management of women with RFM
 The initial goal of antenatal fetal surveillance for RFM is to :
1. Exclude fetal death
2. Exclude fetal compromise
3. Identify pregnancies at risk of adverse pregnancy outcome while avoiding
unnecessary interventions.
1) Clinical history
 assess woman‟s risk factors for stillbirth and FGR:
 multiple consultations for RFM,
 known FGR,
 hypertension,
 diabetes,
 advanced maternal age,
 primiparity,
 smoking,
 placental insufficiency,
 congenital malformation,
 obesity,
 racial/ethnic factors,
 poor past obstetric history (FGR and stillbirth),
 genetic factors and issues.
 A history of RFM should include:
 the duration of RFM or absence of fetal movements,
 is it the 1st time to perceived RFM or not.
 Reassure women If proved not to have RFM, there are no risk factors for stillbirth and
there is positive fetal heart on auscultation.
 if the woman still has concerns, she should be advised to attend her maternity unit.
 Women with a sudden change in fetal activity or with risk factors for stillbirth should
report to their maternity unit for further investigation.
2) clinical examination
 auscultate the fetal heart using a handheld Doppler device to exclude fetal death.
 Assess fetal size to detect SGA fetuses.
 If no FHR - refer for US scan for assessment of fetal cardiac activity
 The RCOG guidelines recommend use of a customised fundal height chart
 measure blood pressure and test for proteinuria in women with RFM to diagnose pre-
eclampsia.
3) CTG
 CTG to exclude fetal compromise if the pregnancy is over 28+0 weeks and fetal
viability and RFM has been confirmed.
 CTG monitoring for at least 20 mins
 Normal CTG with acceleration on FM – normal functioning ANS
 Term fetus with no FHR accelerations >80 mins – fetal compromise
 56% of women with a risk factors and RFM had an abnormal CTG.
 9/10 with abnormal CTG associated with an adverse perinatal outcome.
4) ultrasound scanning
 undertaken for a woman presenting with RFM after 28+0 weeks of gestation if:
 persistent RFM despite a normal CTG
 there are additional risk factors for FGR/stillbirth.

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  It should be performed within 24 hours if necessary.
 Ultrasound scan assessment should include:
 AC and/or EEW to detect the SGA fetus,
 Amniotic fluid volume.
 Anomaly scan after maternal consent if not previously performed.
 Umbilical artery Doppler alone did not provide valuable information in any case.
 women with RFM with no risk factors did not require further follow-up if the CTG and
the amniotic fluid volume were normal.
 Recommendation: If no fetal movements - Do CTG and US within 2 hours If RFM -
Do CTG and US within 12 hours
5) Biophysical profile (BPP)
 There may be a role for the selective use of BPP in the management or investigation of
RFM.
 the evidence does not support the use of BPP for fetal wellbeing in high-risk
pregnancies.
 however, BPP in high-risk women has good negative predictive value.
What is the optimal surveillance method for women with RFM in whom investigations
are normal?
 70%of pregnancies with a single episode of RFM are uncomplicated.
 No data to support use of kick charts after RFM in those who have normal
investigations.
 Women with normal investigations after one episode of RFM should contact maternity
unit if they have another episode.
What is the optimal management of the woman who presents recurrently with reduced
RFM?
 When awoman recurrently perceives RFM:
 Should reviewed to exclude predisposing causes.
 Should has ultrasound as part of the investigations.
 Poor perinatal outcome increase with recurrent RFM.
 Decision whether or not to induce labour at term when the growth, liquor volume and
CTG appear normal must be made after careful consultant-led counselling of the
pros and cons of IOL.
What is the optimal management of RFM before 24+0 weeks of gestation?
 fetal heartbeat should be confirmed by auscultation with a Doppler handheld device.
 If fetal movements have never been felt by 24 weeks, refer to a fetal medicine centre.
What is the optimal management of RFM between 24+0 and 28+0 weeks of gestation?
 fetal heartbeat should be confirmed by auscultation with a Doppler handheld device.
 History must include evaluation of risk of stillbirth and FGR.
 There is no evidence to recommend the routine use of CTG surveillance and
ultrasound assessment in this group.
 If there is clinical suspicion of FGR, consideration should be given to the need for
ultrasound assessment.
What should we document in the maternal records?
 It is important that full details of assessment and management are documented.
 It is also important to record the advice given about follow-up and when/where to
present if a further episode of RFM is perceived.

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LATE INTRAUTERINE FETAL DEATH AND STILLBIRTH
Background
 (CEMACH)3 defined stillbirth as „a baby delivered with no signs of life known to have
died after 24 completed weeks of pregnancy‟.
 IUFD refers to babies with no signs of life in utero.
 in the UK stillbirth rate was 3.9 per 1000.
 >1/3 of stillbirths are SGA ,1/2 unexplained and 1/2 with suboptimal care.
 rising obesity rates and average maternal age might be behind the lack of improvement
the stillbirth rate.
Diagnosis
the optimal method for diagnosing late IUFD
 Real-time ultrasonography is essential for the accurate diagnosis of IUFD.
 A second opinion should be obtained whenever practically possible.
 Mothers should be prepared for the possibility of passive fetal movement.
 Offer repeat scan If the mother reports passive fetal movement after the scan to
diagnose IUFD.
 If Imaging technically difficult, (maternal obesity, abdominal scars and
oligohydramnios), views can be augmented with colour Doppler of the fetal heart and
umbilical cord.
 other secondary features for IUFD might be seen:
 spalding sign,
 hydrops and gross skin oedema
 unrecognisable fetal mass due to maceration.
 Intrafetal gas (within the heart, blood vessels and joints)
 occult placental abruption.
discussing the diagnosis and subsequent care
 If the woman is unaccompanied, offer should be made to call her partner, relatives or
friends.
 Discussions should support maternal/parental choice.
 offer written information to supplement discussions.
Investigation of the cause of late IUFD
The general principles of investigation
 Clinical assessment and investigation should be recommended to:
 assess maternal wellbeing including:
 coagulopathy. risk of DIC: 10% within 4 weeks of late IUFD, rising to 30%
thereafter.
Tests should be repeated twice weekly in women who choose expectant
management.
 pre-eclampsia,
 chorioamnionitis
 placental abruption.
 determine the cause of death,
 the chance of recurrence.
 Avoiding further pregnancy complications.
 No specific cause is found in half of stillbirths.
 When a cause is found it can crucially influence care in a future pregnancy.
 Abnormal tests may not related to the IUFD and should correlated to postmortem
examination.

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  use customised weight charts with contributing factors should be used to categorise
late IUFDs.
recommendations for women with an IUFD who are rhesus D-negative
 Kleihauer test for RhD-negative women to assess FMH.
 Anti-RhD should be administered and dose should be adjusted according to Kleihauer
test.
 The baby‟s blood group can be obtained from the baby or cord or using (ffDNA) from
maternal blood.
Tests to identify the cause of late IUFD
 Tests should be directed to identify scientifically proven causes of late IUFD.
 Commonly associated antepartum conditions include :
 congenital malformation,
 congenital fetal infection,
 antepartum haemorrhage,
 pre-eclampsia
 maternal disease such as diabetes mellitus.
 Commonly associated intrapartum conditions include:
 placental abruption,
 maternal and fetal infection,
 cord prolapse,
 idiopathic hypoxia–acidosis
 uterine rupture.
 Transplacental infections associated with IUFD include:
 Cytomegalovirus.
 Syphilis.
 Parvovirus.
 Listeria.
 Rubella.
 Toxoplasmosis.
 herpes simplex.
 coxsackievirus,
 leptospira,
 Q fever,
 Lyme disease.
 Malaria parasitaemia
 Ascending infection, with or without membrane rupture, with Escherichia coli,
Klebsiella, Group B Streptococcus, Enterococcus, mycoplasma/ureaplasma,
Haemophilus influenzae and Chlamydia are more common infectious causes
in developed countries.

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What precautions should be taken when sexing the baby?
 Two experienced healthcare practitioners (midwives, obstetricians, neonatologists or
pathologists) should examine external genitalia of extremely preterm, severely
macerated or hydropic infants.
 rapid karyotyping should be offered If there is any difficulty or doubt.
The best practice guidance for cytogenetic analysis of the baby
 Written consent should be taken.
 Samples from multiple tissues are used to increase the chance of culture.
 More than one cytogenetic technique should be available.
 Culture fluid should be stored in a refrigerator and thawed thoroughly before use.
 6% of stillborn babies will have a chromosomal abnormality.
 Some abnormalities are potentially recurrent.
the guidance on perinatal postmortem examination
 Postmortem examination provides more information than other tests.
 Individual, cultural and religious beliefs must be respected when offering postmortem
examination.
 Written consent must be obtained.
 Parents should be offered a description of the procedure and the appearance of the
baby afterwards..
 Discussions should be supplemented by the offer of a leaflet.
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  Postmortem examination should include :
 Birth weight,
 External
 Autopsy
 Microscopy
 X-ray
 Placenta and cord.
 Parents who decline full postmortem might be offered a limited examination such as
needle biopsies, but these are much less informative.
 Ultrasound and (MRI) should not be offered as a substitute for conventional
postmortem.
 MRI can be a useful adjunct to conventional postmortem.
Labour and birth
timing and mode of birth
 Options for timing and mode of birth depends on:
 the mother‟s preferences
 her medical condition
 previous intrapartum history.
 immediate delivery is concidered if there is
 sepsis,
 preeclampsia,
 placental abruption
 membrane rupture
 Well women with intact membranes and no evidence of DIC or bleeding should have
the option of immediate delivery versus expectant management because > 85% of
women will labour spontaneously within three weeks of diagnosis
 Women who delay labour for > 48 hours should be advised to have testing for DIC
twice weekly.
 Women with expectant management should be advised that:
 the value of postmortem may be reduced.
 The baby's appearance may deteriorate.
 Vaginal birth is the recommended mode of delivery, but CS may be considered with
some.
 Vaginal birth can be achieved within 24 hours of induction of labour in about 90% of
women.
IOL for a woman with an unscarred uterus
 Combination of mifepristone and a prostaglandin preparation are recommended as 1st
line for IOL
 Mifepristone reduce the time interval by about 7 hours compared with regimens not
including mifepristone.
 misoprostol use for late IUFD should be adjusted according to gestational age:
 100 micrograms 6-hourly before 26 weeks;
 25–50 micrograms 4-hourly after 26 weeks or more.
 Misoprostol and prostaglandin E2 have equivalent safety and efficacy with lower cost
for misoprostol.
 vaginal misoprostol is as effective as oral but associated with less adverse effects(GIT,
shivering and pyrexia)
IOL for a woman with an scarred uterus
 should be undertaken by a consultant obstetrician.
 Mifepristone alone increase the chance of labour significantly within 72 hours:
 200 mg three times a day for 2 days.
 Or mifepristone 600 mg once daily for 2 days.
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  In women with a single LSCS, IOL with prostaglandin is safe but not without risk.
 Women with two LSCS the risk of IOL is only a little higher than for women with a single
previous LSCS.
 Women with more than two LSCS deliveries or atypical scars the safety of induction of
labour is unknown.
What are considered suitable facilities for labour?
 Women with uncomplicated IUFD should be monitored in a separate labour room with a
companion, away from the sounds of other women and babies.
 Care in labour should given by an experienced midwife.
What are the recommendations for intrapartum antimicrobial therapy?
 Women with sepsis should be treated with intravenous broad-spectrum antibiotic.
 Routine antibiotic prophylaxis should not be used.
 Intrapartum antibiotic prophylaxis for women colonised with group B streptococcus is
not indicated.
Are there any special recommendations for pain relief in labour?
 Diamorphine should be used in preference to pethidine.
 Epidural anaesthesia should be available after assessment for DIC and sepsis.
Puerperium
thromboprophylaxis
 Women should be routinely assessed for thromboprophylaxis, but IUFD is not a risk
factor.
 Heparin thromboprophylaxis should be discussed with a haematologist if the woman
has DIC.
suppression of lactation
 Cabergoline is superior to bromocriptine.
 Dopamine agonists should not be given to women with hypertension or pre-eclampsia.
Who should be informed of events?
 All staff responsible for care of the woman during pregnancy and afterwards should be
informed of events.
 All existing appointments should be cancelled.
Psychological and social aspects of care
What psychological problems can follow late IUFD?
 Women at increased risk of prolonged severe psychological reactions including post-
traumatic stress disorder
 Men have less guilt, anxiety than women, but they can also develop post-traumatic
stress disorder.
 Parental relationships have a 40% higher risk of dissolving after stillbirth compared with
live birth.
What is best practice for use of interventions that might aid psychological recovery?
 Carers should be aware of to possible variations in individual approaches to death.
 Counselling should be offered to all women and their partners and other family
members.
 Parents should be advised about support groups.
What is the evidence for seeing, holding, naming and mementos?
 Parents should be offered, but not persuaded, to have contact with their stillborn baby.
 If parents named their baby, carers should use the name, including at follow–up
meetings.
 Parents should be offered, but not persuaded, to retain artefacts of remembrance. If
they do not wish, store them securely in the maternal case record for future access..
 Verbal consent should be sought from the parents and for clinical photography.
What advice should be given about fertility?
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  Information about fertility and contraception should be offered to mothers before
returning home.
 Mothers are vulnerable to psychological disorders when conception occurs soon after
the loss.
 Some women not be aware they might conceive before their first menstrual period.
Follow-up
What are the options for follow-up meetings?
 woman and her partner should be shared when arranging follow-up.
 Before the visit, ensure that all available results are readily to hand.
What are the recommendations for the content of the follow-up appointment?
 the cause of late IUFD, chance of recurrence and any means of preventing further loss.
 General prepregnancy advice: support for smoking cessation and to consider weight
loss if BMI>25.
 benefit of delaying conception until severe psychological issues have been resolved.
 The meeting should be documented for the parents in a letter that includes an agreed
outline plan for future pregnancy.
Recommendations for pregnancy following unexplained stillbirth
 Carers should ensure they read all the notes of stillbirth thoroughly before seeing the
woman.
 Women with a previous unexplained IUFD should be recommended to:
 have obstetric antenatal care.
 have screening for gestational diabetes.
 serial assessment of growth by ultrasound biometry if the stillborn was SGA.
Recommendations for the management of future delivery after unexplained stillbirth
 birth at a specialist maternity unit.
 Maternal request for scheduled birth should take into account:
 The gestational age of the previous IUFD,
 previous intrapartum history
 the safety of induction of labour.
Recommendations for maternal care after the next birth
 aware for postpartum depression particularly if women conceived within <12 months
from IUFD
 maternal bonding can be adversely affected.

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PREGNANCY IN WOMEN WITH EPILEPSY
INTRODUCTION
 incidence 1 /200 women attending antenatal clinics.
 Epilepsy itself is associated with a 25% higher risk of giving birth to a malformed child.
The risk increased to three-fold with anti-epileptic drugs.
 >90% of babies born to epileptic mothers are normal
 The babies of women with epilepsy are at increased risk of HDNB and „abstinence
syndrome‟
 pregnancy is assocciated with increase in seizure in 1/3 and altered metabolism of anti-
epileptic drugs.
PRE-PREGNANCY CARE AND COUNSELLING
 Pregnancies in women with epilepsy should be planned pregnancies. (GRADE C)
 The avoidance of unplanned pregnancy requires effective contraception.
 The efficacy of hormonal contraception is reduced in women on enzyme-inducing
anticonvulsants (carbamazepine, phenytoin, primidone, phenobarbitone). COC
containing at least 50μg oestrogen/day or non-hormonal methods should be chosen.
(GRADE B)
 Provide women with epilepsy with the following information even if not immediately
planning pregnancy:
1. The majority of babies born to mothers with epilepsy are normal.
2. women with epilepsy, especially those on anti-epileptic drugs have increased risk
of baby with major malformations, minor anomalies or dysmorphic features
compared to women without epilepsy.
3. some of this risk is caused by a genetic predisposition inherent in some families.
4. Pre-natal screening using serum testing and ultrasound can detect many major
malformations.
5. Tonic-clonic convulsions during pregnancy carry risks for both mother and fetus.
6. Anticonvulsant is associated with an increased risk of NTD.
7. the aim should be the lowest dose of anticonvulsants protects against seizures.
Pre-pregnancy withdrawal of anticonvulsants and a change from poly to
monotherapy could be considered.
Hormonal Contraception for Women taking Enzyme-inducing Anticonvulsants
 COC
 Use a 50μg oestrogen pill (eg Norinyl-1, Ovran).
 If break through bleeding BTB occurs, combine pills to provide 80 or 100 (maximum)
μg oestrogen.
 The use of 4 packs of COCs consecutively with a reduced pill-free interval of 4 days
after the fourth pack is recommended.
 Maintain extra contraceptive cover for 8 weeks if enzyme-inducers withdrawn.
 POP
 Probably best avoided. If no other method, doubling the daily dose of POP reported
to be effective.
 Depo-provera
 Reduce interval between depo-provera injections from 12 weeks to 10.
 Norplant
 Currently, not recommended in long-term users of enzyme-inducing drugs.
FOLIC ACID
 Advise women with epilepsy to take folic acid 5mg daily preconception and for at least 12
weeks after
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 NTD occur more commonly in women on anti-epileptic medication, particularly with
sodium valproate
VITAMIN K
 The babies of women on enzyme-inducing anticonvulsants are at increased risk of
HDNB caused by deficiency of vitamin K-dependent clotting factors.
 Women on these drugs should be treated prophylactically with vitamin K (Konakion)
20mg orally daily from 36 weeks until delivery and their babies should receive vitamin K
1mg IM at birth.
 vitamin K can cross the placenta from maternal to fetal circulation and improve clotting in
the neonate.
 A case control study showed an absence of PIVKA II (reflecting adequate vitamin K
levels) in all cord blood samples from infants of mothers on enzyme-inducers treated
with antenatal vitamin K.
MANAGEMENT OF WOMEN AT RISK OF PRETERM DELIVERY
 Steroid metabolism is potentiated by enzyme-inducing anticonvulsants.
 Women taking these drugs, requiring antenatal steroid should receive a total of 48mg
rather than 24mg.
 Risk of preterm delivery also constitutes an indication to commence oral vitamin K at
20mg daily
ANTICONVULSANT DRUGS BEFORE AND DURING PREGNANCY
 Preconception history taking to review epilepsy diagnosis and presentation of specific
epileptic syndrome
 women presenting preconceptually with seizure-free for >2 yrs, management may
include supervised withdrawal of anticonvulsant medication over 3-6 months.
 For women presenting preconceptually and for whom drug withdrawal is inappropriate
consideration should be given to converting multiple drug regimens to single drug
regimens.
 The treatment chosen for each woman should be at the lowest dose that protects against
seizures.
 Where sodium valproate is the single agent of choice, high plasma levels should be
avoided by dividing the required daily dose over at least two doses or by using a slow
release preparation.
 For women who first present pregnant, modification of an effective anticonvulsant
regimen is not recommended as the potential for reducing risks of teratogenesis is
minimal.
 There is little clinical experience relating to the effects of anti-epileptic agents in
pregnancy.
LABOUR AND DELIVERY
 The most appropriate place of delivery for women with epilepsy is in a consultant-led unit
 Women with epilepsy should be reassured that most will have a normal, vaginal delivery.
 usual anti-epileptic regimen should be continued during labour. Missed doses are to be
avoided.
 seizures occur in 1 - 2% of women with epilepsy during labour.
 Fits in labour may be managed with intravenous diazepam 10-20mg (the first 10mg as a
bolus with slow injection of further 2mg boluses, as required). Oxygen should be
administered. If diazepam fails to control seizures, phenytoin intravenously at 18mg/Kg
may be administered.
 Repeated seizures in labour put the fetus at risk of anoxia and constitute an indication for
CS under GA.
 Offer Women with epilepsy same range of methods of pain relief in labour including
epidural analgesia
CARE OF THE INFANT AND POST-PARTUM CARE
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 Epilepsy and anticonvulsants are not contraindications to breast feeding. encourage and
support to do.
 Parents should be reassured that risk of epilepsy to their children is only around 3% for
most forms of epilepsy but significantly higher with a familial tendency to epilepsy or
certain specific syndromes.
 Advise regarding suitable settings for feeding(seated on the floor)and for other aspects
of infant care in order to minimise danger to the infant when seizure occur.
 review of the anticonvulsant regimen,
 advice about appropriate contraception and importance of preconceptual care in
subsequent pregnancy.

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RENAL DISEASE IN PREGNANCY
General
 Multidisciplinary team is requires, an obstetrician, a renal/obstetric physician and a
specialist midwife, all with expertise in the management of kidney disease in
pregnancy.
Prepregnancy
 Women of childbearing age with kidney disease should be made aware of the
implications regarding reproductive health and contraception.
 Women with kidney disease considering pregnancy should be offered prepregnancy
counselling by the MDT and should involve her partner.
 Prepregnancy counselling should allow discussion and modification of remediable
risk factors, including consideration of familial conditions and optimisation of
medications.
 Women with kidney disease considering IVF/assisted reproduction should be
referred for prepregnancy counselling to the MDT. Recommendation should be given
to single-embryo transfer if IVF is required.
 Women with normal or mildly decreased prepregnancy renal function (serum
creatinine <125 μmol/l (1.4 mg/dl)) advised that obstetric outcome is usually
successful without adverse effects on long-term course of their disease, although
there is increased risk of antenatal complications including pre-eclampsia.
Antenatal
 Women found or suspected to have kidney disease in pregnancy should be referred
to a nephrologist.
 Women with kidney disease should be offered low-dose aspirin as prophylaxis
against pre-eclampsia.
 The use of eGFR (estimated glomerular filtration rate) cannot be recommended for
use in pregnancy.
 Women with +1 or more dipstick positive proteinuria (in the absence of infection)
should be quantified.
 Baseline quantification of proteinuria is undertaken by 24 hour collection for urine
protein and by protein/creatinine ratio (PCR). Follow-up may then be undertaken with
PCR.
 Persistent proteinuria (>500 mg/day) before 20 weeks of gestation should prompt
referral to a nephrologist.
 Nephrotic syndrome is an indication for thromboprophylaxis in pregnancy and the
puerperium.
 Lesser degrees of proteinuria may constitute a risk for venous thromboembolism.
 Asymptomatic bacteriuria and urinary tract infection (UTI) in pregnancy should be
treated.
 Antibiotic prophylaxis should be given to women with recurrent bacteriuria/UTIs and
kidney disease.
 Women known to have lupus nephritis or suspected lupus flare should be referred to
the MDT.
 In pregnant women with kidney disease the target blood pressure should be below
140/90 mmHg.
 Prednisolone, azathioprine, ciclosporin or tacrolimus do not appear to be associated
with fetal abnormality and should not be discontinued in pregnancy, whereas the
safety of mycophenolate mofetil/enteric-coated mycophenolic acid,
sirolimus/everolimus or rituximab is yet to be determined.

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  Caring for women with renal transplantation and/or lower urological surgery should
involve the appropriate surgical team, as part of the delivery plan, where considered
necessary.
 Renal units, in conjunction with obstetric units, should formulate a „protocol for
management of women receiving or starting dialysis in pregnancy‟.
Postpartum
 Women with kidney disease in pregnancy should have early postpartum renal review.
 Women with kidney disease in pregnancy should be offered early contraceptive
advice.
 Postnatal evaluation of women with early-onset (necessitating delivery before 32
weeks of gestation) pre-eclampsia is important to identify women with underlying
renal disease.
 Isolated microscopic haematuria with structurally normal kidneys does not need to be
investigated during pregnancy but should be evaluated if persistent postpartum.

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MANAGEMENT OF WOMEN WITH OBESITY IN PREGNANCY
Purpose and scope
 Obesity in pregnancy defined as a Body Mass Index (BMI) of 30 kg/m or more at
booking.
 Classes of obesity:
 Class I; BMI 30.0–34.9
 Class 2; BMI 35.0–39.9
 Class 3 or morbid obesity: BMI 40 and over
Background and introduction
 The prevalence of obesity in pregnancy rising from 9–10% in 1990s to 16–19% in the
2000s.
 Obesity in pregnancy is associated with an increased risk of:
 miscarriage,
 prematurity,
 congenital anomalies,
 stillbirth .
 macrosomia
 neonatal death.
 lower breastfeeding
 obesity and metabolic disorders in childhood
 thromboembolism,
 gestational diabetes,
 pre-eclampsia,
 induced labour,
 dysfunctional labour,
 caesarean section,
 anaesthetic complications
 postpartum haemorrhage,
 wound infections,
 maternal death: the CEMACH report one maternal deaths in the 2003–2005
Pre-pregnancy care
 Women with a BMI >30 should receive information and advice about the risks of obesity
during pregnancy and childbirth, and supported to lose weight before conception.
 Loss of at least 4.5 kg in obese women before pregnancy reduced the risk of developing
GDM by 40%.
 Some weight loss regimens during the first trimester may increase the risk of fetal NTD.
 Women with a BMI >30 wishing to become pregnant should take 5mg folic acid
supplementation daily, starting at least one month before conception and continuing
during the first trimester of pregnancy.
 Women with a booking BMI >30 are adviced to take 10micrograms Vitamin D daily
during pregnancy because they are at increased risk of vitamin D deficiency.
Measuring weight, height and BMI
 Pregnant women should have their weight, height measured and their body mass index
calculated at booking.
Information-giving during pregnancy
What information should be provided to women with maternal obesity?
 Women with a BMI >30 should receive information and advice about the risks of obesity
during pregnancy and childbirth and how they may be minimized. including:
1) Obesity in pregnancy is associated with an increased risk of:
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  Miscarriage
 Prematurity
 congenital anomalies
 stillbirth
 macrosomia
 neonatal death.
 lower breastfeeding
 obesity and metabolic disorders in childhood
 thromboembolism,
 gestational diabetes,
 pre-eclampsia,
 induced labour,
 dysfunctional labour,
 caesarean section,
 anaesthetic complications
 postpartum haemorrhage,
 wound infections,
 maternal death: the CEMACH report one maternal deaths in the 2003–2005
2) increased maternal and fetal monitoring;
3) difficulties in fetal surveillance and screening for anomalies due to poor
ultrasound visualisation;
4) difficulties in anaesthesia and CS requiring senior obstetric anaesthetist and
antenatal anaesthetic assessment
 in order to prevent weight gain and GDM, Women should be aware about healthy eating
and exercise provided by trained professional early in the pregnancy.
Risk assessment during pregnancy
 Pregnant women with a booking BMI >40 should have an antenatal consultation with an
obstetric anaesthetist, to anticipate:
 Difficulties with venous access,
 Difficulties with regional(Epidural re-site and failure of epidural cannulation)
 Difficulties with general anaesthesia(aspiration, difficult intubation and
postoperative atelectasis).
 Co-morbidites such as hypertension and ischaemic heart disease.
 An anaesthetic management plan for labour should be discussed and documented in the
medical records.
 Women with a booking BMI >40 should have a documented assessment in the third
trimester by professional to determine manual handling requirements including safe
working loads of beds and theatre tables.
Thromboprophylaxis
 Women with BMI >30 should be assessed at booking and throughout pregnancy for the
risk of thromboembolism.
 If BMI >30 + two or more additional risk factors for thromboembolism, should LMWH
antenatally.
 Women receiving LMWH antenatally should usually continue until six weeks postpartum,
but a postnatal risk assessment should be made.

 If BMI >30 should be encouraged to mobilise as early as possible following childbirth.

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 If BMI >40 should receive postnatal LMWH for a minimum of 1 week regardless the
mode of delivery.
 If BMI >30 + one or more additional persisting risk factors for thromboembolism should
receive LMWH for 7 days after delivery.
 If BMI >30 + two or more additional persisting risk factors should receive TED stockings
in addition to LMWH.
Maternal surveillance and screening
What specific considerations should be given to maternal surveillance for women with
obesity?
 Appropriate cuff should be used for BP measurements.And the cuff size should be
documented in the records.
 Incidence of pre-eclampsia 1.4% in women with a BMI 19.8–26 and 3.5% in those with
morbid obesity BMI >40.
 Women with booking BMI >35 have increased risk of preeclampsia and should have
surveillance during pregnancy
1) Women with a booking BMI >35 and at least one additional risk factor for preeclampsia
should have referral early in pregnancy for specialist care. Additional risk factors
include:
1. first pregnancy or > 10 years interpregnancy interval
2. previous or family history of pre-eclampsia,
3. booking diastolic BP >80mmHg,
4. booking proteinuria >1+ on more than one occasion or >0.3g/24 hours,
5. multiple pregnancy,
6. medical conditions such as antiphospholipid antibodies or hypertension, renal
disease or DM.
2) Women with booking BMI >35 and no additional risk factor can have community
monitoring for preeclampsia at a minimum of 3 weekly intervals between 24 and 32
weeks gestation, and 2 weekly intervals from 32 weeks.
 All pregnant women with a booking BMI >30 should be screened for gestational diabetes
Planning labour and delivery
 Women with a booking BMI >30 should have an informed discussion antenatally about
intrapartum complications associated with a high BMI, and management plan which
documented in the notes.
 There is an increased risk of:
 Slow labour progression,
 Shoulder dystocia
 Emergency CS.
 PPH.
 Difficult CS
 Higher risk of anaesthetic complications
 Difficulties with intravenous access, regional anaesthesia and fetal surveillance
in labour,
 VBAC in women with a booking BMI >30 should have an individualised decision
because:
 Obesity is a risk factor for unsuccessful VBAC, uterine rupture and neonatal
injury during VBAC
 Emergency CS in women with obesity is associated with an increased maternal
morbidity
Care during childbirth
birth place?
 Women with a BMI >35 should give birth in a consultant-led obstetric unit with neonatal
services,
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 babies born to mothers with obesity are 1.5 times more likely to be admitted to a NICU
indication for induction of labour
 In absence of other obstetric or medical indications, obesity alone is not an indication for
IOL.
 IOL carries the risk of failed induction and emergency caesarean section with high
maternal morbidity.
lines of communication
 If a women with a BMI >40 is admitted to the labour:
1. Inform the duty anaesthetist if delivery or operative intervention is anticipated.
2. Alerted operating theatre staff .
3. An obstetrician and an anaesthetist at Specialty Trainee year 6 and above.
midwifery support
 Women with a BMI >40 who are in established labour should receive continuous
midwifery care.
specific interventions required during labour
 Women with a BMI >40 should have venous access established early in labour.
 Women with a BMI >30 should be recommended to have active management of the third
stage of labour.
 Women with a BMI >30 having CS should receive prophylactic antibiotics at the time of
surgery
 Women undergoing CS who have more than 2cm subcutaneous fat, should have
suturing.
Postnatal care and follow-up after pregnancy
initiation and maintenance of breastfeeding in women with maternal obesity
 Obesity is associated with low breastfeeding initiation and maintenance rates.
 Women with a booking BMI >30 should receive advice and support antenatally and
postnatally for breastfeeding.
ongoing care provided to women with maternal obesity following pregnancy
 Women with a booking BMI >30 should continue to receive nutritional and weight
reduction advice after birth.
 All women with a booking BMI >30 and GDM should have:
1. GTT 6 weeks after birth
2. regular follow up with the GP to screen for the development of type 2 diabetes.
3. annual screening for cardio-metabolic risk factors,
4. lifestyle and weight management advice.

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248
OBSTETRIC CHOLESTASIS
Background
 Prevelance in UK is 0.7% of pregnancies in multiethnic populations and 1.2–1.5% of
women of Indian–Pakistani origin.
 Prevalence is influenced by genetic and environmental factors .
 Obstetric cholestasis is characterised by pruritus in the absence of a skin rash with
abnormal LFTs ,neither of which has an alternative cause and both of which resolve
after birth.
 Obstetric cholestasis is associated with increased risk of preterm birth(spontaneous,
iatrogenic) and fetal death.
 There can also be maternal morbidity associated with the intense pruritus and sleep
deprivation.
How is obstetric cholestasis diagnosed?
 Obstetric cholestasis is diagnosed by pruritus in the absence of a skin rash with
abnormal LFTs and/or raised bile acids ,neither of which has an alternative cause
and both of which resolve after birth.
 Pruritus that involves the palms and soles is suggestive.
 Pregnancy-specific reference ranges for LFTs should be used.
 Women with persistent pruritus and normal biochemistry should have LFTs repeated
every 1–2 weeks.
 Postnatal resolution of pruritus and abnormal LFTs should be confirmed.
o Pruritus affecting 23% of pregnancies, of which a small proportion will have obstetric
cholestasis.
o The pruritus of obstetric cholestasis is typically worse at night, and widespread
involving palms and soles.
o Care must be taken to differentiate dermatographia artefacta(skin trauma from
intense scratching)which may be seen in obstetric cholestasis, from other common
skin conditions such as eczema or atopic eruption of pregnancy. If a rash present
consider, polymorphic eruption of pregnancy or pemphigoid gestations.
o Other evidence of cholestasis should be sought, including pale stool, dark urine and
jaundice.
o Risk factors for obstetric cholestasis include: personal or family history, multiple
pregnancy, carriage of hepatitis C and gallstones.
o History should include a drug history, before abnormal LFTs are determined to be
unexplained.
o Bile acid levels can rise significantly after a meal.
o Exclude other causes of pruritus and abnormal LFTs : viral screen for hepatitis A, B,
and C, Epstein Barr and cytomegalovirus, anti-smooth muscle for chronic active
hepatitis and antimitochondrial antibodies for primary biliary cirrhosis
o Pre-eclampsia and acute fatty liver of pregnancy form differential diagnosis in atypical
or early cases.
How should obstetric cholestasis be monitored?
 LFTs weekly until delivery.
 Postnatally, LFTs should be deferred for at least 10 days.
o Transaminases will range from just above the upper limit of normal to several
hundreds.
o Regular LFTs, along with a general review, BP measurement and urine check,
allow monitoring of the condition and exclusion of other diagnoses.
o If LFTs return to normal, obstetric cholestasis is not likely to be the diagnosis.
o If LFTs escalate very rapidly, additional diagnoses need to be considered.
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 o A coagulation screen should be performed.
o In normal pregnancy, LFTs may increase in the first 10 days of the puerperium.
routine measurement of LFTs should be deferred beyond this time and before to
the postnatal follow-up visit.
What is the risk of stillbirth for pregnancies complicated by obstetric cholestasis?
 the additional risk of stillbirth in obstetric cholestasis above the general population is
likely to be small.
What additional risks associated with pregnancies complicated by obstetric cholestasis?
 Obstetric cholestasis associated with increased risk of:
o premature birth, especially iatrogenic.
o meconium passage, fetal distress and delivery by CS
o PPH.
 Women with obstetric cholestasis should be booked under consultant-led care and
birth in a hospital.
Can fetal death be predicted and prevented?
 Poor outcome can't be predicted by biochemical results and delivery decisions
should not base on results alone.
 No specific method of antenatal fetal monitoring for the prediction of fetal death can
be recommended.
 Continuous fetal monitoring in labour should be offered.
 Fetal death is usually sudden.
 Placental insufficiency, FGR and oligohydramnios are not features of the disease
Should women with obstetric cholestasis be offered elective early delivery?
 A discussion should take place with women regarding induction of labour after 37+0
weeks.
 Women should knows:
o There is increased risk of perinatal morbidity from early intervention (after 37+0
weeks).
o intervention (after 37+0 weeks of gestation) may be stronger in those with more
severe biochemical abnormality (transaminases and bile acids).
o There is increased risk of maternal morbidity from intervention at 37+0 weeks of
gestation.
o There is inability to predict stillbirth if the pregnancy continues.
 Stillbirths in obstetric cholestasis have been reported across all gestations.
What treatment, if any, should be used to treat obstetric cholestasis?
 There is no evidence that any specific treatment improves fetal or neonatal
outcomes.
 All such therapies should be discussed with the individual woman with this in mind.
1) Topical emollients
 Topical emollients are safe but their efficacy is unknown.
2) Systemic treatment
 colestyramine,a bile acid-chelating agent,which may improve pruritus in some
women but may also exacerbate vitamin K deficiency.
 Antihistamines may provide some sedation at night but do not have a significant
impact on pruritus.
 Activated charcoal and guar gum do not relieve pruritus.
3) S-adenosyl methionine SAMe
 There is insufficient evidence to demonstrate whether SAMe is effective for either
control of maternal symptoms or for improving fetal outcome.
4) Ursodeoxycholic acid 8-12mg/kg/day UDCA
 UDCA improves pruritus and liver function in women with obstetric cholestasis.
5) Dexamethasone

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  Dexamethasone should not be first-line therapy for treatment of obstetric
cholestasis.(10 mg orally for 7 days and then stopping over 3 days)
What is the role of vitamin K?
 Prolonged PTT indicate the use of water-soluble vitamin K in doses of 5–10 mg daily.
 Women should be advised that when if prothrombin time is normal, vitamin K in low
doses should be used only after careful counselling about the benefits but small
theoretical risk.
follow-up offered to women who had a pregnancy affected by obstetric cholestasis
 Women should be offered follow-up with expertise healthcare professional:
o To provide appropriate counselling
o To ensure that LFTs have returned to normal, pruritus resolves,
o All investigations carried out during the pregnancy have been reviewed
o Reassurance about the lack of long-term sequelae for mother and baby
o the high recurrence rate (45–90%).
o contraceptive choices (usually avoiding estrogen-containing methods) .
o LFTs at 6 weeks after delivery and an appointment at 8 weeks is a suggested
model.

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ANTENATAL CARE
Antenatal information
Give information that:
 is easily understood, including women additional needs such as physical, sensory or
learning disabilities, and women who do not speak or read English
 enables women to make informed decisions
 is clear, consistent, balanced and accurate, and based on the current evidence
 is supported by written information and may also be provided in different formats.
Remember to:
 respect a woman‟s decisions, even when her views are contrary to your own
 provide an opportunity for her to discuss concerns and ask questions
 make sure she understands the information
 give her enough time to make decisions
 explain details of antenatal tests and screening in a setting conducive to discussions
(group setting or one-to-one). This should happen before the booking appointment.
Information should cover:
 where the woman will be seen and who by
 the likely number, timing and content of antenatal appointments
 participant-led antenatal classes and breastfeeding workshops
 the woman‟s right to accept or decline a test.
Basic principles of antenatal care
 Midwives and GPs should care for women with an uncomplicated pregnancy, providing
continuous care throughout the pregnancy.
 Obstetricians and specialist teams should be involved where additional care is needed. A
system of clear referral paths should be established
 Antenatal appointments should take place in a location that women can easily access.
 The location should be appropriate to the needs of women and their community to
discuss sensitive issues such as domestic violence, sexual abuse, psychiatric illness and
illicit drug use.
 Maternity records should be structured, standardised, , held by the woman.
 In an uncomplicated pregnancy, there should be 10 appointments for nulliparous women
and 7 appointments for parous women. women should receive written information about
the number, timing and content of antenatal appointments associated with different
options.
 Each antenatal appointment should have a structure and a focus.
 Appointments early in pregnancy should be longer to provide information and time for
discussion about screening so that women can make informed decisions.
 If possible, incorporate routine tests into the appointments to minimise inconvenience to
women.
 Women should feel able to discuss sensitive issues and disclose problems. Be alert to
the symptoms and signs of domestic violence.
Schedule of appointments
First contact with a healthcare professional
Give specific information on:
 folic acid supplements
 food hygiene, including how to reduce the risk of a food-acquired infection
 lifestyle, including smoking cessation, recreational drug use and alcohol consumption

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 all antenatal screening, including risks, benefits and limitations of the screening tests.
Booking appointment (ideally by 10 weeks)
Checks and tests
 Identify women who may need additional care and plan pattern of care.
 Measure height and weight and calculate BMI.
 Measure blood pressure and test urine for proteinuria.
 Determine risk factors for pre-eclampsia and gestational diabetes.
 check blood group and rhesus D status, and screening for anaemia,
haemoglobinopathies, red-cell alloantibodies, hepatitis B virus, HIV, rubella susceptibility
and syphilis.
 Offer screening for asymptomatic bacteriuria.
 Inform women younger than 25 years about the high prevalence of chlamydia infection in
their age group.
 Offer screening for Down‟s syndrome.
 Offer early scan for gestational age assessment and ultrasound screening for structural
anomalies.
 Identify women with FGM.
 Ask about any past or present severe mental illness or psychiatric treatment.
 Ask about mood to identify possible depression.
 Ask about the woman‟s occupation to identify potential risks.
Give specific information on:
 how the baby develops during pregnancy
 nutrition and diet, including vitamin D supplements
 exercise, including pelvic floor exercises
 antenatal screening, including risks and benefits of the screening tests
 the pregnancy care pathway
 planning place of birth
 breastfeeding, including workshops
 participant-led antenatal classes
 maternity benefits.
For women who choose to have screening, arrange as appropriate:
 blood tests (blood group, rhesus D status, screening for anaemia,
 haemoglobinopathies, red-cell alloantibodies, hepatitis B virus, HIV, rubella
 susceptibility and syphilis), ideally before 10 weeks
 urine tests (proteinuria and asymptomatic bacteriuria)
 ultrasound scan to determine gestational age using:
 crown–rump measurement between 10 weeks 0 days and 13 weeks 6 days
 head circumference if crown–rump length is above 84 mm
 Down‟s syndrome screening using either:
 combined test between 11 +0 and 13 +6
 serum screening test (triple or quadruple test) between 15 +0 and 20 +0
 ultrasound screening for structural anomalies, normally between 18 +0 and 20 +6.
16 weeks
Checks and tests
 Review, discuss and record the results of screening tests.
 Measure blood pressure and test urine for proteinuria.
 Investigate a haemoglobin level below 11 g/100 ml and consider iron supplements.
Give specific information on:
 the routine anomaly scan.
Anomaly scan: 18 to 20 weeks

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Checks and tests
 scan should be performed between 18 +0 and 20 +6 to detect structural anomalies.
 For a woman whose placenta extends across the internal cervical os, offer another scan
at 32 weeks.
25 weeks for nulliparous women
Checks and tests
 Measure blood pressure and test urine for proteinuria.
 Measure and plot symphysis–fundal height.
28 weeks
Checks and tests
 Measure blood pressure and test urine for proteinuria.
 Offer a second screening for anaemia and atypical red-cell alloantibodies.
 Investigate a haemoglobin level below 10.5 g/100 ml and consider iron supplements.
 Offer anti-D prophylaxis to women who are rhesus D-negative.
 Measure and plot symphysis–fundal height.
31 weeks for nulliparous women
Checks and tests
 Review, discuss and record the results of screening tests undertaken at 28 weeks.
 Measure blood pressure and test urine for proteinuria.
 Measure and plot symphysis–fundal height.
34 weeks
Checks and tests
 Review, discuss and record the results of screening tests undertaken at 28 weeks.
 Measure blood pressure and test urine for proteinuria.
 Offer a second dose of anti-D prophylaxis to women who are rhesus D-negative1.
 Measure and plot symphysis–fundal height.
Give specific information on:
 plan for labour and birth, , recognising active labour and coping with pain.
36 weeks
Checks and tests
 Measure blood pressure and test urine for proteinuria.
 Measure and plot symphysis–fundal height.
 Check the position of the baby. If breech, offer external cephalic version.
Give specific information (at or before 36 weeks) on:
 breastfeeding
 care of the new baby, vitamin K prophylaxis and newborn screening tests
 postnatal self-care, awareness of „baby blues‟ and postnatal depression.
38 weeks
Checks and tests
 Measure blood pressure and test urine for proteinuria.
 Measure and plot symphysis–fundal height.
Give specific information on:
 options for management of prolonged pregnancy2.
40 weeks for nulliparous women
Checks and tests
 Measure blood pressure and test urine for proteinuria.
 Measure and plot symphysis–fundal height.
 Further discussion of management of prolonged pregnancy2.
41 weeks
Checks and tests
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For women who have not given birth by 41 weeks:
 offer a membrane sweep2
 offer induction of labour2
 measure blood pressure and test urine for proteinuria
 measure and plot symphysis–fundal height.
From 42 weeks, offer women who decline induction of labour increased monitoring (at least
twice-weekly cardiotocography and ultrasound examination of maximum amniotic pool
depth).
Antenatal interventions NOT routinely recommended
 Repeated maternal weighing.
 Breast or pelvic examination.
 Iron or vitamin A supplements.
 Routine screening for chlamydia, cytomegalovirus, hepatitis C virus, group B
streptococcus, toxoplasmosis, bacterial vaginosis.
 Routine Doppler ultrasound in low-risk pregnancies.
 Ultrasound estimation of fetal size for suspected large-for-gestational-age unborn babies.
 Routine screening for preterm labour.
 Routine screening for cardiac anomalies using nuchal translucency.
 Gestational diabetes screening using fasting plasma glucose, random blood glucose,
glucose challenge test or urinalysis for glucose.
 Routine fetal-movement counting.
 Routine auscultation of the fetal heart.
 Routine antenatal electronic cardiotocography.
 Routine ultrasound scanning after 24 weeks.
Lifestyle advice
Working during pregnancy
 The majority of women can be reassured that it is safe to continue working during
pregnancy.
 A woman’s occupation should be ascertained to identify those at increased risk through
occupational exposure.
Nutritional supplements
 dietary supplementation with folic acid, before conception and up to 12 weeks, reduces
the risk of having a baby with NTD.
 The recommended dose is 400 micrograms per day.
 Iron supplementation should not be offered routinely to all pregnant women. It may have
unpleasant maternal side effects.
 vitamin A supplementation > 700 micrograms may be teratogenic and should be
avoided. liver and liver products may also contain high levels of vitamin A, consumption
of these products should also be avoided.
 It is important for mother and baby’s health to maintain adequate vitamin D stores
during pregnancy and breastfeeding. women may choose to take 10 micrograms of
vitamin D per day.
 women at greatest risk for vitamin D deficiency are following:
 women of South Asian, African, Caribbean or Middle Eastern
 women who have limited exposure to sunlight.
 women who eat a diet particularly low in vitamin D, such as women who consume no
oily fish, eggs, meat, vitamin D-fortified margarine or breakfast cereal
 women with a pre-pregnancy body mass index above 30 kg/m2.
Food-acquired infections
 offer information on how to reduce the risk of listeriosis by:
 drinking only pasteurised or UHT milk
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  not eating ripened soft cheese such as Camembert, there is no risk with hard
cheeses, such as Cheddar,
 not eating pate (of any sort, including vegetable)
 not eating uncooked or undercooked ready-prepared meals.
 offer information on how to reduce the risk of salmonella infection by:
 avoiding raw or partially cooked eggs or food such as mayonnaise
 avoiding raw or partially cooked meat, especially poultry.
Prescribed medicines
 medicines should be used as little as possible during pregnancy and limited to where the
benefit outweighs the risk.
Over-the-counter medicines
 few over-the-counter (OTC) medicines have beenestablished as being safe to take in
pregnancy.
Complementary therapies
 few complementary therapies have been established as being safe and effective during
pregnancy and they should be used as little as possible.
Exercise in pregnancy
 beginning or continuing a moderate course of exercise during pregnancy is not
associated with adverse outcomes.
 There is dangers of certain activities: contact sports, high-impact sports and that may
Result in abdominal trauma, falls or excessive joint stress.
Sexual intercourse in pregnancy
 sexual intercourse in pregnancy is not known to be associated with any adverse
outcomes.
Alcohol and smoking in pregnancy
 avoid drinking alcohol in the first 3 months of pregnancy because it may be associated
with an increased risk of miscarriage.
 If choose to drink alcohol no more than 1 to 2 UK units once or twice a week
 At the first contact with the woman, discuss her smoking status,
 informed about the specific risks of smoking during pregnancy (low birth weight and
preterm birth).
 advice and support on how to stop smoking.
 Monitor smoking status and offer smoking cessation advice,
 Discuss the risks and benefits of nicotine replacement therapy (NRT) with pregnant
women who smoke,
 Advise women using nicotine patches to remove them before going to bed.*
Cannabis use in pregnancy
 The direct effects of cannabis on the fetus are uncertain
 Cannabis use is associated with smoking, which is known to be harmful
Air travel during pregnancy
 long-haul air travel is associated with an increased risk of VTE,
 wearing compression stockings is effective at reducing the risk.
Car travel during pregnancy
 informed about the correct use of seatbelts that is, three-point seatbelts ‘above and
below the bump, not over it’.
Travelling abroad during pregnancy
 they should discuss considerations such as flying, vaccinations and travel insurance with
their midwife or doctor.
Management of common symptoms of pregnancy
Nausea and vomiting in early pregnancy

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 most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to
20 weeks
 nausea and vomiting are not usually associated with a poor pregnancy outcome.
 the following interventions effective in reducing symptoms:
1. nonpharmacological:
 ginger
 P6 (wrist) acupressure
2. pharmacological:
 antihistamines.
Heartburn
 Offer information regarding lifestyle and diet modification.
 Offer antacids to women whose heartburn remains troublesome despite lifestyle and diet
modification.
Constipation
 Offer information regarding diet modification, such as bran or wheat fibre
supplementation.
Haemorrhoids
 Offer information concerning diet modification.
 If clinical symptoms remain troublesome, standard haemorrhoid creams should be
considered.
Varicose veins
 varicose veins are a common symptom of pregnancy that will not cause harm
 compression stockings can improve the symptoms but will not prevent varicose veins
from emerging.
Vaginal discharge
 increase in vaginal discharge is a common physiological change that occurs during
pregnancy.
 If this is associated with itch, soreness, offensive smell or pain on passing urine there
maybe an infective cause and investigation should be considered.
 1 week course of a topical imidazole should be considered for vaginal candidiasis in
pregnant women.
 The effectiveness and safety of oral treatments for vaginal candidiasis in pregnancy is
uncertain
Backache
 exercising in water, massage and group or individual back care classes might help.
Clinical examination of pregnant women
Measurement of weight and body mass index
 Maternal weight, height and BMI should be measured at the first antenatal appointment,
 Repeated weighing during pregnancy should be confined to circumstances where clinical
management is likely to be influenced.
Breast examination
 Routine breast examination during antenatal care is not recommended for the promotion
of postnatal breastfeeding.
Pelvic examination
 Routine antenatal pelvic examination does not accurately predict preterm birth or
cephalopelvic disproportion.
Female genital mutilation
 FGM should be identified early in antenatal care
 Antenatal examination will then allow planning of intrapartum care.
7.5 Domestic violence

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 be alert to the symptoms or signs of domestic violence and women should havethe
opportunity to disclose domestic violence in secure environment
Prediction, detection and initial management of mental disorders
 ask about:
 past or present severe mental illness including schizophrenia, bipolar disorder,
psychosis and severe depression
 previous treatment by specialist mental health team, including inpatient care
 family history of perinatal mental illness.
 At first contact, at booking visit and postnatally ask two questions to identify possible
depression:
 During the past month, have you often been bothered by feeling down, depressed
or?
 During the past month, have you often been bothered by having little interest in doing
things?
 A third question should be considered if the woman answers yes:
 Is this something you feel you need or want help with?
 If the woman has, or is suspected to have, a severe mental illness refer to a specialist
mental health service,
Screening for haematological conditions
Anaemia
 early in pregnancy (at the booking appointment) and at 28 weeks when other blood
screening tests are being performed.
 This allows enough time for treatment if anaemia is detected. [B]
 Haemoglobin levels outside the normal (11 g/100 ml at first contact and 10.5 g/100 ml at
28 weeks) should be investigated and iron supplementation considered if indicated.
Blood grouping and red cell alloantibodies
 offer blood group and rhesus D status in early pregnancy.
 Women should be screened for atypical red cell alloantibodies in early pregnancy and
again at 28 weeks, regardless of their rhesus D status.
Haemoglobinopathies
 Preconception counselling and testing should be available to women at higher risk of
haemoglobinopathies,
 Information about screening for sickle cell diseases and thalassaemias, including carrier
status and the implications should be given to pregnant women at the first contact
 Offer Screening for sickle cell diseases and thalassaemias to all women as early as
possible in pregnancy ideally by 10 weeks.
 Offer laboratory screening Where prevalence of sickle cell disease is high.
 Offer screening for haemoglobinopathies using the Family Origin Questionnaire
Where prevalence of sickle cell disease is low
 If the Family Origin Questionnaire indicates a high risk of sickle cell disorders,
laboratory screening should be offered.
 If the mean corpuscular haemoglobin is below 27 picograms, laboratory screening
should be offered.
 If the woman is identified as a carrier of significant haemoglobinopathy then the father
should be offered counselling and appropriate screening without delay.
Screening for fetal anomalies
Screening for structural anomalies
 routinely offered, normally between 18 +0 = and 20 +6.
 At the first contact women should be given information about the purpose of the anomaly
scan to enable them to make an informed choice.
 The purpose of the scan is to identify fetal anomalies and allow:
 reproductive choice (termination of pregnancy)
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  parents to prepare (for any treatment/disability/ termination of pregnancy)
 managed birth in a specialist centre
 intrauterine therapy.
 Detection rates of anomaly scan vary by the type of fetal anomaly, the woman’s body
mass index and the position of the baby at the time of the scan.
 Fetal echo involving the four chamber view of the fetal heart and outflow tracts is
recommended as part of the routine anomaly scan.
 Routine screening for cardiac anomalies using nuchal translucency is not recommended.
 When routine ultrasound screening is performed to detect NTDs, AFP is not required.
Screening for Down s syndrome
 at 11–14 weeks only:
1. nuchal translucency (NT)
2. combined test (NT + hCG + pregnancy associated plasma protein-A)
 at 15 – 20 weeks only:
1. double test (hCG, uE3)
2. triple test (hCG, uE3, AFP)
3. quadruple test (hCG, uE3, AFP, inhibin A)
 at 11–14 weeks and then at 15–20 weeks:
1. integrated test (combined test at 11–14 weeks, followed by AFP, uE3 and inhibin
A at 15–20 weeks)
2. serum integrated test (PAPP-A and hCG at 11–14 weeks, followed by AFP, uE3
and inhibin A at 15–20 weeks).
 the chance of the fetus having Down’s syndrome is calculated taking into account
screening test, maternal age and gestation.
 When a screen-positive result is returned, the woman is offered a diagnostic test, either
chorionic villus sampling (following a first-trimester screening test) or amniocentesis
(following a second-trimester screening test).
 When a woman is offered a diagnostic test she should be informed of:
 the risks associated with the invasive testing
 other chromosomal abnormalities, not just Down’s syndrome, may be identified
 in some cases the prognosis for the fetus may not be clear.
 Information about screening for Down’s syndrome should be given to at the first
contact with a healthcare professional and should include:
 the screening pathway for both screen-positive and screen-negative results
 the decisions that need to be made at each point along the pathway
 the fact that screening does not provide a definitive diagnosis
 information about chorionic villus sampling and amniocentesis
 balanced and accurate information about Down’s syndrome.
 The routine anomaly scan (at 18 weeks 0 days to 20 weeks 6 days) should not be
routinely used for Down’s syndrome screening
Screening for infections
Asymptomatic bacteriuria
 offer routine screening for asymptomatic bacteriuria by MSU culture early in pregnancy.
 Identification and treatment of asymptomatic bacteriuria reduces the risk of
pyelonephritis.
Asymptomatic bacterial vaginosis
 Don‟t offer routine screening for bacterial vaginosis because identification and treatment
of asymptomatic bacterial vaginosis does not lower the risk for preterm birth
Chlamydia trachomatis
 inform pregnant women younger than 25 years about the high prevalence of chlamydia
in their age group
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 Chlamydia screening should not be offered as part of routine antenatal care.
Cytomegalovirus
 The available evidence does not support routine cytomegalovirus screening in pregnant
women
Hepatitis B virus
 Offer Serological screening for hepatitis B virus to pregnant women to decrease the risk
of mother-to-child transmission.
Hepatitis C virus
 There is insufficient evidence to support routine screening for hepatitis C virus
HIV
 Offer screening for HIV infection early in antenatal care because appropriate antenatal
interventions can reduce mother-to-child transmission of HIV infection.
Rubella
 Rubella susceptibility screening should be offered early in antenatal care to identify
women at risk of infection and to enable vaccination in the postnatal period
Streptococcus Group B
 Don‟t offer routine antenatal screening for group B streptococcus because its cost-
effectiveness remains uncertain.
Syphilis
 Offer Screening for syphilis at an early stage in antenatal care because treatment of
syphilis is beneficial to the mother and baby.

Toxoplasmosis
 Don‟t offer Routine antenatal serological screening for toxoplasmosis
 Advise about measures to avoid toxoplasmosis infection:
 washing hands before handling food
 thoroughly washing all fruit and vegetables, including ready-prepared salads, before
eating
 thoroughly cooking raw meats and ready-prepared chilled meals
 wearing gloves and thoroughly washing hands after handling soil and gardening
 avoiding cat faeces in cat litter or in soil.
Screening for clinical conditions
Gestational diabetes
 Screening for gestational diabetes using risk factors is recommended in a healthy
population.
 In order to make an informed decision about screening for GDM women should be
informed that:
 in most women, GDM will respond to changes in diet and exercise
 10% - 20% will need oral hypoglycaemic agents or insulin
 if GDM is not detected and controlled there is a small risk of birth complications such
as shoulder dystocia
 a diagnosis of GDM lead to increased monitoring and interventions during pregnancy
and labour.
 Screening for gestational diabetes using only OGTT.
Pre-eclampsia
 Do blood pressure measurement and urinalysis for protein at each antenatal visit.
 Determine the following risk factors for pre‑eclampsia at the booking:
 age 40 years or older
 nulliparity
 pregnancy interval of more than 10 years
 family history of pre‑eclampsia
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  previous history of pre‑eclampsia
 body mass index 30 kg/m2 or above
 pre‑existing vascular disease such as hypertension
 pre‑existing renal disease
 multiple pregnancy.
 Consider more frequent blood pressure measurements for pregnant women who have
risk factors.
Preterm birth
 Routine screening for preterm labour should not be offered.
Placenta praevia
 only a woman whose placenta extends over the internal cervical os should be offered
another transabdominal scan at 32 weeks.
 If the TAS is unclear, TVS should be offered.
Fetal growth and wellbeing
Determining fetal growth
 Measure and record Symphysis–fundal height at each antenatal appointment from 24
weeks.
 Ultrasound estimation of fetal size for suspected large-for-gestational-age should not be
undertaken in a low-risk population.
 Routine Doppler ultrasound should not be used in low-risk pregnancies.
Abdominal palpation for fetal presentation
 Assess Fetal presentation by abdominal palpation at 36 weeks or later,
 Suspected fetal malpresentation should be confirmed by an ultrasound assessment.
Routine monitoring of fetal movements
 Routine formal fetal-movement counting should not be offered. [A]
Auscultation of fetal heart
 Auscultation of the fetal heart confirm that the fetus is alive but unlikely to have any
predictive value and routine listening is therefore not recommended.
Cardiotocography
 The evidence does not support the routine use of antenatal CTG for fetal assessment in
women with an uncomplicated pregnancy
Ultrasound assessment in the third trimester
 The evidence does not support the routine use of scan after 24 weeks.
Management of specific clinical conditions
Pregnancy after 41 weeks
 Prior to formal IOL, women should be offered membrane sweeping. with uncomplicated
pregnancies offer IOL beyond 41 weeks.
 offered increased antenatal monitoring from 42 weeks if women decline IOL, at least
twice-weekly CTG and scan for maximum amniotic pool depth.
Breech presentation at term
 Offer ECV foruncomplicated singleton breech pregnancy at 36 weeks should
The ‘Antenatal assessment tool’
 Using structured questions, the tool aims to identify women who may require additional
care.
 The tool identifies women who:
 can remain within or return to the routine antenatal pathway of care
 may need additional obstetric care for medical reasons
 may need social support and/or medical care for a variety of socially complex
reasons.
Why this is important
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 to group pregnant women into low-risk (midwiferyonly care) and increased-risk
(midwifery and obstetric care).
 The validated tool should have the potential to identify a third group of women who are
particularly vulnerable and at increased risk of maternal and perinatal death.

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ANTENATAL CORTICOSTEROIDS
What are the benefits of antenatal corticosteroids?
 Antenatal steroids are associated with a significant reduction in rates of:
 neonatal death by 31%,
 RDS by 44% and
 intraventricular haemorrhage by 46% .
 Antenatal corticosteroid use is also associated with a reduction in:
 necrotising enterocolitis,
 respiratory support,
 intensive care admissions
 systemic infections in the first 48 hours.
At what gestation should antenatal steroids be used?
 For women between 24+0 and 34+6 weeks of gestation who are at risk of preterm birth.
 can be considered for women between 23+0 and 23+6 weeks of gestation who are at
risk of preterm birth.
 Corticosteroids at gestations less than 24+0 weeks should be made at a senior level.
 Antenatal corticosteroids should be given to all women with elective caesarean section
prior to 38+6 weeks of gestation to reduce the risk of respiratory morbidity.
 There is no evidence to support prophylactic steroids in women with a previous history of
preterm delivery or multiple pregnancy who show no signs of preterm birth.
 A retrospective cohort study showed that a prophylactic corticosteroids every 2 weeks
from 24 to 32 weeks of gestation was not associated with a significant reduction in RDS,
but associated with:
 reduced birth weight in term by 129 g.
 reduced head circumference
 growth delay
 brain developmental delay
 lung development problems
 necrotising enterocolitis
 maternal and neonatal sepsis
 adrenal gland insufficiency
 placental infarction
How long after administration is a course of antenatal corticosteroids most effective?
 most effective in reducing RDS if delivery occur 24 hours after and up to 7 days after
administration of the second dose of antenatal corticosteroids.
 Before that for neonatal death and therefore should still be given even if delivery is
expected less than 24 hrs.
How safe is the use of antenatal corticosteroids?
 a single course of antenatal corticosteroids is not associated with any significant short-
term or long term maternal or fetal adverse effects.
 There is still insufficient evidence on the longer-term benefits and risks of multiple
courses.
Are there any contraindications to the use of antenatal corticosteroids?
 Caution should be taken when giving corticosteroid to women with systemic infection
including TB.
 Senior opinion should be taken to delay delivery for steroid in cases of chorioamnionitis.
 Clinical chorioamnionitis is significantly associated with periventricular leucomalacia and
CP. This suggest that with chorioamnionitis, corticosteroids may be started, but should

263
 not delay delivery if indicated by maternal or fetal condition.Senior opinion should be
taken
In multifetal pregnancy
 The optimal dose in multiple pregnancies is not clearly understood. Evidence suggests
that multiple pregnancy attenuates the effect of steroids.
In women with diabetes mellitus
 Diabetes mellitus is not a contraindication to antenatal corticosteroid.
 Women with impaired glucose tolerance or diabetes who are receiving fetal steroids
should have additional insulin.
In pregnancies with fetal growth restriction
 Pregnancies affected by FGR between 24+0 and 35+6 weeks of gestation at risk of
delivery should receive antenatal corticosteroids.
o There were increase in the survival rate without disability or handicap at 2 years
of age, but there were more children with physical growth problems in the
corticosteroid group.
o The benefits from antenatal corticosteroids for preterm growth-restricted infants
appear to outweigh the possible adverse effects.
What is the best dose and route of administration for a course of antenatal
corticosteroids?
 Betamethasone 12 mg given intramuscularly in two doses or dexamethasone 6 mg
given intramuscularly in four doses.
o betamethasone reduce RDS more than dexamethasone.
o oral administration increase the incidence of neonatal sepsis only.
When should an antenatal course of corticosteroids be repeated?
 A single rescue course may be considered with caution where the 1st course was
given less than 26+0 weeks and another indication arises later in pregnancy.
 Senior opinion should be taken if a rescue course is to be considered.

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ANTI-D IMMUNOGLOBULIN FOR RHESUS D PROPHYLAXIS
Background and introduction
 Deaths attributed to RhD alloimmunisation fell from 46/100 000 births before 1969 to
1.6/100000 in 1990.
 the most important cause of anti-D antibodies is immunization during pregnancy
 Late immunization, during the 3rd trimester of 1st pregnancy, is responsible for 18–
27% of cases.
 Immunisation during a second or subsequent pregnancy probably accounts for a
similar proportion.
 It should be noted that anti-D Ig does not protect against the development of other
antibodies which can cause haemolytic disease of the newborn.
Test for the size of FMH
1) A Kleihauer screening test should be performed within 2 hours of delivery to identify
large FMH> 4 ml who require additional anti-D Ig.
 99% of women have an FMH < 4 ml at delivery.
 50% of FMH > 4 ml occurred during normal delivery.
 The following are more likely to be associated with a large FMH:
1. traumatic deliveries including CS
2. manual removal of the placenta
3. stillbirths and fetal deaths
4. abdominal trauma during the third trimester
5. twin pregnancies (at delivery)
6. unexplained hydrops fetalis.
 If Kleihauer testing to quantify the FMH not done at delivery, it is reasonable to
administer a standard postnatal dose of 1500 iu anti-D.
2) Flow cytometry offers an alternative technique for quantifying the size of FMH.
 results are more accurate than Kleihauer test and can detects RhD-positive cells.
3) The rosetting technique is a simple serological method for quantifying FMH of RhD-
positive red cells >4 ml.
Anti-D preparations licensed for use in the UK
 The following preparations are obtained from US donors, are available in the UK:
 D-GAM: 250 iu, 500 iu, 1500 iu and 2500 iu vials for intramuscular use only
 Partobulin SDF: 1250 iu prefilled syringe for intramuscular use only
 Rhophylac: 1500 iu prefilled syringe for intramuscular or intravenous use
 WinRho SDF: 1500 and 5000 IU vials for intramuscular or intravenous use (in the UK
this product is used solely for the treatment of idiopathic thrombocytopenic purpura).
 Dose of 500 iu of anti-D will neutralize FMH of up to 4 ml. then For each excess milliliter
of FMH a further 125 micrograms of anti-D is required.
 Minimum recommended doses of anti- D for<20+0 weeks is 259 iu and for≥ 20+0 weeks
is 500 iu.
 The only source of therapeutic anti-D is human plasma. Donors undergo specific virology
testing and the product viral inactivation process so there is no risk of viral transmission.
Administration
 Anti-D Ig should be given as soon as possible after the sensitising event but always
within 72 hrs.
 If not given before 72 hrs., effort should still be made to give because it still provide some
protection within 10 d.
 Ideally, anti-D Ig should be administered into the deltoid muscle.

265
 Women who have a bleeding disorder should receive anti-D via the subcutaneous or IV
route.
 Consent should be obtained and recorded in the case notes.
Prophylaxis following miscarriage, ectopic pregnancy and termination of pregnancy
 When indicated, anti-D is given in a dose of 250 iu up to 19+6 weeks and in a dose of
500 iu thereafter.
 A test for the size of FMH should be performed when anti-D Ig is given at or after 20+0
weeks.
 Give Anti-D to all non-sensitised RhD-negative women who have:
1. Spontaneous or threatened miscarriage ≥12+0 weeks.
2. Surgical or medical evacuation regardless of gestation.
3. Intermittent bleeding after 12+0 weeks of gestation, should be given at 6-weekly
intervals.
4. Heavy or repeated bleeding or associated abdominal pain as gestation approaches
12+0 weeks.
5. Ectopic pregnancy, regardless of management.
6. Therapeutic termination of pregnancy by surgical or medical methods, regardless
gestational age.
Prophylaxis following sensitising events before delivery
 250 iu is recommended for prophylaxis following sensitizing events up to 19+6 weeks.
 500 iu is recommended For events ≥20+0 weeks and a test for FMH performed and
additional anti-D is given as required.
 In recurrent vaginal bleeding after 20+0 weeks, anti-D should be given at a minimum of
6-weekly intervals.
 If there is concern about the frequency or amount of FMH, Kleihauer test can be
performed at 2-weekly intervals; if positive, an additional dose of anti-D can be
administered.
 Sensitizing events during pregnancy:
 Invasive prenatal diagnosis
 Other intrauterine procedures (insertion of shunts, embryo reduction, laser)
 APH
 External cephalic version of the fetus
 Any abdominal trauma (direct/indirect, sharp/blunt, open/closed)
 Fetal death.
Routine antenatal anti D prophylaxis(RAADP)
 Why RAADP:
 Maternal alloimmunisation continues to occur despite administration of anti-D for
sensitizing events.
 In 55–80% there is no recognised sensitising event and sensitisation is „silent‟
secondary to occult FMH.
 < 10% of silent FMH occur before 28 weeks of gestation and most after that.
 In the absence of RAADP, approximately 1% of RhD-negative women who deliver an
RhD-positive baby will become sensitised.
 RAADP should be offered to non-sensitised RhD-negative women and not required for
RhD sensitized women.
 There are two regimens for providing RAADP with same efficacy: two doses of 500 iu
anti-D Ig at 28 and 34 weeks of gestation, or a single dose of 1500 iu at 28 weeks of
gestation.
 Women should have written information before making an informed decision and
consent for treatment.
 The routine 28-week antibody screening sample must be taken before administration of
RAADP.
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What are the maternal and fetal effects of RAADP?
 RAADP not associated with adverse events to mother or baby, other than possibility of
blood-borne infection.
How should women who decline RAADP be managed?
 Women should have discussion about the benefits and risks of RAADP so they can
make an informed choice.
 The information leaflet about RAADP is recommended by NICE.
 If RAADP is declined, this should be documented in the case notes along with the
reasons for the decision.
 women who object on religious grounds
 women who will be sterilised after the birth
 women who are certain they will have no more children
 women who are who have children and father is known or found to be RhD-negative.
 If RAADP is declined perform antibody screening at booking and 28 weeks to identify
cases of sensitisation.
 Sensitisation occurring in the third trimester is unlikely to cause significant fetal problems
in that pregnancy.
Postnatal prophylaxis
 Give 500 IU of anti-D to non-sensitised RhD-ve woman within 72 hrs after delivery of
RhD+ve infant.
 A test to detect FMH > 4ml must also be undertaken so that additional anti- D can be
given as appropriate.
 If pregnancy is nonviable and no sample can be obtained from baby give anti-D to a non-
sensitised RhD-ve
 There is no universal policy regarding the postnatal dose; 1500 iu (300 micrograms) in
the USA, 500–600 iu in Canada and 1000–1250 iu in many European countries except
the UK, Ireland.
What is the role of non-invasive assessment of fetal blood type?
 At present, it is recommended that all RhD-negative women are offered RAADP.The
disadvantage of this is that 40% of RhD-ve women receive unnecessary antenatal anti-D
while carrying an RhD-ve child.
 Fetal blood group genotyping has come with the development of cffDNA with accuracy of
96.5%.
 cffDNA can identify K (Kell),Rh C,c and E.
Transfusion of RhD-positive blood components
 if RhD-positive platelets are transfused, prophylaxis against Rh alloimmunisation should
be given.
 Women who have marked thrombocytopenia should be given the anti-D subcutaneously.
How should inadvertent transfusion of RhD-positive blood be managed?
 Anti-D should be given to RhD-ve women of reproductive capacity who inadvertently
receive RhD+ve blood.
 When >15 ml of RhD+ve blood hase been transfused standarddose of anti-D Ig should
be given.
 When >15 ml has been transfused use the larger anti-D IM preparation 2500 iu or 5000
iu.
 When > 2 units of RhD+ve blood have been transfused, consider exchange transfusion
to reduce the load of RhD+ve red blood cells in the circulation and anti-D is required to suppress
immunization.
 Immediate single-blood-volume exchange will achieve a 65–70% reduction in
RhD+ve cells, and 2 volume exchange 85–90%.
 After exchange transfusion, residual volume of RhD+ve red cells is estimated by flow
cytometry or rosetting.
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 IV anti-D is the preparation of choice, being twice as effective as IM anti-D.
 Follow-up tests for RhD+ve cells is done every 48 hrs. and further anti-D given until
all RhD+ve cells cleared.

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 Green-top Guideline No. 65 May 2014
THE MANAGEMENT OF WOMEN WITH RED CELL ANTIBODIES
DURING PREGNANCY
Introduction and background epidemiology
 The presence of maternal red cell antibodies during pregnancy is a relatively
common finding and occurred as a result of previous pregnancy, transfusion or
transplantation.
 requires close collaboration between the blood transfusion laboratory, obstetric and
neonatal care providers.
 Haemolytic disease of the fetus and newborn (HDFN) is a condition in which
transplacental passage of maternal immunoglobulin G (IgG) antibodies results in
immune haemolysis of fetal/neonatal red cells
 Some antibodies (including anti-D, anti-K (-Kell) and anti-c) confer significant fetal
and neonatal risks such as;
 Anaemia requiring intrauterine or neonatal transfusion,
 jaundice
 perinatal loss
Prepregnancy counseling
Is prepregnancy counselling necessary for women known to have red cell
antibodies prior to pregnancy?
Women with red cell antibodies, particularly if there is a risk of fetal anaemia or if compatible
donor red cells for transfusion may be difficult to obtain, should attend for prepregnancy
counselling with a clinician with knowledge and expertise of this condition,and in most cases
this will be a fetal medicine specialist.
Assisted reproductive techniques (ART)
Do assisted reproductive techniques (ART) increase the risk of red cell
antibodies developing?
 There is no evidence that ART increases the risk of red cell alloimmunisation.
However, if donor eggs are used for a mother with an alloantibody and the donor red
cell antigen status is not known, fetal genotyping may be required.
Red cell antibodies in pregnancy
What is the incidence of red cell antibodies in pregnancy?
 The prevalence of positive antibody screens was 1:80, with a 1:300 prevalence of
clinically significant alloantibodies other than anti-D.
 Previous blood transfusion is an important cause for alloimmunisation with antibodies
other than anti-D implicated in HDFN.
What red cell antibodies are clinically significant (maternal and fetal)
during pregnancy?
 All women should have their blood group and antibody status determined at booking
and at 28 weeks of gestation
 The risk of fetal anaemia is greatest with anti-D, anti-c and anti-K antibodies.
What are the implications for the fetus and neonate from red cell
antibodies?
 Clinicians should be aware that severe fetal anaemia can result in hydrops which
significantly worsens the perinatal outcome.

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  Untreated, severe fetal anaemia can result inhydrops, preterm birth or perinatal
death.
 The overall perinatal survival in pregnancies following treatment was reported to
be 84%, with nonhydropic fetuses having better survival (94%) than hydropic
fetuses (74%).
 Anti-K causes anaemia secondary to erythroid suppression and immune
destruction of early erythroid progenitor cells, but hyperbilirubinaemia is not a
prominent feature, severe fetal anaemia can occur even at relatively low antibody
titres.
When and how should paternal and fetal genotyping be performed?
 Non-invasive fetal genotyping using maternal blood is now possible for D, C, c, E, e
and K antigens.
 This should be performed in the first instance for the relevant antigen when maternal
red cell antibodies are present.
 For other antigens, invasive testing (chorionic villus sampling [CVS] or
amniocentesis) may be considered if fetal anaemia is a concern or if invasive testing
is performed for another reason (e.g. karyotyping).
Is karyotyping contraindicated in the presence of maternal red cell
antibodies?
 Invasive testing is not contraindicated if alloimmunisation has occurred.
 Anti-D prophylaxis should be given to cover invasive testing if the mother is RhD
negative and is not sensitised
If the fetus is at risk of anaemia, when should referral to a fetal medicine
specialist take place?
 Referral to a fetal medicine specialist should occur when there are rising antibody
levels/titres, ie;level/titre above a specific threshold or ultrasound features suggestive
of fetal anaemia.
 Referral should take place if there is a history of unexplained severe neonatal
jaundice, neonatal anaemia requiring transfusion or exchange transfusion, in order to
exclude HDFN as the cause.
 For antibodies other than anti-D, anti-c and anti-K, the following should prompt
referral to a fetal medicine specialist: a history of previous significant HDFN or IUT, or
a titre of 32 or above, especially if the titre is rising as rising titres correlate with
increasing risk and severity of anaemia.
What thresholds should be used for the various antibodies that could
cause fetal anaemia to trigger referral for further investigation or
monitoring?
 An anti-D level of > 4 iu/ml but < 15 iu/ml correlates with a moderate risk of HDFN
and an anti-D level of > 15 iu/ml can cause severe HDFN.
 Referral for a fetal medicine opinion should therefore be made once anti-D levels are
> 4 iu/ml.
 An anti-c level of > 7.5 iu/ml but <20 iu/ml correlates with a moderate risk of HDFN,
whereas an antic level of > 20 iu/ml correlates with a high risk of HDFN.
 Referral for a fetal medicine opinion should therefore be made once anti-c levels are
> 7.5 iu/ml.
 For anti-K antibodies, referral should take place once detected, as severe fetal
anaemia can occur even with low titres.
 The presence of anti-E potentiates the severity of fetal anaemia due to anti-c
antibodies so that referral at lower levels/titres is indicated (unless the fetus has only
one of these antigens).
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Once detected how often should antibody levels be monitored during
pregnancy?
 Anti-D and anti-c levels should be measured every 4 weeks up to 28 weeks of
gestation and then every 2 weeks until delivery.
 Although anti-K titres do not correlate well with either the development or severity of
fetal anaemia, titres should nevertheless be measured.
 For all other antibodies, retesting at 28 weeks is advised with the exception of
women who have a previous history of pregnancies affected with HDFN when early
referral to a fetal medicine specialist is also recommended.
 For antibodies that could potentially cause problems with cross-matching or issues
with the availability of appropriate blood, discussion with the blood transfusion
service is required regarding the frequency of antenatal testing. This may depend on
the type of antibody as well as the likelihood of requiring blood at short notice.
How should pregnancies at risk of fetal anaemia be monitored?
 The cause of the alloimmunisation, relevant past history and pregnancy outcomes
should be ascertained in order to generate an assessment of risk of HDFN.for
example;
 Inadequate or omitted anti-D prophylaxis
 Previous blood transfusion.
 Details of previously affected pregnancies,particularly IUTs and the gestation
at which they were commenced
 neonatal anaemia
 Gestation at delivery and the need for exchange transfusions or phototherapy
should also be obtained.
 Ultrasound monitoring should commence once there is a moderate or severe risk of
fetal anaemia.
 If the fetus carries the corresponding antigen for a maternal antibody which is
capable of causing fetal anaemia and if the antibody levels/titres rise beyond the
levels, then the pregnancy should be monitored weekly by ultrasound, specifically
assessing the fetal middle cerebral artery peak systolic velocities (MCA PSV).
 MCA PSV monitoring is predictive of moderate or severe fetal anaemia with 100%
sensitivity and a false positive rate of 12%.
 Referral to a fetal medicine specialist for consideration of invasive treatment should
take place if the MCA PSV rises above the 1.5 multiples of the median (MoM)
thresholds or if there are other signs of fetal anaemia.which include; polyhydramnios,
skin oedema and cardiomegaly.
 If monitoring of the MCA indicates anaemia (MCA PSV > 1.5 MoM), fetal blood
sampling (FBS) and possibly IUT are indicated, The risks and benefits of IUT should
always be discussed with the woman who should be made aware of the
consequences of untreated severe fetal anaemia (i.e. hydrops, preterm birth,
perinatal death, severe neonatal jaundice and kernicterus) as well as the risks of
neonatal exchange transfusion.
 Monitoring with MCA PSV should be used with caution after 36 weeks as its
sensitivity for the detection of fetal anaemia decreases.
 If there are concerns beyond this gestation because of raised MCA PSV, further
advice should be sought from a fetal medicine specialist experienced in managing
fetal anaemia.

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  Further management should also be discussed with a fetal medicine specialist if
MCA PSV levels are normal despite high or increasing antibody levels beyond 36
weeks of gestation.
 The risk of fetal loss following an FBS is 1–3%, but is higher if the fetus is hydropic.
 Fetal monitoring is required (as above) once anti-K is detected.
If fetal transfusion is required what type of donor blood should be used?
 Red cell preparations for IUT should be group O (low titre haemolysin) or ABO
identical with the fetus (if known) and negative for the antigen(s) corresponding to
maternal red cell antibodies.
 IUTs should be performed only in fetal medicine units that have the requisite invasive
skills and appropriate perinatal haematology expertise.
What are the implications for the mother from red cell antibodies?
 For antibodies other than anti-D, anti-c, anti-C, anti-E or anti-K, maternity staff should
liaise with their local transfusion laboratory to assess and plan for any possible
transfusion requirements, as obtaining the relevant blood may take longer.
 The implications relate to possible transfusion problems for the mother in terms of the
availability and provision of compatible blood.
How often should pregnant women with red cell antibodies who are at
high risk of requiring a transfusion (placenta praevia, sickle cell disease
etc.) be tested?
 Pregnant women with red cell antibodies, who are assessed as being at high risk of
requiring a blood transfusion, should have a cross-match sample taken at least every
week.
 Current BCSH guidelines require a sample no more than 72 hours old for providing
compatible blood in pregnancy, but do allow a deviation to the 3-day rule for
individual cases such as high-risk women with placenta praevia without red cell
antibodies where weekly samples can be taken, as long as a risk assessment is
made and recorded in each individual case. In high-risk women with red cell
antibodies where a sample every 72 hours is not feasible, a sample should be taken
once a week and if transfusion is required a new sample should be taken
immediately, to exclude new antibody development.
 However, in the event of life threatening haemorrhage, urgent transfusion should not
be delayed and close liaison with the hospital transfusion laboratory is vital.
If maternal transfusion is required, what type of donor blood or blood
components should be used?
 Red cell components of the same ABO group and RhD type, and that are K negative
and CMV negative, should be selected.
 An IAT cross-match must be used if the woman‟s plasma contains or has previously
Contained clinically significant red cell alloantibodies.
 For planned antenatal transfusions, CMV-negative blood should be transfused.
 Screening for CMV should not delay transfusion in an emergency situation
Should RhD-negative women who have anti-D or non-anti-D antibodies
receive routine antenatal or postnatal prophylaxis?
 Anti-D immunoglobulin should be given to RhD-negative women with non-anti-D
antibodies for routine antenatal prophylaxis, for potential antenatal sensitising events
and postnatal prophylaxis.
 If immune anti-D is detected, prophylaxis is no longer necessary.
 Discussion and liaison with the transfusion laboratory are essential in determining
whether anti-D antibodies are immune or passive in women who have previously
received anti-D prophylaxis.
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Requirements for blood
What are the logistics of obtaining blood or blood components for the
woman, fetus or neonate?
Blood or blood components for the woman;
 Close collaboration between the maternity, neonatology and haematology staff is
essential.
 When blood is required for women with multiple antibodies or antibodies against high
prevalence antigens, planning is required as rare blood donors may need to be called
up to donate, or frozen blood may need to be obtained.
 Local blood transport time and time for cross-match should be taken into account
when the decision for transfusion is made.
Blood for intrauterine transfusion (IUT);
 Blood should be ABO compatible with the neonate and mother (to avoid ABO HDFN
from the woman‟s anti-A or -B antibodies present), RhD negative (or RhD identical
with neonate), K negative, negative for the corresponding antigen to which the
woman has an antibody and cross-match compatible with the woman‟s blood
sample.
 Blood should be less than 5 days old (to ensure low supernatant potassium levels),
CMV negative and irradiated unless the risk to the baby of delaying exchange
transfusion while obtaining irradiated blood outweighs this. It should be plasma
reduced (rather than in saline-adenine-glucose-mannitol [SAGM] additive solution),
with a haematocrit of 0.50–0.60.
Blood for neonatal small volume (‘top-up’) transfusion;
 Blood should be CMV negative but does not need to be irradiated unless the neonate
has had a previous IUT and blood can be stored in SAGM (rather than plasma
reduced) and be up to 35 days old (as a topup transfusion is a much smaller volume
than an exchange transfusion).
 Clinicians considering transfusion in a neonate must check if the baby has had an
IUT, as if so, blood must be irradiated to prevent transfusion-associated graft-versus-
host disease.
What blood or blood components can be administered in the emergency
situation to a woman known to have red cell antibodies?
 The decision to use ABO-, RhD- and K-compatible blood that is not matched for
other antibodies (or O negative, where the woman‟s ABO and RhD groups are
unknown) should be made on the balance of risks (severe haemorrhage versus a
haemolytic transfusion reaction).
 Transfusion should not be delayed in the event of life-threatening haemorrhage.
Close liaison with the transfusion laboratory is essential.
Birth
What is the optimum mode, place and timing of birth?
 Timing of delivery for women with red cell antibodies that can cause fetal anaemia
will depend on the antibody levels/titres, rate of rise as well as if any fetal therapy has
been required. The mode, timing and place of delivery are otherwise dependent on
standard obstetric grounds.
 In general, for red cell antibodies that could cause fetal anaemia but which
have been stable throughout pregnancy, delivery should take place between
37 and 38 weeks of gestation.
 If an IUT has not been required but antibody levels are rising then
consideration for earlier delivery may be necessary.

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  If an IUT has been required, delivery will need to be timed to ensure that the
fetus is not significantly anaemic at birth.
 This will depend on the gestation that the last IUT was performed as well as
the estimated rate of drop of fetal haemoglobin/haematocrit.
 Decisions about the timing of delivery are most appropriately made by the
fetal medicine team managing these pregnancies.
 Prior IUT is not in itself an indication for elective caesarean section.
 The neonatal team should be advised of the timing of delivery in the event that
further neonatal care is required.
 If a woman is at risk of requiring significant amounts of transfused blood either
antenatally, intrapartum or postnatally, consideration should be given to transferring
her care to a centre capable of processing cross-match samples and providing
appropriate compatible blood rapidly.
 As these are „high-risk‟ pregnancies, continuous electronic fetal heart monitoring is
advised during labour.
Cord blood investigations
What cord blood investigations should be performed?
 If a woman has clinically significant antibodies then cord samples should be taken for
a direct antiglobulin test (DAT), haemoglobin and bilirubin levels
 Cord blood investigations (DAT, haemoglobin and bilirubin levels) should be
undertaken in addition to ABO and RhD typing where the mother is known to
have immune red cell antibodies.
 A positive DAT indicates that the infant‟s red cells are coated with antibody
but in itself cannot predict severity of haemolysis.
 Notably the DAT may be negative in ABO HDFN.
 It is therefore essential to also determine haemoglobin and bilirubin levels to
ascertain the degree of anaemia and haemolysis at birth and this helps guide
managemen as below.
Management
How should the neonate be managed?
 This depends on the risk of haemolysis or anaemia conferred by the relevant red cell
antibody.
 The neonate should have regular clinical assessment of its neurobehavioural state
and be observed for the development of jaundice and/or anaemia.
 Regular assessment of bilirubin and haemoglobin levels should be made and early
discharge is not advisable.
 The mother should be encouraged to feed the baby regularly to guard against
dehydration, since dehydration can increase the severity of jaundice.
 Clinicians should be aware that if bilirubin levels rise rapidly or above the
interventional threshold, phototherapy and/or exchange transfusion may be required.
 Pregnancies complicated by red cell alloimmunisation with a minimal or no risk of
fetal or neonatal anaemia require no specific treatment.
Future risks
What is the risk of recurrence in a future pregnancy?
 A woman with a history of a pregnancy or infant affected by HDFN should be referred
for early assessment to a fetal medicine specialist in all further pregnancies.
 The risk of recurrence of HDFN depends on the type of antibody, the paternal
genotype as well as the severity and gestational onset of the fetal anaemia.
Long-term consequences of red cell antibodies to women and their offspring
What are the long-term health consequences for the woman?
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  Women can be advised that there is no long-term adverse health consequences
associated with the presence of red cell antibodies. but an antibody card should be
carried in case transfusion is required
What are the long-term health concerns for the children of women with
red cell antibodies during pregnancy?
 Clinicians should be aware that some infants may experience anaemia persisting for
a few weeks following birth. Is usually the result of passively acquired maternal
antibodies causing continued haemolysis
 Clinicians should be aware that some infants may develop late anaemia which is
usually due to hyporegenerative anaemia (transient suppression of neonatal
erythropoiesis, itself due to transfusion. Babies who have required several IUTs are
at particular risk).

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277
ANTEPARTUM HAEMORRHAGE
Purpose and scope
 (APH) is defined as bleeding from or in to the genital tract, from 24+0 weeks of
pregnancy and prior to birth.
 The most important causes are placenta praevia and placental abruption, but are not the
most common.
 APH complicates 3–5% of pregnancies.
 one-fifth of very preterm babies are born in association with APH, this explain the
association of APH with cerebral palsy.
Introduction and background
 Obstetric haemorrhage cause of up to 50% of maternal deaths that occur globally each
year.
 It is not uncommon to fail to identify a cause for APH when it is then described as
„unexplained APH: failure to identify a cause for APH.
 the amount of blood lost is often underestimated and part of blood may be concealed, so
It is important when estimating the blood loss, to assess for signs of clinical shock and
the presence of fetal compromise or fetal demise.
 the following definitions have been used:
 Spotting – staining, streaking or blood spotting noted on underwear
 Minor haemorrhage – blood loss less than 50 ml
 Major haemorrhage – blood loss of 50–1000 ml, with no signs of clinical shock
 Massive haemorrhage – blood loss more than 1000 ml and/or signs of clinical shock.
Prediction and prevention of antepartum haemorrhage?
What are the risk factors for placental abruption?
 advanced maternal age
 low body mass index (BMI),
 multiparity,
 Assisted conception
 smoking
 drug misuse (cocaine and amphetamines) during pregnancy.
 Maternal thrombophilias.
 previous abruption. The risk is 19–25% with two previous pregnancies with
abruption.
 pre-eclampsia,
 FGR,
 non-vertex presentations,
 polyhydramnios,
 intrauterine infection,
 PROM,
 abdominal trauma
 First trimester bleeding
What are the risk factors for placenta praevia?
 Advanced maternal age (>40 years)
 Multiparity
 Assisted conception
 Smoking
 Multiple pregnancy
 Previous placenta praevia OR 9.7
 Previous caesarean sections

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 o One previous caesarean section OR 2.2
o Two previous caesarean sections OR 4.1
o Three previous caesarean sections OR 22.4
 Previous termination of pregnancy
 Deficient endometrium due to presence or history of:
o uterine scar
o endometritis
o manual removal of placenta
o curettage
o submucous fibroid
 abruption is more likely to be related to conditions occurring during pregnancy and
placenta praevia is more likely to be related to conditions existing prior to pregnancy.
Can APH be predicted?
 APH cannot reliably be predicted, 70% of placental abruption occur in low-risk
pregnancies.
Can APH be prevented?
 Women should be advised change modifiable risk factors (smoking and drug misuse).
 folic acid and multivitamins during pregnancy significantly reduce the risk of placental
abruption .
 There are insufficient data to support a role for low dose aspirin +/– LMW heparin in
the prevention of abruption in women with thrombophilia.
 It is good practice to avoid vaginal, rectal examinations and penetrative sexual
intercourse in women with placenta praevia.
Is APH associated with any specific pregnancy complications and outcomes?
 APH is associated with maternal and perinatal morbidity and mortality.
 Complications are more likely when haemorrhage is due to a placental cause, when the
bleeding is heavy and when the bleeding occurs at early gestations.
 unexplained APH are also at increased risk of adverse maternal and perinatal outcomes:
 preterm delivery
 induction of labour at term,
 babies are more likely to be smaller, admitted to NICU and develop
hyperbilirubinaemia
Complications of APH
 Maternal complications
 Anaemia
 Infection
 Maternal shock
 Renal tubular necrosis
 Consumptive coagulopathy
 Postpartum haemorrhage
 Prolonged hospital stay
 Psychological sequelae
 Complications of blood transfusion
 Fetal complications
 Fetal hypoxia
 SGA and FGR
 Prematurity
 Fetal death
Where should the woman presenting with APH be managed?
 Women with APH presenting to any health services should be assessed, stabilised and
transferred to a maternity hospital with facilities for resuscitation (anaesthetic support,
blood) and performing emergency operative delivery.
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 A multidisciplinary team should provide clinical assessment:
 triage to access whether urgent intervention is required for maternal or fetal
compromise. assess pain, the extent of vaginal bleeding, the cardiovascular
condition of the mother, and fetal wellbeing.
 If there is no maternal compromise a full history should be taken:
 Placental abruption should be considered when the pain is continuous. Labour
should be considered if the pain is intermittent.
 Risk factors for abruption and placenta praevia should be identified.
 fetal movements and auscultate the fetal heart.
 Consider vasa praevia if the APH is associated with rupture of the fetal membranes.
 History of Previous cervical smear to exclude neoplastic lesion of the cervix as cause
of bleeding.
Abdominal palpation
 Assess for tenderness or signs of an acute abdomen.
 Assess for uterine contractions.
 The tense or „woody‟ uterus indicates a significant abruption.
 A soft, non-tender uterus suggest a lower genital tract bleeding, placenta or vasa
praevia.
Speculum examination
 To identify cervical dilatation or lower genital tract cause for the APH.
Digital vaginal examination
 Should not be performed until an ultrasound has excluded placenta praevia.
 assess cervical dilatation if APH is associated with pain or uterine activity.
What investigations should be performed in women presenting with APH?
Maternal investigations
 The maternal investigations will depend on the amount of bleeding.
 Kleihauer test in (RhD)-negative women to quantify fetomaternal haemorrhage to
calculate the dose of (anti-D Ig.
 The Kleihauer test is not a sensitive for diagnosing abruption.
 Ultrasound confirm placenta praevia but does not exclude abruption.
 Placental abruption is a clinical diagnosis and there are no reliable diagnostic tests .
 Ultrasound will fail to detect three-quarters of cases of abruption.
 However, when the ultrasound suggests an abruption, the likelihood is high.
Fetal investigation
 CTG once the mother is stable or resuscitation has commenced, to support the decision
for the mode of delivery.
 Ultrasound to establish fetal heart pulsation if fetal viability cannot be detected using
external auscultation.
 expectant management is safe in preterm pregnancies with placental abruption and a
normal CTG, but abnormal CTG is associated with poor fetal outcome and delivery
should be expedited.
 tests to differentiate between fetal and maternal blood in vasa praevia are often not
applicable because thy delay delivery.
Should women with APH be hospitalised, and if so, for how long?
 Women with spotting and no longer bleeding and placenta praevia has been excluded
can go home after a reassuring initial clinical assessment.
 women with heavier than spotting or with ongoing bleeding should remain in hospital at
least until the bleeding has stopped.
Should corticosteroids be administered to women with APH before term?
 To women between 24+0 and 34+6 weeks of gestation at risk of preterm birth.
 If the most likely cause is lower genital tract bleeding, and preterm delivery is unlikely,
corticosteroids unlikely to be benefit, but could still be considered.
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Should tocolytic therapy be used in women with APH who have uterine activity?
 Tocolysis should not be used to delay delivery in a major APH or if there is fetal
compromise.
 A senior openion should be taken regarding the use of tocolysis in an APH.
Should the antenatal care of a woman be altered following APH?
 In APH from a lower genital tract, subsequent antenatal care need not be altered.
 In APH from placental or unexplained APH, the pregnancy should be signed as „high
risk‟ with consultant-led antenatal care and Serial growth and fetal wellbeing scan.
 unexplained APH is associated with an increased risk of :
 oligohydramnios
 PROM.
 FGR
 preterm labour .
 caesarean delivery .
Labour and delivery
When should women with APH be delivered and what mode of delivery?
 If fetal death and no maternal compromise, vaginal birth is recommended.
 If APH is associated with maternal and/or fetal compromise immediate delivery should
be considered, a caesarean section with concurrent resuscitation of the mother is
suitable.
 The optimum timing of delivery with unexplained APH and no maternal and/or fetal
compromise is not established. A senior openion should be obtained
 In APH before 37+0 weeks and no maternal or fetal compromise and bleeding has
settled, there is no evidence to support premature delivery of the fetus.
o If the woman presents after 37+0 weeks of gestation:
o if the APH is spotting or streaking with mucus it is likely to be blood stained show and
unlikely to require active intervention. However, if the APH is minor or major
induction of labour should be considered with continuous fetal monitoring in order
to avoid adverse consequences associated with a placental abruption.
What intrapartum fetal monitoring
 continuous electronic fetal monitoring for:
 Women in labour with active vaginal bleeding.
 women with history of major or recurrent minor APH in current pregnency,
 suspicion of an abruption.
 Women with minor APH with evidence of placental insufficiency (such as fetal growth
restriction or oligohydramnios)
 intermittent auscultation for:
 women with one episode of minor APH and no concerns about maternal or fetal
wellbeing.
What is the optimal mode of anaesthesia?
 Regional anaesthetic is recommended for operative delivery.
 with maternal or fetal compromise, a general anaesthetic is recommended for c/s to
facilitate maternal resuscitation and to expedite delivery.
 A consultant anaesthetist should be involved if APH is associated with compromise.
What is the appropriate management of the third stage of labour?
 PPH should be anticipated in women with APH.
 Active management of the third stage of labour is strongly recommended .
Should women presenting with APH who are RhD-negative be given anti-D Ig?
 Anti-D Ig should be given to all non-sensitised RhD-negative women with APH, whether
routine antenatal prophylactic anti-D has been administered or no.
 In recurrent APH after 20+0 weeks, anti-D Ig should be given at a minimum every 6
weeks.
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 At least 500 iu anti-D Ig should be given followed by a test to identify FMH, if greater
than 4 ml; additional anti-D Ig should be given as required.
How should massive APH be managed?
 The management of massive APH should follow protocols for massive obstetric
haemorrhage with multidisciplinary a broach.
What blood products should be ordered and made available for women with APH?
 The principles of fluid replacement and administration of blood products are the same for
APH as they are for PPH.
How should the woman with an APH who develops a coagulopathy be managed?
 In a massive blood loss or a major abruption, DIC should be considered.
 Clotting studies and a platelet count should be urgently requested.
 Up to 4 units of FFP and 10 units of cryoprecipitate may be given whilst awaiting the
results of the coagulation studies.
How should the woman with an APH who is 0n anticoagulant therapy be managed?
 Women should be advised that if they have any vaginal bleeding:
 they should not take more anticoagulant medication.
 They should attend hospital urgently,
 further doses should only be administered after consultation with medical staff.
In women with APH, how should the neonate be managed and by whom?
 Major or massive APH, the neonate should be assessed by a senior
paediatrician/neonatologist.
 In minor APH, clinical judgement should be used. With continuing haemorrhage, request
paediatric support at the time of delivery.
How should extremely preterm pregnancy(24+0-26+0 weeks)and APH be managed?
 Regardless of the gestation, the mother‟s life should take priority. She should be
resuscitated and stabilised before any decision for delivery of the baby.
 A senior paediatrician/neonatologist should be involved in the counselling
What are the postnatal issues need to be addressed in women with APH?
 Thromboprophylaxis
 debriefing and clinical incident reporting.

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PLACENTA PRAEVIA, PLACENTA ACCRETA AND VASA PRAEVIA
Background and introduction
Placenta praevia and placenta praevia accreta
 The number of cases of placenta praevia and its complications, including placenta
accreta, will continue to increase due to the rising incidence of caesarean sections
combined with increasing maternal age.
 if the placenta lies over internal os, it is considered a major praevia; if the leading edge of
the placenta is in the lower uterine segment but not covering the os, minor or partial
praevia exists.
Vasa praevia
 Vasa praevia describes fetal vessels coursing through the membranes between the
internal os and the fetal presenting part, unprotected by placental tissue or the umbilical
cord:
 Type 1vasa praevia: a velamentous cord inserted in a single or bilobed placenta.
 Type 2vasa praevia : fetal vessels running between lobes of a placenta with
accessory lobes .
 The incidence is 1/2000 to 1/6000 pregnancies with mortality rate around 60%.
 Unlike placenta praevia, vasa praevia carries no major maternal risk, but is associated
with significant risk
 Vasa praevia often presents with fresh vaginal bleeding at the time of membrane rupture
and fetal heart rate abnormalities such as decelerations, bradycardia, a sinusoidal trace
or fetal demise.
 More rarely, bleeding can occur in the absence of membrane rupture.
 Very rarely, fetal heart abnormalities in the absence of bleeding may be present
secondary to compression of the fetal vessels by the fetal presenting part.
 Because the fetal blood is around 80–100 ml/kg, the loss of small amounts of blood can
have major implications
 Risk factors for vasa praevia include:
 placental anomalies such as a bilobed placenta or succenturiate lobes
 history of low-lying placenta in the second trimester.
 multiple pregnancy.
 IVF, the incidence of vasa praevia has been reported to be as high as 1/300.
Screening and diagnosis for placenta praevia/accreta
 Clinical suspicion should be raised in all women with:
 vaginal bleeding after 20 weeks of gestation.
 A high presenting part,
 an abnormal lie
 painless or provoked bleeding, irrespective of previous imaging results.
 the definitive diagnosis usually relies on ultrasound imaging.
 Routine ultrasound scanning at 20 weeks should include placental localization as
screening for lowlying placenta.
 Transvaginal scans improve the accuracy of placental localisation and are safe, so the
suspected diagnosis of placenta praevia at 20 weeks by TAS should be confirmed by
TVS.
Which women need further imaging if the placenta is low at 20 weeks of gestation?
 All women require follow-up imaging if:
1. The placenta covers or overlaps the cervical os at 20 weeks of gestation.
2. Women with a previous caesarean section

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 Placental migration from lower segment during 2nd and 3rd trimesters is less likely to
occur if:
1. The placenta is posterior
2. The placenta covering the internal os
3. There is a previous caesarean section.
When should further imaging occur?
 Women who bleed should be managed individually according to their needs.
 In asymptomatic women with suspected minor praevia, follow-up imaging can be done at
36 weeks.
 In asymptomatic suspected major placenta praevia or accrete, imaging should be
performed at 32 weeks to confirm the diagnosis and allow planning for 3rd trimester
management and delivery.
How can a morbidly adherent placenta be diagnosed?
 Risk factors for placenta accrete:
1. Previous caesarean section with Placenta praevia
2. Previous caesarean section with anterior placenta underlying the old scar at 32
weeks.
3. Silent placenta praevia.

 Criteria for diagnosis:

1. Greyscale:
 Loss of the retroplacental sonolucent zone
 Irregular retroplacental sonolucent zone
 Thinning or disruption of the serosa–bladder interface
 Focal masses invading the urinary bladder
 Abnormal placental lacunae.
2. Colour Doppler:
 Vascular lakes with turbulent flow
 Hypervascularity of serosa–bladder interface
 Dilated vessels in peripheral subplacental zone.
3. Three-dimensional power Doppler:
 Numerous vessels involving the whole uterine serosa–bladder interface
 Hypervascularity (lateral view)
 Inseparable cotyledonal and intervillous circulations.
4. The main MRI features of placenta accreta include:
 Uterine bulging
 Heterogeneous intensity within the placenta
 Dark intraplacental bands.
Antenatal management
 Prevention and treatment of anaemia during antenatal period is recommended.
 In the 3rd trimester women with PP should be counseled for the risks of preterm delivery
and obstetric Hge.
 Any home-based care requires:
1. Minor placenta praevia or asymptomatic major placenta praevia
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 2. Close proximity to the hospital
3. Ready access to the hospital
4. The constant presence of a companion
5. Full informed consent by the woman.
 those with major praevia who have previously bled should be admitted from
approximately 34 weeks.
 woman managed at home, should attend immediately when experiences any bleeding,
contractions or any pain.
 There is insufficient evidence to support the use of cervical cerclage to reduce bleeding
and prolong pregnancy.
Is there a place for tocolytics in women who bleed?
 Tocolysis for treatment of bleeding due to placenta praevia may be useful in selected
cases.
 10 mg of ritodrine IM QID for 7 days was associated with prolongation of pregnancy and
increased birth weight.
Is there a place for the use of prophylactic tocolytics in women to prevent bleeding?
 Prophylactic terbutaline to prevent bleeding has not been found to benefit women with
PP.
Precautions against venous thromboembolism for inpatients
 Encourage mobility, the use of thromboembolic deterrent stockings and adequate
hydration.
 anticoagulation in women at high risk of bleeding can be hazardous so,
thromboprophylaxis should be limited to those at high risk of thromboembolism.
Preparations for delivery
 women with placenta praevia and their partners should have a discussion regarding:
 delivery,
 indications for blood transfusion
 hysterectomy .
 any concerns, queries or refusals of treatment should be exeplored and documented.
 The mode of delivery should be based on clinical judgement and sonographic
information.
 If placental edge < 2 cm from the internal os in the third trimester delivery by CS is likely,
especially if the placenta is thick, but the evidence for this is poor and further research in
this area is needed.
 As the lower uterine segment continues to develop beyond 36 weeks of gestation, TVS
is recommended if the fetal head is engaged prior to planned caesarean section.
At what gestation should elective delivery occur?
 Elective CS in asymptomatic women is not recommended before 38 weeks for placenta
praevia, or before 36–37 weeks of gestation for suspected placenta accreta. Although
40% of women deliver before 38+0 weeks.
What preparations should be made before surgery?
 PP without previous CS carries a risk of massive obstetric haemorrhage and
hysterectomy and should be carried out in a unit with a blood bank and facilities for high
dependency care.
 The care bundle for suspected placenta accreta should be applied:
1. Consultant obstetrician
2. Consultant anaesthetist
3. Blood and blood products available
4. Multidisciplinary involvement in pre-op planning
5. Discussion and consent includes possible interventions (hysterectomy, leaving the
placenta, cell salvage and intervention radiology)
6. local availability of a level 2 critical care bed.
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What blood products are needed?
Placenta praevia
 whether ready cross-matched blood is required and its amount depend on the clinical
features of each individual case and the local blood bank services available.
 When women have atypical antibodies, they should be a direct communication with the
local blood bank
 There is no evidence to support the use of autologous blood transfusion for placenta
praevia.
 Cell salvage may be considered in women at high risk of massive haemorrhage and who
refuse donor blood.
Suspected placenta accreta
 Cross-matched blood and blood products should be readily available.
 Cell salvage should be considered.
When is interventional radiology indicated?
 In a woman with suspected placenta accreta and refuses donor blood, she should be
transferred to a unit with an interventional radiology service.
 The place of prophylactic catheter for balloon occlusion or in readiness for embolisation if
bleeding ensues.
What anaesthetic is most appropriate for delivery of the baby?
 The choice of anaesthetic for CS for PP and suspected placenta accreta must be made
by the anaesthetist.
 No insufficient evidence to support any technique. Evidence from the USA support
regional anaesthesia.
 In a large retrospective study:
 There was more blood loss and transfusion in those having a general anaesthetic,
 The two women with major morbidity (one pulmonary embolus and one cerebral
embolus) both had GA.
 Of the four had regional anaesthesia initially, two required conversion to GA.
What should be included in the consent form for caesarean section?
 Any woman giving consent for CS should understand:
1. The risks associated with caesarean section in general
2. The specific risks of placenta praevia:
 Massive obstetric haemorrhage, approximately 12 times more.
 The need for blood transfusion .
 The chance of hysterectomy.
3. The different risks and treatment options for suspected accreta, this should include the
skin and uterine incisions and conservative management of the placenta or
hysterectomy if accreta is confirmed at surgery.
4. Additional possible interventions in the case of massive haemorrhage should also be
discussed, including cell salvage and interventional radiology.
What grade of obstetrician should attend?
 As a minimum requirement during a planned procedure for placenta praevia and
suspected placenta accreta, a consultant obstetrician and anaesthetist should be present
within the delivery suite.
 When an emergency arises, consultant staff should be alerted and attend as soon as
possible.

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Surgery in the presence of placenta accreta, increta and percreta
1. open the uterus at a site distant from the placenta, and deliver the baby without
disturbing the placenta, in order to enable conservative management of the placenta or
elective hysterectomy if the accreta is confirmed.
 A low transverse skin incision allows access to the lower half of the uterus.
 If, the placenta is anterior and extending towards the level of the umbilicus, a midline
skin incision may be needed to allow for a high upper-segment longitudinal uterine
incision.
2. Going through placenta is associated with more bleeding and chance of hysterectomy
and should be avoided.
3. Conservative management of placenta accreta in a bleeding woman is unlikely to be
success and wasting time.
4. If the placenta fails to separate with the usual measures, leaving it in place and closing,
and proceeding to conservative management or hysterectomy, both associated with less
blood loss than trying to separate it.
5. If the placenta separates, it needs to be delivered and any haemorrhage occurs needs
to be dealt with.
6. If the placenta partially separates, the separated portion(s) need to be delivered and any
haemorrhage occurs needs to be dealt with. Adherent portions can be left in place, but
blood loss in such circumstances can be large.
7. Calling for extra help early should be encouraged and not seen as „losing face‟.
Follow-up of the woman after part or all of the placenta has been retained following
placenta accreta
How should the woman be managed after placental retention?
 Prophylactic antibiotics is helpful in the immediate postpartum period to reduce this risk
of bleeding and infection.
 Neither methotrexate nor arterial embolisation reduces these risks and neither is
recommended routinely.
 Follow-up of with ultrasound and serum beta-hCG weekly to check it falls continuously.
What chance of success can be quoted for a future pregnancy?
 There are insufficient data for prognosis about future pregnancy.
Vasa praevia
Can we diagnose vasa praevia clinically?
 in the absence of vaginal bleeding, there is no method to diagnose vasa praevia
clinically.

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 In intrapartum period, in the absence of vaginal bleeding, vasa praevia can occasionally
be diagnosed clinically by palpation of fetal vessels in the membranes at vaginal
examination.This can be confirmed by amnioscope.
Can we differentiate between fetal and maternal bleeding?
 Various tests(The Kleihauer–Bekte test and haemoglobin electrophoresis) can
differentiate between fetal and maternal blood, but they are often not applicable because
they take a significant amount of time.
Can vasa praevia be diagnosed using ultrasound?
 Vasa praevia can be accurately diagnosed with colour Doppler ultrasound, often utilising
the transvaginal route.
Should we screen for vasa praevia?
 At present, vasa praevia should not be screened for routinely at the time of the mid-
trimester anomaly scan.
How should vasa praevia be managed?
 In the presence of bleeding vasa praevia, delivery should be achieved by category 1
emergency CS.
 In cases of suspected vasa praevia in the absence of fetal compromise, transvaginal
colour Doppler ultrasonography should be carried out to confirm the diagnosis.
 In confirmed cases of vasa praevia at term, delivery should be carried out by elective CS
prior to onset of labour.
 In cases of vasa praevia identified in 2nd trimester, imaging should be repeated in 3rd
trimester to confirm.
 In cases of confirmed vasa praevia in 3rd trimester, antenatal admission from 28 to 32
weeks and administration of corticosteroids is recommended.
 Laser ablation in utero may have a role in the treatment of vasa praevia.

 the use of methotrexate may not reduce placental volume. methotrexate has an
immunosuppressive role and therefore could increase the risk of infection or even
sepsis, which is already increased in patients with abnormal adherent placentation.
 The folloing regimes were used:
1. Intravenous methotrexate (50mg) along with intramuscular folinic acid (5mg) was first
given on alternate days and then twice a week. Broad-spectrum antibiotics (cefoxitin,
metronidazole), intravenous oxytocin, and oral methylergometrine (0.2mg three times
daily) were started. After 5 weeks maternal serum human chorionic gonadotropin
became undetectable."
2. Intramuscular methotrexate (1mg/kg) was given weekly.
3. Methotrexate therapy (1mg/kg per os) was given weekly for 7 weeks.
4. methotrexate intramuscular weekly (1 mg/kg). Four weeks after the methotrexate
therapy was started, maternal serum hCG became undetectable (<5 iu/L), after four
methotrexate injections (total dose 240 mg). The therapy was discontinued two
weeks later."
5. methotrexate given intramuscularly at 50mg/48 h intervals for a total of four doses.
This was followed by Folinic acid rescue 30h after each dose of methotrexate, in line
with the gestational trophoblastic disease regimen at Charing Cross Hospital."

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South West RTC Regional template / guideline April 2014
THE MANAGEMENT OF ANAEMIA IN PREGNANCY AND POSTNATALLY
Introduction:
 Anaemia is the most common medical disorder in pregnancy.
 Pregnancy causes 2-3 fold increase in requirement of iron and 10-20 fold
increase in folate requirement.
 In iron deficiency anaemia, there is a shortage of iron stores (low ferritin),
reduced transport and functional iron (low transferrin) limiting red cell
production (low Hb).
 In pregnant women who are anaemic in the UK, 90% of them are iron
deficient.
 Iron deficiency causes maternal morbidity due to increased
 Susceptibility to infections,
 physical weakness,
 preterm labour,
 increased risk of post partum haemorrhage,
 low birth weight babies and post natal depression.
 Maternal iron depletion also increases the risk of iron deficiency in the
neonate.
 Managing anaemia in pregnancy will therefore help to prevent adverse fetal
and maternal outcomes as well as reduce the need for allogeneic red blood
cell transfusion.
Definition:
 Anaemia is defined as Hb value less than 2 standard deviations below the
mean value for a healthy matched population.
 The definition of anaemia in pregnancy is Hb levels of:
 <110g/l in the first trimester
 <105 g/l in the second and third trimesters
 <100 g/l in the postpartum period.
(British Committee for Standards in Haematology 2011)
Clinical Signs and Symptoms:
 Pregnancy anaemia can be asymptomatic and may be diagnosed following
routine screening.
The signs and symptoms are often non-specific with tiredness being the most
common. Women may also complain of weakness, headaches, palpitations,
dizziness, dyspnoea and hair loss.
 Signs of anaemia can occur in the absence of a low Hb.
 In this instance it would be diagnosed by a full blood count with a reduced
MCV (Mean Cell Volume) and MCHC (Mean Corpuscular Haemaglobin
Concentration).
 In these patients, a ferritin needs to be checked and if it is <30μ/l iron therapy
should be commenced.
Diagnosis:
 A trial of oral iron therapy can be both diagnostic and therapeutic.
 If haemaglobinopathy status is unknown, then it is reasonable to start oral iron
therapy whilst screening is carried out. A trial of oral iron should demonstrate

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 a rise in Hb within 2 to 3 weeks. If there is a rise then this confirms the
diagnosis of iron deficiency.
 If there is no rise, further tests must be carried out.
 In patients with a known haemaglobinopathy serum ferritin should be checked
first.
 Ferritin levels below 30μ/l should prompt treatment and levels below 15μ/l are
diagnostic of established iron deficiency.
Management:
 NICE guidelines recommend that women are screened for anaemia at
booking and again at 28 weeks gestation.
 All women should be given advice regarding diet in pregnancy with details of
foods rich in iron along with factors that may promote or inhibit the absorption
of iron.
 This should be backed up with written information.
 Dietary changes alone are not sufficient to correct an existing iron deficiency
in pregnancy and
 iron supplements are necessary.
Antenatal

 Women should be counselled as to how to take oral iron supplementation

correctly. This should be on an empty stomach, 1 hour before meals, with a
source of vitamin C to maximise absorption. Other medications or antacids,
tea or coffee should not be taken at the same time.
 Women with a norman Hb but a low MCV should have their ferritin checked
and if ferritin is <30μ/l, oral iron should be commenced.
 Repeat Hb levels 3 weeks after commencement of iron therapy (this should fit
in with 15-16 week antenatal appointment) and a rise in Hb should be
demonstrated. If there is no rise in Hb despite compliance with therapy serum
ferritin should be checked and concomitant causes of the anaemia need to be
excluded. Referral to consultant obstetrician is required.
 If at Booking Hb <90 g/l Oral iron - 200mg elemental iron in divided
doses/day should be commenced and follow up as above. Referral to
consultant obstetrician if symptomatic.
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  If at Booking Hb <70g/l send an urgent referral to joint obstetric/haematology
clinic to investigate further and make management plan.
 Do not offer blood transfusion unless symptomatic or currently actively
bleeding.
 Consider total dose IV iron infusion (See later)
200mg of elemental iron / day (N.B. if 200mg ferrous sulphate used,
need 3-4 tablets/day) if taken correctly will give a rise in Hb of 20g/l
every 3 weeks.
 Once Hb is within the normal range, treatment should be continued for a
further 3 months.
 At 28 weeks. All women should have their Hb re-checked (NICE 2008)
 If at 28 weeks Hb < 105g/l Trial of oral iron as above. Re-check Hb in 3
weeks. If no reponse, check serum ferritin and refer to consultant
obstetrician to consider total dose iron infusion.
 If at 28 weeks Hb <90g/l Start oral iron - 200mg elemental iron in divided
doses/day, as above. Consultant Obstetrician referral if symptomatic.
 If at 28 weeks Hb <70g/l Urgent referral to joint obstetric/haematology
clinic to investigate and make management plan. Do not offer blood
transfusion unless symptomatic or currently actively bleeding. Consider
total dose IV iron infusion. (See later)
NB Gastrointestinal toxicity affects 35-59% of patients and can result in non
adherence to treatment with oral preparations (Auerbach and Ballard 2010)
These effects can be reduced by taking oral iron with food or taking a reduced
dose.
 Parenteral iron can be considered from the second trimester onwards
and during the third trimester for women with confirmed iron deficiency
who fail to respond to or are intolerant of oral iron. Intravenous iron is
the appropriate treatment for those patients with active inflammatory
bowel disease where oral preparations are not tolerated or
contraindicated.
Management of Labour and Delivery
 With effective management of anaemia antenatally, anaemia at delivery is
usually avoided.
 If this occurs, all measures must be taken to avoid blood loss at delivery:
 Deliver in consultant unit
 IV access and Group and screen on admission
 Active management of third stage of labour
 In the event of a PPH prompt active management is required to stop
bleeding.
 Consider the use of prophylactic syntocinon infusion.
 Postnatal FBC and serum ferritin on day 1 and iron replacement as
below.
Postnatal
 Hb <100g/l in postnatal period. Haemoglobin measurement is not required
following an uncomplicated, normal birth Check FBC and serum ferritin on day
1 post delivery in the following cases:
 PPH of >500mls
 Uncorrected antenatal anaemia
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  Known iron deficiency anaemia
 Any woman with signs or symptoms of anaemia Clinical assessment
alongside Hb concentration is necessary postpartum to make a decision on
the best method of iron replacement. In fit, healthy asymptomatic women
there is little evidence to support blood transfusion.
 Hb 80-100g/l If asymptomatic and haemodynamically stable, offer 200mg
elemental iron per day for 3 months.
 FBC and ferritin should be checked after 3 weeks to ensure that Hb and iron
stores are replete.
 Hb<80g/l Consider total dose intravenous iron. Repeat FBC and ferritin at 10
days to ensure response and at 3 months in community to ensure Hb and iron
stores are repelete.
 Hb<70g/l Consider and discuss alternatives with the woman . Consider
transfusion and/or total dose IV iron.
 Minimum transfusion volumes should be considered; Review after 1 unit.
 Women who are symptomatic of anaemia, haemodynamically unstable
or continuing to bleed heavily will need a full senior obstetric review to
investigate the origin of the blood loss and decide further treatment.
Contraindications to IV iron therapy.
1. First trimester of pregnancy
2. Previous hypersensitivity to IV iron
3. Anaemia not attributable to iron deficiency
4. Iron Overload
5. Acute infection/inflammation
6. Clinical or biomedical evidence of liver damage
7. Asthma
8. Acute renal failure
9. Active Rheumatoid Arthritis

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BLOOD TRANSFUSION IN OBSTETRICS
Background
 Obstetric haemorrhage remains a major cause of maternal mortality in the UK, with
substandard management identified in 80% of the cases with blood transfusion either
„too little, or late‟.
 The major risk of blood transfusion, is receiving an „incorrect blood component‟.
How can the chance of transfusion be reduced?
1-Optimisation of haemoglobin in the antenatal period
Diagnosis
 Anaemia in pregnancy is defined as first trimester haemoglobin (Hb) less than 110 g/l,
second/third trimester Hb less than 105 g/l, and postpartum Hb less than 100 g/l,
 Pregnant women should be offered screening for anaemia at booking and at 28
weeks.
 Women with multiple pregnancies should have an additional full blood count done at
20–24 weeks.
2-Treatment and management
 for normocytic or microcytic anaemia, a trial of oral iron should be considered as the
first step and further tests should be undertaken if there is no demonstrable rise in Hb
at 2 weeks and compliance has been checked.
 Supplement Oral iron as first-line treatment for iron deficiency.
 Parenteral iron if oral iron is not tolerated, absorbed or patient compliance is in doubt.
o Parenteral therapy offers a shorter duration and a quicker response than oral
therapy.
o Iron sucrose is given in multiple doses whereas iron dextran as a single total-dose
infusion.
o Recombinant human erythropoietin is used in anaemia of end-stage renal disease
without any adverse maternal, or fetal effects.
o Women should receive information on improvement of dietary iron intake and factors
affecting absorption of dietary iron.
 Anaemia not due to haematinic deficiency (haemoglobinopathies and bone marrow
failure syndromes)should be managed by blood transfusion in close conjunction with a
haematologist.
 Blood loss at delivery should be minimized by:
1. Active management of the third stage of labour
2. Women at high risk of haemorrhage should deliver in hospital.
3. Optimal management of women on anticoagulants.
General principles of blood transfusion
I-Consent for blood transfusion
 Valid consent should be obtained where possible prior to administering a blood
transfusion.
 In an emergency, where it is not feasible to get consent, information on blood
transfusion should be provided retrospectively.
 The reason for transfusion and a note of the consent discussion should be
documented in the patient‟s case notes.
II-Requirements for group and screen samples and cross-matching:
 All women should have blood group and antibodies status at booking and at 28 weeks.
 Women should have a group-and-save or crossmatch sample depending on the
diagnosis
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 Group and screen samples used for provision of blood in pregnancy should be less than
3 days old.
 In a woman at high risk of emergency transfusion, e.g. placenta praevia, and with no
clinically significant alloantibodies, group and screen samples should be sent once a
week to exclude or identify any new antibody formation and to keep blood available if
necessary. Close liaison with the hospital transfusion laboratory is essential.
 For women with placenta praevia, make 2 units of crossmatched red cells in the issue
fridge. These units should be replaced every week by newly crossmatched units.
 Women should have a group and screen sample taken in line with clear locally agreed
protocols for provision of blood.
 NICE suggested that neither a group-and-save nor crossmatch sample should be
taken from healthy women with an uncomplicated history who are due to have a
caesarean section.
III-Blood product specification in pregnancy and the puerperium:
 ABO-, rhesus D- (RhD-) and K- (Kell-) compatible red cell units should be transfused.
If clinically significant red cell antibodies are present, then blood negative for the
relevant antigen should be cross-matched before transfusion; close liaison with the
transfusion laboratory is essential to avoid delay in transfusion in life-threatening
haemorrhage.
 Cytomegalovirus- (CMV-) seronegative red cell and platelet components should be
provided for elective transfusions during pregnancy.
What are the strategies to minimise the use of banked blood?
1. In pregnancy, autologous blood transfusion is not recommended.
 There is concerns about placental insufficiency,
 whether the woman will make up her Hb before delivery.
 whether the collected units will be sufficient in the event of major haemorrhage.
 This procedure does not prevent the major risk of blood transfusion „incorrect blood
component transfused‟, or the risk of bacterial contamination.
2. Cell salvage is recommended for patients where the anticipated blood loss is great
enough to induce anaemia or expected to exceed 20% of estimated blood volume.
 Consent should be obtained for IOCS where possible and its use in obstetric patients
should be subject to audit and monitoring.
 Cell salvage should only be performed by multidisciplinary teams who develop
regular experience of IOCS (intraoperative cell salvage (IOCS).
 Where IOCS is used during caesarean section in RhD-negative, previously
nonsensitised women and where cord blood group is confirmed as RhD positive (or
unknown), a minimum dose of 1500 iu anti-D immunoglobulin should be
administered following the reinfusion of salvaged red cells.
A maternal blood sample should be taken for estimation of fetomaternal
haemorrhage 30–40 minutes after reinfusion in case more anti-D is indicated.
 IOCS has a role in the management of patients who refuse allogenic blood
transfusions.
How can major haemorrhage be managed?
 There should be a clear local protocol with early involvement of multydisciplinary a
broach (a consultant obstetrician, anaesthetist and haematologist and the blood bank).
 The protocol should be updated annually and practised in „skills drills‟ to inform and train
relevant personnel.
 Massive blood loss may be defined as:
o loss of 1 blood volume within a 24-hour
o 50% blood volume loss within 3 hours
o a rate of loss of 150 ml/minute.
 Normal blood volume in the adult is taken as approximately 7% of ideal body weight

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What blood components can be used for obstetric haemorrhage?
Red cells
 There are no firm criteria for initiating red cell transfusion. The decision to provide
blood transfusion should be made on clinical and haematological grounds.
 if no history of irregular antibodies during screening, group-specific compatible blood can
be provided within 10 minutes plus transport time.
 If there is irregular antibodies, blood must be crossmatched.
 In an extreme situation when blood group is unknown, O Rh D negative red cells should
be given.
 Staff working in obstetric units should be aware of the location of the satellite blood
fridge (where available) and should ensure that access is possible for blood collection.
fresh frozen plasma (FFP) and cryoprecipitate
 FFP at a dose of 12–15 ml/kg should be administered for every 6 units of red cells
during major obstetric haemorrhage.
 Subsequent FFP transfusion should be guided by the results of clotting tests if they
are available in a timely manner, aiming to maintain prothrombin time (PT) and
activated partial thromboplastin time (APTT) ratios at less than 1.5 x normal.
 It is essential that regular full blood counts and coagulation screens (PT, APTT and
fibrinogen) are performed during the bleeding episode.
 Cryoprecipitate at a standard dose of two 5-unit pools should be administered early in
major obstetric haemorrhage.
 Subsequent cryoprecipitate transfusion should be guided by fibrinogen results, aiming
to keep levels above 1.5 g/l.
 The FFP and cryoprecipitate should ideally be of the same group as the recipient.
 If unavailable, FFP of a different ABO group is acceptable providing that it does not
have a high titre of anti-A or anti-B activity.
 No anti-D prophylaxis is required if a RhD-negative woman receives RhD-positive
FFP or cryoprecipitate.
platelets
 should not be allowed to fall below 50 x 109/l in the acutely bleeding patient
 A platelet count of 50 x 109/l may be anticipated when two blood volumes have been
replaced.
 A platelet transfusion trigger of 75 x 109/l is recommended to provide a margin of safety.
 The platelets should ideally also be group compatible.
 Rh D-negative women should receive Rh D-negative platelets
o Anti-Rh D immunoglobulin (250 iu) will be needed if the platelets are Rh D positive
and the recipient Rh D negative. This is not necessary with a caesarean
hysterectomy.
o Anti- D is given subcutaneously to minimise bruising and haematomata.
o Transfusion of platelets through a set previously used for red cells is not
recommended.
recombinant factor VIIa
 The use of rFVIIa may be considered as a treatment for life-threatening postpartum
haemorrhage but should not substitute or delay other procedure.
 There is no evidence to support the prophylactic use of rFVIIa to reduce blood loss for
c/s.
Is there a role for fibrinogen concentrate therapy
 Fibrinogen concentrate is not licensed in the UK for the management of acquired
bleeding disorders. Thus, its use in PPH should be considered only in the context of
clinical trials.

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Is there a role for antifibrinolytics
 For those centres not participating in clinical trials, consideration should be given to
using tranexamic acid during major obstetric haemorrhage.
How should intrapartum anaemia be managed?

 In addition to major haemorrhage guidelines, obstetric units should have guidelines on

criteria for red cell transfusion in anaemic women who are not actively bleeding.
 If the Hb is less than 70 g/l in labour or in the immediate postpartum period, the
decision to transfuse should be made according to the individual‟s medical history and
symptoms.
How should the woman be managed in the postnatal period?
 If the Hb is less than 7–8 g/dl in postnatal period, the decision to transfuse should be
made on an informed individual basis.
 In fit, healthy, asymptomatic patients no need for blood transfusion.
 If unexpected severe bleeding occurred, investigations should be made for bleeding
diatheses.
How should women who refuse blood transfusion be managed?
 Hb should be optimised prior to delivery to prevent avoidable anaemia.
 Use of pharmacological, mechanical and surgical procedures to avert the use of
banked blood and blood components should be considered early.
 IOCS has a role in the management of patients who refuse allogeneic blood
transfusion.
 Consent/refusal of blood and components or other transfusion-sparing techniques
should be discussed and documented during the antenatal period.

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PREGNANCY AND BREAST CANCER
Background
 Breast cancer is the most common cancer in females, with a lifetime risk of 1/9 in the
UK, and is the leading cause of death in women aged 35–54 years.
 Fifteen percent of cases are diagnosed before the age of 45 years.
 In women aged 30 yrs. or less, 10-20% of breast cancer may be associated with
pregnancy or 1 yr. postpartum.
 The prognosis is improving, with 5-year survival 80% for <50s age group; however
survival rate is lower in very young women.
 Treatment of pregnancy-associated cancer should be in a multidisciplinary team with
inclusion of the obstetric team as core members.
What is the optimal management of breast cancer diagnosed during pregnancy?
Prognosis
 Pregnancy does not worsen the prognosis.
 breast cancer occurs in a younger population may carry a higher risk of metastases such
as high-grade tumours and estrogen receptor negative tumours, these younger women
may have an inferior prognosis.
 Prognostic factors affecting individual woman are: tumour size, grade, nodal status,
estrogen and progesterone receptor and HER2 status.
Diagnosis
 Women presenting with a breast lump during pregnancy should be referred to a breast
specialist team and any imaging or further tests should be conducted in conjunction with
the multidisciplinary team.
 Diagnosis may be difficult in women who are pregnant or lactating.
 Ultrasound is used first to assess a discrete lump, but if cancer is confirmed,
mammography is necessary (with fetal shielding) to assess extent of disease and
contralateral breast.
 Scan-guided biopsy for histology rather than cytology,as change in pregnancy makes
cytology inconclusive.
 Staging for metastases is made only if there is high clinical suspicion and should include
chest X-ray and liver scan if possible.
 Bone scanning and pelvic X-ray CT to establish or exclude metastases are not
recommended because of the effect of irradiation on the fetus.
 Gadolinium enhanced MRI is not recommended unless there is a need to investigate a
clinical problem.
 Tumor markers such CA15-3,CEA and CA125 not used in early stages and may be
misleading in pregnancy.
Consideration of termination of pregnancy
 The decision to continue the pregnancy should be based on discussion of the cancer
prognosis, treatment and future fertility with the woman and her partner and
multidisciplinary team.
Treatment during pregnancy
 Surgical treatment including loco-regional clearance can be undertaken in all trimesters.
 Breast conserving surgery or mastectomy can be considered, based on tumour
characteristics and breast size. Reconstruction should be delayed to avoid prolonged
anaesthesia and to allow symmetrisation of the breasts.
 Sentinel node biopsy is indicated in women who have a negative result from a
preoperative axillary ultrasound and needle biopsy.
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  If the axilla is positive, axillary clearance is indicated.
 Radiotherapy is contraindicated till delivery unless it is lifesaving or preserve function
(spinal cord compression) with fetal shielding or, depending on GA, early delivery could
be discussed.
 Routine breast/chest wall radiotherapy can be deferred until after delivery.
 Systemic chemotherapy is contraindicated in the first trimester because of a high rate of
fetal abnormality,but is safe from the second trimester.
 Anthracyline regimens are safe; there are fewer data on taxanes, which should be
reserved for high-risk (node-positive) or metastatic disease.
 Standard antiemetics including 5HT3 serotonin antagonists and dexamethasone
should be used
 There is no evidence for increased rate of 2nd trimester miscarriage or fetal growth
restriction.
 a decision may be made to offer neoadjuvant chemotherapy before surgery to allow
tumour downstaging and to facilitate surgery.
 Tamoxifen and trastuzumab(monoclonal antibody targeted against the human epidermal
growth factor receptor 2 HER2) are contraindicated in pregnancy because of adverse
fetal outcome.
Timing of delivery of the baby
 Timing of birth should be after discussion with the woman and the multidisciplinary team.
 Most women can go to full term and have a normal or IOL.
 If early delivery of the baby is necessary, consider corticosteroids for fetal lung
maturation.
 Birth should be more than 2–3 weeks after the last chemotherapy session to allow
maternal bone marrow recovery and to minimize problems with neutropenia.
Lactation
 Trastuzumab or tamoxifen are contraindication for breastfeed because transmission in
breast milk is unknown.
 These drugs may cause neonatal leucopenia with a risk of infection.
 There should be a time interval of 2–3 weeks from the last chemotherapy session to
start breastfeeding.
 If chemotherapy is restarted, breastfeeding must cease.
 A short period of lactation may be psychologically beneficial after a stressful
pregnancy and to baby.
Contraceptive choices to avoid pregnancy after treatment of breast cancer
 Non-hormonal contraceptive methods are recommended.
 Hormonal contraception is contraindicated in women with current or recent breast cancer
 This advice does not differentiate between hormone-sensitive and hormone-insensitive
tumours.
 hormonal contraception may be considered after at least 5 years free of recurrence
 LNG-IUS may reduce the endometrial abnormalities during tamoxifen therapy, but further
evidence is required on its safety in breast cancer. No overall increase in recurrence
found in a retrospective study of LNG-IUS users compared with nonusers.
What advice should be given to women planning pregnancy after breast cancer?
 Women planning a pregnancy after treatment for breast cancer:
 should consult their multidisciplinary team.
 Women on tamoxifen are advised to stop this treatment 3 months before trying to
conceive
 To have any routine imaging to avoid the need for imaging during pregnancy.
 Women with metastatisis advised against pregnancy as life expectancy is limited and
treatment of metastatisis will be compromised.
Impact of pregnancy on risk of recurrence
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 Women can be reassured that long-term survival after breast cancer is not adversely
affected by pregnancy.
 Since many breast cancers are estrogen receptor positive, women used to be
advised against pregnancy because of concerns of worseninig. However, the
evidence from the published studies is reassuring.
Time interval before pregnancy
 Advice on interval before pregnancy should be individualized, based on treatment and
prognosis over time.
 Most women should wait at least 2 years after treatment, during which cancer recurrence
is highest.
 Women with estrogen receptor positive advised that the recommended tamoxifen
treatment is for 5 years.
 This is of great importance to the woman desiring pregnancy to weigh up the benefit of
postponing conception, against the risk of infertility as a result of delay.
Outcome of pregnancy
 After completion of treatment for breast cancer:
 The majority of pregnancies proceed to live birth.
 There may be an increased miscarriage rate
 No increase in congenital malformations or stillbirth among the offspring.
What is the optimal management of pregnancy following treatment for Ca breast?
 Pregnancy following breast cancer should be jointly supervised by multidisciplinary team.
 Echocardiography during pregnancy for women at risk to detect cardiomyopathy.
advice to women wishing to breastfeed following treatment for breast cancer
 Women can be reassured that they can breastfeed from the unaffected breast.
 Radiotherapy causes fibrosis, making lactation unlikely.
 There is no evidence that previous chemotherapy affects the safety of breastfeeding.
 In view of recognized benefits of breastfeeding to the baby, women wish to breastfeed
should be encouraged.
What is the effect of breast cancer treatment on the woman s fertility?
 The effect of treatment on fertility should be discussed and written information should be
provided.
 Counseling and referral to a fertility specialist should be available.
What is the effect of adjuvant chemotherapy on fertility?
 Chemotherapy-induced gonadotoxicity may cause:
 permanent amenorrhoea with complete loss of germ cells
 transient amenorrhoea,
 menstrual irregularity and subfertility.
 Degree of gonadotoxicity depends on the agents used, the cumulative dose and the
woman‟s age
 Alkylating agents such as cyclophosphamide have well-recognised gonadotoxicity:
 CMF regimen (cyclophosphamide,methotrexate, 5-fluorouracil) causes a higher
incidence of amenorrhoea than anthracycline regimens such as FEC (5-fluorouracil,
epirubicin, cyclophosphamide).
 The newer taxanes appear to be less gonadotoxic.
What is the effect of adjuvant hormonal therapy on fertility?
 The adjuvant hormonal therapy do not in themselves cause long-term effects on fertility.
 Tamoxifen often causes menstrual irregularity and increased risk of endometrial
pathology.
 Because of teratogenicity of tamoxifin, washout period‟ of 2–3 months is advised before
conception.

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 GnRH analogues cause amenorrhoea and profound estrogen deficiency, but the effect is
entirely reversible.
 Trastuzumab is a monoclonal antibody binds to the HER2 protein expressed by some
breast cancers; there is no evidence that it impairs fertility, but pregnancy is not advised
during treatment.
What advice should be given about postponement of pregnancy?
 Women are advised to postpone pregnancy for at least 2 yrs after treatment and to
continue tamoxifen for 5 yrs.
 age is a major determinant of fertility and delay with already poor ovarian function owing
to chemotherapy is likely to lead to infertility.
Can fertility be preserved before treatment?
 Minority of women undertake fertility-preservation procedures and there are no data on
long-term outcome.
1) GnRH analogues
 There are insufficient level 1 data to support the routine use of GnRH analogues for
ovarian protection in estrogen receptor positive breast cancer.
 GnRH have therapeutic use in hormone-sensitive breast cancer, inducing profound
ovarian suppression.
 Concomitant GnRH may lessen tumour response to chemotherapy in estrogen
receptor positive cancer.
 A recently reported randomised controlled trial found that co-treatment with GnRH
during chemotherapy lessened the risk of ovarian damage.
2) Cryopreservation
 Ovarian stimulation for egg or embryo freezing requires careful discussion due to
unknown long-term risks.
 Modified stimulation regimes should be considered for women with estrogen-sensitive
Ca breast .
 There are insufficient data to support ovarian tissue storage for fertility preservation in Ca
breast.
 The National Institute for Health and Clinical Excellence recommended universal access
to sperm, egg and embryo storage for people undergoing gonadotoxic treatment.
Assisted reproduction after treatment for breast cancer
 Fertility treatment after chemotherapy is limited by loss of ovarian reserve.
 The stimulation aspect of IVF carries a theoretical risk as it is a hyperestrogenic state,.
 Women who have chemotherapy-induced menopause can become pregnant with
donated eggs; this requires short-term HRT, which again carries a theoretical risk.
 Replacement of cryopreserved embryos is also performed in a medicated HRT cycle.
 Women for whom pregnancy is contraindicated may wish to consider surrogacy.

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THE DIAGNOSIS AND TREATMENT OF MALARIA IN PREGNANCY
Background
 75% of cases are caused by Plasmodium falciparum and mortality rate is 0.5–1.0%
 Maternal deaths from malaria are unlikely to be reported when they occur in endemic
countries.
 the risk of adverse effects from untreated malaria in pregnancy outweigh those of
treatment.
 P. falciparum, P. vivax, P. malariae and P. ovale extremely rarely P. knowlesi are
transmitted by the bite of anopheline mosquito.
 P. falciparum infection alters the red cell membrane result in erythrocytes stick inside
the small blood vessels of brain, kidneys and other affected organs. Which interfere with
microcirculatory flow and metabolism of vital organs.
 The hallmark of falciparum malaria in pregnancy is parasites sequestered in the
placenta.
 Sequestered parasites evade host defence mechanisms: splenic processing and
filtration.
 the adverse effects of malaria infection result from:
1. the systemic infection, which may result in: maternal and fetal mortality, miscarriage,
stillbirth and premature birth
2. the parasitisation itself: fetal growth restriction and low birth weight, maternal and
fetal anaemia, interaction with HIV, susceptibility of the infant to malaria.
 P. falciparum causes greater morbidity (maternal and fetal, principally low birth weight
and anaemia) and mortality than non-falciparum infections
 P. vivax is not as benign as had been previously thought.
 The higher the transmission of malaria, the greater the degree of prior immunity and the
more likely the woman will respond favourably to a drug treatment.
Definition of terms used in this guideline
Severe and complicated malaria

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Uncomplicated malaria
 is defined as fewer than 2% parasitised red blood cells with no signs of severity and no
complicating features.
Congenital malaria
 results from the passage of parasites or infected red blood cells from the mother to the
newborn while in utero or during delivery
.
Artemisinin combination therapy
 Artemisinin combination therapy is a combination of artemisinin or one of its derivatives
with antimalarials of a different class.
Resistance
 is defined as the ability of a parasite to survive and multiply despite the administration
and
absorption of a medicine given in doses equal to or higher than those usually recommended
but within the tolerance of the subject.
Diagnosis of malaria in pregnancy
Why is malaria diagnosis difficult?
 In its early stages, the symptoms and signs of malaria can mimic influenza and other
common viral infections.
 A history of travel to a malaria endemic area should be sought in a pregnant woman with
pyrexia of unknown origin.

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 Misdiagnosis and delay of treatment are the most common reasons cited for death from
malaria in Europe and the USA.
 For the non-falciparum malarias, the history of travel may be more than 1 year before the
onset of symptoms and, and prophylaxis does not rule out the diagnosis of malaria.
How should malaria in pregnancy be diagnosed?
 for malaria diagnosis a blood film is vital.
 Rapid detection tests may miss low parasitaemia, which is more likely in pregnant
women
 rapid detections tests are relatively insensitive in P. vivax malaria.
 A positive rapid diagnostic test should be followed by microscopy to quantify the
parasitaemia and to confirm the species and the stage of parasites.
 In a febrile patient, three negative malaria smears 12–24 hours apart rules out the
diagnosis of malaria.
 Other important factors that should be reported on a peripheral blood smear result are:
1. the presence and count of mature trophozoites and schizonts of P. falciparum
2. finding malaria pigment in more than 5% of the polymorphonuclear leucocytes in the
peripheral blood film.
Is the severity of malaria a useful aid in managing the infection?
 Women with malaria should have the severity of their condition assessed and
documented .
 The clinical condition is the most important indicator of severity
 The severity of malaria determines the treatment and predicts fatality rate.
 In uncomplicated malaria, fatality rates 0.1% for P. falciparum.
 In severe malaria, fatality rates 15–20% in nonpregnant women compared with 50%
in pregnancy.
 The non-falciparum species are rarely fatal but caution should still be observed.
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 Once the disease has been classified as severe/complicated or uncomplicated malaria
prompt treatment should be instituted.
How is malaria infection treated during pregnancy?
 Treat malaria in pregnancy as an emergency.
 Admit pregnant women with uncomplicated malaria to hospital and pregnant women with
severe and complicated malaria to ICU.
 Intravenous artesunate is the treatment of choice for severe falciparum malaria. Use
intravenous quinine if artesunate is not available.
 Use quinine and clindamycin to treat uncomplicated P. falciparum (or mixed, such as P.
falciparum and P. vivax).
 Use chloroquine to treat P. vivax, P. ovale or P. malariae.
 Primaquine should not be used in pregnancy.
 Seek advice from infectious diseases specialists, especially for severe and recurrent
cases.
 Do not persist with oral therapy if vomiting is persistent.
 Treat the fever with antipyretics.
 Screen women with malaria for anaemia and treat appropriately.
 Write a management plan for follow-up, to ensure detection of relapse.
7.1 Drug treatment

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Where should treatment of uncomplicated malaria infection take place?
1. hospitalise all pregnant women with P. falciparum, as the clinical condition can
deteriorate rapidly.
 Monitor BF every 24 hours but clinical deterioration is an indication for a repeat blood
film.
 The 7-day course of quinine has significant adverse effects, principally cinchonism,19
which includes tinnitus, headache, nausea, diarrhoea, altered auditory acuity and
blurred vision. This can lead to non-compliance,
2. non-falciparum malaria can be managed on an outpatient basis, admission ensures
compliance and any risk of vomiting or rapid deterioration is minimised.
What happens if the patient vomits?
 Vomiting is a symptom of malaria and adverse effect of quinine.

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 If the patient vomits, use an antiemetic( metoclopramide is considered safe, even in the
first trimester).
 After the antiemetic has had time to take effect, repeat the dose.
 Repeat vomiting after antiemetic is an indication for parenteral therapy.

What other medication should be provided alongside treatment of uncomplicated

malaria infection?
 fever of malaria is associated with premature labourand fetal distress.
 paracetamol at the standard dose is fundamental to the treatment of fever
 Despite the massive burden of malaria-related anaemia in pregnancy, there are very few
studies about routine iron and folate supplementation as part of uncomplicated malaria
treatment.
 Mild and moderate malaria associated anaemia is treated with ferrous sulphate and folic
acid at the usual doses.
Does pregnancy affect the efficacy of malaria treatments?
 Treatments in pregnancy may have lower efficacy than in non-pregnant patients due to
lowered concentrations of antimalarials in pregnancy.
 Most recurrence is around day 28–42 but late reported recurrence, so far unique to
pregnancy, has been reported to occur at 85 days with quinine, 98 days with artesunate,
 Weekly screening by blood film until delivery allows these women to be detected positive
before becoming symptomatic.
How should recurrence be treated?
 The cure rates for uncomplicated malaria with quinine fell from 77.0% to 61.0% and for
mefloquine from 72.0% to 62.5% when these drugs were used to treat primary and
recurrent infections.
 The alternative regimen for recurrent malaria was artesunate monotherapy, which had a
cure rate of 84%.
How are pregnancy-related complications of severe malaria managed?
 Monitor for hypoglycaemia regularly, as it can be profound and persistent and can be
exacerbated by quinine(caused by hyperinsulinaemia).
 Hypoglycaemia is commonly asymptomatic, although it may be associated with fetal
bradycardia
 Prevent mortality from pulmonary oedema and acute respiratory distress syndrome by
clinical assessment of jugular venous or central venous pressure, keeping right arterial
pressure less than 10 cm H2O.
 Women who are severely anaemic should be transfused slowly with packed cells and
intravenous frusemide 20 mg. Alternatively, exchange transfusion may be considered.
 Secondary bacterial infection should be suspected if the patient becomes hypotensive.
 Blood cultures should be taken if the patient shows signs of shock or fever returns
after apparent fever clearance,
 Broad-spectrum antibiotics (such as ceftriaxone) should be started immediately
 In patients on quinine, abnormal behaviour, sweating and sudden loss of consciousness
are the usual manifestations.
 Quinine at treatment doses does not induce abortion or labour.
 Pulmonary oedema is a grave complication of severe malaria, with a high mortality of
over 50%.The first indication of impending pulmonary oedema is an increase in the
respiratory rate
 In some women, acute respiratory distress syndrome can occur in addition to the
pulmonary oedema.

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Obstetric management specific to malaria infection in pregnancy
Common obstetric problems with acute symptomatic malaria
 Preterm labour, fetal growth restriction and fetal heart rate abnormalities(tachycardia,
bradycardia or late decelerations) can occur in malaria in pregnancy.
 Maternal hypoglycaemia should be excluded as the cause of fetal distress
 In severe malaria complicated by fetal compromise, a multidisciplinary team approach
(intensive care specialist, infectious disease specialist, obstetrician, neonatologist) is
required to plan optimal management of mother and baby.
 Stillbirth and premature delivery in malaria in pregnancy are best prevented with prompt
and effective antimalarial treatment.
 Uncomplicated malaria in pregnancy is not a reason for induction of labour.
 Pharmacological thromboprophylaxis should be weighed up against the risk of
haemorrhage and should be withheld if there is thrombocytopenia.
 Peripartum malaria is an indication for placental histology and placenta, cord and baby
blood films to detect congenital malaria at an early stage.
 Inform women of the risk of vertical transmission and, in the presence of positive
placental blood films,
 fever in the infant could indicate malaria; a blood film from the baby is required for
confirmation.
What antenatal care after recovery from an episode of malaria in pregnancy is advised?
 Regular antenatal care, including assessment of maternal haemoglobin, platelets,
glucose and fetal growth scans, is advised following recovery from an episode of malaria
in pregnancy.
 Regular fetal growth assessment is advised and, if growth restriction is identified, routine
obstetric management for this condition applies
 Inform the woman about the risk of relapse, try to prevent it and develop a clear plan with
the woman in the event of symptom recurrence.
What is the risk of vertical transmission of malaria infection to the baby?
 Vertical transmission to the fetus can occur particularly when there is infection at the time
of birth and the placenta and cord are blood film positive for malaria.
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 All neonates whose mothers developed malaria in pregnancy should be screened for
malaria with standard microscopy of thick and thin blood films at birth and weekly blood
films for 28 days.
 The reported prevalence of congenital malaria varies from 8% to 33%.

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THE PREVENTION OF MALARIA IN PREGNANCY
Background
 Malaria can be life-threatening but it is preventable
 In 2008, there were six deaths reported in the UK from malaria.
What are the medical complications of malaria in pregnancy?
 The principal effect of malaria in pregnancy in women from endemic countries is low birth
weight.
 In endemic areas, pregnant women are twice as likely to be bitten by anopheline
mosquitoes and to contract and die from malaria than their non-pregnant counterparts.
 The clinical manifestations in pregnancy depend on premunition; that is, the degree of
naturally acquired host immunity to malaria Which depends on repeated exposure.
Prevention of malaria infection in pregnancy
 Pregnant women should consider the risks of travel to malaria endemic countries and
consider postponing their trip, unless travel is unavoidable.

If travel is unavoidable what advice should pregnant women receive about preventing
malaria infection?
 Advise the woman to seek guidance from a centre with expertise on malaria risks and
avoidance strategies.
 Advise women that a fever or flu-like illness while travelling or upon returning home, up
to 1 year or more, may indicate malaria and requires medical attention.
 Advise the woman on the risk of being exposed to malaria at her intended area of travel.
 The „ABCD‟ of malaria prevention is a useful:
 Awareness of risk.
 Bite prevention.
 Chemoprophylaxis .
 Diagnosis and treatment which must be prompt .
 The risk of malaria is dependent on a variety of factors, including:
 the level of transmission in the area(s) of travel
 the time of year (rainy or dry season),
 the presence of drug resistant strains of P. falciparum or P. vivax,
 whether rural or urban sleepovers are planned,
 length of travel
 the availability and the likelihood of uptake of malaria prevention interventions.
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 Despite applying effective anti-mosquito measures and good compliance to
chemoprophylaxis, women can still contract malaria.
How should bites be prevented?
 Inform women about bite prevention measures, including:
1. skin repellents applied to the exposed areas of the arms and legs twice daily.
 In a sweaty environment, the effect of repellent is lowered and more frequent
applications are required
2. knock-down mosquito sprays,
3. insecticide-treated bed nets
4. clothing
5. room protection.
 The anopheline mosquito biting times risk period is from dawn to other mosquito-
bornediseases, such as dengue, which is caused by a daytime-biting mosquito, should
be prevented, so applying mosquito bite prevention measures 24 hours a day is
advisable.
Which drug can be recommended for malaria prevention in pregnancy?
 Inform women (and their general practitioner) of the risks and benefits of
chemoprophylaxis versus the risks of malaria.
 Remind women that there is no malaria prophylaxis regimen that is 100% protective.
1. The choice of drug and advice about chemoprophylaxis in pregnant women depends
on :
 the level of chloroquine-resistant P. falciparum and P. vivax malaria
 the trimester of pregnancy.
2. Chemoprophylaxis for malaria can be causal or suppressive.
 Causal prophylaxis is directed against liver schizont stage, which takes
approximately 7 days to develop so these drugs (for example, atovaquone-
proguanil (Malarone®) need to be continued for 7 days after leaving a malarious
area.
 Suppressive prophylaxis (such as mefloquine) is directed against the red blood
cell stages of the malaria parasite and so should be continued for 4 weeks after
leaving a malarious area.
Chemoprophylaxis for women planning a pregnancy
 it is advisable to wait for complete excretion of the drug, if it was taken for
prophylaxis, before becoming pregnant.
 unplanned conception while taking malaria prophylaxis is not considered a
reason to termination, owing to the low risk of teratogenicity.
Chemoprophylaxis for pregnant or breastfeeding women
 Mefloquine (5mg/kg once a week) is the recommended drug of choice for
prophylaxis in the second and third trimesters for chloroquine-resistant areas.

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Emergency standby treatment in pregnancy?
 Written instructions should be given to a pregnant traveller regarding emergency standby
malaria treatment in the event of suspected malaria without access to medical care.
 The only recommended treatment in the UK for pregnant women is quinine (300
mg tablets, two tablets three times a day for 7 days) and clinda-mycin (150 mg
capsules, three capsules three times a day for 5–7 days).
 If a dose is vomited within 30 minutes, the full dose should be repeated and if the
dose is vomited after 30–60 minutes, half the dose should be repeated.
 The treatment should be finished and mefloquine should be commenced 1 week
after the last treatment done

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BACTERIAL SEPSIS IN PREGNANCY
Background and introduction
 in the UK. In 2003–2005 there were 13 direct deaths from genital tract sepsis in
pregnancy, 5 prior to 24 weeks and 8 from 24 weeks, arising before or during labour.
 substandard care was identified in many of the cases,
 Between 2006 and 2008 sepsis rose to be the leading cause of direct maternal deaths in
the UK,
 Severe sepsis with acute organ dysfunction has a mortality rate of 20 to 40%, which
increases to 60% if septic shock develops.
 survival rates following sepsis are related to early recognition and initiation of treatment.
 Sepsis defined as infection plus systemic manifestations of infection.
 Severe sepsis defined as sepsis plus sepsis-induced organ dysfunction or tissue
hypoperfusion.
 Septic shock is defined as persistence of hypoperfusion despite adequate fluid
replacement.
risk of sepsis in pregnancy

 Urinary tract infection and chorioamnionitis are common infections associated with
septic shock in the pregnant patient.
What should prompt recognition of sepsis in the pregnant woman?
 significant sepsis should trigger an urgent referral to secondary care.
 signs of sepsis, including pyrexia, may not always be present and are not necessarily
related to the severity of sepsis.
 Regular observations of all vital signs should be recorded on a Modified Early Obstetric
Warning Score (MEOWS) chart.
 Disease progression may be much more rapid than in the non-pregnant state.
 Genital tract sepsis may present with constant severe abdominal pain and tenderness
unrelieved by usual analgesia which should prompt urgent medical review.
 Severe infection may be associated with preterm labour.

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313
What are the appropriate investigations when sepsis is suspected?
 Blood cultures and other samples (throat swabs, mid-stream urine, high vaginal swab, or
cerebrospinal fluid) are the key investigation and should be obtained prior to antibiotic
administration.
 If the methicillin-resistant Staphylococcus aureus (MRSA) status is unknown, a pre-
moistened nose swab may be sent for rapid MRSA screening.
 Serum lactate should be measured within six hours of the suspicion of severe sepsis in
order to guide management.
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 Serum lactate ≥4 mmol/l is indicative of tissue hypoperfusion.
 Any relevant imaging should be performed in an attempt to confirm the source of
infection.

Who should be involved in the collaborative care of women with sepsis?

 If sepsis is suspected, regular frequent observations should be made.
 The use of a MEOWS chart is recommended.
 when there is severe or rapidly deteriorating cases There should be:
 urgent referral to the critical care team,
 involvement of a consultant obstetrician.
 expert advice of a consultant microbiologist or infectious disease physician.
 The decision to transfer to intensive care should be decided by the critical care team in
conjunction with the obstetric consultant and the consultant obstetric anaesthetist.

What are the commonly identified organisms, including hospital acquired infection?
 The most common organisms identified in pregnant women dying from sepsis are
Lancefield group A beta-haemolytic Streptococcus and E.Coli.
 Mixed infections with both Gram-positive and Gram-negative organisms are common,
especially in chorioamnionitis.
 Coliform infection is particularly associated with urinary sepsis, preterm PROM, and
cerclage.
 Anaerobes such as Clostridium perfringens are less commonly seen nowadays, with
Peptostreptococcus and Bacteroides spp. predominating.
Empirical and specific antimicrobial therapy
 Administration of intravenous broad spectrum antibiotics is recommended within one
hour of suspicion of severe sepsis, with or without septic shock.
 If genital tract sepsis is suspected, early combination of high-dose broadspectrum
intravenous antibiotics may be lifesaving.

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 The 2003–2005 CEMACH recommend use of cefuroxime and metronidazole for genital
tract sepsis.
 cefuroxime is no longer part of many hospital formularies because of the association
with C. difficile.
 Neither agent provides any MSRA, Pseudomonas or extended-spectrum beta-
lactamases (ESBL) cover

.
What is the role of intravenous immunoglobulin (IVIG)?
 IVIG is recommended for severe invasive streptococcal or staphylococcal infection if
other therapies have failed.
 It has an immunomodulatory effect,
 neutralises the effect of exotoxins,
 inhibits production of tumour necrosis factor (TNF) and interleukins.
 High dose IVIG has been used in pregnant women
 is effective in exotoxic shock but with little benefit in Gram-negative (endotoxin related)
sepsis.
 The main contraindication to IVIG use is a congenital deficiency of immunoglobulin A.
How should the fetus be monitored and when and how should be delivered?
 birth of the baby may be considered if it would be beneficial to the mother or the baby or
to both.
 timing and mode of birth should be made by a senior obstetrician following discussion
with the woman if her condition allows.
 If preterm delivery is anticipated, cautious consideration should be given to the use of
antenatal corticosteroids.
 intrapartum, continuous EFM is recommended.
 Changes in CTG, must prompt reassessment of maternal mean arterial pressure,
hypoxia and acidaemia.
 Epidural/spinal anaesthesia should be avoided in women with sepsis and a general
anaesthetic will usually be required for caesarean section.
 Risk of neonatal encephalopathy and CP is increased in the presence of intrauterine
infection.
 Electronic fetal monitoring is not a sensitive predictor of early onset neonatal sepsis.
 There is insufficient evidence regarding fetal blood sampling in the presence of maternal
sepsis to guide practice.
 delivery in the setting of maternal instability increases the maternal and fetal mortality
rates unless the source of infection is intrauterine.
What prophylaxis should be considered for the neonate, other family members and
healthcare workers?
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 When a mother has been found to have invasive group A streptococcal infection in the
peripartum period, the neonatologist should be informed and prophylactic antibiotics
administered to the baby.
 Close household contacts of women with GAS infection should seek medical attention
when symptoms develop, and the situation may warrant antibiotic prophylaxis.
 Healthcare workers exposed to respiratory secretions of women with GAS infection
should be considered for antibiotic prophylaxis.
What infection control issues should be considered?
 Group A -haemolytic Streptococcus and MRSA are easily transmitted via the hands of
healthcare workers and via close contact in households.
 Local infection control guidelines should be followed for hospital–specific isolation and
contact precautions.

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BACTERIAL SEPSIS FOLLOWING PREGNANCY
introduction
 The most common site of sepsis in the puerperium is the genital tract and in particular
the uterus, resulting in endometritis.
 sepsis in the puerperium remains an important cause of maternal death, accounting for
around 10 deaths per year in the UK.
 Risk of sepsis in the puerperium is same as risk of sepsis in pregnancy
What are the common organisms causing sepsis in the puerperium,
 The major pathogens causing sepsis in the puerperium are:
1. GAS, also known as Streptococcus pyogenes
2. Escherichia coli
3. Staphylococcus aureus
4. Streptococcus pneumoniae
5. meticillin-resistant S. aureus (MRSA), Clostridium septicum and Morganella morganii.
 GAS is directly responsible for 13 of the 29 maternal deaths from infection in the UK
2006–2008.
causes of sepsis outside the genital tract and how might they be identified?
 Women should be assessed clinically and, if unwell or with dehydration or vomiting,
admission should be considered.
1) Mastitis
 may lead to breast abscesses, necrotising fasciitis and toxic shock syndrome.
 Outbreaks of PVL-producing MRSA in neonatal units have been associated with
vertical transmission during breastfeeding.
 Immediate referral to hospital is indicated if:
1. woman is clinically unwell
2. there is no response to oral antibiotics within 48 hours
3. mastitis recurs
4. there are very severe or unusual symptoms.
2) Urinary tract infection
 Gram-negative bacterial infections are particularly associated with urinary tract.
 Acute pyelonephritis should be treated aggressively.
 admit to hospital if there is:
1. signs of sepsis,
2. unable to remain hydrated
3. vomiting
 The ESBLproducing coliforms are resistant to commonly used antimicrobials such as
cephalosporins and co-amoxiclav and may necessitate usage of carbapenems or
colistin.
3) Pneumonia
 Manage Severe pneumonia in consultation with a respiratory physician and a
medical microbiologist.
 A beta-lactam antibiotic together with a macrolide antibiotic is used to cover typical
and atypical organisms.
 Haemoptysis may be a feature of pneumococcal pneumonia.
 Severe haemoptysis and low peripheral white cell count suggest PVL-associated
staphylococcal necrotising pneumonia with mortality rate > 70%.
 urinary sample may be tested for pneumococcal antigen when sputum is not easily
available.
4) Skin and soft-tissue infection
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  Any woman with suspected bacterial sepsis should be examined for skin and soft-
tissue infection, particularly intravenous cannulae, injection sites and caesarean or
episiotomy wounds.
 Swabs should be taken of any discharge.
 If drains are suspected as the source of infection, they should be removed
 The location of intravenous cannula sites should be recorded and inspected twice
daily.
 Skin and soft-tissue infections are particularly associated with toxic shock
syndromes.
 Recurrent abscess formation, including labial abscesses, is a feature of PVL-
producing staphylococci.
 Septicaemic seeding of streptococci from a uterine focus may give rise to a
secondary focus in a limb, simulating a venous thrombosis.
 in early necrotising fasciitis there may be no visible skin changes. As the necrotising
process ascends to the skin, late infection produces blisters and obvious necrosis.
 The cardinal feature of necrotising fasciitis is of agonizing pain, necessitating
increasing amounts of strong analgesia .
5) Gastroenteritis
 Salmonella and Campylobacter rarely cause severe systemic infection and should be
managed symptomatically unless features of bacteraemia are present.
 Diarrhoea and vomiting may be features of toxic shock
 C. difficile is rare but increasingly found in obstetric patients.
6) Pharyngitis
 Most pharyngitis are viral, but 10% of cases in adults are attributable to GAS.
 If three of the four criteria (fever, tonsillar exudate, no cough, tender anterior cervical
lymphadenopathy) are present, treatment with an antibiotic is appropriate.
7) Infection related to regional anaesthesia
 Spinal abscess is a very rare after regional anaesthesia in obstetric patients.
 The usual organism responsible is S. aureus, with streptococci, Gram-negative rods
and sterile specimens accounting for 15% each.
 permanent spinal cord or cauda equina damage may result if neural compression is
prolonged.
What should prompt recognition of sepsis in the puerperium?

 significant sepsis should trigger urgent referral to secondary care.

 These signs, including pyrexia, may not always be present and are not necessarily
related to the severity of sepsis.
 Mastitis must never be overlooked.
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 Abdominal pain, fever (greater than 38°C) and tachycardia are indications for
intravenous antibiotics and senior clinical review.
 Non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided for pain relief in
cases of sepsis as they impede the ability of polymorphs to fight GAS infection.
 Agonising pain out of proportion to the clinical signs suggests a deep infection, and
necrotizing fasciitis/myositis must be considered.
 Some cases of sepsis in the puerperium may present initially only with severe abdominal
pain, in the absence of fever and tachycardia.
 Any widespread rash should suggest early toxic shock syndrome, especially if
conjunctival hyperaemia or suffusion is present.

The optimum way to monitor women with suspected sepsis in the puerperium
 Monitoring of the woman with suspected severe sepsis or established sepsis should be
multidisciplinary(senior obstetrician, intensivist, microbiologist or infectious disease
clinician) but preferably under the leadership of a single consultant.
 Regular observations of all vital signs recorded on MEOWS chart.
 All women who are unwell during the puerperium require regular and frequent
observation.
 Handover arrangements should be robust.
 Regular contact with family members is required.
What infectious disease history/information should be noted?
 A history of recent sore throat or prolonged (household) contact with family members
with known streptococcal infections (pharyngitis, impetigo, cellulitis) has been implicated
in cases of GAS sepsis.
 5/6 women with GAS admitted to hospital with septic shock had a history of recent sore
throat or respiratory infection.
 IV drug misuse carries a high risk of staphylococcal and streptococcal sepsis as well as
generalized immunosuppression of chronic disease, endocarditis and blood-borne
viruses.
 diarrhoea and vomiting may be attributable to food-borne pathogens, C. difficile infection
or early toxic shock.
 Ingestion of unpasteurised milk products raises the possibility of infection with
Salmonella, Campylobacter or Listeria.
 Chlamydophila psittaci is acquired by contact with aborting sheep or infected birds or by
crossinfection from washing contaminated clothing.
 Q fever is caused by Coxiella burnetii after inhalation from birthing animals or
contaminated dust.
features of sepsis in the puerperium that should prompt hospital admission
If sepsis is suspected in the community, urgent referral to hospital is indicated.
 „Red flag‟ signs and symptoms should prompt urgent referral for hospital assessment
and, if the woman appears seriously unwell, by emergency ambulance:
1. pyrexia more than 38°C
2. sustained tachycardia more than 90 beats/minute
3. breathlessness(respiratory rate more than 20 breaths/minute; a serious symptom)
4. abdominal or chest pain
5. diarrhoea and/or vomiting
6. uterine or renal angle pain and tenderness
7. woman is generally unwell or seems unduly anxious or distressed.1
 Early presentation of sepsis (<12 hours post-birth) is more likely to be caused by
streptococcal infection, particularly GAS, and severe continuous pain suggests
necrotising fasciitis.
 The speed of onset or deterioration in symptoms and signs is important.
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 Early antibiotics, whether oral or parenteral, is crucial in determining the outcome.
What are the appropriate triggers for involvement of other specialties?
 All cases of sepsis in the puerperium should be discussed with a clinical microbiologist or
infectious diseases physician.
 Appropriate specimens should be sent for urgent examination.
 Antimicrobials should be started within 1 hour of recognition of severe sepsis.
 Women with previously documented carriage of or infection with multiresistant organisms
(ESBLproducing organisms, MRSA, GAS or PVL-producing staphylococci) should
prompt notification of the infection control team.
 Suspicion of necrotising fasciitis should involve of intensive care physicians and referral
for surgical opinion, ideally plastic and reconstructive surgeons.
What investigations should be performed?
 Blood cultures and other samples (throat swabs, mid-stream urine, high vaginal swab,
cerebrospinal fluid, CS or episiotomy site wound swabs and expressed breast milk) are
the key investigation and should be obtained prior to antibiotic administration.
 If the methicillin-resistant Staphylococcus aureus (MRSA) status is unknown, a pre-
moistened nose swab may be sent for rapid MRSA screening.
 Serum lactate should be measured within six hours of the suspicion of severe sepsis in
order to guide management.
 Serum lactate ≥4 mmol/l is indicative of tissue hypoperfusion.
 Any relevant imaging should be performed in an attempt to confirm the source of
infection.
 Routine blood tests should include FBC, urea, electrolytes and CRP.
 woman with symptoms of tonsillitis/pharyngitis should have a throat swab for culture.
 If the MRSA status of the woman is unknown, a premoistened nose swab may be sent
for rapid MRSA screening.
 If diarrhoea is particularly offensive following antimicrobial therapy, a stool sample should
be submitted for C. difficile toxin testing.
 Thrombocytosis (high platelet count) with a rising CRP and a swinging pyrexia usually
indicates a collection of pus or an infected haematoma in the woman.

How should sepsis in the puerperium be managed?

 The focus of infection should be dealt with. This may be by uterine evacuation or by
drainage of a breast, wound or pelvic abscess.
 Broad-spectrum antibiotics should be given to cover these procedures.
Which antibiotics should be used?
 IV broad-spectrum antibiotics within 1 hour of suspicion of severe sepsis, with or without
septic shock

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 If genital tract sepsis is suspected, early treatment with a combination of high-dose
broadspectrum intravenous antibiotics may be life saving.
 A combination of either piperacillin/tazobactam or a carbapenem plus clindamycin are
one of the broadest treatment for severe sepsis.
 MRSA may be resistant to clindamycin, a glycopeptide such as vancomycin or
teicoplanin may be added until sensitivity is known.
 Breastfeeding limits the use of some antimicrobials.

What are some of the adverse effects of treatment?

 it should be remembered that, particularly in toxic shock, a maculopapular or blanching
erythema may be exotoxin related and not an allergy to the therapy.
 Diarrhoea, particularly if offensive or developing after any antimicrobial therapy, should
be sent for C. difficile toxin testing. The organism does not infect neonates but can cause
up to 30% mortality in mothers if untreated.
What is the role of intravenous immunoglobulin (IVIG)?
 IVIG is recommended for severe invasive streptococcal or staphylococcal infection if
other therapies have failed.
Where should women with sepsis be cared for?
 Early referral to hospital may be life saving.
What are the indications for admission to the intensive care unit (ICU)?
 The presence of shock or other organ dysfunction is an indication for admission to the
ICU.

How should a drug-misusing woman be managed?

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 usually monitored under multiagency care.
 The local drugs advisory specialist team and existing hospital guidelines for care of
substance misusers /drug users should be consulted.
 Any injection-site lesions should be swabbed and an MRSA screen performed.
 Current or former intravenous drug users usually have very difficult vascular access.
What are the infection control issues?
 The woman should be isolated in a single room with en suite facilities to reduce the risk
of transmission of infection.
 Healthcare workers should wear personal protective equipment including disposable
gloves and aprons when in contact with the woman, equipment and their immediate
surroundings.
 Breaks in the skin of the woman or carer must be covered with a waterproof dressing.
 Fluid-repellent surgical masks with visors must be used at operative debridement
/change of dressings of GAS necrotising fasciitis and for other procedures where droplet
spread is possible.
 Visitors should be offered suitable information and relevant personal protective
equipment while the woman is isolated.
What are the neonatal issues if sepsis develops in the puerperium?
 The baby is especially at risk of streptococcal and staphylococcal infection (GAS and
PVL-producing S. aureus)during birth and during breastfeeding.
 The umbilical area should be examined and a paediatrician consulted in the event of
sepsis in the puerperium.
 prophylaxis for MRSA and PVL-producing S. aureus is not indicated, the neonate should
be observed closely
 If either the mother or the baby is infected with invasive GAS in the postpartum period,
both should be treated with antibiotics.
 The infant of a mother colonised with GBS should be managed as in Green-top
Guideline No.36.
What are the indications for prophylaxis to family/staff?
 Close household contacts of women with GAS infection should seek medical attention
when symptoms develop, and situation may warrant antibiotic prophylaxis.
 Only the meningococcus (Neisseria meningitidis) and GAS merit consideration of
prophylaxis for family or staff.
Can sepsis in the puerperium be prevented or detected earlier?
 All pregnant and recently delivered women should be informed of the signs and
symptoms of genital tract infection and how to prevent its transmission.
 Any GAS identified during pregnancy should be treated aggressively.
 the importance of good personal hygiene including avoiding contamination of the
perineum by washing hands before and after using the lavatory or changing sanitary
towels. It is especially necessary when the woman or her family or close contacts have a
sore throat or upper respiratory tract infection.

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PREVENTION OF EARLY ONSET NEONATAL GBS DISEASE
Background
 Group B streptococcus (Streptococcus agalactiae) is the most frequent cause of
severe early onset (within 7 days of age) infection in newborn infants.
 US CDC recommend screening for GBS at 35-37 weeks for pregnant women by
vaginal and rectal swabs.
 The US guidelines advise all women colonised with GBS at 35–37 weeks (or
labouring before this time) should be offered intrapartum antibiotic prophylaxis, in the
form of high-dose IV penicillin or ampicillin.
 Intrapartum antibiotic prophylaxis significantly reduce the risk of early-onset but not
late-onset disease.
 while IAP for colonised mothers reduced the incidence of EOGBS disease, it has not
been shown to reduce all causes of mortality or GBS-related mortality
Population-based screening approaches
 risk factors for early onset GBS disease are:
 previous baby affected by GBS
 GBS bacteriuria detected during the current pregnancy
 Positive GBS swab in a previous pregnancy
 preterm labour
 prolonged rupture of the membranes
 fever in labour.
 Prevalence of risk factors in babies with EOGBS disease:
 19% intrapartum fever > 38ºC24
 34% PROM at term24
 37% < 37 weeks
 22% < 35 weeks of gestation.28
 Detection of GBS increased from 22 to 27% by sampling lower vagina and rectum
rather than only vagina.
 Women who do not have swabs taken, or for whom results are not available at the
time of labour, are offered antibiotic prophylaxis if they have any of the clinical risk
factors defined above.
 26.7% of women in USA offered intrapartum antibiotic to reduce the incidence of early
disease by 86%.
Estimated effects of bacteriological screening
 25% of mothers in the UK are likely to be GBS carriers.
 The mortality from early-onset GBS disease is 6% in term and 18% in preterm infants.
 to prevent 1.4 early-onset GBS disease it require 1000 women to be given
intrapartum antibiotic.
 to prevent 1 neonatal death it require 7000 colonized women to be given intrapartum
antibiotic, which require 24 000 women to be screened.
Estimated effects of risk based screening
 15% of all UK pregnancies have one or more risk factors for early onset GBS disease.
 60% of UK early-onset GBS cases have such risk factors.
 2 cases and 0.2 deaths from GBS disease occur for every 1000 pregnancies with one or more
factors.
 625, 5882 women with one or more factors need to be treated to prevent 1 case and 1 death
consecutively.
Potential risks of screening
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  The incidence of severe anaphylaxis with the use of penicillin in labour is 1/10 000
women treated.
 Fatal anaphylaxis is 1/100000 women treated.
 The widespread use of antibiotics is known to contribute to resistant organisms.
 Antibiotics may affect neonatal faecal flora, with impact on immune development and
later allergy.
Antenatal screening
 Routine screening (either bacteriological or risk based) for antenatal GBS carriage is
not recommended.
Prophylaxis
1. Antenatal treatment is not recommended if GBS is detected incidentally, Because it
doesn't reduce GBS colonisation at delivery.
2. Intrapartum antibiotic prophylaxis (IAP) should be considered if GBS is detected
incidentally.
3. There is insufficient evidence to support intrapartum antibiotic to women with GBS in a
previous pregnancy.
4. IAP should be offered to women with previous baby with GBS disease even if swabs
were negative for GBS.
5. If chorioamnionitis is suspected, broad-spectrum antibiotic including agent active against
GBS should replace GBS-specific antibiotic prophylaxis.
6. IAP should be offered to women with GBS bacteriuria in the current pregnancy after
discussion.
7. IAP is not required for planned CS in the absence of labour and with intact membranes.
8. IAP is not required with PPROM unless there is established labour.
 If these women are known to be colonised with GBS, IAP should be offered.
 IOL should be considered if there is suspicion of chorioamnionitis
9. all women with PROM at ≥37 weeks + 0 should be offered immediate IOL, or induction
after 24 hrs.
 If GBS colonisation was identified earlier in the pregnancy (by a swab taken for
other reasons), immediate IOL and IAP should be offered.
10. Women presenting in established preterm labour with intact membranes with no other
risk factors for GBS should not routinely be offered IAP unless they are known to be
colonised with GBS.
11. Women who are pyrexial in labour should be offered broad-spectrum antibiotics
including an antibiotic for prevention of neonatal EOGBS disease.
12. There is no evidence that intrapartum vaginal cleansing will reduce the risk of neonatal
GBS disease.
Which antibiotics should be given?
 Penicillin or Clindamycin for allergic women should be administered as soon after the
onset of labour.
 penicillin 3 g after the onset of labour and 1.5 g 4hourly until delivery or
Clindamycin 900 mg IV 8hourly.
 Broad-spectrum antibiotics such as ampicillin may increase rates of neonatal Gram
negative sepsis.
 To optimize the efficacy of IAP, the first dose should be given at least 2hs before
delivery.
Management of the newborn infant
 89-94% of early-onset cases were identified on day 1.
 65–67% have one or more risk factors prior to or during labour.
 A significant number will also have signs of fetal distress, an emergency delivery and
low Apgar scores.

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  The majority of early-onset cases presented with sepsis 79.4%, 11.8% had
meningitis, 7.8% had pneumonia and 1% focal infection.
1) Sick infants
 Newborn infants with clinical signs of EOGBS disease should be treated with the necessary
antibiotics.
 Blood cultures should obtained before starting antibiotic treatment and CSF
cultures should be considered.
2) Low-risk term infants
 Postnatal antibiotic prophylaxis is not recommended for low-risk term infants.
 The incidence of early-onset GBS disease in term infants without antenatal risk
factors is 0.2 /1000 births.
 5000, 80 000 infants need to be treated to prevent 1 case and 1death cosicutively.
3) Well infant with risk factor
 Well infants at risk of EOGBS should be observed for the first 12–24 hours after birth
with regular assessments of general wellbeing, feeding, heart rate, respiratory rate
and temperature.
 There is insufficient evidence to support treatment in well newborn infants.
 Argument for treatment in well infants is stronger in the presence of multy risk
factors but is still unproven.
 It is not necessary to perform routine surface cultures or blood cultures on well
infants.
 90%of cases of EOGBS disease present by 12 hours of age before culture results
become available.
4) Previous infant with GBS disease
 For an infant, whose mother had a previous infant with GBS disease offer either of the
following :
1. Clinical evaluation after birth and observation for at least twelve hours
2. Blood cultures obtained and the infant treated with penicillin until the culture results
are available.
Breastfeeding
 Breastfeeding does not increase the risk of neonatal GBS disease.

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328
CHICKEN POX IN PREGNANCY
Purpose and scope
 Primary infection with herpes varicella zoster virus (VZV), in pregnancy associated with:
 increased mortality or serious morbidity.
 fetal varicella syndrome (FVS), previously known as congenital varicella syndrome
 varicella infection of the newborn, previously known as neonatal varicella.
Background
 VZV is a DNA virus and transmitted by respiratory droplets and by direct contact with
vesicle fluid or indirectly via fomites.
 1ry infection is characterized by fever, malaise and a pruritic rash that develops into
crops of maculopapules which become vesicular and crust over before healing.
 The incubation period is 1–3weeks and the disease is infectious 48 hours before the
rash appears until the vesicles crust over(within 5 days).
 >90% of the antenatal population in the UK and Ireland are seropositive for VZV (IgG)
antibody.
 For this reason, primary VZV infection is uncommon; it complicate 0.3% of pregnancies.
 Women from tropical and subtropical areas are more likely to be seronegative for VZV
 After primary infection, the virus remains dormant in sensory nerve root ganglia and
when reactivated cause herpes zoster (HZ).
 herpes zoster in non-exposed sites is considered to be noninfectious. disseminated
zoster or exposed zoster or localized zoster in immunosuppressed patient is considered
to be infectious.
Varicella prevention
In the non-immune woman preconceptually
 Determination of the immune status of women planning a pregnancy or receiving
treatment for infertility by a past history of chickenpox(sensitivity97–99%) and serological
testing for VZIG antibody.
 vaccination prepregnancy or postpartum in seronegative women.
 live attenuated virus vaccine derived from the Oka strain of VZV.
 Vaccination reduce primary infection by 90% and the mortality by 66%.
 Immunity from the vaccine may persist for up to 20 years.
 Vaccinated woman should avoid pregnancy for 3 months and avoid contact with
susceptible pregnant women if post-vaccination rash occur.
 Women who are vaccinated postpartum can be reassured that it is safe to breastfeed
In the pregnant woman at her initial antenatal visit
 Seronegative Women are advised to avoid contact with chickenpox and shingles during
pregnancy and to immediately inform healthcare workers if exposed.
In the pregnant woman who gives a history of contact with chickenpox or shingles
1) A careful history must be taken to confirm:
 the significance of the contact.
 defined as contact in the same room for >15 minutes, face-to-face contact and
contact in the setting of a large open ward.
 and the susceptibility of the patient
 determined by eliciting a past history of chickenpox or shingles and serological
testing.
2) At least 80–90% of women tested are immune and can be reassured.
3) Pregnant women with an uncertain or no previous history of chickenpox, or who come
from tropical or subtropical countries, who have been exposed to infection should have a
blood test to determine VZV immunity or non-immunity.
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4) If the pregnant woman is not immune and has had a significant exposure, she should
have VZIG as soon as possible.
 VZIG is effective when given up to 10 days after contact.
 After VZIG, the pregnant woman considered as infectious from 8–28 days (8–21 days
if no VZIG).
 If a nother exposure is occured after 3 weeks from the last dose, a second dose of
VZIG is required.
 Rare anaphylactoid reactions have occurred
 No blood borne infection has been reported with its use.
 Maternal death has been reported due to varicella pneumonia despite the
administration of VZIG.
5) Women who developed rash regardless of whether or not received VZIG should notify
their doctor early.
The pregnant woman who develops chickenpox
 There is excess morbidity associated with varicella infection in adults, including:
 Pneumonia(10% increase in later gestation, fatality rate less than 1% but five times
higher in pregnancy)
 hepatitis
 encepahalitis
 mortality(75% of deaths occur in adults).
How should the pregnant woman who develops chickenpox be managed?
1) Contact their GP immediately.
2) avoid contact with susceptible individuals;until the lesions have crusted over.
3) Symptomatic treatment and hygiene advised to prevent secondary bacterial infection.
4) oral aciclovir if they present within 24 hours of the onset of the rash and >20 weeks
gestation.
 800 mg five times a day for 7 days.
 Women should be informed of about risk and benefits of treatment with aciclovir.
 there is no increase in the risk of fetal malformation with aciclovir in pregnancy.
5) Indication for immediate referral to a hospital:
 Chest symptoms,
 neurological symptoms,
 haemorrhagic rash or bleeding,
 dense rash
 Immunosuppression or taking corticosteroids in the preceding 3 months.
 If the woman smokes cigarettes,
 has chronic lung disease,
 > 20 weeke gestation
6) Assessment and treatment in hospital with a multidisciplinary team: obstetrician or fetal
medicine specialist, virologist and neonatologist.
7) Timing and mode of delivery must be individualised.
 Delivery during the viraemic period should be deferred unless indicated.
o maternal risks are bleeding, thrombocytopenia, DIC and hepatitis.
o There is a high risk of varicella infection of the newborn with significant morbidity and
mortality.
8) There is no evidence about the optimum method of anaesthesia for caesarean section.
o General anaesthesia may exacerbate varicella pneumonia.
o Risk of transmitting the varicella virus from skins lesions to the CNS via spinal
anaesthesia.
o epidural anaesthesia is safer than spinal anaesthesia
9) Women hospitalised with varicella should be nursed in isolation.
10) Referral to a fetal medicine at 16–20 weeks or 5 weeks after infection for discussion and
detailed scan.
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Risks during pregnancy
Fetal risks of varicella infection in pregnancy
 No added risk for miscarriage if chickenpox occurs in the first trimester.
 A small risk 0.91% for fetal varicella syndrome If varicella occur < 28 weeks.
 FVS is characterised by one or more of the following:
 dermatomal distribution of skin scarring
 eye defects (microphthalmia, chorioretinitis, cataracts)
 hypoplasia of the limbs
 neurological abnormalities (microcephaly, cortical atrophy, dysfunction of
bowel and bladder sphincters).
 FVS does not occur at the time of initial fetal infection but results from a subsequent
reactivations.
 No case of FVS has been reported when maternal infection has occurred after 28
weeks
Can varicella infection of the fetus be diagnosed prenatally?
1) ultrasound examination done by fetal medicine specialist, at 16–20 weeks or 5 weeks
after infection, A time lag of at least 5 weeks after the primary infection is advised
because US performed at 4 weeks has failed to detect the deformities
2) Prenatal diagnosis is possible using detailed ultrasound when findings such as limb
deformity,microcephaly, hydrocephalus, soft-tissue calcification and IUGR can be
detected.
3) Fetal MRI can be useful to look for morphological abnormalities
4) Amniocentesis: is not routinely advised because the risk of FVS is so low, even when
amniotic fluid is positive for VZV DNA.
 The risk of FVS is low, If amniotic fluid is positive for VZV and ultrasound is normal at
17–21 weeks.
 The risk of FVS is remote, If repeat ultrasound is normal at 23–24 weeks.
 It is not known whether VZIG reduces the risk of FVS.
 Amniocentesis should not be performed before the skin lesions have completely
healed.
Neonatal risks of varicella infection in pregnancy
 There is a significant risk of varicella of the newborn If infection occurs at term(1–4
weeks before delivery).
 Route of infection: transplacental, ascending vaginal or direct contact with lesions.
 Severe chickenpox occur if the infant is born within 7 days before or 7 days after the
onset of the mother‟s rash because of low transplacentally acquired maternal
antibodies.
 Elective delivery should normally be avoided until 5–7 days after the onset of
maternal rash to allow for the passive transfer of antibodies from mother to child
 Neonatal ophthalmic examination should be done after birth.
 Neonatal blood should be sent for VZV IgM antibody after delivery and for VZV IgG after
7 months of age.
Treatment following onset of maternal rash at term
 Neonate should receive VZIG, If birth occurs within 7 days before or 7 days after the
onset of the maternal rash.
 The infant should be monitored for signs of infection until 28 days after the onset of
maternal rash .
 Neonatal infection should be treated with aciclovir following discussion with a
neonatologist and virologist.
 VZIG is of no benefit once neonatal chickenpox developed.
 50% of the neonates exposed to maternal varicella will develop chickenpox despite the
administration of VZIG but mortality rates is lower than 30%.
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 VZIG is also recommended for non-immune neonates that are exposed to chickenpox or
shingles (other than maternal) in the first 7 days of life
 Maternal shingles around the time of delivery is not a risk to the neonate because it is
protected by transplacentally acquired maternal antibodies.
The risk to the neonate if a sibling has chickenpox
 if the mother is immune and the contact occur within the first 7 days of life, no
intervention is required.
 if the mother is not immune or if the neonate delivered before 28 weeks or weighs less
than 1 kg, the neonate should be given VZIG.
Precautions for healthcare workers
 The immune status of healthcare workers in maternity and neonatal units should be
determined.
 Non-immune healthcare workers should be offered varicella vaccination.
 If non-immune healthcare workers have significant exposure they should minimise
patient contact from 8–21 days.

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MANAGEMENT OF HIV IN PREGNANCY
Background and introduction
Etiology, natural history and treatment
 HIV is a retrovirus containing reverse transcriptase. This enzyme allows the virus to
transcribe its RNA genome into DNA, which then integrates into host cell DNA.
 HIV preferentially targets lymphocytes expressing CD4 molecules (CD4 lymphocytes).
 When CD4 lymphocytes fall below a critical level, increase the risk of opportunistic
infections and malignancies.
 highly active anti-retroviral therapy HAART(three or more anti-retroviral drugs), resulted
in a dramatic decline in morbidity and an increase in life expectancy.
 The three classes of anti-retroviral drug commonly used in pregnancy are:
1. nucleoside reverse transcriptase inhibitors,
2. non-nucleoside reverse transcriptase inhibitors
3. protease inhibitors.
UK epidemiology of HIV in pregnancy
 The prevalence of HIV infection in women giving birth in England in 2008 was 0.2%.
 The exposed infants who became infected decreased from 12% in 1999 to 2% in 2007.
Risks of mother-to-child transmission in untreated women
 15%-20% in non-breastfeeding women in Europe and 25%-40% in breastfeeding African
populations.
 In the absence of breastfeeding, >80% of transmissions occur perinatally, around time of
delivery.
 there is a linear correlation between maternal viral load and the risk of transmission but
transmissions are rare when plasma viraemia < 50 copies/ml at the time of delivery.
 Obstetric factors associated with transmission are:
1. mode of delivery,
2. duration of membrane rupture
3. delivery before 32 weeks of gestation.
 Breastfeeding doubles the risk of mother-to-child transmission from around 14% to 28%.
Risk of mother-to-child transmission in treated women
Inter-relationship between HIV, pregnancy and HAART
 The decline in CD4 lymphocyte count in pregnancy is due to haemodilution, resolves in
the postpartum period
 HAART are associated with increased risk of obstetric complications:
1. gestational diabetes.
2. pre-eclampsia.
3. preterm .
Antenatal HIV screening
 screening for HIV, syphilis, hepatitis B and rubella in every pregnancy at booking is
recommended.
 If woman declines HIV test, this should be documented with reasons behind and
screening offered again at 28 weeks.
 If a woman tests HIV negative at booking but at high risk of acquiring HIV, offer a repeat
HIV test.
 Midwives and doctors reviewing women should ensure that the HIV result is clearly
documented.
 Fourth-generation assays are recommended as the first-line HIV test for antenatal
screening.
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  In this type of assay p24 antigen is detectable during seroconversion.
 have a high sensitivity (> 99.9%) and specificity (> 99.5%).
 if a woman books at 26 weeks or later, request the urgently and the result issued within
24 hours.
 Rapid HIV tests with results within 20 minutes are recommended with unknown HIV
status in labour.
 Most of rapid-test test for antibody (not p24 antigen), so test is likely to be negative
during seroconversion.
Antenatal care of women who are HIV positive
 multidisciplinary team approach: HIV physician, obstetrician, specialist midwife, health
advisor and paediatrician.
 Social circumstances for newly diagnosed HIV positive.
 Reassure women that confidentiality will be maintained.
 Encourage and support women to disclose their HIV status to their partner.
 Avoid inadvertent disclosure to a woman‟s partner or family, as they may be unaware of
her HIV diagnosis.
 Advice about safer-sex practices and the use of condoms, to prevent HIV and STIs
transmission.
 There is a risk of super infection associated with unprotected sex if both woman and
partner are HIV positive.
 Women with children of unknown HIV status should have them tested for HIV.
 If women refuse interventions to reduce the risk of mother-to-child transmission, a pre-
birth planning meeting should be held with social services to discuss safeguarding
issues.
 There should be a named respondent to notify all HIV positive pregnancies to the
National Study of HIV in Pregnancy and Childhood.
Interventions to prevent disease progression in the mother
 Women who require HIV treatment for their own health should take :
1. HAART and continue postpartum.
2. prophylaxis for Pneumocystis carinii pneumonia (PCP), depending on CD4
lymphocyte count.
 Women already taking HAART and/or PCP prophylaxis before pregnancy should not
discontinued.
Interventions to prevent mother to child transmission of HIV
1) Transmission rates < 2% are associated with:
1. effective HAART,
2. appropriate management of delivery
3. avoidance of breastfeeding.
2) Women require HIV treatment for their health, HAART should be continued through
pregnancy and postpartum.
3) Women do not require treatment for their health, start HAART between 20-28 weeks
and stop at delivery.
4) women do not require treatment for their health with viral load <10 000 copies/ml and
booked for elective CS, an acceptable alternative is zidovudine (ZDV) monotherapy
initiated 20-28 weeks, 250 mg orally twice daily and intravenously at delivery.
5) Delivery by elective CS at 38 weeks to prevent labour and/or ruptured membranes for:
 Women on HAART with viral load > 50 copies/ml
 Women on ZDV monotherapy.
 Women with HIV and hepatitis C virus co-infection.
6) planned vaginal delivery can be offered if women on HAART with viral load of < 50
copies/ml.

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 7) Delivery by elective CS for obstetric indications or maternal request at 39+ weeks if
viral load < 50 copies/ml.
Antenatal care of pregnant women who are HIV positive
 Screening at booking for:
1. syphilis, hepatitis B and rubella like general population+ hepatitis C, varicella zoster,
measles and toxoplasma.
2. gestational diabetes for women on HAART.
3. genital infections and again at 28 weeks. Any infection should be treated even if
asymptomatic
 Screening for aneuploidy like general population.
 Dating and anomaly scans.
 Hepatitis B and pneumococcal vaccination is recommended .Influenza vaccination is
also safe in pregnancy .
 Varicella zoster and measles, mumps and rubella vaccines are contraindicated in
pregnancy.
 Monitoring of plasma viral load and drug toxicities directed by the HIV physicians.
 A plan of therapy and mode of delivery should be made at 36 weeks following detailed
discussion.
Management of antenatal complications
 HIV complications should be considered as a cause of acute illness in pregnant women
with unknown HIV status.
 In these circumstances, a rapid HIV test should be considered.
 Pregnant women with advanced HIV are at increased risk of opportunistic infections,
particularly PCP with fever, dry cough shortness of breath and hypoxia.
 HAART regimens are associated with GIT disturbances, skin rashes, hepatotoxicity and
Lactic acidosis.
 Symptoms suggestive of pre-eclampsia, cholestasis or signs of liver dysfunction may
indicate drug toxicity.
Management of preterm delivery and PPROM
1) initial assessment for threatened preterm labour is like the general population.
2) multidisciplinary team should be involved for clear plan and choice of anti-retroviral
therapy.
3) Screening for genital infections and any infection should be treated even if
asymptomatic.
4) Apply the usual indications for steroids.
5) Women should be counselled about the increased risk of preterm delivery with HAART.
6) Administering anti-retroviral therapy to the mother < 32 weeks of gestation just before
and during delivery will provide prophylaxis to the neonate.
7) If PPROM after 34 weeks, delivery should be expedited. Augmentation may be
considered if the viral load < 50 copies/ml. and start broad-spectrum intravenous
antibiotics.
8) If PPROM occurs before 34 weeks, oral erythromycin should be started with expectant
management yf there is no Evidence of chorioamnionitis and fetal distress.
Management of delivery
1) A maternal sample for plasma viral load and CD4 count taken at delivery.
2) Women on HAART should have their medications before delivery and, if indicated, after
delivery.
3) Elective caesarean section:
 If IV ZDV is indicated, start infusion 4 hrs. before CS and continue until the umbilical
cord has been clamped.
 Haemostasis as much as possible and avoid rupturing the membranes until delivery
of head through the incision.

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  Peripartum antibiotics.
 Take a maternal sample for viral load and CD4 lymphocyte count at delivery.
4) Planned vaginal delivery:
 plan of care for delivery should be reviewed and recent viral load results should be
confirmed as < 50 copies/ml.
 HAART should be prescribed and administered throughout labour.
 Invasive procedures such as fetal blood sampling are contraindicated.
 Amniotomy should be avoided till delivery is imminent.
 Amniotomy and oxytocin may considered for augmentation of labour.
 If instrumental delivery is indicated, low-cavity forceps are preferable.
5) PROM:
 delivery should be expedited. If the viral load > 50 copies/ml, augmentation may be
considered.
 Broad-spectrum intravenous antibiotics if there is evidence of infection.
6) Prolonged pregnancy:
 For women on HAART and viral load > 50 copies/ml, IOL for prolonged pregnancy
should be individualised.
 There is no contraindication to membrane sweep.
7) VBAC: can be considered for women on HAART with viral load < 50 copies/ml.
8) HIV diagnosed in labour:
 multidisciplinary team should be involved for clear plan and choice of anti-retroviral
therapy.
 Delivery should be by caesarean section and, where possible should be timed with
antiretroviral administration.
Postpartum management of women who are HIV positive
1) Advice about formula feeding.
2) Oral cabergoline to suppress lactation.
3) Women taking HAART should have their medication administered.
4) Guidance about contraception should be given in the immediate postpartum period.
 There are many interactions between hormonal contraception and HAART.
5) MMR and varicella zoster immunisation, according to the CD4 lymphocyte count.
Management of the neonate
1) All neonates should be treated with anti-retroviral therapy within 4 hours of birth.
2) ZDV monotherapy is accepted
3) If neonates at high risk of HIV infection concider HAART and rophylaxis against PCP.
4) Infants should be tested at 1 day, 6 weeks and 12 weeks of age. If tests are negative
and the baby is not breastfed, the child is not HIV-infected. A confirmatory HIV test is
performed at 18 months of age.
Prepregnancy management
1) Couples who are serodiscordant :
1. choosing to have intercourse should be advised to use condoms.
2. The female is HIV negative should be advised that assisted conception with either
donor insemination or sperm washing is significantly safer than timed unprotected
intercourse.
2) Couples should be advised to delay conception until:
1. plasma viraemia is suppressed,
2. prophylaxis for PCP is no longer required
3. any opportunistic infections have been treated.
3) Folate supplementation should be administered in accordance with national guidelines.
4) annual cervical cytology, because of the association of HIV, immunosuppression and
cervical neoplasia.

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MANAGEMENT OF GENITAL HERPES IN PREGNANCY
Background
 Neonatal herpes has a high morbidity and mortality commonly acquired at or near the
time of delivery.
 Incidence in UK 1 in 60 000 live births annually, in the USA 1 in 15 000 .
 Can be caused by (HSV-1) or (HSV- 2), as either viral type can cause genital herpes.
 Around 2% of women acquire genital HSV infection in pregnancy, most are
asymptomatic or unrecognised.
 Classified into three subgroups:
 disease localized to skin, eye and/mouth,
 have the best prognosis.
 Death is unusual.
 with treatment, neurological morbidity is less than 2%.
 local central nervous system (CNS) disease (encephalitis alone).
 present late (between 10 days and 4 weeks postnatally).
 with treatment, mortality is 6% and neurological morbidity 70%.
 disseminated infection with multiple organ involvement(more common in preterm
infants).
 Have the worst prognosis.
 with treatment, mortality is 30% and neurological morbidity 17%.
 Disseminated disease and local CNS disease can present with or without localized
disease.
 Almost all cases of neonatal herpes occur as a result of direct contact with infected
maternal secretions, although cases of postnatal transmission have been described.
 Factors influencing transmission include:
 The type of maternal infection (primary or recurrent),
 The presence of Transplacentally acquired HSV antibodies,
 The duration of rupture of membranes before delivery (less or more than 4 hrs.).
 The use of fetal scalp electrodes.
 Mode of delivery.
 Very rarely, congenital herpes may occur as a result of transplacental intrauterine
infection.
 Recurrent herpes at the time of delivery:
 Has a very low risk of neonatal herpes
 commonly asymptomatic or unrecognised,
 may cause the three subgroups forms of neonatal herpes.
 It may be difficult to distinguish clinically between recurrent and primary genital HSV
infections, as many first episode HSV infections are not true primary infections.
 Disseminated adult herpes:
 present with encephalitis, hepatitis, disseminated skin lesions or a combination of
these conditions,
 rare but more commonly reported in pregnancy, particularly in the
immunocompromised.
 Maternal mortality is high.
 immunocompromised women during pregnancy, such as HIV virus, are at increased risk
of more severe, recurrent genital herpes and asymptomatic shedding of HSV at term.
 Genital reactivation of HSV may increase the risk of perinatal transmission of both HIV
and HSV.
 Specimens are collected from the base of the ulcer and vesicular fluid and tested by
culture or PCR.
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Primary episode of genital herpes during pregnancy
 Women should be referred to a genitourinary physician.
 Offer oral or intravenous acyclovir(200 mg five times daily or 400 mg three times daily
for 5 days).
 Supportive treatment ( saline bathing and analgesia ).
 Acyclovir is associated with a reduction in the duration, severity of disease and in
duration of viral shedding.
 Testing for IgG and IgM can help to differentiate between primary and recurrent
infections if a woman presents with a first episode of genital herpes in the third trimester.
 Aciclovir should be used with caution before 20 weeks of gestation.
Primary genital herpes at the time of delivery.
 Caesarean section should be recommended to all women presenting with primary
episode genital herpes lesions at the time of delivery, or within 6 weeks of the expected
date of delivery.
 For women who develop primary genital herpes lesions within 6 weeks of delivery and
opt for a vaginal birth:
 Avoid rupture of membranes and invasive procedures.
 Intrapartum IV aciclovir to the mother and to the neonate.
 The neonatologist should be informed.
 There is insufficient evidence to recommend the use of daily aciclovir from 36 weeks to
reduce the HSV lesions at term in women with primary genital herpes earlier in the
current pregnancy.
Recurrent episodes of genital herpes during pregnancy
 Antiviral is rarely indicated for recurrent genital herpes during pregnancy.
 The majority of recurrent genital herpes are short lasting and resolve within 7–10 days
without antiviral.
 Cultures during late gestation to predict viral shedding at term are not indicated.
 A recurrent genital herpes during pregnancy is not an indication for caesarean section.
 Women with recurrent genital herpes and opt for CS if HSV lesions detected at the onset
of labour, daily aciclovir from 36 weeks of gestation until delivery can be given to reduce
the likelihood of HSV lesions at term.
How should we manage the pregnant woman with recurrent episodes of genital herpes
at the onset of labour?
 Risk of neonatal herpes is small1–3% in women presenting with recurrent genital herpes
at the onset of labour.
 CS is not routinely recommended for women with recurrent genital herpes lesions at the
onset of labour.
 The mode of delivery should be according to the clinical circumstances and the woman‟s
preferences.
 Women with recurrent genital herpes and PROM should have delivery expedited by the
appropriate means.
 Women with recurrent genital herpes and PPROM the risk of neonatal herpes is very low
and is outweighed by the morbidity and mortality of premature delivery
 Invasive procedures in labour should be avoided.
 The neonatologist should be informed at the time of labour.

How can postnatal HSV transmission to the neonate be prevented?

 Healthcare workers and family members with active HSV infection, such as orolabial
herpes, should take measures to avoid transmission of the virus to the neonate.
 Breastfeeding is only contraindicated in the event of a herpetic lesion on the breast.
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PARVOVIRUS B19 INFECTION
How should I manage suspected parvovirus B19 in a pregnant woman?
 In adults, parvovirus B19 is often indistinguishable from rubella.
 Contact the Health Protection Unit (HPU) if rubella or parvovirus B19 infection is
suspected at any stage of pregnancy, irrespective of previous testing or immunization
status to rubella.
 The HPU will advise on parvovirus B19 and rubella screening.
 Recommend rest, adequate fluids, and paracetamol for symptoms of viremia and
arthropathy if necessary (although symptoms are usually mild).
 it is not usually necessary to stay off work, as the infection is no longer contagious by the
time the rash or arthropathy appears.
 if the woman has not been fully immunized against rubella, it is important to avoid
contact with other pregnant women as it is difficult to clinically differentiate between
parvovirus B19 and rubella.
 Further screening for rubella is recommended in pregnant women with a rubella-like rash
regardless of the results of previous testing or immunization status because of the
possibility of:
 laboratory or documentation error,
 failed immunization,
 symptomatic rubella reinfection,
 parvovirus B19 infection
How should I manage a pregnant woman who has been in possible contact with
parvovirus B19?
1) Determine whether the woman has had significant contact with parvovirus B19
or rubella.
 Significant contact means being in the same room for 15 minutes or more, or face-to-
face contact, within the previous 3 weeks.
 The infectious phase of parvovirus B19 usually occurs before the rash appears, so
ask about contact before the appearance of the rash.
 It is not possible to differentiate between rubella and parvovirus B19 on clinical
grounds, For this reason, women should be managed as they may have rubella
infection, exept if there has been a local outbreak of parvovirus B19, or the woman
was in contact with a child with classical symptoms of 'slapped cheek' syndrome.
 If the pregnant woman is known to be susceptible to rubella, contact for less than
15 minutes should also be considered as possible exposure.
2) Contact HPU immediately regarding investigation for parvovirus B19, unless
there is previous documented laboratory evidence that the woman has
immunity.
3) Screen for rubella if the woman does not fulfil the criteria for immunity to
rubella, that is she has:
 Received at least two documented doses of rubella vaccine, or
 Received a documented dose of rubella vaccine and has a previous rubella antibody
screening test result which has detected antibodies.
What information should I give to a pregnant woman about testing for parvovirus B19?
 Inform the woman that:
 Testing for rubella and parvovirus B19 will initially only involve testing of blood
samples. More invasive tests, such as amniocentesis, are rarely needed.
 Rubella is a serious illness in pregnancy but it is now extremely rare in the UK.
Rubella tests are routine and are likely to confirm absence of the infection.
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  Parvovirus B19 is a more likely cause of symptoms than rubella. If the infection is
confirmed, transmission to the fetus is unlikely. If transmission to the fetus occurs, the
prognosis for the fetus is generally good, and there are effective treatment options
available.
How should I manage a pregnant woman with confirmed parvovirus B19?
1) Refer the woman to an obstetrician within 4 weeks for fetal ultrasound and
ongoing management.
2) Advise the woman that the prognosis is partly dependent on the stage of
pregnancy that parvovirus B19 is contracted at, but that the complications of
infection can be treated at all stages.
 Transplacental transmission occurs in about 25% of women, with a mean of about
6 weeks between maternal infection and fetal symptoms.
 The fetus is most vulnerable when it is infected in the second trimester, with the peak
risk occurring at 17–24 weeks'.
 the estimated fetal loss rate during pregnancy is about 5–10%. babies that survive to
full term are usually born healthy.
When should a pregnant woman with suspected parvovirus B19 infection be admitted
or referred?
1) Refer all women with confirmed active parvovirus B19 infection to an
obstetrician. The woman should be seen within 4 weeks of the start of illness or
estimated time of seroconversion.
2) Admit those women who develop:
 Symptoms of aplastic anaemia (dyspnoea, lassitude , or confusion), especially if they
are known to have an underlying haemolytic disorder (sickle cell anaemia or
thalassaemia).
 Maternal pre-eclampsia-like syndrome due to parvovirus B19 infection ('mirror
syndrome'). This presents later in pregnancy when hydrops fetalis is present, with
swollen legs, hypertension, proteinuria, and maternal anaemia.
 Severe or persistent anaemia, especially if the woman is immunocompromised.
What management is available in secondary care for parvovirus B19 infection in
pregnancy?
 In secondary care, pregnant women will be closely monitored using fetal ultrasound:
 The first scan around 4 weeks after the onset of symptoms or estimated time of
seroconversion.
 Then every 1–2 weeks until 30 weeks of gestation.
 Fetal hydrops initially presents on ultrasound with the development of ascites and
thickening and enlargement of the fetal heart.
 If an abnormality is found that suggests hydrops fetalis, the woman will be referred to
tertiary care. Tertiary care may provide:
 Doppler assessment of the middle cerebral artery and parvovirus B19 genome
detection in amniotic fluid.
 Fetal blood sampling and intrauterine transfusion of erythrocytes.
 Early delivery of the baby if it is near full term (amniocentesis for lung maturity and
treatment with corticosteroids may be indicated).

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EXERCISE IN PREGNANCY
 Many women 42% exercising during pregnancy and many strongly desire to continue
to do so.
Key points
 the American College of Obstetricians and Gynecologists, the Royal College of
Obstetricians and Gynaecologists (RCOG) suggests that:
 women should be encouraged to participate in aerobic and strength-conditioning
exercise during pregnancy
 this should be to maintain a good fitness level throughout pregnancy
 exercise should be with low risk of loss of balance and fetal trauma
 no adverse pregnancy or neonatal outcomes are increased with exercising
 pelvic floor exercises in the postpartum period reduce the risk of urinary incontinence
 moderate exercise during lactation does not affect the quantity or quality of breast
milk.
Physiological adaptive changes in pregnant women affecting physical activity
 musculoskeletal alterations in the pregnant woman could raise the risk of injury during
exercise.
 Hormonal changes lead to raised joint laxity and hypermobility.
 Both exercise and pregnancy raise the metabolic rate and that maternal core
temperatures. >39.2 degrees are teratogenic in the first trimester.
 Advise maintaining adequate hydration and avoiding exercising in very hot, humid
environment
 adequate calories and limiting exercise sessions to less than 45 minutes reduce the risk
of hypoglycaemia.
 avoid Exercise in the supine position after 16 weeks of gestation
 avoid overexertion in altitudes over 2500 metres ( high altitudes lower uterine blood
flow).
 evidence suggests that fetuses of exercising womentolerate labour better than those of
non-exercisers.
Benefits of exercise in pregnancy
 Maternal benefits are both physical and psychological in nature.
 complaints of pregnancy, including fatigue, varicosities and swelling of extremities,
are reduced.
 experience associated with less insomnia, stress, anxiety and depression.
 weight-bearing exercise can reduce the length of labour and decrease delivery
complications.
 women who exercise during pregnancy are more likely to exercise postpartum.
 Exercise improve glycaemic control in women with gestational diabetes and may
prevent it's developing.
Conditions requiring medical supervision while undertaking exercise in pregnancy
 Cardiac disease
 Chronic lung disease
 Hypertensive disorders with pregnancy
 Poorly controlled diabetes mellitus
 Poorly controlled seizures
 Poorly controlled thyroid disease
 Anaemia (haemoglobin less than 10 g/l).
 Orthopaedic limitations
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 Extremely sedentary lifestyle
 Heavy smoker > 20 cigarettes a day
 Morbid obesity
 Malnutrition or eating disorder
 Multiple gestation
 Vaginal bleeding
 Placenta praevia
 Cervical weakness/cerclage
 Preterm labour
 PROM
 FGR
Warning signs to terminate exercise
 Dizziness
 Headache
 Excessive fatigue
 Muscle weakness
 Shortness of breath
 Chest pain or palpitations
 Uterine contractions or preterm labour
 Leakage of amniotic fluid
 Vaginal bleeding
 Reduced fetal movement
 Abdominal pain
 Pelvic girdle pain
 Calf pain or swelling.
Advising exercise in pregnancy
 assessment of fitness, current exercise activities.
 Careful consideration for the intensity, the duration and frequency of exercise
sessions.
 A maximal heart rate of 60–70% for women who were sedentary prior to pregnancy
and 60–90% of maximal heart rate for exercising women
 Talk test is used to measure exercise intensity
 Sedentary women should start with 15 minutes aerobic continuous exercise three
times a week, increasing to 30-minute four times a week to daily.
 Avoid scuba dive in pregnancy, as the fetus is not protected for decompression
sickness.
 monitoring blood glucose, regulating meal times, rest periods in women with GDM.
 If a woman is exercising in water the water temperature should not exceed 32
degrees.
Postpartum exercise
 Benefits of postpartum exercise include:
 improved cardiovascular fitness,
 weight loss,
 improve mood,
 reduce anxiety and depression
 pelvic floor muscles exercise reduce the risk of urinary stress incontinence
 Women need to return to prepregnancy exercise levels gradually, not resuming high
impact activity too soon.

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FEMALE GENITAL MUTILATION
INTRODUCTION
Definition
 Defined as partial or total removal of the external female genitalia or any injury to the
female genital organs for non-therapeutic reasons.
 According to WHO, the use of the word mutilation reinforces the idea of violation of the
human rights and helps to promote its abandonment.
 in 1999, the UN Special Reporter suggests that the term „cutting‟ may be more
acceptable.
UK law
 All health professionals must be aware of the Female Genital Mutilation Act 2003 in
England, Wales and Northern Ireland and the Prohibition of Female Genital Mutilation
(Scotland) Act 2005 in Scotland. Both Acts provide that:
I. FGM is illegal unless it is a surgical operation on a girl or woman irrespective of her
Age:
(a) Which is necessary for her physical or mental health.
(b) She is in any stage of labour, or has just given birth, for purposes connected
with the labour or birth.
II. It is illegal to arrange, or assist in arranging, for a UK national or UK resident
to be taken overseas for the purpose of FGM.
III. It is an offence for those with parental responsibility to fail to protect a girl
From the risk of FGM.
IV. If FGM is confirmed in a girl under 18 years of age (either on examination or
because the patient or parent says it has been done), reporting to
the police is mandatory and this must be within 1 month of confirmat
 Female genital cosmetic surgery (FGCS) may be prohibited unless it isnecessary for
the patient‟s physical or mental health.
 All surgeons who undertake FGCS must take appropriate measures to ensure
compliance with the FGM Acts.
 Re-infibulation is illegal; there is no clinical justification for re-infibulation and it should
not be undertaken under any circumstances.
What are the principles of FGM management in obstetric and gynaecological
practice?
 All acute trusts/health boards should have a designated consultant and midwife
responsible for the care of women with FGM.
 All gynaecologists, obstetricians and midwives should receive mandatory training on
FGM and its management, including the technique of de-infibulation.
How should women who have undergone genital mutilation be identified and
assessed?
 A system should be in place to questioning all women born in places associated with
FGM.
 Discussions must take into account language difficulties, psychological and cultural
differences.
 Assess psychological condition and discus referral to a psychologist with the woman.
 Physical examination by an obstetrician or specialist midwife to identify the need for
surgery and to identify those undergone infibulation after defibulation.
 A diagram or medical photography (with consent) for:
 limit repetitive examinations
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  explanations to the woman
 communicate with specialized hospital or clinic
How should FGM be managed in gynaecological practice?
What should the referral pathway be for women with FGM?
 Women may be referred by their general practitioner (GP) to a hospital gynaecology
clinic. The referral should be directed to FGM services, if available, or to the
designated consultant obstetrician and/or gynaecologist responsible for the care of
women and girls with FGM.
 Women should be able to self-refer.
 All children with FGM or suspected FGM should be seen within child safeguarding
services.
How should women with FGM be assessed in gynaecological practice?
 Women with FGM may present with symptoms directly attributable to their FGM or
with co-existing gynaecological morbidity.
 Gynaecologists should ask all women from communities that traditionally practise
FGM whether they have had the procedure.
 Clinicians should be aware that psychological sequelae and impaired sexual function
can occur with all types of FGM.
 Examination should include inspection of the vulva to determine the type of FGM and
whether de-infibulation is indicated, as well as to identify any other FGM-related
morbidity, e.g. epidermoid inclusion cysts.
 All women should be offered referral for psychological assessment and treatment,
testing for HIV, hepatitis B and C and sexual health screening.
 Where appropriate, women should be referred to gynaecological subspecialties, e.g.
psychosexual services, urogynaecology, infertility.
What is the role of clitoral reconstruction?
 Clitoral reconstruction should not be performed because current evidence suggests
unacceptable complication rates without conclusive evidence of benefit.
Prevalence and geographical variation
 female genital mutilation is practised mainly in Africa but is also found in India and
Indonesia.
 The type of mutilation varies within and between countries.
 complications differ in type and severity according to the different types of mutilation.
Classification of types of female genital mutilation procedures (WHO):
Type Definition
I : Partial or total removal of the clitoris and/or the prepuce
clitoridectomy
II : excision Partial or total removal of the clitoris and the labia minora, with
or without excision of the labia majora
III : infibulation Narrowing of the vaginal orifice with creation of a covering seal
by cutting and appositioning the labia minora and/or
the labia majora, with or without excision of the clitoris
IV : other All other harmful procedures to the female genitalia for non-
medical purposes, e.g. pricking, piercing,a incising, scraping
and cauterizing
 90% of female genital mutilation are type I, II and IV. Type III procedures account for the
10
Ethical duty in practice
 Healthcare workers must not undertake or assist with female genital mutilation.
 Terminology used with women should not cause upset or a sense of disapproval.

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 It must be appreciated that women did not choose mutilation and procedure is carried
out in childhood, when they are too young to give consent.
 mutilation is done in societies where such practices are traditional and normal.

Acute complications of female genital mutilation include:

 death
 severe pain
 local infection
 septicaemia
 tetanus
 haemorrhage
 acute retention of urine
 hepatitis and HIV.
Females admitted acutely after female genital mutilation
How should recent FGM be managed?
 Healthcare professionals should be vigilant and aware of the clinical signs and
symptoms of recent FGM, which include pain, haemorrhage, infection and urinary
retention.
 Examination findings should be accurately recorded in the clinical records.
 Some type 4 FGM, where a small incision or cut is made adjacent to or on the
clitoris, can leave few, if any, visible signs when healed.
 Consideration should be given to photographic documentation of the findings at
acute presentation.
 assess quickly for signs of acute blood loss and sepsis,
 offer analgesia and tetanus toxoid vaccination.
 Offer antibiotic prophylaxis
 Consider the need for urinary cauterization.
late gynaecological complications of female genital mutilation
 Legal and regulatory procedures must be followed; all women and girls with acute or
recent FGM require police and social services referral.
 psychological and stress disorder
 Superficial dyspareunia and apareunia
 sexual dysfunction with anorgasmia
 pelvic infection and chronic pain
 keloid scar formation
 dysmenorrhoea including haematocolpos
 urinary outflow obstruction and recurrent urinary tract infections
 HIV and hepatitis infection
 dermoid cysts
 difficulty passing urine and faeces (WHO 2008)
 labial fusion (type II)
 repeated mutilation (type III)
 difficulty conceiving (failed intercourse)
 difficulty in gynaecological examination
 difficulty in cervical cytology screening
 difficulty evacuation of the uterus.
 a case–control study from Sudan showed increased rate of difficulty conceiving with type
III mutilation than types I and II.
How should women with FGM be identified in pregnancy?
 All women, irrespective of country of origin, should be asked for a history of FGM at their
booking antenatal visit so that FGM can be identified early in the pregnancy.
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 This should be documented in the maternity record.
 The midwife or obstetrician should ensure that all relevant information is documented in
the clinical records
Obstetric and neonatal consequences of previous FGM
 1-2/100 additional risk for perinatal deaths
 Potential maternal consequences of female genital mutilation include:
 fear of childbirth
 increased likelihood of :
1. caesarean section
2. PPH
3. Episiotomy
4. Severe vaginal lacerations
 extended hospital stay
 difficulty :
1. vaginal examinations in labour
2. applying fetal scalp electrodesand
3. fetal blood sampling
4. catheterisation.
Antenatal care
How should antenatal care be managed?
 Referral for psychological assessment and treatment should be offered.
 The vulva should be inspected to determine the type of FGM and whether de-
infibulation is indicated.
 If the introitus is sufficiently open to permit vaginal examination and if the urethral
meatus is visible, then de-infibulation is unlikely to be necessary.
 Screening for hepatitis C should be offered in addition to the other routine
antenatal screening tests (hepatitis B, HIV and syphilis).
 De-infibulation may be performed antenatally, in the first stage of labour or at the
time of delivery and can usually be performed under local anaesthetic in a
delivery suite room.
 It can also be performed perioperatively after caesarean section The midwife or
obstetrician should discuss, agree and record a plan of care.
 This may be documented in a preformatted sheet. Women should be informed
that re-infibulation will not be undertaken under any circumstances.
 Hospitals with a high number of women with FGM should have a specialist midwife
and an obstetrician.
 Complications of FGM should be taken into account when planning for antenatal and
delivery.
Where and when should defibulation be carried?
 Defibulation is recommended before conception, especially if difficult surgery is
anticipated.
 Defibulation can be done in the antenatal period or intrapartum around 20 weeks of
gestation to reduce the risk of miscarriage and allow time for healing before the birth.
 Preoperative test:
 Urine for bacteriuria
 Blood and serum save because of the risk of haemorrhage.
 Defibulation can be done in equipped outpatient room for minor procedures.
What technique should be used for defibulation?
 identify the urethra and a pass a catheter.
 Incise along the vulval excision scar preferred by Cutting diathermy to reduce bleeding.
 use fine absorbable suture material such as polyglactin 910.
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 Offer Prophylactic antibiotic.
 Offer adequate analgesia to limit the risk of further psychological harm.
Intrapartum care
How should intrapartum care be managed?
What recommendations should be made about mode of delivery?
 If a woman requires intrapartum de-infibulation, the midwife and obstetrician caring for
her should have completed training in de-infibulation or should be supervised
appropriately.
 If de-infibulation planned for the time of delivery is not undertaken because of
recourse to caesarean section, then the option of perioperative de-infibulation (i.e. just
after caesarean section) should be considered and discussed with the woman.
 Labial tears in women with FGM should be managed in the same manner as in
women without FGM.
 Repairs should be performed where clinically indicated, after discussion with the
woman and using appropriate materials and techniques.
 FGM is not an absolute indication for caesarean birth unless there was anatomical
distortion that makes defibulation impossible.
 Episiotomy is recommended with caution to avoid severe trauma to surrounding tissues.
How should intrapartum care be managed for women identified as
having FGM in pregnancy for whom there has been no agreed
documented plan of care?
 The impact of FGM on labour and delivery should be sensitively discussed and a plan of
care agreed.
What recommendations should be made about vaginal birth for a woman
with FGM?
 Women with FGM should deliver in a maternity unit with immediate access to emergency
obstetric care.
 Women with successful defibulation and an uncomplication can birth in midwifery-led
units.
 Epidural anaesthesia should be recommended if anterior episiotomy is needed in labour.
postnatal care
How should postnatal care be managed?
 A woman whose planned de-infibulation was not performed because of delivery by
caesarean section should have follow-up in a gynaecology outpatient or FGM clinic
so that de-infibulation can be offered before a subsequent pregnancy.
 The discharging midwife should ensure that all legal and regulatory processes have
been adhered to prior to discharge

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IMPROVING PATIENT HANDOVER
Introduction
 Patient handover between shifts and teams is therefore a necessary and vital part
of practice in order to reduce the risk of medical errors.
 It is important to optimise communication of critical information as an essential
component of risk management and patient safety.
 Information must be transferred in a written format because verbal information is
prone to loss.
 Many organisations have published on safe handover
 The cornerstones for efficiency of the handover process include regular reviews of
the handover process, written guidelines for handover, and use of a preprepared
handover sheet.
Effective communication
1) SBAR tool for improving communication within the team
 The SBAR (situation – background – assessment – recommendation) tool can be
used to efficiently hand over individual patients in 30–60 minutes.
 it also allows all members of the team lower down the hierarchy to add to the
conversation in an organised fashion.
 The steps involved in using SBAR are:
1. Situation: describe the situation about a patient, including name, consultant,
patient location, vital signs, resuscitation status and any specific concerns.
2. Background: including date of admission, diagnosis, current medications,
allergies, laboratory results, progress during the admission
3. Assessment: this involves critical assessment of the situation, clinical impression
and detailed expression of concerns.
4. Recommendation: this involves the management plan. Any order that is given,
especially over the telephone or when discussed with a doctor who has been
woken from sleep, needs to be repeated back to ensure accuracy.
2) SHARING tool for improving and standardising handover between teams
 SHARING (Staff, High risk, Awaiting theatre, Recovery ward, Inductions, NICU,
Gynaecology) is a mnemonic that represents the first letter from each clinical area
 It is usual for the most senior doctor on the delivery suite to be responsible for the
process of handover. This individual would be expected to complete the form and
participate in a team discussion with the departing and incoming teams prior to
leaving.
 Junior trainees should be involved and assist in the collation of data for the
handover,
 Use of the SHARING pro forma throughout the preceding shift can make handover
more efficient and ensure important messages get passed on even in the busiest
units.
 The handover process should also aim to include a management plan for each
patient (possibly using a tool such as SBAR) so that the incoming team can
immediately prioritise their duties.
 The document should contain all patients in the delivery suite, those awaiting IOL
and planned CS, patients with problems on the ward as well as new admissions
during the shift and patients on other specialty wards.
Conclusion and recommendation
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 Achieving effective handover is the duty of every doctor.
 It is a skill that needs to be taught, learned, practised and developed.
 SHARING is an effective standardised handover pro forma to be used in obstetrics
and gynaecology.

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THE MANAGEMENT OF BREECH PRESENTATION
Background
 The incidence of breech presentation 20% at 28 weeks of gestation and 3–4% at term.
 Persistent breech presentation may indicate abnormalities of the baby, the amniotic fluid
volume, the placental localisation or the uterus.
 perinatal mortality and morbidity higher in breech than cephalic presentation, due to:
prematurity, congenital malformations, birth asphyxia and trauma.
 in North Europe and America caesarean section is the preferable mode for breech
delivery.
 breech presentation, whatever the mode of delivery, is associated with increased risk of
handicap.
information should be given to women with breech presentation
 Women should be informed of the benefits and risks, for current and future pregnancies,
of planned caesarean section versus planned vaginal delivery for breech presentation at
term.
 planned caesarean section compared to vaginal delivery for breech presentation at term
carries :
1. A reduced perinatal mortality and early neonatal morbidity.
2. No evidence about the long term health of babies regarding the mode of delivery.
3. A small increase in serious immediate maternal complications.
4. No additional risk for maternal long-term health.
5. The impact on future pregnancy outcomes is uncertain.
What factors affect the safety of vaginal breech delivery?
 Women should be assessed for favorability for vaginal breech birth.
 Women with unfavourable features for vaginal breech birth have increased maternal and
fetal risk.
 Routine radiological pelvimetry is not necessary.
 Diagnosis of breech presentation during labour is not a contraindication for vaginal
breech birth.
 unfavourable Factors for vaginal breech birth:
1. contraindications to vaginal birth
2. footling or kneeling breech presentation
3. large baby > 3800 g
4. FGR < 2000 g
5. Hyperextended fetal neck in labour diagnosed by ultrasound or X-ray
6. lack of training in vaginal breech delivery
7. previous caesarean section.
 10% of women planned to deliver by caesarean section will delivere vaginally.
Intrapartum management
 Vaginal breech birth should take place in a hospital with facilities for emergency
caesarean section.
 Induction of labour may be considered.
 Augmentation of labour is not recommended.
 Epidural analgesia should not be routinely advised.
 Continous electronic fetal monitoring.
 Fetal blood sampling from the buttocks is not advised.
 CS should be considered if there is any delay in the descent in the second stage of
labour.
 the dorsal or lithotomy position for breech delivery.
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 Episiotomy only when indicated to facilitate delivery.
 Breech extraction should not be used routinely.
Management of delayed delivery of the arms :
1. sweeping them across the baby‟s face
2. the Lovset manoeuvre.
Management of delayed engagement in the pelvis of the aftercoming head :
1. Suprapubic pressure by an assistant to assist flexion of the head.
2. The Mauriceau-Smellie-Veit manoeuvre if necessary by displacing the head
upwards and rotating to the oblique diameter to facilitate engagement.
Management of obstructed delivery of the aftercoming head :
 If the above methods fail, symphysiotomy or caesarean section should be performed.
Delivery of the aftercoming head :
1. Forceps
2. Mariceau-Smellie-Veit manoeuvre
3. Burns-Marshall method.
o No evidence to favor which method.
o Burns-Marshall method if used incorrectly may lead to over-extension of the baby’s neck.
Management of the preterm breech and twin breech
 Routine caesarean section for preterm breech presentation is not recommended.
 The mode of delivery should be discussed on an individual basis with a woman and her
partner.
 lateral incisions of the cervix is considered with head entrapment during delivery.
Management of a first twin in breech presentation at term :
 Women should be informed of the benefits and risks of planned caesarean section for
first twin in breech presentation at term (same as singleton) .
Management of a second twin in breech presentation :
 Routine caesarean section should not be performed.
Training: skill, experience and judgement of the intrapartum attendant
 A skilled practitioner should be present at all vaginal breech births.
 Women who wish to choose a planned vaginal breech birth should be referred to a unit
where this option is available.
Documentation
 Document all details should be, including counselling and the identity of those involved in
the procedures.

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EXTERNAL CEPHALIC VERSION
The impact of ECV on the incidence of breech presentation and CS rate at delivery
 ECV reduces the chance of breech presentation and caesarean section at delivery.
 Spontaneous version rates for nulliparous 8% after 36 weeks but < 5% after
unsuccessful ECV.
 Spontaneous reversion to breech presentation after successful ECV less than 5%.
 Labour with a cephalic presentation following ECV is associated with a higher rate of
intervention compared with spontaneous cephalic presentation.
What is the success rate of ECV and what influences it?
 success rates of ECV are 30–80% .
 Factors increase successful rate:
1. Tocolysis with beta-sympathomimetics(a slow intravenous or subcutaneous
salbutamol or terbutaline either routinely or if an initial ECV attempt has failed)
2. Skilled practitioner
3. Multiparity
4. non-white ethnicity
5. relaxed uterus
6. not engaged breech
7. head is easily palpable.
8. increasing liquor volume, but may be associated with spontaneous reversion.
 Independent or less influencing factors:
1. Maternal weight
2. placental position
3. gestation
4. fetal size
5. position of the legs
 if the initial ECV fails concider:
1. second attempt, particularly with a second operator after discussion with the
mother.
2. tocolysis if it has not been used first.
3. fetal acoustic stimulation where the back is in the midline.
4. regional analgesia, epidural but not spinal analgesia. As maternal pain might
indicate a complication.
When should ECV be offered?
 from 36 weeks in nulliparous and from 37 weeks in multiparous.
 Successes reported at 42 weeks and can be performed in early labour with intact
membranes.
Is ECV safe?
 ECV has a very low complication rate including:
1. placental abruption,
2. uterine rupture
3. fetomaternal haemorrhage.
4. 0.5% immediate emergency caesarean
5. Alterations in fetal parameters(fetal bradycardia, a nonreactive CTG, alterations in
umbilical artery and middle cerebral artery Doppler and an increase in amniotic
fluid volume).
 No increase in perinatal morbidity and mortality or initiation of labour .
 ECV should be performed where facilities for monitoring and immediate delivery are
available.
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 The standard preparations for caesarean section are not necessary.
Is ECV painful?
 ECV can be painful and the procedure will be stopped if women wish.
Absolute contraindications to ECV(increased mortality or morbidity):
1. Vaginal delivey is contraindicated
2. APH within the last 7 days
3. abnormal CTG
4. major uterine anomaly
5. ruptured membranes
6. multiple pregnancy (except delivery of second twin).
Relative contraindications to ECV (increased complications):
1. SGA with abnormal Doppler
2. pre-eclampsia
3. oligohydramnios
4. major fetal anomalies
5. scarred uterus
6. unstable lie.
 ECV is contraindicated only in 4% of women with a breech presentation at term.
Increasing the uptake of ECV
 ECV may not be performed because:
o breech is not diagnosed in about 25%
o is not offered or available or refused
o not recommended.
Alternatives to ECV
 There is insufficient evidence to support postural management over ECV.
 Moxibustion should not be recommended.

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HOME BIRTHS
Summary
 The Royal College of Midwives (RCM) and RCOG support home birth for uncomplicated
pregnancies.
 The rate of home births within the UK remains low 2%,
benefits and harms
 Randomised controlled trials to assess the safety of home births are not currently
feasible.
 Observational data show that planned home birth compared with hospital birth
associated with:
 lower intervention rates(induction, augmentation, episiotomy, instrumental delivery
and CS).
 less perineal trauma
 higher maternal satisfaction.
 less pain and less analgesia.
 distinction needs to be made between women who plan for a home birth and those who
have an unintended home birth which associated with a higher rate of maternal and
perinatal complications.
 Causes of transfer to hospital during home birth:
 slow progress
 need for epidural anaesthesia.
 maternal haemorrhage,
 concerns about fetal wellbeing
 neonate born in an unexpectedly poor condition.
Provision of information, informed choice and user involvement in planning the services
 provide unbiased information about the potential advantages or disadvantages of home
birth.
 Written information regarding place of birth should be available
 Women participate actively in antenatal care
 Women can make the choice for place of birth at any stage in pregnancy linked to clinical
assessment.
 There are no risk assessment tools which can predict outcomes in the antenatal period
and labour.
 Women‟s individual needs should be taken while planning for home birth.
 Fathers/partners involvement in planning and attending home birth is encouraged
Service structure support
 Withdrawn of the choice of home birth late in pregnancy or in labour is not acceptable
and lead to further pressure on labour wards and midwives
 Any possibility of not being able to provide the service should be highlighted in early
pregnancy.
 local multidisciplinary arrangements are in place for emergency situations, including
transfer in labour and midwives referring directly to the obstetrician on the labour ward
and/or to the paediatrician.
 Other agencies have an integral role in the management of home birth, particularly the
regional ambulance service.
 It is the employer‟s responsibility to set minimum agreed levels of equipment for midwifes
tocarry out the role, including equipment for communication.
 All organisations must ensure that there are adequate numbers of midwives to ensure
24-hour access.
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BIRTH AFTER PREVIOUS CAESAREAN BIRTH
Antenatal care schedule
What is the recommended schedule of antenatal care for pregnant women with
previous caesarean delivery?
Implementation of a vaginal birth after previous caesarean delivery (VBAC) versus
elective repeat caesarean section (ERCS) checklist or clinical care pathway is
recommended to facilitate best practice in antenatal counselling, shared decision
making and documentation.
Suitability for planned VBAC
Which women are best suited to have a planned VBAC?
 Planned VBAC is appropriate for and may be offered to the majority of women with a
singleton pregnancy of cephalic presentation at 37+0 weeks or beyond who have
had a single previous lower segment caesarean delivery, with or without a history
of previous vaginal birth.
Can women with two or more prior caesareans be offered planned VBAC?
 Women who have had two or more prior lower segment caesarean deliveries may be
offered VBAC after counselling by a senior obstetrician.
 This should include the risk of uterine rupture and maternal morbidity, and the
individual likelihood of successful VBAC (e.g. given a history of prior vaginal delivery)
 Labour should be conducted in a centre with suitable expertise and recourse to
immediate surgical delivery.
What factors are associated with an increased risk of uterine rupture in women
undergoing VBAC?
 An individualised assessment of the suitability for VBAC should be made in women
with factors that increase the risk of uterine rupture.
Antenatal counselling
How should women be counselled in the antenatal period?
 Women with one uncomplicated lower-segment transverse caesarean section,
uncomplicated pregnancy at term, no contraindication to vaginal birth, should be able
to discuss the option of planned VBAC and ERCS.
 The antenatal counselling should be supported by a patient information leaflet and
documented in the notes.
 A final decision for mode of birth should be agreed between the woman and her
obstetrician before the expected/planned delivery date (ideally 36 weeks).
What are the risks and benefits of planned VBAC versus ERCS from 39+0 weeks of
gestation?
 Women should be made aware that successful VBAC has the fewest complications
and therefore the chance of VBAC success or failure is an important consideration
when choosing the mode of delivery.
 Women should be made aware that the greatest risk of adverse outcome occurs in a
trial of VBAC resulting in emergency caesarean delivery.
 Women should be informed that planned VBAC is associated with an approximately 1
in 200 (0.5%) risk of uterine rupture.
 Women should be informed that the absolute risk of birth-related perinatal death
associated with VBAC is extremely low and comparable to the risk for nulliparous
women in labour.
 Women should be informed that ERCS is associated with a small increased risk of
placenta praevia and/or accreta in future pregnancies and of pelvic adhesions
complicating any future abdominopelvic surgery.

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  The risk of perinatal death with ERCS is extremely low, but there is a small increase
in neonatal respiratory morbidity when ERCS is performed before 39+0 weeks of
gestation. The risk of respiratory morbidity can be reduced with a preoperative
course of antenatal corticosteroids.
 considering should include:
1. successful planned VBAC are 72–76%.
2. maternal and perinatal risks and benefits of planned VBAC and ERCS :
 1% additional risk of either blood transfusion or endometritis.
o No additional risk for hysterectomy, thromboembolic disease or maternal
death.
 0.02–0.03/100 additional risk of birth-related perinatal death.
 0.08/100 risk of the infant developing hypoxic ischaemic encephalopathy
compared with ERCS (zero rate).
 VBAC probably reduces the risk of fetal respiratory problems after birth: rates
are 2–3% with planned VBAC and 3–4% with ERCS.
 the risk of anaesthetic complications is extremely low for VBAC or ERCS.
 ERCS increase the risk of serious complications in future pregnancies.
o placenta accreta;
o injury to bladder, bowel or ureter; ileus;
o the need for postoperative ventilation;
o intensive care unit admission;
o hysterectomy;
o blood transfusion requiring four or more units
o increase the duration of operative time and hospital stay.
3. Previous vaginal birth, particularly previous VBAC, is the single best predictor
for successful VBAC (87–90%)
 23 Risk factors for unsuccessful VBAC(successful VBAC less than 40%):
o induced labour.
o no previous vaginal birth,
o body mass index greater than 30.
o previous caesarean section for dystocia.
o VBAC at or after 41 weeks of gestation.
o birth weight greater than 4000 g.
o no epidural anaesthesia,
o previous preterm caesarean birth,
o cervical dilatation at admission less than 4 cm.
o iterpregnancy interval less than 2 years.
o advanced maternal age.
o non-white ethnicity.
o short stature and.
o male infant.
 There is conflicting evidence on the effect of cervical dilatation when the
primary caesarean performed for dystocia.
What are the contraindications to VBAC?
 previous classical caesarean section (2–9/100 risk of uterine rupture)
 women with a prior inverted T or J incision (1.9/100 rupture risk).
 women with prior low vertical incision (2/100 rupture risk).
 previous uterine rupture- risk of recurrent rupture is unknown
 three or more previous caesarean deliveries, risks of rupture unknown.
 in certain extreme circumstances (such as miscarriage, intrauterine fetal death) for
some women in the above groups, vaginal route with risk may be considered.
Planned VBAC in special circumstances
Preterm birth
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  planned preterm VBAC has similar success rates to planned term VBAC but with a
lower risk of uterine rupture.
Twin gestation, fetal macrosomia, short interdelivery interval
 A cautious is advised when considering VBAC in women with twin gestation, fetal
macrosomia and short interdelivery interval, as there is uncertainty in the safety.
Intrapartum support and intervention during planned VBAC
Where and how should VBAC be conducted?
 VBAC should be conducted in a staffed and equipped delivery suite, with continuous
intrapartum monitoring and access to immediate caesarean section and advanced
neonatal resuscitation.
 Epidural anaesthesia is not contraindicated in planned VBAC.
o Successful rate is higher with epidural anaesthesia (73.4% versus 50.4%).
 continuous electronic fetal monitoring following the onset of uterine contractions.
o An abnormal cardiotocograph (CTG) is the most consistent finding in uterine
rupture.
 the presence of any of the following peripartum should raise the concern of the
possibility of rupture uterus:
o abnormal CTG
o severe abdominal pain, especially if persisting between contractions
o chest pain or shoulder tip pain, sudden onset of shortness of breath
o acute onset scar tenderness
o abnormal vaginal bleeding or haematuria
o cessation of previously efficient uterine activity
o maternal tachycardia, hypotension or shock
o loss of station of the presenting part.
 The routine use of intrauterine pressure catheters in the early detection of uterine
scar rupture is not recommended.
Induction and augmentation
 There is two- to three-fold increased risk of uterine rupture and around 1.5-fold
increased risk of caesarean section in induced and/or augmented VBAC.
 there is a higher risk of uterine rupture with induction of labour with prostaglandins.

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PRETERM PRELABOUR RUPTURE OF MEMBRANES
Background
 PPROM complicates only 2% of pregnancies
 PPROM is associated with 40% of preterm deliveries and in significant neonatal
morbidity and mortality.
 The three causes of neonatal death associated with PPROM are
1. Prematurity.
2. Sepsis(mortality four times higher with sepsis)also women with intrauterine
infection deliver earlier
3. pulmonary hypoplasia.
 1/3 of pregnancies with PPROM have positive amniotic fluid cultures
 Studies have shown that bacteria have the ability to cross intact membranes.
How is the diagnosis of PPROM best achieved?
 The diagnosis of PPROM is best achieved by maternal history followed by a sterile
speculum examination.
 A range of tests have been used to confirm membrane rupture:
1. Nitrazine test, which detects pH change.
2. ferning tast of amniotic fluid owing to its sodium chloride and protein
content
3. examination for lanugo hair and fetal epithelial cells stained with Nile blue.
 Sensitivity of Nitrazine and ferning tests is 90%.The false-positive is 17% for
Nitrazine test, due to contamination with urine, blood or semen, and 6% for the
ferning test,due to cervical mucus
 Ultrasound examination is useful in some cases to help confirm the diagnosis.
 Avoide digital vaginal examination unless there is a strong suspicion of labour.
What antenatal tests should be performed?
 Women should be observed for signs of clinical chorioamnionitis.
 Weekly high vaginal swab need not be performed.
 It is not necessary to carry out weekly maternal full blood count or C-reactive protein
because the sensitivity of these tests in the detection of intrauterine infection is low.
 Cardiotogography is useful - fetal tachycardia is used in the definition of clinical
chorioamnionitis.
 Biophysical profile score and Doppler velocimetry can be carried out, but these tests are
of limited value in predicting fetal infection.
 Abnormal biophysical profile scores and increased systolic/diastolic ratios in the umbilical
artery have been shown to be markers of intrauterine infection?.
 The criteria for the diagnosis of clinical chorioamnionitis include:
 maternal pyrexia,
 tachycardia,
 leucocytosis,
 uterine tenderness,
 offensive vaginal discharge and
 fetal tachycardia(Fetal tachycardia predicts 20–40% of cases of intrauterine
infection).
The frequency of maternal temperature, pulse and fetal heart rate auscultation
should be between every 4 hrs.
What is the role of amniocentesis?
 Although there is an association between subclinical intrauterine infection and adverse
neonatal outcome, the role of amniocentesis in improving outcome remains
undetermined.
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 There is insufficient evidence to recommend the use of amniocentesis in the diagnosis of
intrauterine infection.
 Positive amniotic fluid cultures increase the risks of:
 preterm delivery,
 neonatal sepsis,
 respiratory distress syndrome,
 chronic lung disease,
 periventricular leukomalacia,
 intraventricular haemorrhage
 cerebral palsy.
 Rapid tests on amniotic fluid such as Gram stain and assay of cytokines(interleukins 6
and 18)which indicate intrauterine infection,may be performed.
Management
1) Erythromycin for 10 days following the diagnosis of PPROM. This is associated with:
 reduction in chorioamnionitis
 reduction in the numbers of babies born within 48 hours.
 Reduced Neonatal infection significantly.
 Reduction in number of babies with abnormal cerebral scan prior discharge from
hospital
 no significant reduction in perinatal mortality.
co-amoxiclav increased the risk of neonatal necrotising enterocolitis and is best
avoided.
Erythromycin or penicillin appears the antibiotic of choice.
2) Antenatal corticosteroids. Reduce the risk of:
 respiratory distress syndrome
 intraventricular haemorrhage
 necrotising enterocolitis
 neonatal death
They do not appear to increase the risk of infection in either mother or baby.
3) Prophylactic or therapeutic tocolysis in women with PPROM is not recommended
because this treatment does not increase the interval between membrane rupture and
delivery or significantly improve perinatal outcome.
4) Delivery should be considered at 34 weeks of gestation.
5) when expectant management is considered beyond this gestation, women should be
informed of the increased risk of chorioamnionitis and the decreased risk of
respiratory problems.
 Neonatal minor morbidity such as hyperbilirubinaemia and TTN was significantly
higher among pregnancies delivered at 34 weeks of gestation or less compared
with those delivered at 36 weeks.
 Major neonatal morbidity including RDS and intraventricular haemorrhage not
significantly different.
6) Hospital versus outpatient monitoring:
 There are insufficient data to make recommendations for home and outpatient
monitoring rather than continued hospital admission in women with PPROM.
 Conceder that women presenting with PPROM and subclinical intrauterine
infection deliver earlier than non-infected patients.
 It is reasonable to keep woman in hospital for at least 48 hours before a decision
is made to allow her home.
 This method of management should be individualised and restricted to certain
women.
 Women should be instructed to take regular temperature recordings at home
every 4–8 hours.
Should amnioinfusion in labour be carried out?
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  Amnioinfusion during labour is not recommended in women with preterm rupture of
membranes.
What is the role of transabdominal amnioinfusion in the prevention of pulmonary
hypoplasia?
 There is insufficient evidence to recommend amnioinfusion in very preterm PPROM
as a method to prevent pulmonary hypoplasia.
What is the role of fibrin glue in the sealing of chorioamniotic membranes to prevent
pulmonary hypoplasia?
 There is insufficient evidence to recommend fibrin sealants as routine treatment for
second-trimester oligohydramnios caused by PPROM.

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MAGNESIUM SULPHATE TO PREVENT CEREBRAL PALSY
FOLLOWING PRETERM BIRTH
Background
 the prevalence of CP has risen because survival of infants born preterm has improved.
 The incidence of CP decreases with increasing GA: 14.6% at 22–27 weeks, 6.2% at
28–31 weeks, 0.7% at 32–36 weeks and 0.1% in term infants.
 Perinatal origin of cerebral palsy in preterm children 49and in term children 35%.
Neuroprotection
 Magnesium sulphate to prevent eclamptic seizures or as tocolysis showed a reduction
in rates of cystic periventricular leucomalacia (PVL) and cerebral palsy
 The exact mechanism of action of magnesium as a neuroprotective agent is unknown:
1. N-methyl-D-aspartic acid (NMDA) receptors on oligodendrocytes are thought to
be important in the glial injury process. Magnesium sulphate may reverse the
harmful effects of hypoxic/ischaemic brain injury by blocking NMDA receptors.
2. Magnesium sulphate also protect against free radical activity,
3. Magnesium sulphate act as a vasodilator, and prevents hypoxic damage
4. Magnesium sulphate has anti-apoptotic actions.
Effect on cerebral palsy
 antenatal magnesium sulphate reduced the risk of cerebral palsy with a relative risk of
0.68.
 There was also a significant reduction in the rate of substantial gross motor dysfunction
RR 0.61
Gestation at administration
 The University of Adelaide guideline panel in Australia recommend magnesium
sulphate should be considered in women at less than 30 weeks of gestation.
 The magnitude of effect is likely to be largest at earliest gestations.
Dose and timing of administration
 intravenous 4 g loading dose over 20–30 minutes by a 1 g/hr maintenance for 24 hours
or until birth, whichever occurred soonest.
 A further bolus dose should be given If women suspected to deliver > 6 hours after
stopping.
 infusion should be started at least 4 hrs. before birth, but there may still benefit if given
less than 4 hrs. before delivery.
Side effects
 IV magnesium sulphate is associated with maternal side effects(facial flushing,
hypotension, tachycardia, nausea, vomiting, injection site problems, rarely muscle
weakness and paralysis).
 Cardiovascular and neuromuscular effects may be exaggerated if given in conjunction
with calcium antagonists,.
 No evidence of an effect on maternal death, cardiac respiratory arrest, pulmonary
oedema, respiratory depression, severe postpartum haemorrhage or caesarean section
rates.
 Seventy percent reported side effects such as flushing,
Opinion
 Magnesium sulphate given to mothers shortly before delivery reduces the risk of
cerebral palsy and protects gross motor function in those infants born preterm.
 The effect may be greatest at early gestations and is not associated with adverse long-
term fetal or maternal outcome.

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TOCOLYSIS FOR WOMEN IN PRETERM LABOUR
Background
 For very preterm births < 32+0 weeks mortality in 1st year was 144/1000 live births,
compared with 1.8/1000 live births for babies born at term 38+0 to 41+6 weeks.
 Very preterm birth accounts for 1.4% of UK births but 51% of infant deaths.
 A wide variety of agents have been advocated as suppressing uterine contractions
include:
1. beta-agonists,
2. calcium channel blockers,
3. oxytocin receptor antagonists, atosiban.
4. prostaglandin synthetase inhibitors,
5. nitric oxide donors
6. magnesium sulphate.
 Tocolysis has been advocated for the management of:
 preterm labour.
 intrapartum fetal distress
 impaired fetal growth
 to facilitate external cephalic version at term.
 Restoration of uterine inversion
Uses of tocolysis for women in preterm labour.
 Tocolytic drug is associated with a prolongation of pregnancy for up to 7 days but no
significant effect on preterm birth and no clear effect on perinatal or neonatal morbidity
and mortality.
 Tocolysis should be considered to gain few days for completing corticosteroids or in
utero transfer.
 There is increase in deaths in the 1st year of life associated with atosiban, due to
blockade in fetal vasopressin receptor, which lead to changes in AFV and alterations to
renal and fetal lung development.
When should tocolytic drugs be used?
 Tocolysis may be considered for suspected preterm labour with otherwise uncomplicated
pregnancy.
 It is reasonable not to use any tocolytic drug.
 Tocolysis should not be used where there is a contraindication to prolonging pregnancy.
1) Absolute contraindication:
1. lethal congenital or chromosomal malformation,
2. intrauterine infection,
3. severe pre-eclampsia,
4. placental abruption,
5. advanced cervical dilatation
6. evidence of fetal compromise or placental insufficiency.
2) Relative contraindications:
1. mild haemorrhage due to placenta praevia,
2. nonreassuring cardiotocograph,
3. FGR
4. multiple pregnancy.
Is one tocolytic drug more effective in preventing preterm birth than another?
 Nifedipine and atosiban have comparable effectiveness in delaying birth for up to seven
days.

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 Compared with beta-agonists, nifedipine is associated with improvement in neonatal
outcome.
 There is no clear evidence that magnesium sulphate reduces the risk of preterm birth,
but administration of magnesium sulphate to women at risk of preterm birth reduces the
risk of CP
 Beta-agonists have a high frequency of adverse effects include:
1. Palpitations 38%
2. tremor 39%
3. nausea or vomiting 21%
4. headache 19%
5. chest pain 10%
6. dyspnoea 14%.
7. Pulmonary oedema, usually associated with aggressive intravenous hydration.
 adverse effects for nifedipine include:
1. flushing,
2. palpitations,
3. nausea and vomiting
4. hypotension.
5. Pulmonary oedema if used in woman with cardiac disease, diabetes or multiple
pregnancy.
 adverse effects for atosiban include:
1. nausea
2. injection site reactions.
 COX inhibitors are well tolerated and there is no clear effect on the need to discontinue
treatment
 Using multiple tocolytic drugs is associated with a higher risk of adverse effects and
should be avoided.
Comparative effects for the baby of alternative tocolytic drugs for preterm labour
 Most drugs have been compared with beta-agonists.
 There are insufficient data on long-term effects on the baby for any of these tocolytic
drugs.
 Calcium channel blockers were associated with less neonatal RDS less
necrotising enterocolitis and less intraventricular haemorrhage than other
tocolytic drugs and no specific congenital defects.
 There was no clear difference between the treatment groups either in stillbirths
or in neonatal deaths.
 COX inhibitors cross the placenta and potential adverse effects for the baby
include:
1. premature closure of the ductus arteriosus with consequent pulmonary HTN,
persistent PDA
2. necrotising enterocolitis
3. Intraventricular haemorrhage.
4. exposure to magnesium sulphate was associated with increased risk of fetal,
neonatal or infant death
What are the recommended dose regimens for nifedipine and atosiban?
 The suggested dose of nifedipine is an initial oral dose of 20 mg followed by 10–20 mg
three to four times daily, adjusted according to uterine activity for up to 48 hours.
 A total dose >60 mg appears to be associated with a 3-4 fold increase in adverse events.
 A suggested dose of atosiban of an initial bolus dose of 6.75 mg over 1 minute, followed
by an infusion of 18 mg/hour for 3 hours, then 6 mg/hour for up to 45 hours to a
maximum of 330 mg.
Should tocolysis be used in multiple pregnancy?
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 There is insufficient evidence about benefits of tocolysis in preterm labour in multiple
pregnancy.
 Although both nifedipine and atosiban have been widely used in this context.
 Nifedipine may be associated with pulmonary oedema in multiple pregnancy
and atosiban may be preferable in this context.
Is maintenance tocolytic therapy worthwhile?
 There is insufficient evidence about benefits of maintenance tocolytic therapy following
threatened preterm labour, so it is not recommended.
Summary
 Use of a tocolytic drug is not associated with a clear reduction in perinatal or neonatal
mortality or neonatal morbidity.
 Data on long-term outcome are sparse.
 If decision is made to use a tocolytic drug, nifedipine and atosiban appear to have
comparable effectiveness in delaying delivery, with fewer maternal adverse effects and
less risk of rare serious adverse events.
 There is little information about long-term growth and development of child for any of the
drugs.
 Ritodrine and atosiban are licensed in the UK for the treatment of threatened preterm
labour.
 The available evidence should be discussed with the woman and her partner and their
preferences taken into account in determining her care.

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INDUCTION OF LABOUR
 When labour was induced using medical methods:
 63%gave birth without further intervention
 15% having instrumental births
 22% having emergency caesarean sections.
 IOL has a large impact on the health of women and babies, so needs to be justified.
Information and decision-making
 At the 38 week antenatal visit, women should be offered information about the risks of
prolonged pregnancies > 42 weeks, and their options.
 The information should cover:
1. membrane sweeping:
o reduces the need for formal IOL
o If the cervix will not admit a finger, massaging around the cervix in the
vaginal fornices may achieve a similar effect
o associated with discomfort and/or vaginal bleeding
2. induction of labour between 41+0 and 42+0 weeks
3. expectant management.
 Healthcare professionals should explain the following points to women offered IOL:
 the indication
 when, where and how induction could be carried out
 the arrangements for support and pain relief
 the alternative options if the woman chooses not to have IOL
 the risks and benefits of induction of labour in specific circumstances
 the induction methods
 the failure rate and what are the options.
Induction of labour in specific circumstances
Prevention of prolonged pregnancy
 offer IOL between 41+0 and 42+0 weeks with uncomplicated pregnancies to avoid the
risks of prolonged pregnancy.
 A woman decision not to have IOL should be respected.
 From 42 weeks, women should be offered increased antenatal monitoring at least
twiceweekly CTG and ultrasound for maximum amniotic pool depth.
Preterm prelabour rupture of membranes
 IOL should not be carried before 34 weeks unless there are infection or fetal
compromise.
 After 34 weeks, before IOL discus the following with the mother:
 Using vaginal PGE2
 Risks to the woman (, sepsis, caesarean section)
 Risks to the baby (, sepsis, problems relating to preterm birth)
 Availability of NICU.
Prelabour rupture of membranes at term
 Women PROM should be offered a choice of IOL with PGE2 or expectant management.
 IOL is appropriate 24 hours after PROM at term.
Previous caesarean section
 May be offered IOL with PGE2, caesarean section or expectant management .
 The following risks associated with IOL:
 increased risk of emergency caesarean section
 increased risk of uterine rupture.

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Maternal request
 under exceptional circumstances (if the woman's partner is soon to be posted abroad
with the armed forces), induction may be considered at or after 40 weeks.
Breech presentation
 Induction of labour is not recommended.
 If ECV is unsuccessful and the woman chooses not to have an CS, induction of labour
should be offered, after discussing the associated risks with the woman.
Fetal growth restriction
 IOL in severe FGR with fetal compromise is not recommended.
History of precipitate labour
 IOL should not be routinely offered to women with a history of precipitate labour to avoid
unattended birth.
Intrauterine fetal death
 Offer immediate IOL If there is evidence of ruptured membranes, infection or bleeding.
 The risk of uterine rupture is increased For women who have had a previous CS.
Suspected fetal macrosomia
 In the absence of any other indications, induction of labour is not recommended
Recommended methods for IOL
1) Membrane sweeping
 At the 40 and 41 week, offer membrane sweeping and assess the cervix in nulliparous.
 At the 41 week, offer membrane sweeping and assess the cervix in parous women.
 Additional membrane sweeping may be offered if labour does not start spontaneously.
2) medical methods
 Vaginal PGE2 is the preferred method of IOL,
 administered as a gel, tablet or controlled release pessary.
 The recommended regimens are:
 one cycle of vaginal PGE2 tablets or gel: 1st dose, followed after 6 hours by 2nd
dose if labour is not established
 one cycle of vaginal PGE2 controlled-release pessary: one dose over 24 hours.
 Methods that are not recommended for IOL
 Pharmacological methods:
o oral PGE2
o intravenous PGE2
o extra-amniotic PGE2
o intracervical PGE2
o intravenous oxytocin alone
o hyaluronidase
o corticosteroids
o oestrogen
o vaginal nitric oxide donors.
 Non-pharmacological methods:
o herbal supplements
o castor oil
o hot baths
o enemas
o sexual intercourse.
3) Surgical methods
 Amniotomy, alone or with oxytocin, should not be used as a primary method of IOL
unless there is contraindication for vaginal PGE2(uterine hyperstimulation).
4) Mechanical methods
 Mechanical methods (balloon catheter and laminaria tent) should not be used routinely.

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Setting and timing
 In outpatient setting, IOL can be carried if safety and support procedures are in place.
 In inpatient setting, IOL carried in the morning because of higher maternal satisfaction.
Monitoring
 facilities should be available for continuous electronic fetal heart rate and uterine
contraction monitoring.
1. Assess Bishop score and record it
2. Confirm a normal fetal heart rate pattern by CTG.
3. administr vaginal PGE2
4. once contractions begin, assess fetal wellbeing with continuous electronic fetal
monitoring.
5. Once the CTG is confirmed as normal, use intermittent auscultation unless there are
clear indications for continuous electronic fetal monitoring
6. Reassess Bishop score every 6 hours after vaginal PGE2 tablet or gel, or 24 hours
after controlled-release pessary, to monitor progress
7. If a woman returns home after insertion of vaginal PGE2, she should be asked to
contact her maternity unit when contractions begin, or if no contractions after 6 hours.
Pain relief
 induced labour is likely to be more painful than spontaneous labour.
 Women should be informed of the availability of pain relief options in different settings
 offer support and analgesia as required, and encourage women to use their own coping
strategies for pain relief.
 water immersion is recommended for pain relief.
Prevention and management of complications
1) Uterine hyperstimulation
 Consider tocolysis.
2) Failed induction
 Defined as labour not starting after one cycle of treatment
 If induction fails:
 discuss this with the woman and provide support.
 reassessed maternal and fetal wellbeing.
 discuss further management according to the woman's wishes and clinical
circumstances:
1. a further attempt to IOL
2. caesarean section
3) Cord prolapse
 To reduce the likelihood of cord prolapse, which may occur at the time of amniotomy:
 Before induction, engagement of the presenting part should be assessed.
 palpate for cord during vaginal examination and avoid dislodging baby's head.
 Avoid amniotomy if the baby's head is high.
 check that there are no low lying placenta before membrane sweeping and IOL.
4) Uterine rupture
 If uterine rupture is suspected during IOL, perform emergency CS

367
368
369
INTRAPARTUM CARE
Planning place of birth
 Multiparous and nulliparous women may choose any birth setting which
includes;
 Home – small increase risk of adverse outcomes to baby in nulliparous
(4 per 1000 births)
 Midwifery led unit (standalone) – higher rates of spontaneous vaginal birth
 Midwifery led unit (alongside)
 Obstetric led unit – higher rate of interventions such as instrumental
vaginal delivery, caesarean section, and episiotomy.
 Women should be informed:
 That giving birth is generally very safe for both the woman and her baby.
 We do not have enough information about the possible risks to either the
woman or her baby relating to planned place of birth.
Medical conditions indicating increased risk suggesting planned birth at an
obstetric unit
Disease area Medical condition
Cardiovascular - Confirmed cardiac disease
- Hypertensive disorders
Respiratory - Asthma requiring an increase in treatment or hospital
treatment
- Cystic fibrosis
Haematological -Haemoglobinopathies – sickle-cell disease, beta-
thalassaemia major
- History of thromboembolic disorders
Immune thrombocytopenia purpura or other platelet disorder
or platelet count below 100,000
- Von Willebrand's disease
- Bleeding disorder in the woman or unborn baby
- Atypical antibodies which carry risk of haemolytic disease of
newborn
Infective - Risk factors associated with group B streptococcus whereby
antibiotics in labour would be recommended
- Hepatitis B/C with abnormal liver function tests
- Carrier of/infected with HIV
- Toxoplasmosis – women receiving treatment
- Current active infection of chicken pox/rubella/genital herpes
in the woman or baby
-Tuberculosis under treatment
Immune - Systemic lupus erythematosus
- Scleroderma
Endocrine - Hyperthyroidism
- Diabetes
Renal - Abnormal renal function
- Renal disease requiring supervision by a renal specialist

371
 Neurological - Epilepsy
- Myasthenia gravis
- Previous cerebrovascular accident
Gastrointestinal -Liver disease associated with current abnormal liver function
tests
Psychiatric -Psychiatric disorder requiring current inpatient care
Other factors indicating increased risk suggesting planned birth at an
obstetric Unit
Factor Additional information
Previous -Unexplained stillbirth/neonatal death or previous death related to
Complications intrapartum difficulty
- Previous baby with neonatal encephalopathy
- Pre-eclampsia requiring preterm birth
- Placental abruption with adverse outcome
- Eclampsia
- Uterine rupture
- Primary postpartum haemorrhage requiring additional treatment
or blood transfusion
- Retained placenta requiring manual removal in theatre
- Caesarean section
- Shoulder dystocia
Current - Multiple pregnancy
pregnancy - Placenta praevia
Fetal - Pre-eclampsia or pregnancy-induced hypertension
indications - Preterm labour or preterm prelabour rupture of membranes
- Placental abruption
- Anaemia – haemoglobin less than 8.5 g/dl at onset of labour
- Confirmed intrauterine death
- Induction of labour
- Substance misuse
- Alcohol dependency requiring assessment or treatment
- Onset of gestational diabetes
- Malpresentation – breech or transverse lie
- Body mass index at booking of greater than 35 kg/m2
- Recurrent antepartum haemorrhage
- Small for gestational age in this pregnancy (less than fifth centile
or reduced growth velocity on ultrasound)
- Abnormal fetal heart rate (FHR)/Doppler studies
- Ultrasound diagnosis of oligo-/polyhydramnios
Previous - Myomectomy
gynaecological - Hysterotomy
history
Indications for intrapartum transfer
 indications for EFM including abnormalities of the fetal heart rate on
intermittent auscultation
 delay in the first or second stages of labour
 significant meconium-stained liquor
 maternal request for epidural pain relief

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  obstetric emergency – APH, cord presentation/prolapse, PPH,
 need for advanced neonatal resuscitation
 retained placenta
 maternal pyrexia in labour (38.0°C once or 37.5°C on two occasions 2
hours apart)
 malpresentation or breech presentation diagnosed for the first time at the
onset of labour.
 either raised diastolic blood pressure (over 90 mmHg) or raised systolic
blood pressure (over 140 mmHg) on two readings taken 30 minutes apart
 uncertainty about the presence of a fetal heartbeat
 third- or fourth-degree tear or other complicated perineal trauma requiring
suturing.
Care throughout labour
Communication
 To establish communication with the labouring woman:
 Greet the woman with a smile and a personal welcome, introduce
yourself and explain your role in her care.
 Knock and wait before entering the woman's room.
 Ask how the woman is feeling and her worriers.
 If the woman has a written birth plan, read and discuss it with her.
 Assess the woman's knowledge of strategies for coping with pain
 Ask her permission before all procedures and observations, focusing on
the woman rather than the technology or the documentation.
 When leaving the room let her know when you will return.
 Involve the woman in any handover of care to another professional.
Mobilisation
 Women should be encouraged and helped to move and adopt positions most
comfortable throughout labour.
Support in labour
 A woman in established labour should:
 receive one-to-one care.
 not be left on her own except for short periods.
 be encouraged to have support by birth partner(s) of their choice.
 Team midwifery (defined as a group of midwives providing care and taking
shared responsibility for a group of women from the antenatal, through
intrapartum to the postnatal period) is not recommended.
Controlling gastric acidity
 Neither H2-receptor antagonists nor antacids should be given routinely to low
risk women.
 Consider Either H2-receptor antagonists or antacids for women who receive
opioids or at risk factors for general anaesthetic.
 Women may drink during established labour and isotonic drinks may be more
beneficial than water.
 Women may eat a light diet in established labour unless they have received
opioids or at risk factors for general anaesthetic.
Hygiene measures
 Tap water may be used if cleansing is required prior to vaginal examination.
 Routine hygiene measures should be taken by staff.
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Coping with pain in labour: non-epidural
Pain-relieving strategies
 breathing and relaxation techniques in labour should be supported.
 massage techniques in labour that have been taught to birth partners should
be supported.
 labour in water is recommended for pain relief.
 Acupuncture, acupressure and hypnosis should not be provided.
 Support the playing of music of the woman's choice in the labour ward.
Non-pharmacological analgesia
 TENS should not be offered to women in established labour.
Inhalational analgesia
 Entonox (a 50:50 mixture of oxygen and nitrous oxide) should be available in
all birth settings as it may reduce pain in labour.
Intravenous and intramuscular opioids
 Pethidine, diamorphine or other opioids should be available.
 opioids will provide limited pain relief during labour and may have significant
side effects for woman and her baby
 opioids may interfere with breastfeeding.
 administer antiemetic with intravenous or intramuscular opioid.
 Women should not enter water within 2 hours of opioid administration.
Pain relief in labour: regional analgesia
Information about regional analgesia
 information about choosing epidural analgesia:
 It is only available in obstetric units.
 more effective than opioids.
 associated with a longer 2nd stage of labour and an increased
instrumental birth.
 No long-term backache.
 No longer 1st stage of labour and no increased chance of CS.
 Need more intensive level of monitoring and intravenous access.
 Modern epidural solutions contain opioids which cross the placenta and
in larger doses may cause short-term respiratory depression in the baby
and drowsy.
Timing of regional analgesia
 Women in labour who desire regional analgesia should not be denied it,
including women in severe pain in the latent first stage of labour.
Care and observations for women with regional analgesia
 Encourage Women to move and adopt their comfortable position.
 unless the woman has an urge to push or the baby's head is visible, pushing
should be delayed for at least 1 hour and longer.
 After full dilatation birth should occur within 4 hours regardless of parity.
 Continuous EFM for at least 30 min during establishment and after each
bolus.
Establishing and maintaining regional analgesia
 It is recommended that combined spinal–epidural analgesia is established
with bupivacaine and fentanyl.

373
  epidural analgesia is established and maintained with a low concentration
local anaesthetic and opioid (10–15 ml of 0.0625–0.1% bupivacaine with 1–2
micrograms per ml fentanyl).
 Either patient-controlled epidural analgesia or intermittent bolus is used for
maintenance of epidural analgesia.

Normal labour: first stage

 Don‟t offer Clinical intervention where labour is progressing normally and the
woman and baby are well.
Definition of the first stage
 Latent first stage of labour : when there are painful contractions, and some
cervical change, including cervical effacement and dilatation up to 4 cm.

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  Established first stage of labour : when there are regular painful contractions,
and there is progressive cervical dilatation from 4 cm.
Duration of the first stage
 first labours(primi)1cm/h last on average 8-10 hours and considered delay if
less than 2/4h. unlikely to last over 18 hours.
Second and subsequent labours(multi)2cm/h last on average 5 hours and
considered delay if less than2/4h. unlikely to last over 12 hours.
Definition of delay in the established first stage

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Observations on presentation in suspected labour
 initial assessment by a midwife should include:
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 1. listening to her story, considering her emotional and psychological needs,
2. reviewing her clinical records
3. physical observation – temperature, pulse, blood pressure, urinalysis
4. length, strength and frequency of contractions
5. abdominal palpation – fundal height, lie, presentation, position and station
6. vaginal loss – show, liquor, blood
7. assessment of the woman's pain, including options for pain relief.
8. The FHR should be auscultated for a minimum of 1 minute immediately after
a contraction.
9. If the woman does not appear to be in established labour, after a period of
assessment offer a vaginal examination.
10. If the woman appears to be in established labour, offer vaginal examination.
 For vaginal examination:
 be sure that the vaginal examination is really necessary
 ensure the woman's consent, privacy, dignity and comfort
 explain the procedure and reason for the examination.
 explain the findings and their impact.
 women having pain without cervical change are not in labour, they may
consider themselves 'in labour' by their own definition. Offer them support
and occasionally analgesia, and encouraged to return home.
 The use of admission cardiotocography (CTG) in low-risk pregnancy is not
recommended.
Observations during the established first stage
 Use partogram with 4-hour action line once labour is established.
 Observations by a midwife during the first stage of labour include:
 4-hourly temperature and blood pressure
 hourly pulse
 half-hourly documentation of frequency of contractions frequency of
emptying the bladder
 vaginal examination 4-hourly, or where there is concern about progress
and after vaginal loss.
 Intermittent auscultation of the fetal heart every 15 minutes.
 Encourage women to communicate their need for analgesia at any point
during labour.
Possible routine interventions in the first stage
 active management of labour (one-to-one continuous support; early routine
amniotomy; routine 2-hourly vaginal examination; oxytocin if labour becomes
slow) should not be offered routinely.
 In normally progressing labour, amniotomy should not be performed routinely.
 Combined early amniotomy and oxytocin should not be used routinely.
Fetal heart assessment and reasons for transfer to continuous EFM
 Intermittent auscultation of the FHR is recommended for low-risk women in
established labour.
 Advise Changing from intermittent auscultation to continuous EFM in low-risk
women for the following reasons:
1. significant meconium-stained liquor, and consider it for light meconium
2. abnormal FHR detected by intermittent auscultation is: < 100 bpm, > 160
bpm; any decelerations after a contraction
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 3. maternal pyrexia (defined as 38.0C once or 37.5C on two occasions 2
hours apart)
4. fresh bleeding in labour
5. oxytocin use for augmentation
6. the woman's request.
 Inform women that continuous EFM will restrict their mobility.
Normal labour: second stage
Definition of the second stage
 Passive 2nd stage of labour: at full dilatation of the cervix with absence of
involuntary expulsive contractions.
 active 2nd stage of labour: at full dilatation of the cervix with involuntary
expulsive contractions
Duration and definition of delay in the second stage
 Nulliparous women: Birth expected within (2hrs, 3hrs with epidural) of the start
of the active 2nd stage.
 Parous women: Birth expected within (1hrs, 2hrs with epidural) of the start of
the active 2nd stage.
Observations during the second stage
 All observations should be documented on the partogram:
 hourly BP and pulse, temperature and vaginal examination
 half-hourly frequency of contractions frequency of emptying the bladder
 assessment of woman's emotional and psychological needs.
 maternal behaviour, effectiveness of pushing and fetal wellbeing,.
 Intermittent auscultation of the fetal heart should occur after a contraction
for at least 1 minute, at least every 5 minutes.
 consideration should be given to the woman's position, hydration, coping
strategies and pain relief throughout the second stage.
Women's position and pushing in the second stage
 discouraged lying supine or semi-supine in the second stage of labour.
 Inform Women that in the 2nd stage they should be guided by their urge to
push.
 If pushing is ineffective strategies to assist birth can be used: support, change
of position, emptying of the bladder and encouragement.
Intrapartum interventions to reduce perineal trauma
 Perineal massage should not be performed in the 2 nd stage of labour.
 Either the 'hands on' (guarding the perineum and flexing the baby's head) or
the 'hands poised' (with hands off) technique can be used.
 Lidocaine spray should not be used to reduce pain in the 2 nd stage of labour.
 A routine episiotomy should not be carried out unless there is a clinical need
such as instrumental birth or fetal compromise.
 the recommended technique is a mediolateral episiotomy
 provide effective analgesia prior to episiotomy except in emergency such as
fetal compromise.
 Inform women that their risk of repeat severe perineal trauma is not increased
in a subsequent birth. And episiotomy should not be offered routinely.
 In woman with previous third- or fourth-degree trauma to make an informed
choice, discussion should encompass:
1. current urgency or incontinence symptoms
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 2. the degree of previous trauma
3. risk of recurrence
4. the success of the repair undertaken
5. the psychological effect of the previous trauma
6. management of her labour.
 Inform women with infibulated genital mutilation about the risks of:
1. difficult vaginal examination, catheterisation and fetal scalp electrodes.
2. delay in the second stage
3. spontaneous laceration
4. the need for an anterior episiotomy
5. the possible need for defibulation in labour.
Water birth
 there is insufficient evidence to either support or discourage birth in water.

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Normal labour: third stage
Active management of the third stage
 Active management of the third stage involves 3 components:
1. uterotonic drugs(oxytocin10 IU by intramuscular injection)
2. early clamping and cutting of the cord
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 3. controlled cord traction.
 Explain to the woman that active management:
 shortens the third stage compared with physiological management
 is associated with nausea and vomiting in about 100 in 1000 women
 is associated with an approximate risk of 13 in 1000 of a haemorrhage of
more than1 litre
 is associated with an approximate risk of 14 in 1000 of a blood transfusion.
Physiological management of the third stage
 Physiological management involves 3 components:
1. no uterotonic drugs
2. no clamping of the cord until pulsation has ceased
3. delivery of the placenta by maternal effort.
 Explain to the woman that physiological management:
 is associated with nausea and vomiting in about 50 in 1000 women
 is associated with an approximate risk of 29 in 1000 of a haemorrhage of
more than1 litre
 is associated with an approximate risk of 40 in 1000 of a blood transfusion.
Prolonged third stage
 if not completed within 30 minutes of the birth of the baby with active
management and 60 minutes with physiological management.
Observations in the third stage
4. general physical condition,
1. report of how she feels
2. vaginal blood loss.
3. in the presence of haemorrhage, retained placenta or maternal collapse,
frequent observations to assess the need for resuscitation are required.
Physiological and active management of the third stage
 Women at low risk of PPH who request physiological management of the third
stage should be supported in their choice.
 Changing from physiological management to active management of the third
stage is indicated in the case of:
 haemorrhage
 failure to deliver the placenta within 1 hour
 the woman's desire to shorten the third stage.
 Pulling the cord or palpating the uterus should only be carried after oxytocin.
 Don‟t use routinely umbilical oxytocin infusion nor prostaglandin.
Normal labour: care of the baby and woman immediately after birth
Initial assessment of the newborn baby and mother infant bonding
 The Apgar score at 1 and 5 minutes should be recorded routinely.
 If the baby is born in poor condition (the ABS at 1 minute ≤5):
 Record the time to the onset of regular respirations
 cord double-clamped to allow paired cord blood gases to be taken.
 continue to record ABS until the baby's condition is stable.
 encourage skin-to-skin contact as soon as possible after the birth.
 to keep the baby warm, should be dried and covered with a warm, dry
blanket.
 Avoid separation of a woman and her baby within the first hour of the birth for
routine postnatal procedures, for example weighing,.
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  Encourage breastfeeding as soon as possible, ideally within 1 hour.
 Record Head circumference, body temperature and birth weight soon after the
first hour.
 Initial examination should be undertaken to detect any major physical
abnormality.
 Any examination or treatment of the baby should be undertaken with the
consent and in the presence of the parents or with their knowledge.
Initial assessment of the woman following birth
 temperature, pulse, blood pressure, uterine contraction, lochia
 examination of placenta and membranes their condition, cord vessels and
completeness
 assessment of maternal emotional/psychological condition in response to
labour and birth
 successful voiding of the woman's bladder

Perineal care
 Systematic assessment of genital trauma should include:
1. explanation of what to do and why
2. The woman should usually be in lithotomy
3. confirm tested effective local or regional analgesia is in place
4. visual assessment of the extent of trauma to include the structures
involved, the apex of the injury and assessment of bleeding
5. a rectal examination to assess external or internal anal sphincter.
 The timing of this systematic assessment should not interfere with mother–
infant bonding unless the woman has bleeding.
 The systematic assessment and its results should be fully documented.
 Repair of the perineum should be undertaken as soon as possible.
 Perineal repair should only be undertaken with tested effective analgesia in
place using infiltration with up to 20 ml of 1% lidocaine or equivalent, or
topping up the epidural.
 Women should be advised :
 in first-degree trauma, the wound should be sutured to improve healing,
unless the skin edges are well opposed.
 in 2nd degree trauma, the muscle should be sutured to improve healing
and If the skin is opposed there is no need to suture it.
 skin should be sutured by continuous subcuticular technique.
 Use continuous non-locked suturing technique for the vaginal wall and muscle
layer.
 An absorbable synthetic suture material should be used.
 Rectal non-steroidal anti-inflammatory drugs should be offered routinely
following perineal repair of first- and second-degree trauma.
 Apply the following basic principles when performing perineal repairs:
1. aseptic techniques.
2. Check and count quipment and swabs and needles before and after the
procedure.
3. Good lighting.
4. Difficult trauma should be repaired by experienced practitioner in theatre.
5. An indwelling catheter should be inserted for 24 hours to prevent.
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 6. Good anatomical alignment of the wound should be achieved,
7. Rectal examination should be carried after completing the repair.
8. Following completion of the repair, should be documented.
9. Information should be given to the woman regarding the extent of the
trauma, pain relief, diet, hygiene and the importance of pelvic-floor
exercises.
Prelabour rupture of the membranes at term

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Meconium-stained liquor
Monitoring and treatment of women with meconium-stained liquor

384
 significant meconium stained liquor defined as either dark green or black
amniotic fluid that is thick or tenacious, or any meconium-stained amniotic
fluid containing lumps of meconium.
 Amnioinfusion should not be used for the treatment of women with
meconiumstained liquor.

385
ELECTRONIC FETAL MONITORING.
 Overall care

 Do not make any decision about a woman's care in labour on the basis of
cardiotocography (CTG) findings alone.

 Take into account any antenatal and intrapartum risk factors, the current wellbeing of
the woman and unborn baby, and the progress of labour when interpreting the CTG
trace.

 Remain with the woman at all times in order to continue providing one-to-one support.

 Ensure that the focus of care remains on the woman rather than the CTG trace.

 Make a documented systematic assessment of the condition of the woman and the
unborn baby (including CTG findings) hourly, or more frequently if there are concerns.

 Principles for intrapartum CTG trace interpretation.

 When reviewing the CTG trace, assess and document all 4 features (baseline fetal
heart rate, baseline variability, presence or absence of decelerations, presence of
accelerations).

 It is not possible to categorise or interpret every CTG trace. Senior obstetric input is

important in these cases.

 Accelerations

 The presence of fetal heart rate accelerations is generally a sign that the unborn baby
is Healthy.

 If a fetal blood sample is indicated and the sample cannot be obtained, but the
associated scalp stimulation results in fetal heart rate accelerations, decide whether to
continue the labour or expedite the birth in light of the clinical circumstances and in
discussion with the woman.

Description Baseline Variability Decelerations

Normal/Reassuring 100- 160bpm 5bpm or None or early
more
Non-reassuring 161-180bpm <5bpm for Variable decelerations dropping from baseline
30-90mins by 60 beats or less andtaking 60 secs or less
to recover, present >90mins, and occurring
>50% of contractions OR Variable
decelerations dropping from baseline by
>60bpm and/or taking >60 secs to recover –
present up to 30mins, occurring >50% of
contractions OR
Late decels present up to 30mins and
occurring >50% of contractions
Abnormal >180bpm or <5bpm for Non reassuring variable decelerations
<100bpm 90 mins observed >30mins after starting conservative
measures, occurring >50% of contractions
OR Late decelerations present over 30mins,

386
 do not improve with conservative measures,
and occurring >50% of contractions OR
Bradycardia/single prolonged deceleration
lasting 3mins or more

Management based on interpretation of cardiotocograph traces

Category Definition Interpretation Management

CTG is normal/ All 3 features are Normal CTG, no -Continue CTG and normal
reassuring normal/ non-reassuring or care.
reassuring abnormalfeatures -If CTG was start because
, of concerns arising from
healthy fetus intermittent auscultation,
remove CTG after 20 min
if there are no non
reassuring or abnormal
features and no ongoing
risk factors.

CTG is 1 non-reassuring Combination of Think about possible

non-reassuring feature features that may underlying causes.If the
and suggests AND 2 normal/ be associated baseline fetal heart rate is
need for reassuring with increased over 160 bpm check the
conservative features risk of fetal woman's temperature and
measures acidosis; if pulse. If either are raised,
accelerations are offer fluids and
present, acidosis paracetamol.
is unlikely =Start 1 or more
conservative measures:
-encourage the woman
to mobilise or adopt a
left-lateral position,and in
particular to avoid being
supine
-offer oral or
intravenous fluids
-reduce contraction
frequency by stopping
oxytocin if being used
and/or offering tocolysis.
=Inform coordinating
midwife and obstetrician.

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CTG is 1 abnormal Combination of -Think about possible
abnormal and feature features that is underlying causes.
indicates need OR morelikely to be -If the baseline fetal heart
for 2 non-reassuring associated with rate is over 180 bpm
conservative Features fetal acidosis check the woman's
measures AND temperature and pulse. If
further testing either are raised, offer
fluids and paracetamol.
-Start 1 or more
conservative measures
If non-reassuring
-Inform coordinating
midwife and obstetrician.
-Offer to take an FBS (for
lactate or pH) after
implementing conservative
measures, or expedite birth
if an FBS can`t be obtained
and no accelerations are
seen as a result of scalp
stimulation.
-Take action sooner than
30 minutes if late
decelerations are
accompanied by
tachycardia
and/or reduced baseline
variability.
-Inform the consultant
obstetrician if any FBS
result is abnormal.
-Discuss with theconsultant
obstetrician if an FBS
cannot. be obtained or a
third FBS is thought to be
needed.

CTG is Bradycardia or a An abnormal Start 1 or moreconservative

abnormal and single prolonged featurethat is very measures
indicates need deceleration with likely to be if non-reassuring.Inform
for urgent baseline below associated with coordinating
intervention 100bpm current fetal midwife.Urgently seek
persisting for 3 acidosis obstetric help.Make
minutes or more* or imminent rapid preparations for urgent
development of birth.Expedite birth if
fetal acidosis persists for9 minutes.
If heart rate recovers
before 9 minutes, reassess
388
 decision to expedite birth in
discussion with the
woman.
Abbreviations: CTG, cardiotocography; FBS, fetal blood sample.
* A stable baseline value of 90–99 beats/minute with normal baseline variability (having
confirmed that this is not the maternal heart rate) may be a normal variation; obtain a
senior obstetric opinion if uncertain

Record-keeping
 Check date/time clock on EFM machine.
 Label FHR traces with mother‟s name, date and hospital number.
 Sign trace and record date, time and mode of birth.
 Note events, e.g. vaginal exam, FBS, epidural siting on trace.
 Store traces securely.
 Contraindications to FBS include:
 maternal infection (HIV, hepatitis viruses and herpes simplex virus)
 fetal bleeding disorders (for example, haemophilia)
 prematurity < 34 weeks.

Lactate (mmol/l) pH Interpretation

≤ 4.1 ≥ 7.25 Normal

4.2–4.8 7.21–7.24 Borderline

≥ 4.9 ≤ 7.20 Abnormal

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Complicated labour: first stage
 Where delay in the first stage is suspected the following should be
considered:
 parity
 cervical dilatation and rate of change
 uterine contractions
 station and position of presenting part
 the woman's emotional state
 referral to the appropriate healthcare professional.
 Women should be offered support, hydration, and appropriate and
effective painrelief.
 If delay in the first stage of labour is suspected, consider amniotomy for all
women with intact membranes,

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  Advise vaginal examination 2 hours later, and if progress is less than 1 cm a
diagnosis of delay is made.
 When delay in the first stage of labour is confirmed in nulliparous, the use of
oxytocin should be considered.
 The woman should be informed that the use of oxytocin following
spontaneous or ARM will bring forward her time of birth but will not influence
the mode of birth or outcomes.
 Multiparous with confirmed delay in the first stage should be seen by
obstetrician before making a decision about the use of oxytocin.
 Women should be offered an epidural before oxytocin is started.
 Where oxytocin is used, the time between increments of the dose should be
no more frequent than every 30 minutes.
 advise vaginal examination 4 hours after commencing oxytocin. If there is less
than 2 cm progress after 4 hours of oxytocin, further obstetric review is
required to consider caesarean section.
 Amniotomy alone is not an indication to commence continuous EFM.
 Where a diagnosis of delay in the established first stage of labour is made,
continuous EFM should be offered.
Complicated labour: second stage
 support and sensitive encouragement and the woman's need for
analgesia/anaesthesia are particularly important
 Nuliparous;
 Suspect delay if progress (in terms of rotation and/or descent of the
presenting part) is inadequate after 1 hour of active second stage.
 Offer vaginal examination and then offer amniotomy if the membranes are
intact.
 Multiparous;
 suspect delay if progress (in terms of rotation and/or descent of the
presenting part) is inadequate after 30 minutes of active second stage.
 Offer vaginal examination and then offer amniotomy if the membranesare
intact.
 Women with confirmed delay in the second stage should be assessed by an
obstetrician but oxytocin should not be started.
 ongoing obstetric review should be maintained every 15–30 minutes.

Instrumental birth and delayed second stage

 Instrumental birth is an operative procedure that should be undertaken with
tested effective anaesthesia.

Complicated labour: third stage

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392
UMBILICAL CORD PROLAPSE
Background
 Cord prolapse has been defined as the descent of the umbilical cord through the
cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured
membranes.
 Cord presentation is the presence of the umbilical cord between the fetal presenting
part and the cervix, with or without membrane rupture.
 The incidence of cord prolapse 0.1%-0.6%. In breech presentation, the incidence is
slightly higher than 1%.
 It has been reported that male fetus appear to be predisposed to cord prolapse.
 The incidence is is higher where there is a large percentage of multiple gestations.
 perinatal mortality rate of 91/1000.
 Prematurity and congenital malformations account for the majority of adverse
outcomes associated with cord prolapse in hospital settings but birth asphyxia is also
associated with cord prolapse.
 Asphyxia may also result in hypoxic–ischaemic encephalopathy and cerebral palsy.

 these factors predispose to cord prolapse by preventing close application of the

presenting part to the lower part of the uterus and/or pelvic brim.
 cord abnormalities (such as true knots or low content of Wharton‟s jelly) and fetal
hypoxia–acidosis may alter the turgidity of the cord and predispose to prolapse.
 50% of cases is preceded by obstetric manipulation. IOL with prostaglandins is not
associated with prolapse.
Can cord presentation be detected antenatally?
 Routine ultrasound examination is not sufficiently sensitive or specific to identify cord
presentation antenatally and should not be performed
Can cord prolapse or its effects be avoided?

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 1) With transverse, oblique or unstable lie, elective admission to hospital after 37+6
weeks should be discussed and women advised to present if there are signs of labour
or suspicion of membrane rupture.
2) Women with noncephalic presentations and PPROM should be offered admission.
3) ARM should be avoided whenever possible if the presenting part is mobile.
4) If it becomes necessary for ARM, this should be performed with arrangements in
place for immediate CS.
5) Upward pressure on the presenting part should be kept to a minimum during PV and
obstetric intervention.
6) Avoide rupture of membranes if the cord is felt below the presenting part. When cord
presentation is diagnosed in established labour, caesarean section is usually
indicated.
When should cord prolapse be suspected?
 Cord presentation and prolapse may occur without signs and with a normal fetal heart
rate pattern.
 The cord should be examined for:
1. at every vaginal examination in labour
2. after SROM if risk factors are present
3. if cardiotocographic abnormalities commence soon after SROM .
 vaginal examination is not indicated if SROM occur in the presence of a normal fetal
heart rate patterns, absence of risk factors for cord prolapse and clear liquor.
 Perform speculum and/or digital examination at preterm gestations when cord prolapse
is suspected.
What is the optimal initial management of cord prolapse in hospital settings?
1) Call for assistance prepare for immediate delivery in theatre.
2) manual replacement of the prolapsed cord above the presenting part to allow
continuation of labour is not recommended, there is insufficient evidence.
3) Minimal handling of loops of cord lying outside the vagina to prevent vasospasm.
4) to prevent cord compression.
A. Cord compression can be reduced by:
B. Elevate presenting part either manually or by filling the urinary bladder
C. Adopting the knee–chest position or head-down tilt (preferably in left-lateral
position).
D. Tocolysis(terbutaline 0.25 mg S.C) while preparing for CS if there are persistent
fetal heart rate abnormalities after attempts to prevent compression mechanically
and when delivery is likely to delay.
5) the measures described above are useful during preparation for CS, but must not result
in unnecessary delay.
6) swabs soaked in warm saline are wrapped around the cord has unproven benefit.
 Manual elevation is by inserting a gloved hand or 2 fingers in the vagina and pushing
the presenting part upwards and remove the hand from the vagina once presenting part
is above pelvic brim and apply continuous suprapubic pressure upwards.Excessive
displacement may encourage more cord to prolapse.
 Bladder filling is achieved by inserting the end of a blood giving set into Foley‟s
catheter. catheter should be clamped once 500–750 ml has been instilled. It is
essential to empty the bladder before delivery.
What is the optimal mode of delivery with cord prolapse?
1) category 1 CS is the recommended mode of delivery when vaginal delivery is not
imminent if there is a suspicious or pathological fetal heart rate pattern but without
risking maternal safety.
2) Verbal consent is satisfactory.
3) Category 2 caesarean section is appropriate for women in whom the fetal heart rate
pattern is normal.
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 4) Regional anaesthesia may be considered in consultation with an experienced
anaesthetist.
 Use of measures above reduce cord compressionand making regional
anaesthesia technique of choice.
 Repeated attempts at regional anaesthesia should be avoided.
5) Vaginal birth in most cases operative can be attempted at full dilatation if quick and
safe delivery is anticipated.
6) Breech extraction can be performed under some circumstances; after internal podalic
version for 2nd twin.
7) Expert practitioner in the resuscitation of the newborn should attend all deliveries with
cord prolapse.
 Neonates born live after cord prolapse have high rate of low Apgar scores; 21% at
1 min and 7% at 5 min.
8) Take paired cord blood samples for the exclusion of intrapartum related hypoxic
ischemic encephalopathy.
What is the optimal management in community settings?
1) Women should be advised to assume the knee–chest face-down position while waiting
for hospital transfer.
2) During emergency ambulance transfer, the knee–chest is unsafe and the left-lateral
position should be used.
3) Women should be transferred to the nearest consultant-led unit, unless vaginal delivery
is imminent and preparations for transfer should still be made.
4) The presenting part should be elevated during transfer by either manual or bladder
filling methods.
5) To prevent vasospasm, there should be minimal handling of loops of cord lying outside
the vagina.
What is the optimal management of cord prolapse before viability?
1) Expectant management should be discussed for cord prolapse with gestational age at
the limits of viability.
2) Uterine cord replacement may be attempted.
3) Women should be counselled on both continuation and termination of pregnancy.
 Prolongation of pregnancy at such GA creates a chance of survival but morbidity
from prematurity remains a frequent serious problem.
 Delivery should be considered if there are signs of severe fetal compromise once
viability has been reached or a gestational age associated with a reasonable
neonatal outcome is achieved.
Clinical governance
Debriefing
 Postnatal debriefing should be offered by a professional competent in counselling to
woman with cord prolapse.
 After severe obstetric emergencies, women may have postnatal depression, post-
traumatic stress disorder or fear of further childbirth.
 Women who undergo urgent transfer to hospital might be vulnerable to emotional
problems.
Clinical incident reporting
 Clinical incident forms should be submitted for all cases of cord prolapse.

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OPERATIVE VAGINAL DELIVERY
Background
 Operative vaginal delivery rates have remained stable at between 10% and 13% in the
UK.
 With careful practice the overall rates of neonatal morbidity in relation to operative
vaginal delivery is low.
 CS in 2nd stage of labour is an alternative but carries significant morbidity and
implications for future births
Preparation for operative vaginal delivery
 Factors which can reduce the need for operative vaginal delivery:
 continuous support during labour
 Use of upright or lateral positions
 avoiding epidural analgesia.
 starting oxytocin in the second stage of labour in women with an epidural.
 Delayed pushing in primiparous with an epidural (for 1 to 2 hours or until a strong
urge to push).
 A standard classification of operative vaginal delivery should be used.

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 A vacuum extractor should not be used at gestations of less than 34 weeks +0 days
because of the susceptibility of the preterm infant to cephalohaematoma, intracranial
haemorrhage, subgaleal haemorrhage and neonatal jaundice.
 The safety of vacuum extraction at between 34 weeks +0 days and 36 weeks +0 days of
gestation is uncertain and should therefore be used with caution.
 Fetal bleeding disorders (alloimmune thrombocytopenia) or a predisposition to fracture
(osteogenesis imperfecta) are relative contraindications to operative vaginal delivery.
 Blood-borne viral infections of the mother are not a contraindication. However, it is
sensible to avoid difficult operative delivery and fetal scalp clips or blood sampling during
labour.
 Vacuum extractors are contraindicated with a face presentation.
 Forceps and vacuum extractor deliveries before full dilatation of the cervix are
contraindicated.
 at present there is insufficient evidence to recommend routine use of ultrasound to
determine fetal head position as part of assessment for operative vaginal delivery.

What type of consent is required?

 Women especially during their first pregnancy should be informed in the antenatal period
about operative vaginal delivery including:
 strategies effective in reducing the need for operative vaginal birth.
 preferences for or objections to a particular instrument.
 In delivery room, verbal consent should be obtained and discussion documented in the
notes
 Information should be given to women in labour between contractions.
 If circumstances allow, written consent may also be obtained.
 For trial of operative vaginal delivery in theatre written consent should be obtained.
Performing operative vaginal delivery
Who should perform operative vaginal delivery?
 Operative vaginal delivery should be performed by an operator who has the knowledge,
experience and skills necessary to assess and to use the instruments and manage
complications that may arise.
 Obstetricians should have experience in spontaneous vertex delivery before training in
operative delivery.
 Competency should be achieved before conducting unsupervised deliveries
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Where should operative vaginal delivery take place?
 Operative vaginal births that have a higher risk of failure should be considered a trial and
conducted in a place where immediate caesarean section can be undertaken.
 Higher rates of failure are associated with:
 maternal BMI over 30
 estimated fetal weight over 4000 g or clinically big baby
 occipito-posterior position
 mid-cavity delivery or when 1/5th of the head palpable per abdomen.
What instruments should be used for operative vaginal delivery?
 The operator should choose the instrument most appropriate to the clinical
circumstances and their skill.
 The options available for rotational delivery include:
 Kielland forceps,
 manual rotation followed by direct traction forceps
 rotational vacuum extraction.
 Soft vacuum cups compared with rigid cups were associated with a significant failure but
less trauma.
 Vacuum extraction compared with forceps is:
 more likely to fail delivery with the selected instrument.
 more likely to be associated with cephalhaematoma.
 more likely to be associated with retinal haemorrhage.
 more likely to be associated with maternal worries about baby.
 less likely to be associated with significant maternal perineal and vaginal trauma .
 no more likely to be associated with delivery by caesarean section .
 no more likely to be associated with low 5-minute Apgar scores .
 no more likely to be associated with the need for phototherapy.
 There is no evidence to favour either a rapid (over 2 minutes) or a stepwise pressure
vacuum extraction.
When should operative vaginal delivery be abandoned?
1. where there is no evidence of progressive descent with moderate traction during
each contraction
2. where delivery is not imminent following three contractions of a correctly applied
instrument.
 Paired cord blood samples should be processed and recorded following operative
vaginal delivery.
sequential use of instruments
 The use of sequential instruments is associated with an increased risk of trauma to the
infant.
 The operator must balance the risks of a CS following failed vacuum extraction with the
risks of forceps delivery following failed vacuum extraction.
 Second stage CS is associated with an increased risk of major obstetric
haemorrhage, prolonged hospital stay and admission of the baby to NICU
compared with completed instrumental delivery.
 sequential use of instruments compared with forceps alone was associated with an
increased risk of:
 need for mechanical ventilation.
 intracranial haemorrhage.
 retinal haemorrhage.
 feeding difficulty.
 The neonatologist should be informed to ensure appropriate management of the baby.
episiotomy for operative vaginal delivery

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 There is insufficient evidence to support routine use of episiotomy in operative vaginal
delivery.
Should prophylactic antibiotics be given?
 There are insufficient data to justify the use of prophylactic antibiotics in operative
vaginal delivery.
 Good standards of hygiene and aseptic techniques are recommended.
Aftercare following operative vaginal delivery
Thromboprophylaxis
 Women should be reassessed after an operative vaginal delivery for risk of
thromboembolism.
 risk factors for thromboembolism:
 Mid-cavity delivery.
 prolonged labour.
 immobility.
Analgesia after delivery
 Paracetamol and diclofenac should be offered after an operative vaginal delivery.
Care of the bladder after delivery
 The timing and volume of the first void urine should be monitored and documented.
 A post-void residual should be measured if retention is suspected.
 Women with Operative delivery, prolonged labour a spinal anaesthetic or an epidural are
at increased risk of retention and should have an indwelling catheter in place for at least
12 hours.
 Women should be offered physiotherapy to prevent urinary incontinence.
How can we reduce psychological morbidity for the mother?
 The woman should be reviewed prior to hospital discharge to discuss the indication for
operative delivery, management of any complications and the prognosis for future
deliveries.
 Best practice would be for woman to be reviewed by the obstetrician who conducted
delivery.
How should we advise women for future deliveries?
 Aim is spontaneous vaginal delivery in a subsequent pregnancy as there is a high
success 80%.
 Care should be individualised for women who have sustained a 3rd or 4th degree perineal
tear.

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 OPERATIVE VAGINAL DELIVERY RECORD Patient Details

Date..............................................................................
Operator Name ...................................................... Grade ................
Supervisor Name .................................................. Grade ................

Indication(s) for delivery: .......................................................................................................

Classification of OVD: outlet / low / midcavity Rotation > 45º: yes / no
Fetal wellbeing: CTG: normal / suspicious / pathological Liquor: clear / meconium

Prerequisites: Examination
Place of delivery: room / theatre 1/5th per abdomen: ...............
Analgesia: local / pudendal / regional Dilatation:…………………….
Consent: verbal / written Position: ...............................
Catheterised: yes / no Station: .................................
Moulding:……………………..
Caput:...................................

Procedure Multiple instrument use: yes / no

Instrument used: Examination before second
Vacuum extractor : silastic / Kiwi / metal anterior / metal instrument
1/5th per abdomen:............................
posterior
Position:
Forceps: rotational / non-rotational / outlet ..............................................
Number of pulls: ................................................ Station:
Traction: easy / moderate / strong ................................................
Moulding: ............................................
Maternal effort: minimal / moderate / good
Caput:..................................................
Placenta: CCT/ manual Reasons for second instrument:
Episiotomy: yes / no ............................................................
Perineal tear: 1st degree ............................................................
............................................................
2nd degree
3rd / 4th degree (complete pro forma)
Other (complete suturing pro forma if necessary)
EBL: ..........................................................................................................................................

Baby: M / F Birth weight: .......... (kg) Apgar: 1..... 5..... 10..... Cord pH: Arterial.......Venous…
Post-delivery care:
Level of care: routine / high dependency
Syntocinon infusion: yes / no
Catheter: yes / no Remove ............................
Vaginal pack: yes / no Remove ............................
Diclofenac 100 mg PR: yes / no Analgesia prescribed: yes / no
Thromboembolic risk: low / medium / high
Thromboprophylaxis prescribed: yes / no
Signature: .......................................................................... Date: ............................................

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OPERATIVE VAGINAL DELIVERY
1. Name of proposed procedure or course of treatment
 Operative vaginal delivery
2. The proposed procedure
 Describe the nature of vacuum assisted delivery/forceps delivery.
 woman should be aware that an episiotomy may be required, particularly with forceps
delivery.
Note: If it is a trial of operative delivery such that vaginal delivery is not certain, this must be
made clear to the woman and consent obtained for proceeding to caesarean section if
necessary.
3. Intended benefits
 The benefits may include any or all of the following:
 expedited delivery where fetal compromise is suspected
 relief where the second stage of labour is delayed owing to maternal exhaustion
or other reasons
 Safer delivery in cases where maternal pushing is not advisable.
4. Serious and frequently occurring risks
 Higher rates of failure and serious or frequent complications are associated with:
 higher maternal body mass index
 ultrasound-estimated fetal weight greater than 4000 g or clinically large baby
 occipitoposterior position
 mid-cavity delivery or when 1/5 fetal head palpable abdominally.
4.1 Serious risks include:
 Maternal:
 third- and fourth-degree perineal tear, 1–4 in 100 with vacuum-assisted delivery
(common) and 8–12 in 100 with forceps delivery (very common)
 extensive or significant vaginal/vulval tear, 1 in 10 with vacuum 1 and in 5 with
forceps.
 Fetal:
 subgaleal haematoma, 3–6 in 1000 (uncommon)
 intracranial haemorrhage, 5–15 in 10 000 (uncommon)
 facial nerve palsy (rare).
4.2 Frequent risks
 Maternal:
 postpartum haemorrhage, 1–4 in 10 (very common)
 vaginal tear/abrasion (very common)
 anal sphincter dysfunction/voiding dysfunction.
 Fetal:
 forceps marks on face (very common)
 chignon/cup marking on the scalp (practically all cases of vacuum-assisted
delivery) (very common)
 cephalhaematoma 1–12 in 100 (common)
 facial or scalp lacerations, 1 in 10 (common)
 neonatal jaundice /hyperbilirubinaemia, 5–15 in 100 (common)
 retinal haemorrhage 17–38 in 100 (very common).
5. Any extra procedures which may become necessary during the procedure
 Episiotomy (5–6 in 10 for vacuum assisted delivery, 9 in 10 for forceps)
 Manoeuvres for shoulder dystocia
 Caesarean section

411
  Blood transfusion
 Repair of perineal tear
 Manual rotation prior to forceps or vacuum-assisted delivery.
7. Statement of patient: procedures which should not be carried without further
discussion
 If the woman objects to the use of a particular instrument, this should be documented
here.
8. Preoperative Information
 A record should be made of any sources of information given to the woman prior to surgery.
9. Anaesthesia
 Where possible, the woman must be aware of the form of anaesthesia planned and be
given an opportunity to discuss this in detail with the anaesthetist before surgery.
 It should be noted that, with obesity, there are increased risks, both surgical and
anaesthetic.

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SHOULDER DYSTOCIA
Background
 Shoulder dystocia is defined as a delivery that requires additional manoeuvres to release
the shoulders after gentle downward traction has failed.
 incidence of shoulder dystocia in North America and the UK found is 0.6% incidence.
 It is associated with high perinatal mortality and morbidity even when it is managed
appropriately.
 Brachial plexus injuries are one of the most important complications:
 Complicating 4–16% of such deliveries and 1/2300 live births.
 Independent of operator experience.
 Most cases resolve without permanent disability, < 10% resulting in permanent
dysfunction.
 Neonatal brachial plexus injury is the most common cause for litigation related to
shoulder dystocia.
 Not all injuries are due to excess traction. There is now evidence that maternal
propulsive force may contribute to some of these injuries andminority of these
injuries are not associated with dystocia.
 It is important to determine whether the affected shoulder was anterior or posterior
at the time of delivery, because damage to the plexus of the posterior shoulder is
not due to action by the operator.
 In shoulder dystocia 47% of the babies died within 5 minutes of the head being
delivered .
 Maternal morbidity is also increased, particularly:
 PPH (11%).
 4th perineal tears (3.8%), and their incidence remains unchanged by the
manoeuvres applied.
Prediction
 Risk assessments for shoulder dystocia are insufficiently predictive and prevention.
 The majority of cases occur in the children of women with no risk factors.
 Fetal size is not a good predictor for shoulder dystocia:
 The majority of infants ≥4500 g do not develop shoulder dystocia
 48% of shoulder dystocia occur in infants with a birth weight < 4000 g.
 Clinical fetal weight estimation is unreliable and third-trimester scans have 10%
margin for error for actual birth weight and a sensitivity of 60% for macrosomia
(over 4.5 kg).
 Clinicians must always be alert to the possibility of shoulder dystocia with any delivery.

Prevention
1. There is no evidence to support IOL at term in women without diabetes and with
suspected fetal macrosomia.

413
 2. IOL in women with diabetes does not reduce the maternal or neonatal morbidity of
shoulder dystocia.
3. ECS is not recommended in women without diabetes and with suspected fetal
macrosomia.
 ACOG has recommended that an EFW > 5 kg should prompt consideration of
delivery by CS.
4. ECS recommended in women with diabetes and with suspected fetal macrosomia.
5. Either CS or vaginal delivery is appropriate after a previous shoulder dystocia.The
decision should be made by the woman and her carers. Decision should be
augmented by:
 Recurrence rate of shoulder dystocia 1% -16%.
 Severity of shoulder dystocia,
 Previous poor maternal or fetal outcome.
 EFW
 Maternal choice should all be considered.
Management
Intrapartum
 If shoulder dystocia is anticipated then some preparation may help.
 An experienced obstetrician should be available on the labour ward for the 2nd
stage of labour.
Delivery
 Routine traction in an axial direction may be employed to diagnose shoulder dystocia.
 Lateral and downward traction may cause nerve avulsion and should be avoided in the
management of dystocia.
 Shoulder dystocia can be recognized by:
 Difficulty with delivery of the face and chin
 The head tightly applied to the vulva or retracting
 Failure of restitution of the fetal head
 failure of the shoulders to descend.
How should shoulder dystocia be managed?
 Shoulder dystocia should be managed systematically.
 Immediately after recognition of shoulder dystocia
1. extra help should be called(midwifery assistance, obstetrician, paediatric
resuscitation team, anaesthetist).
2. Maternal pushing should be discouraged, as this may lead to further impaction of the
shoulders.
3. Woman should be manoeuvred to bring the buttocks to the edge of the bed.
4. No fundal pressure, It is associated with unacceptably neonatal complications and
uterine rupture
5. Episiotomy is not necessary for all cases.
 It doesn't decrease the risk of brachial plexus injury.
 Reserve episiotomy to facilitate manoeuvres such as delivery of the posterior arm
and internal rotation.
6. 1st line: McRoberts‟ manoeuvre is the single most effective intervention and should
be performed.
 is flexion and abduction of the maternal hips, positioning the maternal thighs on her
abdomen.
 It straightens the lumbo-sacral angle and increase in uterine pressure and
amplitude of contractions.
 Success rates is high as 90% with low rate of complication.
7. Suprapubic pressure is useful.
 Together with McRoberts‟ manoeuvre improve success rates.

414
  It reduces the bisacromial diameter and rotates the anterior shoulder into the
oblique pelvic diameter.
 It is applied in a downward and lateral direction to push the posterior aspect of the
anterior shoulder towards the fetal chest .
 It is applied for 30 seconds.
 No clear difference in efficacy between continuous pressure or „rocking‟ movement.
8. Fours-position is more appropriate for a slim mobile woman without epidural
anaesthesia and with a single midwifery attendant.
9. 2nd line: Internal manoeuvres are more appropriate for a less mobile woman with
epidural anaesthesia and a senior obstetrician in attendance,.
 There is no advantage between delivery of the posterior arm and internal rotation
manoeuvres and clinical judgement and experience can be used to decide their
order.
 Internal rotation may involve either rotation into an oblique diameter or by full 180-
degree rotation.
10. 3rd line: require careful consideration to avoid unnecessary maternal morbidity and
mortality.These include:
1) Cleidotomy (bending the clavicle with a finger or surgical division),
2) Symphysiotomy (dividing the symphyseal ligament)
3) Zavanelli manoeuvre, Cephalic replacement of the head and delivery by CS.
 After delivery, attendant Should be alert to the possibility of PH and 3rd - 4th perineal
tears.
 HELPERR mnemonic from American Life Support Organisation .

415
Documentation
 It is important to record:
 the time of delivery of the head
 the direction the head is facing after restitution
 the manoeuvres performed, their timing and sequence
 the time of delivery of the body
 the staff in attendance and the time they arrived
 the condition of the baby (Apgar score)
 umbilical cord blood acid-base measurements.

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3RD AND 4TH DEGREE PERINEAL TEARS
Definition of perineal trauma
 The perineum extends from the pubic arch to the coccyx and is divided into the anterior
urogenital and posterior anal triangle.
 Anterior perineal trauma is defined as injury to the labia, anterior vagina, urethra or
clitoris.
 Posterior perineal trauma: any injury to posterior vagina, perineal muscles, anal
sphincters and anal epithelium.
 Perineal trauma may occur spontaneously or by a surgical incision (episiotomy) during
vaginal birth.
 following classification, described by Sultan, and adopted by the RCOG:

Introduction and background

 The incidence of obstetric anal sphincter injury is 1% of all vaginal deliveries.
 Increase in detection of anal sphincter injury is due to
1. increased awareness and training.
2. Use of endoanal ultrasound
 Obstetric anal sphincter injury include both third- and fourth-degree perineal tears.
 Factors that contribute to the extent of trauma and perineal tear during childbirth are:
 Ethnicity
 Age
 Nutritional state in the prepregnancy years.
 birth weight over 4 kg (up to 2%)
 persistent occipitoposterior position (up to 3%)
 nulliparity (up to 4%)
 induction of labour (up to 2%)
 epidural analgesia (up to 2%)
 second stage longer than 1 hour (up to 4%)
 shoulder dystocia (up to 4%)
 midline episiotomy (up to 3%)
 forceps delivery (up to 7%).
 Direct occipitoposterior position
 Precipitate birth.
 The folowing may reduce the risk of perineal damage:

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  Antenatal perineal massage
 support during labour,
 position for delivery,
 epidural anaesthesia,
 type of pushing,
 mode of delivery
 mediolateral episiotomy
 The overall rates of episiotomy is: 8% in the Netherlands, 14% in England, 50% in the
USA and 99% in the Eastern European. This mean that episiotomy is not always
justified.
 If episiotomy indicated, the mediolateral technique is recommended with the angle cut
away from the midline.
 following childbirth approximately:
 Over 85% will have some degree of perineal trauma and of these 60–70% will
have suturing
 23–42% of will have short-term perineal pain for 10–12 days .
 8–10% of will have longterm pain for 3–18 months.
 23% of will have superficial dyspareunia for 3 months.
 3–10% will have faecal incontinence and 19% some degree of urinary
incontinence.
 The type of suturing material, the technique of repair and the skill of the operator are the
three main factors that influence the outcome of perineal repair.
Prediction and prevention of obstetric anal sphincter injury
 Clinicians need to recognise the risk factors for obstetric anal sphincter injury but
knowing these risk factors do not allow its prediction or prevention.
Classification and terminology
 The IAS plays a role in the maintenance of continence.
 In acute obstetric trauma, identification of the IAS may not be possible but identification
of the degree of EAS damage (more or less than 50%) should be possible in all cases.
 Buttonhole tear: tear involves only anal mucosa with intact anal sphincter complex.
Identification of obstetric anal sphincter injuries
 Women with evidence of post-delivery genital tract trauma should be examined by an
experienced practitioner systematically to assess the severity of damage before suturing.
Surgical techniques
 For external anal sphincter, either an overlapping or end-to-end method can be used,
with equivalent outcome.
 If the IAS can be identified, it should be repaired separately with interrupted sutures.
 Repair of 3rd and 4th degree tears should be operating theatre, under regional or
general anaesthesia.
 The following are associated with less short-term pain:
1. Continuous subcuticular sutures for perineal skin rather than interrupted sutures.
2. A loose, continuous non-locking technique to appose each layer (vaginal tissue,
perineal muscle and skin).
 The 2 layer procedure of perineal repair, where the skin is not sutured, is associated with
an increase in wound gaping up to 10 days but less dyspareunia at 3 months postpartum
than a 3layer technique with skin closure.
Choice of suture materials
 The absorbable synthetic material (PDS and polyglactin 910) compared with catgut for
repair of perineal trauma is associated with less perineal pain, analgesic, dehiscence
and resuturing, but increased suture removal.
 For EAS muscle, monofilament sutures PDS or braided sutures polyglactin (Vicryl) have
equivalent outcome.
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 For IAS muscle, fine size such as 3-0 PDS and 2-0 Vicryl may cause less irritation and
discomfort.
 During anal sphincter repairs, burying of surgical knots beneath the superficial perineal
muscles is recommended to prevent knot migration to the skin.
 There is possibility of knot migration, with long-acting and non-absorbable suture
materials.
 The more rapidly absorbed form of polyglactin 910 compared with standard one for
repair of perineal trauma is associated with a significant reduction in pain and a reduction
in suture removal.
 By evidence, rapid-absorption polyglactin 910 is the most appropriate suture material for
perineal repair.
Principles of repair
 The following basic principles should be observed when performing perineal repairs:
 Suture as soon as possible following delivery to reduce bleeding and infection.
 Check equipment and count swabs prior and after the procedure.
 Good lighting.
 Ask for more experienced assistance if in doubt regarding the extent of trauma.
 Difficult trauma should be repaired by an experienced operator in theatre under
regional or general anaesthesia – insert an indwelling catheter for 24 hours to
prevent urinary retention.
 Ensure good anatomical alignment of the wound and give consideration to
cosmetic results.
 Rectal examination after completing the repair will ensure that suture material has
not been accidentally inserted through the rectal mucosa.
 Following completion of the repair, inform the woman regarding the extent of trauma and
discuss pain relief, diet, hygiene and the importance of pelvic-floor exercises.
Postoperative management
 Postoperative antibiotics is recommended to reduce the incidence of infections and
wound dehiscence.
 metronidazole is advisable to cover the possible anaerobic contamination from
faecal matter.
 Postoperative laxatives for 10 days after the repair is recommended to reduce the risk of
wound dehiscence.
 Physiotherapy and pelvic-floor exercises for 6–12 weeks after obstetric anal sphincter
repair is recommended.
 Women with obstetric anal sphincter repair should be reviewed 6–12 weeks by a
consultant obs and gynae.
 Refer woman with incontinence or pain at follow-up to a specialist gynaecologist or
colorectal surgeon for endoanal ultrasound and anorectal manometry.
 A small number of women may require referral to a colorectal surgeon for secondary
sphincter repair.
Non-suturing
 leaving 1st and 2nd degree perineal tears unsutured is associated with poorer wound
healing and nonsignificant differences in short-term perineal pain.
Prognosis
 Prognosis following EAS repair is good, with 60–80% asymptomatic at 12 months.
 Most symptomatic women have incontinence of flatus 59% or faecal urgency 26%.
Future deliveries
 Women with previous obstetric anal sphincter injury should be:
1. counseled about the risk of developing anal incontinence or worsening symptoms
with subsequent VD.

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 2. advised that there is no evidence to support the role of prophylactic episiotomy in
subsequent deliveries.
 Women with previous obstetric anal sphincter injury and who are symptomatic or have
abnormal endoanal ultrasound and/or manometry should have the option of elective CS.
Risk management
 Audit of perineal repair practice ensures high standards of clinical care.
 Mismanagement of perineal trauma is a source of obstetric litigation.
 Accurate and comprehensive documentation is vital; records should be made in
black ink, including a diagram to illustrate the extent of the trauma, and the
operator should sign and print their name.
 Women who explicitly request not to have sutures inserted must be given the
opportunity to discuss their concerns with the person providing care.
 For those women who refuse to be examined it is essential to inform them of
potential risks which may occur if trauma to the sphincters remains undetected.
 Women should be given information regarding the extent of perineal trauma
sustained and how and when to seek advice if problems occur.

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SECONDARY SUTURING COMPARED TO NON-SUTURING FOR BROKEN
DOWN PERINEAL WOUNDS FOLLOWING CHILDBIRTH
Incidence of dehisced perineal wounds
 0.1% to 0.2%, dependent upon the degree of the initial trauma.
How the intervention might work
 The traditional approach towards the management of dehisced perineal
wounds(expectant management), often results in a protracted period of significant
morbidity for women including:
 Persistent pain and discomfort at the perineal wound site,
 Urinary retention,
 Defecation problems,
 Dyspareunia
 Psychological issues from embarrassment and altered body image
 Disturbance to relationship with her newborn baby, and to breastfeed due to the
distress
 Disturbance of relationship with her partner which may lead to relationship or
marriage breakdown.
 Costs to the women (hospital visits, transport costs and delay in returning to
employment)
 There are some reports suggest that early repair of perineal wound dehiscence is
safe, effective and avoids the prolonged period of disability and distress due to
healing by secondary intention
 Re-suturing within the first two weeks following child birth may result in :
 Reduction in the perineal pain
 Reduction in dyspareunia
 Continuation of exclusive breastfeeding up to six months
 Increased satisfaction with the aesthetic results of the perineal wound.

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CAESAREAN SECTION
Caesarean section
Carrying out the procedure
 The following interventions should be used to decrease morbidity from CS:
– regional anaesthesia
– antibiotic prophylaxis
– thromboprophylaxis
– antacids
– anti-emetics.
Offer planned CS to women with:
 A term singleton breech (if external cephalic version is contraindicated or has failed)
 A twin pregnancy with breech first twin
 HIV
 Both HIV and hepatitis C
 Primary genital herpes in the third trimester
 Grade 3 and 4 placenta praevia
Do not routinely offer planned CS to women with:
 Twin pregnancy (first twin is cephalic at term)
 Preterm birth(the effect of planned CS in improving neonatal morbidity and mortality
uncertain)
 A „small for gestational age‟ baby(the effect of planned CS in improving neonatal
morbidity and mortality remains uncertain)
 Hepatitis B virus (there is insufficient evidence that cs reduces mother-to-child
transmission, can be reduced by baby receives immunoglobulin and vaccination)
 Hepatitis C virus
 Recurrent genital herpes at term
Maternal request for CS
 Is not on its own an indication for CS
 Explore and discuss specific reasons
 Discuss benefits and risks of CS
 Offer counselling (such as cognitive behavioural therapy) to help her to address her
fears in a supportive manner.
 The clinician can decline a request for CS, but should refer for a second opinion
Factors affecting likelihood of CS during intrapartum care
Planning place of birth
 with anticipated uncomplicated pregnancies:
 Home birth reduces CS
 Birth in a „midwifery-led unit‟ does not affect CS
Reducing CS rates
 Offer external cephalic version if breech at 36 weeks
 Facilitate continuous support during labour
 Offer induction of labour beyond 41 weeks
 Use a partogram with a 4-hour action line in labour
 Involve consultant obstetricians in CS decision
 Do fetal blood sampling before CS for abnormal cardiotograph in labour
 Support women who choose VBAC
 Women should be informed that eating a low-residue diet during labour (toast, crackers,
low-fat cheese) results in larger gastric volumes, but the effect on the risk of aspiration if
anaesthesia is required is uncertain.
412
 Women should be informed that having isotonic drinks during labour prevents ketosis
without a concomitant increase in gastric volume.
No influence on likelihood of CS
 Walking in labour
 Non-supine position during the second stage of labour
 Immersion in water during labour
 Epidural analgesia during labour
 Active management of labour(early amniotomy to augment the progress of labour)
The effects of CS compared with vaginal birth for women and their babies
Increased with CS
 Short term
 Abdominal pain
 Bladder injury
 Ureteric injury
 Hysterectomy
 Need for further surgery
 Intensive therapy/high dependency unit admission
 Length of hospital stay
 Thromboembolic disease
 Readmission to hospital
 Neonatal respiratory morbidity
 Maternal death
 Long term
 stillbirth in future pregnancies
 Placenta praevia
 Uterine rupture
 Not having more children
No difference after CS
 maternal
 Haemorrhage
 Infection
 Genital tract injury
 Faecal incontinence
 Back pain
 Dyspareunia
 Postnatal depression
 fetal
 Neonatal mortality (except breech)
 Intracranial haemorrhage
 Brachial plexus injuries
 Cerebral palsy
Reduced with CS
 Perineal pain
 Urinary incontinence
 Uterovaginal prolapse
Making the decision for CS
 Pregnant women should be given evidence-based information on caesarean section
(CS) including indications, what the procedure involves, risks and benefits, and
implications for future pregnancies.
 Consent for CS should be requested after providing pregnant women with evidence-
based information

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  A competent pregnant woman can refuse the treatment such as CS, even it clearly
benefit her or her baby.
 A record should be made of all the factors that influence the decision
Timing of planned CS:
 CS should be carried out after 39 weeks‟ gestation to decrease the risk of respiratory
morbidity.
Document the urgency of CS
1. Immediate threat to the life of the woman or fetus
2. Maternal or fetal compromise which is not immediately lifethreatening
3. No maternal or fetal compromise but needs early delivery
4. Delivery timed to suit woman or staff
Surgical techniques
Do
 Wear double gloves for CS for women who are HIV-positive
 Use a transverse lower abdominal incision (Joel Cohen incision) less postoperative
pain and an improved cosmetic effect
 subsequent tissue layers are opened bluntly and if necessary extended with scissors
and not a knife because it is associated with shorter operating times and reduced
postoperative febrile morbidity.
 Use blunt extension of the uterine incision because it reduces blood loss, incidence
of postpartum haemorrhage and the need for transfusion at CS
 Give oxytocin (5 IU) by slow intravenous injection
 Use controlled cord traction for removal of the placenta
 Close the uterine incision with two suture layers
 In midline incision, mass closure with slowly absorbable continuous sutures are used
because this results in fewer incisional hernias and dehiscence.
 Check umbilical artery pH if CS performed for fetal compromise
 Consider women‟s preferences for birth (such as music playing in theatre)
 Facilitate early skin-to-skin contact for mother and baby
Don t
 Close subcutaneous space (unless > 2 cm fat) because it does not reduce the
incidence of wound infection.
 Use superficial wound drains
 Use separate surgical knives for skin and deeper tissues
 Use forceps routinely to deliver baby‟s head
 Suture either the visceral or the parietal peritoneum
 Exteriorize the uterus because it is associated with more pain and does not improve
operative outcomes such as haemorrhage and infection.
 Manually remove the placenta
 The effects of different suture materials or methods of skin closure are uncertain
 A practitioner skilled in the resuscitation of the newborn should be present at CS with a
general anaesthetic or with presumed fetal compromise
 the risk of fetal lacerations is about 2%
Postoperative monitoring
 Recovery area – one-to-one observations until the woman has airway control and
cardiorespiratory stability and can communicate
 In the ward – half-hourly observations for 2 hours, then hourly if stable
 Intrathecal opioids – hourly observation for 12 hours for diamorphine and 24 hours for
morphine
 For epidural opioids and patient-controlled analgesia with opioids – hourly monitoring
during the CS, plus 2 hours after discontinuation
Care of the woman and her baby after CS
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 Provide support to start breastfeeding as soon as possible
 Diamorphine 0.3–0.4 mg intrathecally or 2.5–5 mg epidurally to reduce need for further
analgesia
 non-steroidal anti-inflamatory analgesics to reduce the need for opioid analgesics
 offered thromboprophylaxis
 Women with no complications can eat or drink when they feel hungry or thirsty
 After regional anaesthesia remove catheter when woman is mobile (> 12 hours)
 Remove wound dressing after 24 hours; keep wound clean and dry
 Discuss the reasons for the CS and implications before discharge
 Offer earlier discharge (after 24 hours) to women with no complications
Recovery following CS
 Prescribe regular analgesia
 Monitor wound healing
 Inform women that they can resume activities (such as driving, exercise) when pain not
distracting
Consider CS complications:
 Endometritis if excessive vaginal bleeding
 Thromboembolism if cough or swollen calf
 Urinary tract infection if urinary symptoms
 Urinary tract trauma (fistula) if leaking urin
Common first CS:
 failure to progress (25%),
 fetal compromise (28%) and
 breech presentation (14%).
Common indications for repeat CS:
 previous CS (44%),
 maternal request (12%),
 failure to progress (10%),
 fetal compromise (9%)
 breech presentation (3%).
Procedural aspects of CS
Pre-operative testing before CS
 Hb assessment before CS.
 Pregnant women with uncomplicated pregnancies should not routinely be offered the
following tests before CS:
 grouping and saving of serum
 cross-matching of blood
 a clotting screen
 pre-operative ultrasound for localisation of the placenta(will not improve CS
morbidity:major blood loss, injury of the infant, and injury to the cord or adjacent
structures).
 Women having CS with regional anaesthesia require an indwelling urinary catheter to
prevent over-distension of the bladder,
Anaesthesia for CS
 women should be given information on different types of post-CS analgesia
 regional anaesthesia is safer and results in less maternal and neonatal morbidity than
general anaesthesia. This includes women who have a diagnosis of placenta praevia.
 Women with regional anaesthesia should be offered intravenous ephedrine or
phenylephrine, and pre-loading with iv fluids to reduce the risk of hypotension.
 Antacids before CS to reduce the risk of aspiration pneumonitis.
 antiemetics to reduce nausea and vomiting during CS.
415
 preoxygenation, cricoid pressure and rapid induction to reduce the risk of aspiration in
general anaesthesia for emergency CS.
 a lateral tilt of 15° of the operating table to reduces maternal hypotension.
 Offer a prophylactic antibiotics at induction of anaesthesia.

Care of the baby born by CS

 trained practitioner in the resuscitation of the newborn should be present at CS
performed under general anaesthesia or there is fetal compromise.
 Babies born by CS are more likely to have a lower temperature, and should have thermal
care.
 Early skin-to-skin contact improves maternal perceptions of the infant, mothering skills,
and breastfeeding outcomes, and reduces infant crying.
 Women who have had a CS need additional support to to start breastfeeding as soon as
possible after the birth of their baby.

Grade Criterion Decision to Examples of indications

delivery interval
1 Immediate thread to Aim to deliver FBSph<7.2 and CTG remain
life of mother or fetus within 30 min abnormal,severe fetal bradycardia of at
least 3min,cord prolapse with abnormal
CTG ,abruption,uterine rupture,actively
bleeding placenta previa.
2 Distress not Aim to deliver FBS ph 7.2-7.25,suspicion of fetal distress
immediately life- within 30-75min and FBS impossible or failed
threatening
tomother or fetus
3 Need early delivery Earliest Booked for EL CS but in labour or with
but no maternal or possible at a SROM ,FTP with no fetal distress
fetal distress time to suit the
maternity team
4 Elective cs At a time to suit Primi breech,twin with 1st non cephalic,PP
the women and major,HIV,primary genital herpes
maternity team

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CLAMPING OF UMBILICAL CORD
Background
 Active management of the third stage of labour is associated with a reduction in the risk
of PPH
 Prophylactic uterotonic drugs are a key component.
 The importance of the other two components:immediate cord clamping and controlled
cord traction, unclear.
Physiology of the placental transfusion
 Placental transfusion: additional blood volume(80–100 ml) transferred to the infant after
delivery.
 The additional plasma from the placental transfusion is lost to the circulation, leaving a
high red cell mass. This is quickly broken down and the iron stored.
 Immediate cord clamping deprives the infant of 20–30 mg/kg of iron
 Reduction in blood volume and red cell mass after immediate clamping greater in
preterm than term infants
Key determinants of placental transfusion seem to be:
 Magnitude of uterine contration after birth of the baby,
 The level of baby relative to the placenta during this time
 Timing of cord clamping.
 Neither intramuscular oxytocin(acts after 2.5 minutes) nor intramuscular
Syntometrine(acts after 7 minutes), given with delivery of the anterior shoulder, affect
the placental transfusion.
 Baby's level to the placenta affect venous flow to the baby, but not arterial flow
 lowering the baby below the level of the placenta speeds the flow but not affect the
volume of PT transfusion.
 Placing the baby on the mother‟s abdomen at birth may or may not impact on
placental transfusion.
 Placental transfusion at caesarean section appears to be less than for vaginal birth.
Timing of cord clamping for term birth
 Immediate or „early‟ clamping: within the first 15 seconds, or „immediately‟.
 Deferred or „delayed‟ clamping: 2 to 5 minutes, cessation of pulsation or presence of the
placenta in the vagina.
 There were no significant differences between immediate and deferred cord clamping
for: postpartum haemorrhage or manual removal of placenta.
 there is evidence that infants in the immediate cord clamping compared to deferred
clamping :
 had lower Hb
 lower serum ferritin at both 3 and 6 months
 had a lower risk of being given phototherapy for jaundice
 There are insufficient data for short-term outcomes, such as symptomatic
polycythaemia, respiratory problems, hypothermia, infection and need for admission to
special care.
Timing of cord clamping for preterm birth
 Babies with immediate clamping compared to deferred clamping:
 more likely to be transfused for anaemia
 higher risk of ultrasound diagnosis of intraventricular haemorrhage Possible
mechanisms are hypovolaemia or increased fluctuation in blood pressure during the
abrupt transition from fetal to neonatal circulation .
 no difference in temperature on admission to a neonatal unit.
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Discussion
 As draining the placenta may encourage placental separation, it is possible that
immediate clamping may prolong the third stage.
 Arterial and venous cord blood gases are influenced by timing of cord clamping, so
timing of clamping must be recorded
 If there is no need for resuscitation, simple measures such as drying can be applied before
clamping.
 It is possible that deferring cord clamping helps reduce the need for resuscitation at birth.
 while the cord is intact the baby should not be lifted more than 20 cm above the introitus
at a vaginal birth or more than 10 cm above the uterus at caesarean section.

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PERITONEAL CLOSURE
Introduction
 The reason for this is to establish normal anatomical relations, to prevent adhesion
formation between the intestines and fascia or between uterus and fascia, to reduce the
risk of infection and to reduce the risk of herniation or dehiscence.
 The advantages of this technique have not been proved by prospective randomised
trials.
 On the other hand peritonealisation tends to cause tissue ischaemia, necrosis,
inflammation, and foreign body reactions to suture material. These factors may slow
down the healing process and are considered important precursors for adhesion
formation.
 If the peritoneum is left open, experimental studies have shown that a spontaneous
reperitonealisation will appear within 48–72 hours after injuring the peritoneum with
complete healing after five to six days.
Peritoneal closure versus non-closure at caesarean section
 Non-closure of the parietal peritoneum is recommended during caesarean section
because:
 it is associated with lower Early postoperative complications include wound
haematoma, postoperative febrile morbidity, wound infection and postoperative pain
and analgesia.
 it is associated with significantly shorter operating time and postoperative hospital
stay.
 it leads to a quicker return of bowel activity.
 Peritoneal closure increases the incidence of bladder adhesions following caesarean
section.
 Closure of the peritoneum is not costeffective.
Peritoneal closure versus non-closure at hysterectomy
 Visceral and/or parietal peritoneal closure at abdominal hysterectomy is not
recommended because:
 it lengthens the surgical time and anaesthesia exposure without providing immediate
postoperative benefits.
 the number of patients requiring antibiotics for various complications was
 significantly higher in patients of the closed group .
 Peritoneal closure during vaginal hysterectomy is not recommended.
Peritoneal closure at radical abdominal surgery for gynaecological cancers
 Closure of the peritoneum at radical abdominal hysterectomy and node dissection is not
recommended.
 peritoneal non-closure during radical surgery for gynaecological cancers found
improved outcomes (reduced adhesions and reduced fever) where the visceral
peritoneum was left to heal on its own.
 Closure of the peritoneum after pelvic lymphadenectomy is not recommended, as it may
increase the incidence of lymphocysts.
 It is essential that operative details are clearly documented, including the time of onset of
the procedure, details of any adhesions or operative difficulties, operative technique and
suture materials used.

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PREVENTION AND MANAGEMENT OF PPH
Purpose and scope
 PPH is the most common form of major obstetric haemorrhage.
 The traditional definition of primary PPH is the loss of 500 ml or more of blood from the
genital tract within 24 hours of the birth of a baby.
 PPH can be minor (500–1000 ml) in the absence of clinical signs of shock or major
(more than 1000 ml) or has clinical signs of shock (tachycardia, hypotension,
tachypnoea, oliguria or delayed peripheral capillary filling) associated with a smaller
estimated loss.
 Major could be divided to
 moderate (1000–2000 ml).
 severe (more than 2000 ml).
 life-threatening haemorrhage (blood loss 2.5 litres or more or women who received
more than 5 units of blood transfusion or women who received treatment for
coagulopathy after an acute event.
 It is important to be aware that minor PPH can easily progress to major PPH.
 Secondary PPH is defined as abnormal or excessive bleeding from the birth canal
between 24 hours and 12 weeks postnatally.
 Approximate blood volume equals weight in kilograms divided by 12 expressed as litres
Introduction and background
 Obstetric haemorrhage remains one of the major causes of maternal death in developed
and developing countries.
 In the 2003–2005 report of the UK Confidential Enquiries into Maternal Deaths,
haemorrhage was the third highest direct cause of maternal death.
 Even in the UK, the majority of maternal deaths due to haemorrhage must be considered
preventable,with 58% cases in the 2003–2005 triennium judged to have received„major
substandard care‟.
Stratigies to management of postpartum haemorrhage
 minor PPH should prompt basic measures (close monitoring, intravenous access, full
blood count, group and screen) to facilitate resuscitation should it become necessary.
 majour PPH should prompt a full protocol of measures to achieve resuscitation and
haemostasis.
 There is some evidence that iron deficiency anaemia can contribute to atony because of
depleted uterine myoglobin levels necessary for muscle action.
 Allowing for the physiological increase in pregnancy,total blood volume at term is
approximately 100 ml/kg (an average 70 kg woman-total blood volume of 7000 ml)17 a
blood loss of more than 40% of total blood volume (approx 2800 ml) is generally
regarded as „life-threatening‟.
 As visual blood loss estimation often underestimates blood loss, more accurate methods
may be used, such as blood collection drapes for vaginal deliveries and weighing swabs.
Prediction and prevention of postpartum haemorrhage
What are the risks of PPH and how can they be minimised?
 Risk factors may present antenatally or intrapartum.
 Clinicians must be aware of risk factors for PPH and should take these into account
when counselling women about place of delivery essential for the wellbeing and safety of
both the mother and the baby.
 Most cases of PPH have no identifiable risk factors.
 Active management of 3rd stage of labour lowers maternal blood loss and reduces risk of
PPH.
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 Prophylactic oxytocics should be offered routinely in the management of the third stage
of labour in all women as they reduce the risk of PPH by about 60%.
 oxytocin (5 iu or 10 iu by intramuscular injection) is the agent of choice for prophylaxis in
the third stage of labour.For women delivering by caesarean section, oxytocin (5 iu by
slow intravenous injection) should be used to encourage contraction of the uterus and to
decrease blood loss.
 A bolus dose of oxytocin may possibly be inappropriate in some women, such as
those with major cardiovascular disorders, and a low-dose infusion might be a safer
alternative.
 Syntometrine (® Alliance) may be used in the absence of hypertension (for instance,
antenatal low haemoglobin) but increases vomiting.
 Misoprostol is not as effective as oxytocin but it may be used when the latter is not
available, such as the home-birth setting.
 All women who have had a previous caesarean section must have their placental site
determined by ultrasound. Where facilities exist, magnetic resonance imaging (MRI) may
be a useful tool and assist in determining whether the placenta is accreta or percreta.
 Women with placenta accreta/percreta are at very high risk ofmajor PPH (The
incidence appears to be increasing and has been linked to the increase in caesarean
section, particularly repeat caesarean section).
 If placenta accreta or percreta is diagnosed antenatally, there should be consultant-
led multidisciplinary planning for delivery.
 Consultant obstetric and anaesthetic staff should be present,
 prompt availability of blood, fresh frozen plasma and platelets be confirmed
 The timing and location for delivery chosen to facilitate consultant presence and
access to intensive care.
 Available evidence on prophylactic occlusion or embolisation of pelvic arteries in
the management of women with placenta accreta is equivocal. The outcomes of
prophylactic arterial occlusion require further evaluation.
 Leaving placenta in the uterus after delivery of the baby by fundal classical uterine
incision may allow a procedure with very little blood loss.The value of subsequent
treatment with methotrexate is debatable.
 A longer-acting oxytocin derivative, carbetocin, is licensed in the UK specifically for the
indication of prevention of PPH in the context of caesarean delivery.
 Randomised trials suggest that a single dose (100 micrograms) of carbetocin is at
least as effective as oxytocin by infusion.
 Carbetocin is not currently recommended for routine use because of its high price.

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How should PPH be managed?
 Once PPH has been identified,management involves four components, all of which must
be undertaken SIMULTANEOUSLY:
1) communication,
2) resuscitation,
3) monitoring and investigation,
4) arresting the bleeding.
1) Communication
Who should be informed when the woman presents with postpartum haemorrhage?
 Basic measures for MINOR PPH (blood loss 500–1000 ml, no clinical shock):
 Alert the midwife-in-charge.
 Alert first-line obstetric and anaesthetic staff trained in the management of PPH.
 Full protocol for MAJOR PPH (blood loss more than 1000 ml and continuing to bleed OR
clinical shock):
 Call experienced midwife (in addition to midwife in charge).
 Call obstetric middle grade and alert consultant.
 Call anaesthetic middle grade and alert consultant.
 Alert consultant clinical haematologist on call.
 Alert blood transfusion laboratory.
 Call porters for delivery of specimens/blood.
 Alert one member of the team to record events, fluids, drugs and vital signs.
 Clinicians and blood transfusion staff should liaise at a local level to agree:
 a standard form of words (such as „we need compatible blood now‟ or „group-
specific blood‟) to be used in cases of major obstetric haemorrhage
 a timescale in which to produce various products.

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  The use of the term„controlled major obstetric haemorrhage‟ or „ongoing major
obstetric haemorrhage‟may be used to define the urgency for the need of the team.
 It is vital that junior obstetricians and anaesthetists do not perceive the calling of senior
colleagues as involving „loss of face‟.
 Communication with the patient and her birthing partner is important and clear
information of what is happening should be given, as this is a very frightening event.
2) Resuscitation
 A primary survey „ABC‟,with resuscitation taking place as problems are identified; that is,
a process of simultaneous evaluation and resuscitation.
 Basic measures for MINOR PPH (blood loss 500–1000 ml, no clinical shock):
 Intravenous access (14-gauge cannula x 1).
 Commence crystalloid infusion.
 Full protocol for MAJOR PPH (blood loss > 1000 ml and continuing to bleed OR clinical
shock):
 Assess airway.
 Assess breathing.
Evaluate circulation
 Oxygen by mask at 10–15 litres/minute.
 Intravenous access (14-gauge cannula x 2, orange cannulae) 20 ml blood sample
should be taken and sent for diagnostic tests, including full blood count,
coagulation screen, urea and electrolytes and cross match (4 units).
 Position flat.
 Keep the woman warm using appropriate available measures.
 Transfuse blood as soon as possible.
 Until blood is available, infuse up to 3.5 litres of warmed crystalloid Hartmann‟s
solution (2 litres) and/or colloid (1–2 litres) as rapidly as required.
 The nature of fluid infused is of less importance than rapid administration and

warming of the infusion

 The best equipment available should be used to achieve RAPID WARMED
infusion of fluids.
 Special blood filters should NOT be used, as they slow infusions.
 Recombinant factor VIIa therapy should be based on the results of coagulation.
 In the face of life-threatening PPH, and in consultation with a haematologist,

rFVIIa may be used as an adjuvant to standard pharmacological and

surgical treatments.
 A suggested dose is 90 micrograms/kg,which may be repeated in the

absence of clinical response within 15–30 minutes.

 Although there is no clear evidence of thrombosis with the use of rFVIIa in

obstetric practice, there have been case reports of thrombosis with the use
in cardiac surgery.
 rFVIIa will not work if there is no fibrinogen and effectiveness may also be

suboptimal with severe thrombocytopenia (less than 20 x 109/l).Therefore,

fibrinogen should be above 1g/l and platelets greater than 20 x 109/l before
rFVIIa is given.
 If there is a suboptimal clinical response to rFVIIa, these should be checked

and acted on (with cryoprecipitate, fibrinogen concentrate or platelet

transfusion as appropriate) before a second dose is given.
 If crossmatched blood is still unavailable, give uncrossmatched group-specific
blood OR give „O RhD negative‟ blood
 Fresh frozen plasma 4 units for every 6 units of red cells or prothrombin
time/activated partial thromboplastin time > 1.5 x normal (12–15 ml/kg or total 1
litres)
 Platelets concentrates if PLT count < 50 x 109
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  Cryoprecipitate If fibrinogen < 1 g/l.
 coagulation studies and the advice of a haematologist should be used to guide
transfusion of coagulation factors, up to 1 litre of fresh frozen plasma (FFP) and 10
units of cryoprecipitate (two packs) may be given empirically in the face of
relentless bleeding,while awaiting the results of coagulation studies
 Apply clinical judgement on each situation.
 The cornerstones of resuscitation during PPH are restoration of both blood volume and
oxygen-carrying capacity.
 A 2006 guideline from the British Committee for Standards in Haematology summarises
the main therapeutic goals of management of massive blood loss is to maintain:
 haemoglobin > 8g/dl
 platelet count > 75 x 109/l
 prothrombin < 1.5 x mean control
 activated prothrombin times < 1.5 x mean control
 fibrinogen > 1.0 g/l.
 Intraoperative cell salvage is commonly being used in cardiac, orthopaedic and vascular
surgery with relative reduction of blood transfusion by 39%.
 Current evidence supports the use of cell salvage in obstetrics, For women who are
RhDnegative, to prevent sensitisation, the standard dose of anti-D should be given and a
Kleihauer test taken 1hour after cell salvage has finished, to determine whether further
anti-D is required.
 Although evidence is conflicting, there is a consensus view that fibrinolytic inhibitors
(such as tranexamic acid) seldom, if ever, have a place in the management of obstetric
haemorrhage
3) Monitoring and Investigation
What investigations should be performed and how should the woman be monitored?
 for MINOR PPH Consider:
 venepuncture (20 ml) for:
 group and screen

 full blood count

 coagulation screen including fibrinogen

 pulse and blood pressure recording every 15 minutes.

 for MAJOR PPH Consider:
 venepuncture (20 ml) for:
 crossmatch (4 units minimum)

 full blood count

 coagulation screen including fibrinogen

 renal and liver function for baseline.

 Monitor temperature every 15 minutes.

 Continuous pulse, blood pressure recording and respiratory rate (using oximeter,
electrocardiogram and automated blood pressure recording).
 Foley catheter to monitor urine output.
 Two peripheral cannulae, 14- or 16-gauge.
 central line not only to provides a means of accurate central venous pressure
(CVP) monitoring but also a route for rapid fluid replacement.
 Consider arterial line monitoring (once appropriately experienced staff available for
insertion).
 Consider transfer to intensive therapy unit once the bleeding is controlled or
monitoring at high dependency unit on delivery suite, if appropriate.
 Recording of parameters on a flow chart such as the modified obstetric early
warning system charts.
 Documentation of fluid balance, blood, blood products and procedures.

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  once the bleeding is arrested and any coagulopathy is corrected,
thromboprophylaxis is administered, as there is a high risk of
thrombosis.Alternatively, pneumatic compression devices can be used, if
thromboprophylaxis is contraindicated in cases of thrombocytopenia.
 The woman and the partner should be kept informed of the situation and possibly
reassured.
4) Anaesthetic management
 The anaesthetist needs to able to assess the woman quickly, to initiate or continue
resuscitation to restore intravascular volume and provide adequate anaesthesia.
 The presence of cardiovascular instability is a relative contraindication to regional
anaesthesia. Blockage of the sympathetic system can potentially lead to worsening
hypotension due to haemorrhage.
 If cardiovascular stability has been achieved and there is no evidence of coagulation
failure, regional anaesthesia can be used.
 Continuous epidural block is preferred over spinal, as it allows better blood pressure
control and for prolonged surgery.
 When there is continuing bleeding and the cardiovascular stability is compromised,
general anaesthesia is more appropriate.Rapid sequence induction is the gold standard
to reduce the risk of aspiration.Cardiostable induction agents with minimal peripheral
vasodilators should be considered and adrenaline and atropine being available during
induction.
 Ventilation with high oxygen concentrations may be needed until the bleeding is under
control.
5) Arresting the bleeding
 Causes for PPH may be considered to relate to one or more of „the four Ts‟:
 tone (abnormalities of uterine contraction)
 tissue (retained products of conception) (placenta, membranes, clots)
 trauma (of the genital tract):
 vaginal/cervical lacerations or haematoma

 ruptured uterus

 broad ligament haematoma

 extragenital bleeding (for example, subcapsular liver rupture)

 uterine inversion.

 thrombin (abnormalities of coagulation).

 The most common cause of primary PPH is uterine atony.
 When uterine atony is perceived to be a cause of the bleeding, the following
mechanicaland pharmacological measures should be instituted, in turn, until the bleeding
stops:
 Bimanual uterine compression (rubbing up the fundus) to stimulate contractions.
 Ensure bladder is empty (Foley catheter, leave in place).
 pharmacological measures
 Syntocinon 5 units by slow intravenous injection (may have repeat dose).
 Ergometrine 0.5 mg by slow intravenous or intramuscular injection (contraindicated
in women with hypertension).
 Syntocinon infusion (40 units in 500ml Hartmann‟s solution at 125ml/hour) unless
fluid restriction is necessary.
 Carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than
15 minutes to a maximum of 8 doses (contraindicated in women with asthma).
 Direct intramyometrial injection of carboprost 0.5 mg (contraindicated in women
with asthma), with responsibility of the administering clinician as it is not
recommended for intramyometrial use.
 If bleeding occurs at the time of caesarean section, intramyometrial injection

of carboprost should be used and, if laparotomy is undertaken following

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 failure of pharmacological management, intramyometrial carboprost
injection should be the first-line measure once the uterus is exposed. It is
also possible to inject intramyometrial carboprost through the abdominal
wall in the absence of laparotomy.
 Misoprostol 1000 micrograms rectally.
 Where parenteral prostaglandins are not available or where there are
contraindications (usually asthma) to prostaglandin F2_,misoprostol
(prostaglandin E1) may be an appropriate alternative.
 washout period of usually 24 hours should be considered.

 If pharmacological measures fail to control the haemorrhage, initiate surgical

haemostasis sooner rather than later:
 balloon tamponade is an appropriate firstling „surgical‟ intervention(Foley catheter,
Rusch balloon, Bakri balloon,Sengstaken–Blakemore oesophageal catheter and a
condom catheter.)
 success rate is (78%).

 In most cases, 4–6 hours of tamponade should be adequate to achieve

haemostasis and, ideally, it should be removed during daytime hours, in the

presence of appropriate senior staff, should further intervention be
necessary.82,83 Before its complete removal, the balloon could be deflated
but left in place to ensure that bleeding does not reoccur.
 Compression of the aorta may be a temporary but effective measure to allow time
for resuscitation to catch up with the volume replacement and the appropriate
surgical support arrives.
 haemostatic brace suturing (such as using procedures described by B-Lynch or
modified compression sutures).
 It is recommended that a laminated diagram of the brace technique be kept in

theatre.
 success rate is (81%).

 complications For example, a case of pyometria following a uterine brace

suture was reported in 200293 and of partial uterine necrosis in 2004.

 bilateral ligation of uterine arteries
 bilateral ligation of internal iliac (hypogastric) arteries.
 success rate is (61%).

 does not impair subsequent fertility and pregnancy outcomes.96

 selective arterial embolisation.

 Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of
placenta accreta or uterine rupture).
 A second consultant clinician should be involved in the decision for hysterectomy.
 Subtotal hysterectomy is the operation of choice in many instances of PPH
requiring hysterectomy, unless there is trauma to the cervix or lower segment; the
risk of neoplasia developing in the cervical stump several years later is not relevant
in the context of life-threatening haemorrhage.
How should secondary PPH be treated?
 Management include:
 Antibiotics.
 uterotonics.
 evacuation of retained products of conception
 In continuing haemorrhage, insertion of balloon catheter may be effective
 Secondary PPH is often associated with endometritis.
 When antibiotics are clinically indicated, a combination of ampicillin (clindamycin if
penicillin allergic) and metronidazole is appropriate. In cases of endomyometritis (tender
uterus) or overt sepsis, then the addition of gentamicin is recommended.

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 Surgical measures should be undertaken if there is excessive or continuing bleeding,
irrespective of ultrasound findings.
 A senior obstetrician should be involved in decisions and performance of any evacuation
of retained products of conception as these women are carrying a high risk for uterine
perforation.
 Investigations of secondary PPH should include :
 high and low vaginal swabs,
 blood cultures if pyrexial,
 full blood count,
 C-reactive protein.
 A pelvic ultrasound may help to exclude the presence of retained products of
conception, although the appearance of the immediate postpartum uterus may be
unreliable
Documentation
How can successful litigation be avoided when PPH occurs?
 Accurate documentation of a delivery with postpartum haemorrhage is essential.
 PPH should be notified through a clinical incident reporting or risk management
system in place.
 It is important to record:
 the staff in attendance and the time they arrived

 the sequence of events

 the time of administration of different pharmacological agents given, their

timing and sequence

 the time of surgical intervention,where relevant

 the condition of the mother throughout the different steps

 the timing of the fluid and blood products given.

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428
ELECTIVE INTERVENTIONAL RADIOLOGY IN PPH
Indications for using interventional radiology in PPH
1) Emergency intervention
 Interventional radiology should be considered in the management of postpartum
haemorrhage secondary to:
1. atonic uterus following normal or prolonged labour, with or without caesarean
section
2. surgical complications or uterine tears at the time of caesarean section
3. bleeding while on recovery unit or in the postnatal ward following a normal delivery
or a CS
4. bleeding following hysterectomy.
 In all these situations, access to the anterior division of the internal iliac arteries via a
femoral artery approach and subsequent embolisation with a suitable embolic material
(such as absorbable gelatine like Gelfoam) under image guidance should be
considered.
2) Elective and prophylactic intervention
 where there is a known or suspected case of placenta accrete.
 Balloons are placed in the internal iliac or uterine arteries before delivery.
 The balloons can be inflated to occlude the vessels in the event of PPH.
 Embolisation can be performed via the balloon catheters if bleeding continues despite
inflation.
 Even if hysterectomy is required, blood loss, transfusion and numbers of admissions to
ICU can be reduced.
 If this facility is not available locally, arrange transfer to a hospital where it is available
electively.

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MATERNAL COLLAPSE IN PREGNANCY AND THE PUERPERIUM
Background and introduction
 Maternal collapse is defined as an acute event involving the cardiorespiratory systems
and/or brain, resulting in a reduced or absent conscious, in pregnancy and up to 6
weeks after delivery.
 Maternal collapse is a rare 14 - 600/100 000 births in UK, but life-threatening event.
 The outcome for the mother and the fetus, depends on effective resuscitation.
 death and disability may result despite excellent care.
 vasovagal attacks and the postictal state are the most common causes of „maternal
collapse‟.
Clinical issues
Can women at risk of impending collapse be identified early?
 obstetric early warning score chart should be used routinely to allow early recognition of
the critically ill woman.
 In some cases maternal collapse occurs with no prior warning.
What are the causes of maternal collapse?
 these may be pregnancy-related or not related.
 The common reversible causes of collapse are the 4 T‟s and the 4 H‟s. In the pregnant
woman, eclampsia and intracranial haemorrhage, and other obstetric-specific causes
should be added to this list.

Haemorrhage
 Is the most common cause of collapse, and was responsible for 17 maternal deaths in
the last CEMACH.
 incidence of major obstetric haemorrhage is 3.7/1000 maternities.
 Causes of major obstetric haemorrhage include:
 Postpartum haemorrhage,
 Major antepartum haemorrhage: placenta praevia/accreta, abruption, uterine rupture
and ectopic pregnancy.
 Concealed haemorrhage should not be forgotten, including :
 Caesarean section
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  Ruptured ectopic pregnancy.
 Splenic artery rupture.
 Hepatic rupture.
Thromboembolism
 Was responsible for 41 maternal deaths in the last CEMACH, 33 pulmonary embolism.
8 cerebral vein thrombosis.
Amniotic fluid embolism
 The incidence is 2/100 000 maternities.
 Survival rates improved significantly from 14% in 1979 to 30% in 2005 and 80% in
2010.
 Neurological morbidity in survivors is well recognised.
 The perinatal mortality rate is 135/1000 total births.
 Presents as collapse during labour or within 30 minutes of delivery.
 There are different phases to disease progression:
1) pulmonary HTN secondary to vascular occlusion by debris or vasoconstriction, result
in:
 acute hypotension,
 respiratory distress and acute hypoxia
 Seizures
 cardiac arrest may occur.
This often resolves .
2) left ventricular dysfunction or failure.
3) Coagulopathy often develops if mother survives long enough, often giving rise to
massive PPH
 If AFE occurs prior to delivery, profound fetal distress develops acutely.
 Diagnosis of AFE is clinical, as there is no accurate diagnostic test.
Cardiac disease
 Was responsible for 48 maternal deaths in the last CEMACH.
 The majority of deaths secondary to cardiac causes occur in women with no previous
history.
 The main cardiac causes of death are:
 MI
 Aortic dissection, symptoms such as central chest or inter scapular pain, a wide
pulse pressure, systolic hypertension and a new cardiac murmur must prompt
referral to a cardiologist.
 Cardiomyopathy.
 The incidence of primary cardiac arrest in pregnancy is much rarer .
 The incidence of congenital and rheumatic heart disease in pregnancy is increasing
owing to improved management of congenital heart disease and increased
immigration.
 Infective endocarditis
 Pulmonary oedema.
Sepsis
 Substandard care continues to feature in the cases that result in death.
 Bacteraemia, which can be present in the absence of pyrexia or a raised white cell
count, can progress rapidly to severe sepsis and septic shock leading to collapse.
 the most common organisms are the streptococcal groups A, B and D, pneumococcus
and Escherichia coli.
Drug toxicity/overdose
 The common sources in obstetric practice are :
 magnesium sulphate in the presence of renal impairment.
 local anaesthetic agents injected intravenously by accident.
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Eclampsia
 Often the diagnosis of pre-eclampsia has already been made and the seizure
witnessed.
 Epilepsy should always be considered in cases of maternal collapse associated with
seizure.
Intracranial haemorrhage
 As a complication of uncontrolled hypertension, or ruptured aneurysms and A-V
malformations.
 often severe headache precedes the maternal collapse.
Anaphylaxis
 Anaphylaxis is a severe, generalized or systemic hypersensitivity reaction resulting in :
 Circulatory volume redistribution, which can lead to decreased cardiac output.
 Acute ventricular failure
 myocardial ischaemia.
 Upper airway occlusion secondary to angioedema and bronchospasm
 GIT disturbance
 collapse.
 The incidence is 3 - 10/1000, with a mortality rate of around 1%.
 Anaphylaxis is likely when all of the following three criteria are met:
 Sudden onset and rapid progression
 Life-threatening airway, breathing, circulation problems
 Skin and/or mucosal changes (flushing, urticaria, angioedema).
 Exposure to a known allergen for the woman supports the diagnosis.
 Mast cell tryptase levels can be useful.
Other causes
 Hypoglycaemia
 Metabolic/electrolyte disturbances,
 Aspiration/foreign body,
The physiological and anatomical changes in pregnancy that affect resuscitation
 It is essential that anyone involved in the resuscitation of pregnant women is aware of
the physiological differences. This includes paramedics and emergency room staff.
 The physiological changes in pregnancy:
1) Accelerate the development of hypoxia and acidosis
2) Make ventilation more difficult.
3) Increase rapid blood loss and reduced oxygen-carrying capacity.

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 Aortocaval compression significantly reduces:
4) cardiac output by 30–40% from 20 weeks.
5) the efficacy of chest compressions during resuscitation.
 In nonpregnant women, chest compressions achieve 30% of the normal cardiac
output.
 Aortocaval compression further reduces cardiac output to 10% that achieved in
nonpregnant women.
 Difficult intubation is more likely in pregnancy due to:
 Weight gain in pregnancy,
 large breasts inhibiting the working space
 laryngeal oedema .
 Pregnant women are at an increased risk of aspiration(Mendelson syndrome)
secondary to:
 progesterone relaxing the lower oesophageal sphincter and delayed gastric
emptying.
 the raised intra-abdominal pressure secondary to the gravid uterus.
 Mendelson syndrome, can be severe, because the gastric pH is lower than in the
nonpregnant population.

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  Intubation with effective cricoid pressure and the use of H2 antagonists and antacids
are recommended.
 Blood loss is less tolerated if there is a pre-existing maternal anaemia and clotting is
less efficient if there is a significant anaemia.
The optimal initial management of maternal collapse
1) A, B, C approach.
 Left lateral tilt of 15 on a firm surface with using a Cardiff wedge relieve aortocaval
compression.
 The airway should be protected as soon as possible by intubation with ETT.
 It is not acceptable to use a supraglottic device such as the laryngeal mask airway as
an alternative to ETT.
 Capnography is recurrent in the intubated patient.
 High-flow 100% oxygen should be administered as soon as possible whatever method
of ventilation.
 chest compressions should be started In the absence of breathing despite a clear
airway.
 Compressions should be performed at a ratio of 30:2 ventilations unless the woman
is intubated, in which compressions performed at a rate of 100/minute and
ventilations at a rate of 10/minute.
 There should be early recourse to delivery of the fetus and placenta if CPR is not
effective.
 Two wide-bore cannulae should be inserted as soon as possible.
 There should be an aggressive approach to volume except in case of severe pre-
eclampsia and eclampsia,
 Abdominal ultrasound by a skilled operator can assist in the diagnosis of concealed
haemorrhage.
 However, this should not interfere with the resuscitation and should not delay
laparatomy.
 The same defibrillation energy levels should be used as in the nonpregnant patient.
 Uterine monitors should be removed before shock delivery.
 There should normally be no alteration in algorithm drugs or doses.
2) Perimortem caesarean section
 If there is no response to CPR within 4 minutes of maternal collapse or if resuscitation
is continued beyond this in women beyond 20 weeks of gestation, delivery should be
undertaken to assist maternal resuscitation.
 This should be achieved within 5 minutes of the collapse.
 Perimortem CS should be considered in the interests of maternal, not fetal, survival.
 Perimortem caesarean section should be performed where resuscitation is taking
place.
 with a scalpel being the only essential equipment required.
 With no circulation, blood loss is minimal and no anaesthetic is required.
 If resuscitation is successful, transfer to an appropriate environment , anaesthesia,
sedation, and complete the operation.
 this procedure being carried out without consent.
 The operator should use the incision that will facilitate the most rapid access.
 A perimortem caesarean section tray should be available on the resuscitation trolley.
3) The continuing management
 Senior staff with appropriate experience should be involved at an early stage.
 Transfer should be supervised by an adequately skilled team with appropriate
equipment.
Amniotic fluid embolism

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  The management of AFE is supportive rather than specific, as there is no proven
effective therapy.
 Multidisciplinary approach (obstetrician, anaesthetist, haematologist and intensivist).
 Coagulopathy needs early, aggressive treatment, including aggressive use of FFP.
 If undelivered, delivery of the fetus and placenta should be performed as soon as
possible.
 The incidence of uterine atony and PPH are increased
Cardiac disease
 cardiac cases should be managed by an expert cardiology team.
 Thrombolysis is associated with significant bleeding from the placental site, it should be
given to women with acute coronary insufficiency, although caution should be exercised
in the perioperative period.
 If available, percutaneous angioplasty allows accurate diagnosis and definitive therapy.
Sepsis
 Septic shock should be managed in accordance with the Surviving Sepsis Campaign
guidelines.
 A multidisciplinary team approach (obstetricians, anaesthetists, haematologists,
intensivists, microbiologists)
 Care bundle should be applied immediately or within 6 hours:
1. Measure serum lactate.
2. Blood cultures/culture swabs prior to antibiotic administration.
3. Broad-spectrum antibiotic within first hour of recognition of severe sepsis and
septic shock
4. In the event of hypotension and/or lactate >4 mmol/l:
a) Deliver 20 ml/kg of crystalloid/ colloid
b) Once adequate volume replacement has been achieved, a vasopressor
(norepinephrine) and/or an inotrope (dobutamine) used to maintain mean
arterial pressure > 65 mmHg.
5. In the event of hypotension despite fluid resuscitation (septic shock) and/or
lactate > 4 mmol/l:
a) Achieve a central venous pressure of at least 8 mmHg (or over 12 mmHg if
the woman is mechanically ventilated) with aggressive fluid replacement
b) Consider steroids.
6. Maintain oxygen saturation with facial oxygen. Consider transfusion if
haemoglobin is below 7g/dl.
 Continuing management involves:
1. continued supportive therapy.
2. removing the septic focus.
3. administration of blood products if required .
4. thromboprophylaxis.
Drug overdose/toxicity
Magnesium sulphate
 The antidote to magnesium toxicity is 10 ml 10% calcium gluconate given by slow IV
injection.
Local anaesthetic agents
 If local anaesthetic toxicity is suspected:
 stop injecting immediately.
 Lipid rescue should be used.
 Intralipid 20% should be available in all maternity units.
 Intralipid 20% 1.5 ml/kg over 1 min followed by an IV infusion at 0.25 ml/kg/min.
 The bolus injection can be repeated twice at 5-minute intervals if adequate
circulation not restored .
435
  CPR should be continued throughout this process and this may take over an hour.
 Manage arrhythmias as usual, recognising that they may be very refractory to
treatment.
Intracranial haemorrhage
 Management is the same as in the nonpregnant state.
Anaphylaxis
 Causative agents should be removed, and the A, B, C, D, E approach followed.
 The definitive treatment for anaphylaxis is 500 micrograms (0.5 ml) of 1:1000
adrenaline intramuscularly.
 Adrenaline treatment can be repeated after 5 minutes if there is no effect.
 Adjuvant therapy consists of chlopheniramine 10 mg and hydrocortisone 200 mg.
Documentation
 Accurate documentation in all cases of collapse, whether or not resuscitation is
successful, is essential.

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CRITICAL AND MATERNITY CARE
Introduction
 Defining the level of critical care depends on the number of organs requiring support and
the type of support required as determined by the Intensive Care Society‟s „Level of
Care‟ document.

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 Maternal critical care is distinguished from „high risk‟ obstetrics because;
1. Fetal issues are excluded
2. Obstetric complications that require closer observations or intervention, but, not
support of an organ system, are also excluded.
Transfer
1) Transfer to ward from critical care area
 Transfer should be as early as possible during the day.
 Both critical care and maternity ward teams should share care of the patient being
transferred.
 They should jointly ensure that:
1. There is a formal structured handover from critical care to ward staff supported by a
written plan:
o summary of critical care stay, including diagnosis treatment and investigations
o monitoring plan detailing the frequency of observations
o plan for ongoing treatment including drugs, nutrition, infection status .
o physical and rehabilitation needs
o psychological and emotional needs
o specific communication or language needs.
2. The receiving ward, with support from critical care if required, can deliver the agreed
plan
2) Transfer to critical care area from a maternity unit
 Women transfed to a higher level care need to be accompanied by additional maternal,
fetal and postnatal plan and whether pre-delivery shared care between Obstetrics and
Critical Care is essential.
 Maternity units must have facilities and staff to resuscitate, stabilise and transfer critical
care patients:
 non-invasive and invasive cardiovascular monitoring (invasive arterial and venous
pressures)
 ECG
 Oximetry
 Capnography (for ventilated patients)
 Monitor
 Ventilator
 Portable suction
 Syringe drivers
 Transport ventilator.
 Transfer equipment should be dedicated only for transfer.
 The transfer should take place with an appropriately trained practitioner(anaesthetist,
intensivist).
3) The acutely ill parturient in a general critical care area
 Any specific obstetric conditions should be discussed between maternity team and
critical care team

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1) Additional care points for antenatal care
 Maternal position: A left lateral tilt of 15o on a firm surface.
 Thrombophylaxis: pregnant women hospitalised for any length of time need
prophylactic LMWH
 Increased risk of UTI: regular MSU should be taken for C/S.
 Use of drugs: be aware of haemodilution.
 Fluid balance: in cases of severe pre-eclampsia and eclampsia, fluid overload is a
disaster.
 Access to a delivery set/vaginal delivery/caesarean section in case of urgent delivery.
 Listed emergency drugs: hydralazine, MgSo4, oxytocin, , labetolol, eclampsia pack,
PPH pack.
 Antenatal steroids.
 Dietetic input.
 Named obstetrician/midwife: should have daily communication and combined ward
rounds.
 Fetal monitoring plan.
 Regular fetal growth ultrasound.

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  Daily fetal heart rate monitoring if no maternal perception of fetal movements after 28
weeks.
2) Postpartum care
 Breastfeeding
 No TILT required
 A diuresis is normal
 Thromboprophylaxis
 Debriefing and follow up during ICU admission
 OT/PT consults following ICU and midwife to take care of perineum, breastfeeding,
bonding
 Anti-D
 Clinical pharmacists: drug safety, pregnancy and breastfeeding
3) The maternity and general critical care area interface
 The pregnant woman in a general critical care area requires daily review by a
multidisciplinary team including a named obstetric consultant and named senior
midwife.
 Contact numbers for midwifery, obstetric and neonatal staff should appear on the
patient chart.
 management plan should include care during the antepartum, intrapartum and
postpartum periods.
 A neonatologist may be required to advise on management if a pre-term delivery is
possible.
 As these women are critically ill there should be regular communication between
midwives, obstetricians and neonatologists as more complex aspects of obstetric
care are considered.
 The family should know how to contact, there should be named midwife or member
of the unit.
 Awareness of mental health needs monitoring, is required from the midwife with
education of the family members for their role later in the recovery period.

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ANTENATAL AND POSTNATAL MENTAL HEALTH
Prediction and detection
 In both antenatal and postnatal periods, healthcare professionals should ask questions
about:
1. Past or present severe mental illness (schizophrenia, bipolar disorder, psychosis,
severe depression) in the postnatal period
2. Previous treatment by a specialist mental health team including inpatient care
3. Family history of perinatal mental illness.
 Other predictors, such as poor relationships with her partner, should not be used.
 At booking visit and postnatally (4 to 6 weeks and 3 to 4 months), healthcare
professionals should ask two questions to identify possible depression:
1. During the past month, have you often been bothered by feeling down, depressed?
2. During the past month, have you often been bothered by having little interest or in
doing things?
 A third question should be considered if the answers „yes‟ to either of the initial
questions.
3. Is this something you feel you need help with?
Psychological treatments
 Women requiring psychological treatment should be seen within 1 month after initial
assessment, and no longer than 3 months afterwards.
Explaining risks
 Before treatment, discuss with woman the risks with treating and not treating the mental
disorder during pregnancy and the postnatal period. This include:
 the uncertainty surrounding the risks
 the risk of fetal malformations for pregnant women without a mental disorder
 describe risks using natural frequencies rather than percentages and common
denominators (for example,1in100 and 25 in 100, rather than 1 in 100 and 1 in 4)
 use decision aids in a variety of verbal and visual formats
 provide written material to explain the risks.
Management of depression
 while choosing an antidepressant for pregnant or breastfeeding women, take into
account that:
 the safety of these drugs is not well understood
 tricyclic antidepressants(as amitriptyline, imipramine)have lower risks than others
 most tricyclic antidepressants have a higher fatal toxicity index than SSRIs
 fluoxetine is the SSRI with the lowest known risk during pregnancy
 imipramine, nortriptyline and sertraline are present in breast milk at low levels
 citalopram and fluoxetine are present in breast milk at high levels
 SSRIs after 20 weeks‟ is associated with risk of pulmonary HTN in the neonate
 paroxetine taken in the first trimester may be associated with fetal heart defects
 all antidepressants carry the risk of withdrawal or toxicity in neonates.
 For a woman who develops mild or moderate depression during pregnancy or the
postnatal period, the following should be considered:
1. self-help strategies (guided self-help, computerized cognitive behavioural
therapy)
2. non-directive counselling delivered at home
3. brief cognitive behavioural therapy or interpersonal psychotherapy.
Organisation of care
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 Clinical networks should be established for perinatal mental health services.These
networks should provide:
1. multidisciplinary perinatal service in each locality,
2. specialist expert advice on the risks and benefits of psychotropic medication
during pregnancy and breastfeeding
3. clear referral and management protocols for services across all levels of care, to
ensure effective transfer of information and continuity of care
4. pathways of care for service users, with defined roles and competencies.

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OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN
Introduction and background
 Ovarian cysts are common in postmenopausal women than in premenopausal women.
 Ovarian cysts may be discovered by screening, investigations for a suspected pelvic
mass or incidentally.
Diagnosis and assessment of ovarian cysts
 The ovarian cyst in a postmenopausal woman raises two questions:
 What is the most appropriate management
 Where should this management take place?
 women with a low risk of malignancy managed by general gynaecologist, intermediate
risk managed in a cancer unit and high risk in a cancer centre.
 Ovarian cysts in postmenopausal women should be assessed by CA125 and
transvaginal grey scale scan.
 CA125 is raised in over 80% of ovarian cancer and with cut-off of 30 u/ml sensitivity
is 81% and specificity is 75%.
 CA125 is raised in only 50% of stage I ovarian cancer.
 CA125can be raised in many other malignancies and in benign conditions(benign
cysts, fibroids, endometriosis, adenomyosis and pelvic infection).
 Scan is achieving sensitivity of 89% and specificity of 73% when using a morphology
index.
 There is no routine role yet for Doppler, MRI, CT or PET.
 RMI should be used to select those need primary surgery in a cancer centre by a
gynaecological oncologist.
 Using a cut off point of 250 for RMI, sensitivity is 70% and specificity is 90%.
 Those women who are at low risk of malignancy also need to be triaged into:
1. The risk of malignancy is sufficiently low to allow conservative management,
2. Those who still require intervention of some form.

Postmenopausal can be defined as women with no period for > 1 year or women > 50 years
who have had a hysterectomy.
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Management of ovarian cysts
1) LOW RISK: Less than 3% risk of cancer
 Management in a gynaecology unit,by general gynaecologist.
 Simple cysts, unilateral, unilocular , less than 5 cm in diameter with a serum CA125 level
of less than 30 may be managed conservatively.
 Conservative management include repeat scans and serum CA125 every 4months for
one year.
 If does not fit the above criteria or if woman requests surgery then laparoscopic
oophorectomy is acceptable.
2) MODERATE RISK: approximately 20% risk of cancer
 Management in a cancer unit.
 The main reason for Laparoscopy is to exclude an ovarian malignancy.
 Reserved for those are not eligible for conservative management but have a relatively
low risk of malignancy.
 Laparoscopic oophorectomy usually bilateral is recommended rather than cystectomy.
 If malignancy is discovered then a full staging procedure should be undertaken in cancer
centre
 Secondary surgery at a centre should be performed as quickly as feasible.
3) HIGH RISK: greater than 75% risk of cancer
 Management in a cancer centre.
 Full staging procedure including:
1. cytology: ascites or washings
2. laparotomy
3. biopsies from adhesions and suspicious areas
4. TAH, BSO and infra-colic omentectomy
5. May include bilateral selective pelvic and para-aortic lymphadenectomy.
 Some centres may proceed to surgery on the basis of frozen section, and others may
alter the timing of surgery in relation to chemotherapy in advanced cases.
4) Aspiration
 Is not recommended for the management of ovarian cysts in postmenopausal women.
 Sensitivity to distinguish between benign and malignant tumours 25%.
 cyst rupture during surgery has an unfavourable impact on disease free survival.

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SUSPECTED OVARIAN MASSES IN PREMENOPAUSAL WOMEN
Background and introduction
 10% of women will have some form of surgery during lifetime for an ovarian mass.
 In premenopausal women almost all ovarian masses and cysts are benign.
 The incidence of malignancy in symptomatic ovarian cyst in a premenopausal female
1:1000 increasing to 3:1000 at the age of 50.
 Preoperative differentiation between benign and malignant ovarian mass in the
premenopausal woman is problematic with no test of accuracy except for germ cell
tumours with elevations of AFP and hCG.
 10% of suspected ovarian masses are found to be non-ovarian in origin
 To minimise patient morbidity the following management are recommended:
1. Conservative management where possible
2. Laparoscopic techniques where appropriate, and avoiding laparotomy where
possible
3. Referral to a gynaecological oncologist where appropriate.
 Functional or simple ovarian cysts (thin-walled cysts without internal structures) which >
50 mm usually resolve over 2–3 menstrual cycles without intervention.
 laparoscopic approach is considered to be the gold standard for the management of
benign ovarian masses.
Preoperative assessment of women with ovarian masses
1) History and examination
 attention to risk factors or protective factors and a family history of ovarian or breast
cancer.
 Symptoms suggestive of endometriosis should be specifically considered
 Symptoms suggesting possible ovarian malignancy: persistent abdominal distension,
appetite change, pelvic or abdominal pain, increased urinary urgency and/or frequency.
 A careful physical examination of the woman is essential and should include abdominal
and vaginal examination and the presence or absence of local lymphadenopathy.
 In the acute presentation with pain the diagnosis of accident to the ovarian cyst should
be considered (torsion, rupture, haemorrhage).
Table 1. Types of adnexal masses

.
2) Blood tests
1) CA-125
 No need for CA-125 in all premenopausal women when ultrasound made a diagnosis
of a simple ovarian cyst.
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  CA-125 has a reduced sensitivity and specificity for malignant ovarian masses in
premenopausal women.
 CA-125 is raised in numerous conditions, so a raised CA-125 should be interpreted
cautiously
 CA-125 is only raised in 50% of early stage disease.
 serial monitoring of CA-125 is helpful as rapidly rising levels are more likely to be
associated with malignancy than high levels which remain static.
2) LDH, AFP and hCG should be measured in women under age 40 with a complex
ovarian mass because of the possibility of germ cell tumours.
3) Imaging
 Apelvic ultrasound is the single most effective test for evaluating an ovarian mass
 TVS is preferable due to its increased sensitivity over TAS.
 At present CT and MRI not improve the sensitivity or specificity obtained by TVS in
detection of malignancy.
the best way to estimate the risk of malignancy
1) RMI is the most widely used model
 RMI I described by Jacobs in 1990 is the most effective
2) The ultrasound „rules‟: IOTA (International Ovarian Tumor Analysis), have high
sensitivity and specificity and likelihood ratios without the use of CA-125.
Table 2. IOTA Group ultrasound rules to classify masses as benign (B-rules) or malignant (M-rules)

 Women with an ovarian mass with any of the M-rules ultrasound findings should be
referred to a gynaecological oncological service.
Management of ovarian masses presumed to be benign in non-emergency situations
6) Asymptomatic women with simple ovarian cysts
1) Simple ovarian cysts < 50 mm diameter generally do not require follow-up as they are
very likely to be physiological and almost always resolve within 3 menstrual cycles.
2) simple ovarian cysts 50–70 mm in diameter should have yearly ultrasound follow-up
3) simple ovarian cysts > 70 mm should be considered for either further imaging MRI or
surgical intervention.
7) persistent, asymptomatic ovarian cysts
 Ovarian cysts that persist or increase in size unlikely to be functional and may need
surgical management.
 Mature cystic teratomas (dermoid cysts) grow over time, increasing the risk of pain
and ovarian accidents.
 There is no evidence on the size above which surgical management should be
considered
 The use of the COC pill does not promote the resolution of functional ovarian cysts.
8) laparoscopic approach for the elective surgical management of ovarian masses
2) The laparoscopic approach for ovarian masses presumed to be benign is associated
with lower postoperative morbidity and shorter recovery time and cost-effective
because of earlier discharge and return to work.
3) In the presence of large masses with solid components (large dermoid cysts)
laparotomy may be appropriate.
 The appropriate route for the surgical management of ovarian masses depends on:
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 1. the woman (including suitability for laparoscopy and her wishes),
2. the mass (size, complexity, likely nature)
3. the setting (including surgeon‟s skills and equipment).
 Spillage of cyst contents should be avoided as preoperative and intraoperative
assessment cannot absolutely exclude malignancy.Consideration should be given to the
use of a tissue bag to avoid spillage.
 Removal of benign ovarian masses should be via the umbilical port. This results in less
postoperative pain and a quicker retrieval time than when using lateral ports of the same
size.
9) Aspiration
 Aspiration of ovarian cysts, vaginally or laparoscopically, is less effective and associated
with high recurrence.
When should an oophorectomy be performed?
 The pros and cons of electively removing an ovary should be discussed, taking into
consideration the woman‟s wish and the specific clinical circumstances.

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TARGETED THERAPIES FOR MANAGEMENT OF OVARIAN CANCER
Introduction
 Many women present with advanced disease with little prospect of cure.
 The 5- year survival rate for advanced ovarian cancer is approximately 20–40%.
 The current standard of care consists of the combination of radical surgery and
platinum-based chemotherapy but these approaches have led to small improvements
in outcome. There remains a significant risk of recurrence and resistance to therapy
 Novel biologically targeted agents have proven successful in a variety of
malignancies such as leukaemia, breast, colon and renal cancers. These agents
target tumour cells by exploiting specific molecular abnormalities in the tumour with
lower toxicity than traditional modalities such as chemotherapy.
Angiogenesis inhibitors
 Targeting Angiogenesis process is a promising strategy in the treatment of ovarian
cancers.
 Bevacizumab, a monoclonal antibody against vascular endothelial growth factor A
(VEGF-A).
 A phase II trial recently demonstrated a 21%response rate and 40% 6-month
progression-free survival rate in platinum-sensitive recurrent ovarian cancer.
 Adverse effects include:1\ hypertension (22%),2\ proteinuria (32%)3\ gastrointestinal
perforation (5.4%).
 Anti-angiogenic agents enhance the efficacy of chemotherapy when given as
combination.
 Other angiogenesis inhibitors are under evaluation and include AZD2171 (ICON 6).
 The maximum benefit from this approach may be best achieved when the tumour is
small
Poly(ADP-ribose)polymerase inhibitors
 Carriers of BRCA gene mutations harbour DNA repair defects
 Poly(ADP-ribose)polymerase (PARP) inhibitors work by generating specific DNA
lesions in tumor cells that require functional BRCA1 and BRCA2 to repair.
 Observations from women with BRCA mutations and ovarian cancer in a phase I trial
of PARP inhibition are encouraging and indicate low toxicities and promising
radiological and serological clinical responses.
Epidermal growth factor receptor and human epidermal growth factor 2 inhibitors
 Results from phase II trials of EGFR inhibitors and HER2 inhibitor have all been
relatively disappointing.
 EGFR and/or HER2 inhibitors combined with chemotherapy may further improve the
efficiency of chemotherapy.
Other signalling molecules
 Examples of critical signalling molecules: phosphoinositide 3- kinase/protein kinase B
(PI3K/AKT), protein kinase C (PKC), mitogen-activated protein kinase (MAPK) and
platelet-derived growth factor receptor (PDGFR).
 Drugs under development include SF1126 (PI3 kinase inhibitor), GSK690693 (AKT
inhibitor), (raf and VEGF receptor inhibitor).
 The folate receptor is overexpressed in more than 90% of ovarian cancers. MORab-
003 , a monoclonal antibody directed against the folate receptor, is being evaluated
in a phase II trial.
Relevance to other gynaecological cancers
 There are trials in progress of angiogenesis inhibitors in cervical and endometrial
cancers and EGFR inhibitors in vulval cancer.
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POP-Q SYSTEM FOR THE ASSESSMENT OF PELVIC ORGAN PROLAPSE
Definition
 Pelvic organ prolapse is defined as the weakness of the muscles, ligaments, and
connective tissues that normally support the vaginal walls and pelvic o rgans results in
the descent of vaginal walls, u t e rus, bladder, urethra, rectum, or bowel into the vaginal
vault.
 Less frequently, a complete utero-vaginal eversion may develop
 (POP-Q):describes specific anatomic sites to be measured for evaluation and staging of
a pelvic organ prolapse, has become the most accepted evidenced- based tool for
gynecologists and urogynecologists
 In the past, generic terms (cystocele, rectocele, and e n t e rocele) were commonly used
to describe the prolapse without information that identified the exact anatomical structure
behind the vaginal wall weakness
 Prolapses are now best defined in three anatomical terms
1. anterior vaginal prolapse(prolapse in the anterior wall of the vagina, could include an
urethrocele, a cystocele, or an anterior enterocele)
2. posterior vaginal prolapse(could include a rectocele or a posterior enterocele)
3. apical/superior vaginal prolapse (could include the cervix, the uterus, or the vaginal
cuff).
Risk Factors/Etiology
 may be related to multiple risk factors rather that a single cause
 Factors, congenital or acquired, that result in a weakened support mechanism
predispose women to pelvic organ prolapse:
1. Pregnancy, difficult and prolonged labor, forceps delivery, large birth weight babies,
and increased parity
2. Medical conditions, such as multiple sclerosis and muscular dystrophy, produce
3. Genetic collagen disorders, such as Marfan‟s and Ehlers-Danlos Syndrome, have
higher incidence of both urinary incontinence and pelvic organ prolapse
4. Obesity, chronic constipation, and chronic cough, asthma, or bronchitis result in
significant increase in intra-abdominal pre ssure, which linked to pelvic organ
prolapse.
5. Certain occupations linked to heavy lifting may also predispose women to prolapse.
6. Ethnicity, age, menopause, and familial history of prolapse increase the risk for
pelvic organ prolapse.
7. Previous pelvic surgeries, including hysterectomy and prior prolapse repair
Symptoms
 may be asymptomatic or present with mild symptoms that no treatment is needed for
years
 10-20% of women seek medical assistance for this condition
 Symptoms increases when the prolapse has descended to the level of the hymen,
 Symptoms associated with prolapse characterized into 4 primary areas:
1. lower urinary tract symptoms, include hesitancy, urgency, frequency, decreased
force of stream, and incomplete emptying
2. bowel symptoms, include incontinence of flatus and feces, straining to defecate,
incomplete emptying, increased urgency, and/or fecal blockage
3. sexual symptoms, dyspare unia, decreased sensation, and lubrication with
subsequent avoidance of sexual encounters
4. local symptoms include local “bulge” symptoms described as a sensation of fullness,
protrusion in the vagina, or increased vaginal pressure

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 5. others include low back pain, generalized pelvic pain, or blood-stained or purulent
discharge
 Patients may present with any or all of these symptoms and in varying degrees
 these symptoms may be related to other condition, such as pelvic or vaginal mass,
hernias, interstitial cystitis, urinary tract infection, overactive bladder, irritable bowel
syndrome, primary rectal disorder, or sexual disorder unrelated to the prolapse
Assessment and Diagnosis
1) detailed history
2) five-component physical examination:
1. evaluation of the external genitalia
2. internal examination of the vaginal tissue
3. digital rectal-vaginal examination
4. Assessment of the muscle strength
5. evaluation of the prolapse which done during the internal vaginal assessment.
History
1. Should include age, weight, body mass index, number of pregnancies, birth weight of
children, complications during delivery, and any familial history of prolapse
2. Personal history should include any medical condition, tobacco use, chronic
constipation, chronic cough.
3. Surgical history should include any pelvic or retroperitoneal surgeries, especially a
hysterectomy and any prior prolapse repair.
4. Specific symptoms to be evaluated include pelvic pain, back pain, dyspareunia,
abnormal bleeding, vaginal discharg e , urinary symptoms, and defecatory
symptoms
Physical Examination
1. inspection and palpation of the external genitalia, assessing for discoloration,
inflammation, irritation, discharge, rash, or lesions.
2. The vaginal epithelium should also be assessed for vaginal atrophy,
3. bimanual examination is done to assess for any abnormalities in the vaginal wall,
abdomen, or rectum.
Brink scale:
1. assesses the strength of the pelvic floor composed of the levator ani muscles,
coccygeal muscles, and the related fascia, using a transvaginal or transrectal
approach.
2. The examiner‟s finger inserted 4 to 6 cm into the vagina, while asking the patient to
squeeze the pelvic floor muscles without using the accessory muscles
3. Three components of each contraction are assessed:
o the muscle force,
o the vertical displacement of the examiners fingers during contraction
o the duration of the contraction
4. 4-point scale is used to assess each of the 3 components
5. The scores of the 3 components are added and provide an overall score ranging
from 3 to 12

POP-Q assessment tool.

 Use of the POP-Q system requires assessment of the prolapse at maximum protrusion
 Assessment of a prolapse begins with the identification of the hymen as reference
reference point
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 six defined anatomical points in the vagina are given a value in centimeters based on
their position relative to the hymen, either above or below( two points on the anterior
vaginal wall, two points on the posterior wall, and two points on the apical/superior wall).
 “a” representing the anterior vaginal wall, “p” representing the posterior vaginal wall, “A”
and “B” reflect the proximal (A) and distal points (B), “C” represents the cervix or
posterior vaginal cuff and “D” represents the posterior fornix.
Ordinal Stages of Pelvic Organ Prolapse
 POP-Q an ord inal stage is assigned: The prolapse is graded from 0 to IV based on the
extent of maximal pro t rusion.

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Conservative Management
 include lifestyle modifications, use of a pessary, pelvic muscle therapy, and surgery
 Basic goals for conservative management is increasing the strength and support
mechanisms of the pelvic floor muscles, which may prevent worsening of the prolapse or
delay the need for surgery.
 Teaching patients about healthy bowel and bladder habits is also a factor in conservative
management
 improve constipation byincreasing fluid intake, increasing daily consumption of fruits and
vegetables, increasing fiber through diet and exercising, , reduce straining to defecate
 Weight loss, reduced straining with defecation,
 proper lifting techniques can lessen the increase in abdominal
 Smoking cessation programs reduce a chronic cough and the sudden increase in intra-
abdominal pressure
 Pelvic floor muscle training can be done by physical therapists or nurses.
 Electrical stimulation and biofeedback are additional treatment options for conservative
management.
 Pessaries reduce the symptoms of the bulge or pressure sensations, as well as the
need for splinting and improve urinary incontinence
 pessaries are less effective in reducing defecatory pro blems and may worsen these
symptoms.

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POST HYSTERECTOMY VAGINAL VAULT PROLAPSE
Introduction and background
 Post-hysterectomy (apical) vaginal prolapse defined as descent of the vaginal cuff scar
below a point that is 2 cm less than the total vaginal length above the plane of the
hymen.
 The vaginal cuff scar corresponds to point C on the POPQ grid.
 It follows 11.6% of hysterectomies performed for prolapse and 1.8% of those performed
for other indications.
Prevention at the time of hysterectomy
1) McCall culdoplasty and peritoneal closure of cul-de-sac at the time of vaginal
hysterectomy is recommended to prevent enterocele formation.
 The technique involves approximating the uterosacral ligaments using continuous
sutures, so as to obliterate the peritoneum of the posterior cul-de-sac as high as
possible.
2) Suturing the cardinal and uterosacral ligaments to the vaginal cuff and high
circumferential obliteration of the pouch of Douglas at the time of hysterectomy is a
recommended measure to avoid vault prolapse
3) Sacrospinous fixation at the time of vaginal hysterectomy is recommended when the
vault descends to the introitus during closure at the end of anterior vaginal wall closure.
 The sacrospinous fixation took significantly longer to perform and more blood loss.
 more women developed Grade 2 or 3 anterior vaginal prolapse in the sacrospinous
fixation than McCall‟s culdoplasty group.
 There was no significant difference in sexual function or the development of stress
incontinence.
4) Subtotal hysterectomy is not recommended for the prevention of PHVP.
Assessment
Clinicians should work as part of a pelvic floor multidisciplinary team (MDT)
 Assessment should be objective, addressing quality of life, looking for all pelvic floor
defects and should be based on standard tools.
 QoL evaluation by using disease-specific validated quality of life questionnaires.
 Examination should be made according to tools, such as POPQ.
 Assessment of occult stress incontinence of urine may be made with a full bladder
after reducing the prolapse with a pessary or sponge holder, this assessment is not
currently validated by evidence and is not a substitute for adequate patient
counselling about this complication.
 The role of prophylactic surgery for occult stress incontinence is unclear.
 All pelvic floor defects should be identified, to enable surgical repair.
 Women with post-hysterectomy vaginal vault prolapse often have associated
anterior or posterior vaginal wall prolapse.
 Routine urodynamic assessment is not recommended in women with post-
hysterectomy vaginal vault prolapse (PHVP).
Conservative management
 Pelvic floor muscle training (PFMT) is an effective treatment option for women with stage
I–II vaginal prolapse, including PHVP.
 Vaginal pessaries are an alternative treatment option for women with stageII–IV PHVP.
 Conservative measures include pelvic-floor exercises and different types of
pessaries(ring and shelf ).
 Pessaries, are more suitable for women who are not sexually active. require
changing every 6–8 months. If left for a long period, there is a risk of calcium
deposition, erosion and fistula formation.
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  Ring tend to fail in women with deficient perineum, who may require shelf
pessaries instead.
 Local estrogen can be used to improve atrophic changes,
Surgical procedures
 What are the indications for surgery?
Surgical treatment should be offered to women with symptomatic PHVP after
appropriate counselling.
 Who should undertake surgery?
 PHVP surgery should be performed by an RCOG-accredited subspecialist
urogynaecologist, or gynaecologists who can demonstrate an equivalent level of
training or experience.
 What is an acceptable successful result after surgical treatment?
 Patient-reported outcomes,including patient-reported success rates and relief of
presenting symptoms, should be the primary assessment outcomes.
 Objective cure is important as it correlates to symptoms of vaginal bulge; a Pelvic
Organ Prolapse Quantification (POP-Q) stage of I or O in the apical compartment
seems to be acceptable and widely used as the optimum postoperative result.
 Are there preferred suture materials for vault support at the time of hysterectomy?
 There is inadequate and conflicting evidence over the use of permanent sutures in
the short term and no evidence of benefit in the long term; they can be associated
with high suture exposure rates.
1)Vaginal wall repair
 Anterior and posterior repair along with obliteration of the enterocele sac are inadequate
for vault prolapse.
 It is associated with risks of vaginal narrowing, shortening and dyspareunia especially
with posterior repair.
2)Abdominal sacrocolpopexy, sacrospinous fixation and related procedures
 Abdominal sacrocolpopexy is an effective operation for post-hysterectomy vaginal vault
prolapse and have lower failure rate compared to Sacrospinous fixation
 Sacrospinous fixation have lower postoperative morbidity, shorter catheterisation and
hospital stay and less sexual dysfunction.
 Complications of sacrocolpopexy include: blood transfusion, bladder injury, incisional
hernia, mesh rejection, wound infection
 Complications of sacrospinous fixation include: blood transfusion, bladder injury,
rectovaginal haematoma, vaginal pain.
 There is no evidence to recommend bilateral or unilateral sacrospinous fixation.
 The following criteria should be considered when helping women choose between the
two procedures.
 Vaginal sacrospinous fixation requires adequate vaginal length and vault width to
enable reaching the sacrospinous ligament.
 Co-existent anterior and/or posterior vaginal wall prolapse can easily be managed
by anterior and/or posterior repair while performing vaginal sacrospinous fixation.
 Abdominal sacrocolpopexy can be carried out if women require laparotomy for
other indication(s).
 Vaginal sacrospinous fixation is more suitable for physically frail women,.
 There is no difference in pain between abdominal sacrocolpopexy and vaginal
sacrospinous fixation.
 The operative morbidity with sacrocolpopexy is reduced when the procedure is
done laparoscopically.
 Abdominal sacrocolpopexy is more suitable for sexually active women, as
sacrospinous fixation is associated with exaggerated retroversion of the vagina.

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  Vaginal length is well maintained after sacrocolpopexy whereas sacrospinous
fixation can cause vaginal narrowing and/or shortening, especially when carried
with repair of anterior and/or posterior vagina.
 There is insufficient data to support prophylactic continence surgery at the time of
sacrocolpopexy in women who are urodynamically continent.
 Laparoscopic and robotic sacrocolpopexy (LSC and RSC);
 LSC can be equally effective as ASC in selected women with primary PHVP.
 LSC can include mesh extension or be combined with other vaginal
procedures to correct other compartment prolapse.
 There is limited evidence on the effectiveness of RSC; therefore, it should only
be performed in the context of research or prospective audit following local
governance procedures.
1) Iliococcygeus fixation
 Iliococcygeus fixation is not associated with reduced incidence of anterior vaginal wall
prolapse than vaginal sacrospinous fixation and should not be routinely recommended.
2) Vaginal uterosacral ligament suspension
 It is effective for posthysterectomy vaginal vault prolapse, but there is a risk of ureteric
injury.
 Are laparoscopic procedures recommended?
 Laparoscopic sacrocolpopexy appears to be as effective as open sacrocolpopexy.
 The ureters are particularly at risk during laparoscopic uterosacral ligament suspension.
 There is insufficient evidence to judge the value of other laparoscopic techniques.
3) colpocleisis
 Colpocleisis (closure of the vagina)is a safe and effective procedure that can be
considered for those women who do not wish to retain sexual function.
 Different techniques have been described, including vaginectomy, pursestring
closure of the vagina, colpocleisis after performing standard anterior and posterior
vaginal wall repair.
4) Sling procedures
 Sling procedures should not be used without adequate patient counselling.
 It showed significantly longer operating times and more blood loss compared with
sacrospinous fixation.
5) total mesh reconstruction
 There is insufficient evidence to judge the safety and effectiveness of total mesh
reconstruction.
 Under what circumstances would transvaginal mesh (TVM) kits/grafts be considered?
 The limited evidence on TVM kits does not support their use as first-line treatment
of PHVP.
 If TVM is considered, women should be fully informed of the permanent nature of
the mesh and potential mesh complications, some of which are serious and have
long-term effects that can be difficult to treat.
 If TVM is considered, women should be fully informed of alternative surgical and
nonsurgical options and referral to other surgeons/units arranged as appropriate.
 TVM should only be performed by an appropriately trained urogynaecologist, after
discussion of each individual case in an MDT meeting.
 The results of all surgical procedures involving mesh should be prospectively audited
and submitted to a national surgical database (e.g. British Society of Urogynaecology
[BSUG]) and any mesh complications reported to the Medicines and Healthcare
Products Regulatory Agency (MHRA).
6) Vault suspension to the anterior abdominal wall
 Vault suspension to the anterior abdominal wall can be a simple measure. However,
there are not enough studies assessing this technique to judge its value.
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 Is there an indication for concomitant surgery for occult SUI?
 Colposuspension performed at the time of sacrocolpopexy is an effective measure to
reduce postoperative symptomatic SUI in previously continent women.
 Is there an indication for concomitant surgery for PHVP and overt SUI?
 Colposuspension at the time of ASC does not appear to be effective treatment for
SUI.Concomitant mid-urethral sling surgery may be considered when vaginal
surgical approaches are used for the treatment of PHVP.
 What is the optimal treatment of recurrent vault prolapse?
 The management of recurrent vault prolapse should be through a specialist MDT
with experience and training in this field.

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URINARY INCONTINENCE
Introduction
 Urinary incontinence (UI) is a common condition that may affect women of all ages,
may seriously influence the physical, psychological and social wellbeing of affected
individuals.
 UI is defined as „the complaint of any involuntary leakage of urine‟.
1. Stress UI is involuntary urine leakage on effort or exertion or on sneezing or
coughing.
2. Urge UI is involuntary urine leakage accompanied or preceded by urgency (a
sudden desire to urinate that is difficult to defer).
3. Mixed UI is involuntary urine leakage associated with both urgency and exertion,
effort.
4. Overactive bladder syndrome (OAB) is urgency that occurs with or without urge
UI and usually with frequency and nocturia.
A. OAB wet : occurs with urge UI is known as .
B. OAB dry : occurs without urge UI is known as .
Assessment and investigation
1) History-taking and physical examination
 UI should be categorised as:
o stress UI,
o mixed UI, or
o urge UI/OAB.
 identify predisposing and precipitating factors and other diagnoses that may require
referral for additional investigation and treatment.
 Initial treatment should be started on this basis.
 In mixed UI, treatment should be directed towards the predominant symptom.
2) Assessment of pelvic floor muscles
 Routine digital assessment of pelvic floor muscle contraction should be undertaken
before the use of pelvic floor muscle training for the treatment of UI.
3) Assessment of prolapse
 Women with UI who have symptomatic prolapse should be referred to a specialist.
4) Urine testing
 to detect : blood, glucose, protein, leucocytes and nitrites in the urine.
o Symptoms of UTI with leucocytes and nitrites in urine indicate a MSU for C/S.
o Symptoms of UTI with no leucocytes and nitrites in urine indicate a MSU for C/S.
o No symptoms of UTI with leucocytes and nitrites in urine should not be offered
antibiotics without MSU for C/S.
o No symptoms of UTI with no leucocytes and nitrites in urine are unlikely to have
UTI and should not have MSU for C/S.
5) Assessment of post-void residual volume of urine
 Indicated for women with:
1. symptoms suggestive of voiding dysfunction
2. recurrent UTI.
3. palpable bladder on bimanual or abdominal examination after voiding.
 Indications of urgent referral for women with UI to a specialist service:
o Microscopic haematuria if aged 50 years and older
o Visible haematuria
o Recurrent or persisting UTI associated with haematuria if aged 40 years and
older
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 o suspected malignant mass arising from the urinary tract.
 Other Indications of referral for women with UI to a specialist service :
o persisting bladder or urethral pain
o clinically benign pelvic masses
o associated faecal incontinence
o suspected neurological disease
o symptoms of voiding difficulty
o suspected urogenital fistulae
o previous continence surgery
o previous pelvic cancer surgery
o previous pelvic radiation therapy.
6) Symptom scoring and quality-of-life assessment
7) Bladder diaries
 Bladder diaries should be used for a minimum of 3 days in the initial assessment of UI
or OAB.
8) Pad testing are not recommended in the routine assessment of UI.
9) Urodynamic testing
 Multi-channel cystometry, ambulatory urodynamics or videourodynamics is not
recommended before starting conservative treatment.
 Multi-channel filling and voiding cystometry is recommended in before surgery for UI if
there are:
1. Symptoms suggestive of voiding dysfunction or detrusor overactivity .
2. previous surgery for stress UI or anterior prolapse,
10) Other tests of urethral competence
 The Q-tip, Bonney, Marshall, and Fluid-Bridge tests are not recommended in for UI.
11) Cystoscopy is not recommended in the initial assessment of UI alone.
12) Imaging
 MRI, CT, X-ray are not recommended for the routine assessment of women with UI.
 Ultrasound is not recommended other than for the assessment of residual urine
volume.
Conservative management
1) Lifestyle interventions
1. A trial of caffeine reduction is recommended for the treatment of OAB.
2. modification of high or low fluid intake in women with UI or OAB.
3. Weight loss in women with BMI > 30.
2) Physical therapies
 Pelvic floor muscle training for > 3 months should be offered as first-line treatment for
stress or mixed UI. training programmes should include > 8 contractions performed 3
times/d.
 Biofeedback (perineometry or pelvic floor electromyography) should not be used as a
routine in pelvic floor muscle training.
 Electrical stimulation should not routinely be used in the treatment of women with
OAB or in combination with pelvic floor muscle training.
 Electrical stimulation and/or biofeedback should be considered in women who cannot
actively contract pelvic floor muscles.
3) Behavioural therapies
 Bladder training for > 6 weeks should be offered as first-line treatment for urge or
mixed UI.
 Add antimuscarinic agent If women do not achieve satisfactory benefit from bladder
training programmes due to frequency.
 Timed voiding toileting is recommended In women with UI and cognitive impairment.
4) Drug therapies
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  Immediate release non-proprietary oxybutynin should be offered to women with OAB
or mixed UI as first-line drug treatment if bladder training has been ineffective.
 Propiverine is recommended to treat frequency in OAB, but not recommended for
treatment of UI.
 Flavoxate, propantheline and imipramine should not be used for the treatment of UI or
OAB.
 desmopressin is recommended to reduce nocturia in women with UI or OAB.
 Duloxetine is offered as second-line therapy for women with predominant stress UI.
Or if women prefer pharmacological rather than surgicalor are not suitable for surgical
treatment.
 HRT therapy is not recommended for the treatment of UI.
 vaginal oestrogen is recommended for OAB in postmenopausal women with vaginal
atrophy.
5) Non-therapeutic interventions
 Absorbent products, hand held urinals should not be considered as a treatment for UI
but as adjunct to ongoing therapy
 Bladder catheterisation considered for women in whom Ch. urinary retention is
causing UI, infections, or renal dysfunction.
 Indications for the use of long-term indwelling urethral catheters for UI include:
1. Ch. urinary retention in women who are unable to do intermittent self-
catheterisation
2. Skin wounds, pressure ulcers or irritations being contaminated by urine
3. Distress caused by bed and clothing changes
4. Woman preference.
 Indwelling suprapubic catheters considered as an alternative to long-term urethral
catheters.
 Intravaginal and intraurethral devices are not recommended for the routine
management of UI.
6) Complementary therapies are not recommended for treatment of UI or OAB.
7) Preventive use of conservative therapies
 Offer pelvic floor muscle training to women in their first pregnancy as a preventive for
UI.
Surgical management
1) Discussion of benefits and risks of surgical and non-surgical options with
consideration of the woman's child-bearing wishes.
2) Procedures for OAB
1. Sacral nerve stimulation is recommended for UI due to detrusor overactivity not
respondeding to conservative treatments.
2. Augmentation cystoplasty for idiopathic detrusor overactivity in women not
respondeding to conservative treatments and who are willing and able to self-
catheterise.
3. Urinary diversion for OAB only when conservative treatments failed and the
above procedures are not appropriate or are unacceptable to her.
4. Bladder wall injection with botulinum toxin for idiopathic detrusor not responded to
conservative treatments, and who are willing and able to self-catheterise.
5. Botulinum toxin B is not recommended for idiopathic OAB.
3) Procedures for stress UI if conservative management failed
1. Retropubic mid-urethral tape using a „bottom-up‟ approach with macroporous
(type 1) polypropylene meshes
2. Open colposuspension and autologous rectus fascial sling are the recommended
alternatives when clinically appropriate.
3. Retropubic „top-down‟ or a transobturator foramen approach.

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  Slings using materials other than macroporous (type 1) polypropylene are not
recommended.
4. Intramural bulking agents(collagen, silicone, co-polymer)women should be made
aware of:
• repeat injections may be required to achieve efficacy
• efficacy is inferior to that of retropubic suspension or sling anddiminishes
with time.
•Autologous fat and polytetrafluoroethylene for intramural bulking not
recommended
5. Artificial urinary sphincter only if previous surgery has failed.
6. Laparoscopic colposuspension is not recommended as a routine procedure
stress UI.
7. Anterior colporrhaphy, needle suspensions, paravaginal repair and the Marshall–
Marchetti–Krantz procedure are not recommended for the treatment of stress UI.
4) Botulinum toxin A
 There is a gap in our current management of idiopathic detrusor overactivity, between
available conservative treatments of limited effectiveness and major surgical options
associated with a high level of morbidity.
 Botulinum toxin A recently become available to fill this gap for detrusor overactivity.

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468
SURGICAL TREATMENT OF URODYNAMIC STRESS INCONTINENCE
Background and purpose
 83% of women reported improvement three months after surgery, 5% had no change
and 8% reported a worsening in their condition.
 The impact of bladder-neck surgery has been studied only recently; for example, the
occurrence of urge incontinence or voiding difficulty postoperatively
Surgical procedures
3.1 Anterior vaginal repair
 Anterior repair is less successful than retropubic procedures and has been
superseded by sling procedures.
 Anterior repair still has a role in the treatment of prolapse without incontinence.
3.2 Burch colposuspension
 Burch colposuspension is the most effective surgical procedure for stress
incontinence, with a continence rate of 85–90% at one year.
 The continence rate falls to 70% at five years.
3.3 Alternative suprapubic surgery
 The role of other suprapubic operations such as Marshall–Marchetti–Krantz
retropubic procedure, paravaginal repair and laparoscopic colposuspension, is
unclear.
3.4 Needle suspension procedures
 Needle suspension procedures should not be performed: initial success rates are not
maintained with time and the risk of failure is higher than for retropubic suspension
procedures.
3.5 Sling procedures
 Suburethral Sling procedures, using autologous or synthetic materials, produce a
continence rate of approximately 80% and an improvement rate of 90%, with little
reduction in continence over time.
 Only one synthetic sling procedure (tension-free vaginal tape) has been subjected to
randomised study to date.
3.6 Injectable agents
 Injectable agents (bulking agents: collagen, Teflon, fat, silicone, Durasphere) have a
lower success rate than other procedures: a short-term continence rate of 48% and
an improvement rate of 76%. Long term, there is a continued decline in continence.
 the procedure has a low morbidity and may have a role after other procedures have
failed, e.g. when a diagnosis of intrinsic sphincter deficiency is made.
 are injected in a retrograde (more common) or antegrade fashion in the
periurethral tissue around the bladder neck and proximal urethra.
3.7 Artificial sphincters
 Artificial sphincters can be successfully used after previous failed continence surgery
but have a high morbidity and need for further surgery (17%).
 A cure rate of 80% and an improvement rate of 90% can be expected when an
artificial sphincter is inserted as a primary procedure for stress incontinence.
 These benefits must be balanced with the potential need for further surgery 17% .

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VACCINATION AGAINST CERVICAL CANCER
Background
 The licensing of the first vaccine designed to prevent cervical cancer recently was shown
to be 100% effective in the short term at preventing type specific premalignant disease of
the cervix.
1.1 The scale of the problem
 In the UK, the number of deaths from cervical cancer reduced > 50% in the 1980s and
1990s by introduction of the National Health Service Cervical Screening
Programme(NHSCSP).
 without further preventative measures, deaths from cervical cancer will jump 4fold to
>million a year by 2050 as a result of the explosion in human papillomavirus (HPV)
infection
1.2 HPV is the principal causal factor
 HPV is a double-stranded DNA viruses that infect epithelial cells.
 Lowrisk types, such as HPV-6 and -11, cause benign genital warts and respiratory
papillomatosis,
 persistent infection with high-risk types is associated with increased risk of high grade
cervical intraepithelial neoplasia (CIN).
 The virus infects cells in the basal layer of the epithelium
 HPV expresses six early (E) functional proteins and two late (L) structural proteins.
 The oncogenic properties of high-risk HPV are due in part to the combined effect of early
proteins E6 and E7. These proteins interact with two tumour suppressor gene products,
p53 and Rb, respectively.
 HPV infections by oncogenic types are extremely common in young sexually active
women and most clear spontaneously but a proportion develop a persistent infection and
rare of which cause Cervical cancer
 HPV-16 and -18 together account for 70% of cervical cancers across the world. Other
high risk types, including HPV-31, -33 and -45.
HPV prophylactic vaccination
Rationale
 Women previously infected with a particular HPV type are unlikely to become reinfected
by the same type,
 immunity provide antibodies targeted against the major papillomavirus capsid protein L1.
 in the laboratory, L1 protein self-assembles into virus-like particles (VLPs) are highly
immunogenic but not in themselves infectious because they lack the viral genome.
Vaccination trials
 Three HPV prophylactic vaccines have now been tested in humans in large randomised
double-blind placebo-controlled trials.
 The results of this trial established proof of principle for HPV prophylactic vaccination.
 the protection against CIN offered by vaccination was type-specific.
 The vaccine shown to be significantly effective (>88%) against incident and persistent
HPV-16 and -18 infections up to 4 years following vaccination. There was also some
evidence for vaccine-related crossprotection against incident HPV-45 and -31 infections,
the third and fourth most common HPV types associated with cervical cancers.
Challenges for universal HPV prophylactic vaccination
Public acceptability
 One important consideration is whom to vaccinate.

471
 In order to have maximum impact, a prophylactic vaccination programme would need to
target young women prior to the onset of sexual activity.
 It is Sensitive for parents to allow their teenage daughters to be vaccinated against a
sexually transmitted infection.
 Some religious groups may be opposed to the vaccination of young girls, fearing that it
may promote promiscuity.
 Whether boys should be vaccinated is still unresolved.
 Including boys is important for the development of group immunity but male disease is
rare.
 vaccine that additionally provided protection against HPV-6 and -11 protect men
against genital warts.
 Vaccinating males may also prevent anal cancer, an increasing problem in the
homosexual HIV population.
Duration of protection
 HPV-specific antibodies generated by vaccination may wane with time,
 current data indicate that immune responses persist through 5 years.
 It is also unclear whether the strength of immunity generated by vaccination is affected
by the number of HPV types included in the vaccine.
 The need for poster doses is still undetermined.
Reaching women in underdeveloped settings
 The need for HPV vaccines is greatest in underdeveloped countries where the incidence
of cervical cancer is high and there is an extreme shortage of screening and treatment
 The vaccines are expensive, require continuous refrigeration and must be given in
repeated injected doses.
 budgets that are struggling to deliver fresh food, clean water and basic health care may
make HPV prophylactic vaccination unaffordable without foreign aid to deliver the
vaccine.
What about screening?
 An HPV prophylactic vaccine is unlikely to benefit women who have already been
exposed to the relevant virus type.
 It may take a generation before all women at risk of cervical cancer can be vaccinated
 HPV prophylactic vaccination may not be 100% effective and will probably not protect
against all HPV types.
 Cervical screening will, therefore, continue to play an important role in the fight against
cervical cancer.
 Future screening strategies after introduction of vaccination may depend upon primary
HPV testing with cytology being reserved for those women who are HPV positive. By this
the costs of vaccination can be reduced by a reduction in the screening budget.

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REDUCING THE RISK OF THROMBOSIS AND EMBOLISM DURING
PREGNANCY AND THE PUERPERIUM
Introduction and background epidemiology
 Pulmonary embolism remains the leading direct cause of maternal death in the UK
and is the second most common cause of maternal death overall 11% of maternal
deaths.
 NICE estimates that LMWH reduces VTE risk in medical and surgical patients by
60% and 70%, respectively and reduce the risk of VTE in obstetric patients by up to
two-thirds.
 70%-79% of women died from pulmonary embolism had identifiable risk factors
 Many antenatal VTE events occur in the first trimester and therefore prophylaxis, if
given, should begin early in pregnancy.
 The highest risk period for VTE, and pulmonary embolism is during the postpartum
period. CS is a significant risk factor but women having vaginal deliveries are also
at risk
 the relative risk of VTE in pregnancy is increased 4-6 fold and increased 5 times
further postpartum,
 incidence of VTE in pregnancy and the puerperium of 1–2/1000.
Age and obesity
 age over 35 years, obesity and caesarean section contribute most substantially to
the rates of VTE because of their high prevalence.
 obesity is a moderate risk factor for VTE but is important because of its high
prevalence within the population.
 obesity was associated with a higher risk of pulmonary embolism than of deep
venous thrombosis
Immobility and long distance travel
 BMI greater than 25 and antepartum immobilisation (defined as strict bed rest 1
week or more before delivery) had a multiplicative effect on the risk for antepartum
and postpartum VTE
 long-haul air travel increases the risk of VTE but the present guideline considers all
long distance (more than 4 hours) travel (not exclusively by air) to be a risk factor
for VTE in pregnancy.
Recommendations for thromboprophylaxis during pregnancy
 All women should undergo assessment of risk factors for venous thromboembolism
(VTE) in early pregnancy or before pregnancy.
 This assessment should be repeated if the woman is admitted to hospital for any
reason or develops other intercurrent problems.
 Risk assessment should be repeated again intrapartum or immediately postpartum.
 The risk of VTE should be discussed with women at risk and the reasons for
individual recommendations explained.
 Any woman with four or more current risk factors shown in table1(other than
previous VTE or thrombophilia) should be considered for prophylactic low-
molecular-weight heparin (LMWH) throughout the antenatal period and will usually
require prophylactic LMWH for 6 weeks postnatally but a postnatal risk
reassessment should be made.
 Any woman with three current risk factors shown in Table 1 (other than previous
VTE or thrombophilia) should be considered for prophylactic LMWH from 28 weeks
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 and will usually require prophylactic LMWH for 6 weeks postnatally but a postnatal
risk reassessment should be made.
 Any woman with two current risk factors shown in Table 1 (other than previous VTE
or thrombophilia) should be considered for prophylactic LMWH for at least 10 days
postpartum.
 Women admitted to hospital when pregnant (including to the gynaecology ward with
hyperemesis gravidarum or ovarian hyperstimulation syndrome) should usually be
offered thromboprophylaxis with LMWH unless there is a specific contraindication
such as risk of labour or active bleeding.
table1
Pre-existing Previous VTE
Thrombophilia Heritable
Antithrombin deficiency
Protein C deficiency
Protein S deficiency
Factor V Leiden
Prothrombin gene mutation
Acquired
Antiphospholipid antibodies
Persistent lupus anticoagulant and/or
persistent moderate/high titre anticardiolipin
antibodies and/or β2-glycoprotein 1 antibodies
Medical comorbidities e.g. cancer; heart failure; active SLE,
inflammatory polyarthropathy or IBD; nephrotic syndrome; type I
diabetes mellitus with nephropathy; sickle cell disease;49 current
intravenous drug user
Age > 35 years
Obesity (BMI ≥ 30 kg/m2) either prepregnancy or in early
pregnancy
Parity ≥ 3 (a woman becomes para 3 after her third delivery)
Smoking
Gross varicose veins (symptomatic or above knee or with
associated phlebitis, oedema/skin changes)
Paraplegia
Obstetric risk factors Multiple pregnancy
Current pre-eclampsia
Caesarean section
Prolonged labour (> 24 hours)
Mid-cavity or rotational operative delivery
Stillbirth
Preterm birth
Postpartum haemorrhage (> 1 litre/requiring transfusion)
New onset/transient Any surgical procedure in pregnancy or puerperium except
These risk factors are immediate repair of the perineum, e.g. appendicectomy,
potentially reversible and may postpartum sterilisation
develop at later stages in Bone fracture
gestation than the initial risk Hyperemesis, dehydration
assessment or may resolve Ovarian hyperstimulation Assisted reproductive
and therefore what is important syndrome(first trimesteronly) technology (ART), in vitro
is an ongoing individual risk fertilisation (IVF)
assessment Admission or immobility (≥ 3 e.g. pelvic girdle pain
days‟ bed rest) restricting mobility
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 Current systemic infection e.g. pneumonia,
(requiring intravenous antibiotics pyelonephritis, postpartum
or admission to hospital) wound infection
Long-distance travel (> 4 hours)
Previous VTE
How should women with previous VTE be managed in pregnancy?
Single previous VTE;
 Women with previous VTE should be offered prepregnancy counselling and a
prospective management plan for thromboprophylaxis in pregnancy made.
 Those who become pregnant before receiving such counselling should be
referred at the earliest opportunity in pregnancy to a clinician with expertise in
thrombosis in pregnancy.
 Women with previous VTE (except those with a single previous VTE related to
major surgery and no other risk factors) should be offered thromboprophylaxis
with LMWH throughout the antenatal period.
 Women with previous VTE should have a careful history documented. Where
objective documentation is not available, the previous diagnosis of VTE can
be assumed in cases where the woman gives a good history and received
prolonged (greater than 6 weeks) therapeutic anticoagulation.
 recurrence rates is 1.4–11.1%.
 The risk of recurrence appears to be constant over the whole period of
pregnancy.
 All women with prior VTE should receive postpartum prophylaxis, as this is the
period of greatest risk.
 previous VTE can be devided into recurrent or single previous VTE.
 The single previous VTE may be further subdivided into :
unprovoked VTE recurrence rate is 5.9%
estrogen-provoked (estrogen-containing contraception or pregnancy) VTE;
 the recurrence rate of VTE in subsequent pregnancies was 9.5% (95%CI
2.6–28.9%).41 The risk was very similar if the prior VTE occurred during
previous pregnancy.
 women with previous estrogen-related VTE has at high risk of VTE in
pregnancy and the puerperium.
thrombophilia (heritable or acquired) or family history-associated VTE
temporary risk factor (e.g. major trauma or surgery) associated VTE.
Thrombophilia-associated VTE
Heritable thrombophilia;
 Women with previous VTE associated with antithrombin deficiency (who will
often be on long-term oral anticoagulation) should be offered
thromboprophylaxis with higher dose LMWH (either 50%, 75% or full
treatment dose) antenatally and for 6 weeks postpartum or until returned to
oral anticoagulant therapy after delivery.
 Management should be undertaken in collaboration with a haematologist with
expertise in thrombosis in pregnancy and consideration given to antenatal
anti-Xa monitoring and the potential for antithrombin replacement at initiation
of labour or prior to caesarean section.
 Heritable thrombophilia is found in 20–50% of women with pregnancy-related
VTE.

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  Outside pregnancy, the most common heritable thrombophilias do not increase
the risk of recurrence.
 the effect of heritable thrombophilia on the risk of recurrent VTE in pregnancy are
extremely sparse.
 In the retrospective studies, heritable thrombophilia was found to be at most a
weak risk factor for recurrent VTE during pregnancy;
 Testing for thrombophilia will therefore not usually influence thromboprophylaxis
in the current pregnancy unless detected in a woman with previous non-estrogen-
related VTE provoked by a minor risk factor
 Women with antithrombin deficiency (particularly type-1 with reductions in both
activity and antigen) have a very high risk of recurrence and require intermediate
or treatment dose of LMWH in pregnancy and 6 weeks postpartum. They are
likely to be on long-term anticoagulation with warfarin.

Acquired thrombophilia;
 Women with VTE associated with the antiphospholipid syndrome (APS)
(who will often be on long-term oral anticoagulation) should be offered
thromboprophylaxis with higher dose LMWH (either 50%, 75% or full
treatment dose) antenatally and for 6 weeks postpartum or until returned to
oral anticoagulant therapy after delivery.
 Pregnant women with APS and prior VTE or arterial thromboses should be
managed in collaboration with a haematologist and/or rheumatologist with
expertise in this area.
 If anti-Xa levels are measured, a test that does not use exogenous
antithrombin should be used and 4-hour peak levels of 0.5–1.0 iu/ml aimed
for.
 Other heritable thrombophilic defects are lower risk and can be managed
with standard doses of thromboprophylaxis.
Previous recurrent VTE
What extra advice is needed for women with previous recurrent VTE?
 Advice regarding doses of LMWH in pregnancy should be sought from a
clinician with expertise in haemostasis and pregnancy.
 Some women with previous recurrent VTE require higher doses of LMWH.
 Women on long-term warfarin or other oral anticoagulants should be
counselled about the risks of these agents to the fetus and advised to stop
their oral anticoagulant therapy and change to LMWH as soon as pregnancy
is confirmed, ideally within 2 weeks of the missed period and before the
sixth week of pregnancy.
 Women not on warfarin or other oral anticoagulants should be advised to
start LMWH as soon as they have a positive pregnancy test.
Stratification of women with previous VTE
How should women with previous VTE be stratified to determine management in
pregnancy?
 Women with VTE associated with either antithrombin deficiency or APS or
with recurrent VTE (who will often be on long-term oral anticoagulation)
should be offered thromboprophylaxis with higher dose LMWH (either 50%,
75% or full treatment dose)antenatally and for 6 weeks postpartum or until
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 returned to oral anticoagulant therapy after delivery. These women require
specialist management by experts in haemostasis and pregnancy.
 Women in whom the original VTE was unprovoked/idiopathic or related to
estrogen (estrogen-containing contraception/pregnancy) or related to a
transient risk factor other than major surgery or who have other risk factors
should be offered thromboprophylaxis with LMWH throughout the antenatal
period.
 In women in whom the original VTE was provoked by major surgery from
which they have recovered and who have no other risk factors,
thromboprophylaxis with LMWH can be withheld antenatally until 28 weeks
provided no additional risk factors are present (in which case they should be
offered LMWH). They require close surveillance for the development of
other risk factors.
Testing for thrombophilia in women with prior VTE
Which women with prior VTE require thrombophilia testing?
 Prior to testing for thrombophilia, women should be counselled regarding the
implications for themselves and family members of a positive or negative
result. The results should be interpreted by clinicians with specific expertise in
the area.
 Women with a family history of VTE and either antithrombin deficiency or
where the specific thrombophilia has not been detected should be tested for
antithrombin deficiency.
 Women with an unprovoked VTE should be tested for the presence of
antiphospholipid antibodies.
 be aware of the effects of pregnancy on the results of thrombophilia tests. In
particular, protein S levels are reduced by pregnancy and protein S deficiency
cannot be diagnosed in pregnancy.
 There are two reasons for testing women with previous VTE for thrombophilia
before or in early pregnancy:
1. Women with a previous non-estrogen-related VTE provoked by a minor risk
factor, as this will influence management and decisions regarding
thromboprophylaxis antenatally.
2. if antiphospholipid syndrome or antithrombin deficiency are detected, this will
influence the dose of thromboprophylaxis offered in pregnancy.

Asymptomatic heritable thrombophilia

How should women with asymptomatic thrombophilia be treated?
 Women should be stratified according to level of risk associated with their
thrombophilia and the presence or absence of a family history or other risk
factors.
 Women with asymptomatic antithrombin, protein CorS deficiency or those with
more than one thrombophilic defect (including homozygous factor V
Leiden,homozygous prothrombin gene mutation and compound
heterozygotes) should be referred to a local expert and antenatal prophylaxis
considered.
 They should be recommended for six weeks‟ postnatal prophylaxis even in
the absence of additional risk factors.

476
  Heterozygosity for factor V Leiden or prothrombin gene mutation or
antiphospholipid antibodies are considered as risk factors for thrombosis in
asymptomatic women.
 In the presence of three other risk factors such women may be considered for
antenatal thromboprophylaxis, if there are two other risk factors
thromboprophylaxis should be considered from 28 weeks and if there is one
other risk factor postnatal thromboprophylaxis for 10 days should be
considered.
 Women with no personal history or risk factors for VTE but who have a family
history of an unprovoked or estrogen-provoked VTE in a first-degree relative
when aged under 50 years should be considered for thrombophilia testing.
This will be more informative if the relative has a known thrombophilia.
 Exceptions are in women with antithrombin deficiency or more than one
thrombophilic defect or those with additional risk factors where advice for
antenatal prophylaxis.
 If thromboprophylaxis is given antenatally for a persisting risk factor it should
therefore be continued postpartum for 6 weeks.
Factor V Leiden and prothrombin G20210A
 The most common heritable thrombophilia in the UK are factor V Leiden and
prothrombin G20210A, 3–5% and 1% respectively
 individuals heterozygous for these genes are at roughly five-fold increased risk of
VTE in both the general population and in pregnancy.
protein C and protein S deficiency
 Women with protein C or protein S deficiencies who are asymptomatic probably
have a moderately increased risk of VTE associated with pregnancy with most
events occurring postpartum.
Methylene tetrahydrofolate reductase
 MTHFR is sometimes included in thrombophilia testing but there is no evidence of
an association with a clinically relevant increase in the risk of VTE in pregnancy.
Antithrombin deficiency
 Heparins may not be as effective in antithrombin deficiency, as their mode of action
is antithrombin-dependent and it is reasonable to monitor anti-Xa levels in this
setting aiming for a level 4 hours following injection of 0.35–0.5 u/ml.
 Different subtypes of antithrombin deficiency are associated with different levels of
VTE risk
 Treatment should start in early pregnancy and continue for 6 weeks postpartum.

Antiphospholipid antibodies
How should women with antiphospholipid antibodies be treated?
 Persistent antiphospholipid antibodies (lupus anticoagulant and/or anticardiolipin
and/or β2-glycoprotein 1 antibodies) in women without previous VTE should be
considered as a risk factor for thrombosis such that if she has other risk factors she
may be considered for antenatal or postnatal thromboprophylaxis as above.
 Antiphospholipid antibodies and lupus anticoagulants are associated with an
increased risk of recurrent thrombosis. It is common for such women to be on
long-term warfarin after a first thrombotic event.
 Women with antiphospholipid antibodies and were classified as:
1. low risk if asymptomatic
2. high risk in women with a history of ≥ 3pregnancy losses
3. very high risk if prior venous or arterial thrombosis
477
Timing of initiation of thromboprophylaxis
When should thromboprophylaxis be started?
 Antenatal thromboprophylaxis for those with previous VTE should begin as
early in pregnancy as practical.
 Women without previous VTE and without particular first trimester risk factors
or admission to hospital, but with four other risk factors, should be considered
for antenatal prophylaxis throughout pregnancy.
 Women without previous VTE and without particular first trimester risk factors
such as hyperemesis, surgery for miscarriage, termination of pregnancy, EP or
OHSS following IVFor admission to hospital, but with three other risk factors,
can start antenatal prophylaxis at 28 weeks of gestation.
 50-70% of antenatal fatal pulmonary VTE occurred in the first trimester.
First trimester risk factors
What are the first trimester risk factors for VTE and how should they be managed?
 Women admitted with hyperemesis should be considered for
thromboprophylaxis with LMWH and can discontinue thromboprophylaxis
when the hyperemesis resolves.
 Women with ovarian hyperstimulation syndrome should be considered for
thromboprophylaxis with LMWH in the first trimester.
 Women with an IVF pregnancy and three other risk factors should be
considered for thromboprophylaxis with LMWH starting in the first trimester. [
Recommendations for Thromboprophylaxis during labour and delivery,
including the use of regional analgesia
When should thromboprophylaxis be interrupted for delivery?
 Women receiving antenatal LMWH should be advised that if they have any
vaginal bleeding or once labour begins they should not inject any further
LMWH. They should be reassessed on admission to hospital and further
doses should be prescribed by medical staff.
 Regional techniques should be avoided if possible until at least 12 hours after
the previous prophylactic dose of LMWH.
 LMWH should not be given for 4 hours after use of spinal anaesthesia or after
the epidural catheter has been removed and the catheter should not be
removed within 12 hours of the most recent injection.
 When a woman presents while on a therapeutic regimen of LMWH, regional
techniques should be avoided if possible for at least 24 hours after the last
dose of LMWH.
 Women receiving antenatal LMWH having an elective caesarean section
should receive a thromboprophylactic dose of LMWH on the day prior to
delivery and, on the day of delivery, any morning dose should be omitted and
the operation performed that morning.
 The first thromboprophylactic dose of LMWH should be given as soon as
possible after delivery provided there is no postpartum haemorrhage and
regional analgesia has not been used.
 Women at high risk of haemorrhage with risk factors including major
antepartum haemorrhage, coagulopathy, progressive wound haematoma,
suspected intra-abdominal bleeding and postpartum haemorrhage may be
478
 managed with anti-embolism stockings (AES), foot impulse devices or
intermittent pneumatic compression devices. Unfractionated heparin (UFT)
may also be considered.
 If a woman develops a haemorrhagic problem while on LMWH the treatment
should be stopped and expert haematological advice sought.
 Thromboprophylaxis should be started or reinstituted as soon as the
immediate risk of haemorrhage is reduced.
Recommendations for Thromboprophylaxis after delivery
Assessment of risk;
What are the risk factors for VTE after delivery?
 All women with class 3 obesity (BMI greater than or equal to 40 kg/m2) should
be considered for prophylactic LMWH in doses appropriate for their weight for
10 days after delivery.
 Women with two or more persisting risk factors listed in Table 1 should be
considered for LMWH in prophylactic doses appropriate for their weight for 10
days after delivery.
1\Previous VTE
Which women with previous VTE need postpartum thromboprophylaxis?
 All women with a previous history of confirmed VTE should be offered
thromboprophylaxis with LMWH or warfarin for at least 6 weeks postpartum
regardless of the mode of delivery.
2\Asymptomatic thrombophilia
Which women with thrombophilia without previous VTE need postpartum
thromboprophylaxis?
 Women with thrombophilia without previous VTE should be stratified
according to both the level of risk associated with their thrombophilia and the
presence or absence of a family history or other risk factors.
 Women with a family history of VTE and an identified thrombophilia should be
considered for 6 weeks‟ postnatal thromboprophylaxis
3\Caesarean section
What is the magnitude of risk of VTE after caesarean section?
 All women who have had caesarean sections should be considered for
thromboprophylaxis with LMWH for 10 days after delivery apart from those
having an elective caesarean section who should be considered for
thromboprophylaxis with LMWH for 10 days after delivery if they have any
additional risk factors .
For how long should thromboprophylaxis be continued after delivery ?
 Risk assessment should be performed in each woman at least once following
delivery and before discharge and arrangements made for LMWH prescription
and administration (usually by the woman herself) in the community where
necessary.
 Thromboprophylaxis should be continued for 6 weeks in high-risk women and
for 10 days in intermediate-risk women.

479
  In women who have additional persistent (lasting more than 10 days
postpartum) risk factors, such as prolonged admission, wound infection or
surgery in the puerperium, thromboprophylaxis should be extended for up to 6
weeks or until the additional risk factor/s is/are no longer present.
Which agents should be used for thromboprophylaxis?
1. Low-molecular-weight heparin (LMWH);
 LMWHs are the agents of choice for antenatal and postnatal thromboprophylaxis.
 Doses of LMWH are based on weight. For thromboprophylaxis the booking or most
recent weight can be used to guide dosing.
 It is only necessary to monitor the platelet count if the woman has had prior exposure
to unfractionated heparin (UFH).
 Monitoring of anti-Xa levels is not required when LMWH is used for
thromboprophylaxis.
 Doses of LMWH should be reduced in women with renal impairment, Lower doses of
enoxaparin and dalteparin should be employed if the creatinine clearance is less
than 30 ml/minute.
 LMWH is safe in breastfeeding.
 The risk of heparin-induced thrombocytopenia is substantially lower with LMWH.
 Prolonged unfractionated heparin use during pregnancy may result in
osteoporosis and fractures but this risk is very low with LMWH.
 Bleeding occurred in 1.98% in both treatment and prophylactic doses of LMWH

11. Unfractionated heparin;

 In women at very high risk of thrombosis, UFH may be used peripartum in preference
to LMWH where there is an increased risk of haemorrhage or where regional
anaesthetic techniques may be required.
 If UFH is used after caesarean section (or other surgery), the platelet count should be
monitored every 2–3 days from days 4–14 or until heparin is stopped.
 Unfractionated heparin has a shorter half-life than LMWH and there is more
complete reversal of its activity by protamine sulphate.
 The required interval between a prophylactic dose of unfractionated heparin and
regional analgesia or anaesthesia is less (4 hours) than with LMWH (12 hours).
111. Danaparoid;
 Potential use of danaparoid should be in conjunction with a consultant haematologist
with expertise in haemostasis and pregnancy
 Danaparoid is a heparinoid that is mostly used in patients intolerant of heparin,
either because of heparin induced thrombocytopenia or a skin allergy to heparins.
 like heparin, has both anti-IIa and anti-Xa effects, predominantly the latter with a
long anti-Xa half-life of about 24 hours.
 There is no adverse fetal outcomes attributed to danaparoid.
1V.Fondaparinux;
 Fondaparinux should be reserved for women intolerant of heparin compounds.
 Fondaparinux use in pregnancy should be in conjunction with a consultant
haematologist with expertise in haemostasis and pregnancy.
 is a synthetic pentasaccharide that functions by inhibition of factor Xa via
antithrombin.
481
  has similar efficacy to LMWH. There is limited experience of its use in pregnancy
 Although no adverse effects were observed in the newborns, it is premature to
conclude that it is safe
V.Lepirudin;
 is a direct thrombin inhibitor that, like danaparoid, is used in the management of
patients with heparin-induced thrombocytopenia.
 it can cross the placenta and produce embryopathy and Its use is best avoided in
pregnancy unless there is no acceptable alternative.
V1.Low-dose aspirin;
 Aspirin is not recommended for thromboprophylaxis in obstetric
patients.
V1.Warfarin;
 Warfarin use in pregnancy is restricted to the few situations where
heparin is considered unsuitable, e.g. some women with mechanical
heart valves.
 Women receiving long-term anticoagulation with warfarin can be
converted from LMWH to warfarin postpartum when the risk of
haemorrhage is reduced, usually 5–7 days after delivery.
 warfarin crosses the placenta leading to congenital abnormalities including
warfarin embryopathy in 5% of fetuses exposed between 6 and 12 weeks
 this incidence is dose-dependent, with a higher incidence in women taking
> 5 mg/day.
 Other complications associated with warfarin include an increase in the
risk of;spontaneous miscarriage, stillbirth, neurological problems in the
baby and fetal and maternal haemorrhage.
 Warfarin is safe in breastfeeding
V11.Dextran;
 Dextran should be avoided antenatally and intrapartum because of the
risk of anaphylactoid reaction, which has been associated with uterine
hypertonus, fetal distress, fetal neurological abnormalities and death.

V111.Oral thrombin and Xa inhibitors;

 Non-vitamin K antagonist oral anticoagulants (NOACs) should be avoided in
pregnant women.

 Use of NOACs is not currently recommended in women who are

breastfeeding.

Anti-embolism stockings;
 The use of properly applied anti-embolism stockings (AES) of appropriate size and
providing graduated compression with a calf pressure of 14–15 mmHg is
recommended in pregnancy and the puerperium for women who are hospitalised
481
 and have a contraindication to LMWH. These include women who are hospitalised
post-caesarean section (combined with LMWH) and considered to be at particularly
high risk of VTE (e.g. previous VTE, more than four risk factors antenatally or more
than two risk factors postnatally) and women travelling long distance for more than
4 hours.

Contraindications to LMWH
Which women should not be given thromboprophylaxis with LMWH?
 LMWH should be avoided, discontinued or postponed in women at risk of bleeding
after careful consideration of the balance of risks of bleeding and thrombosis.

 Women with previous or current allergic reactions to LMWH should be offered an

alternative preparation or alternative form of prophylaxis.

 Further advice on the management of a woman with both VTE risk factors and
bleeding risk factors or LMWH allergy may be sought from a haematologist with
expertise in the management of thrombosis and bleeding disorders in pregnancy.

 Risk factors for bleeding are:

1. women with active antenatal or postpartum bleeding

2. women considered at increased risk of major haemorrhage (such as placenta
previa)
3. women with a bleeding diathesis, such as von Willebrand‟s disease, haemophilia
or acquired coagulopathy
4. women with thrombocytopenia (platelet count less than 75 x 109)
5. acute stroke in the last 4 weeks (ischaemic or haemorrhagic)
6. severe renal disease (glomerular filtration rate less than 30 ml/minute/1.73 m2)
7. severe liver disease (prothrombin time above normal range or known varices)
8. uncontrolled hypertension (blood pressure greater than 200 mmHg systolic or
greater than 120 mmHg diastolic).

Risk scoring methodologies

 A formal VTE risk assessment with numerical scoring for all pregnant and postpartum
women is recommended

482
Table 2. Estimated absolute risk of pregnancy-associated VTE with different thrombophilic defects in women
with one or more symptomatic first-degree relative
Postpartum Antenatal Pregnancy Thrombophilic defect
(%/pregnancy, (%/pregnancy, (%/pregnancy,
95% CI) 95% CI) 95% CI)
3.0 (1.3–6.7) 1.2 (0.3–4.2) 4.1 (1.7–8.3) Antithrombin, protein C or
protein S deficiency82
11–28 0–40 15–50 Antithrombin deficiency type
1 (range)83–87*
1.7 (0.7–4.3) 0.4 (0.1–2.4) 2.1 (0.7–4.9) V Leiden heterozygous82
1.9 (0.7–4.7) 0.5 (0.1–2.6) 2.3 (0.8–5.3) Prothrombin gene mutation
heterozygous82
1–10 0–5 1.8–15.8 V Leiden homozygous or
compound heterozygosity V
Leiden and prothrombin gene
mutation (range)88,89

483
Appendix III: Risk assessment for venous thromboembolism (VTE)
• If total score ≥ 4 antenatally, consider thromboprophylaxis from the first trimester.
• If total score 3 antenatally, consider thromboprophylaxis from 28 weeks.
• If total score ≥ 2 postnatally, consider thromboprophylaxis for at least 10 days.
• If admitted to hospital antenatally consider thromboprophylaxis.
• If prolonged admission (≥ 3 days) or readmission to hospital within the puerperium consider thromboprophylaxis.

For patients with an identified bleeding risk, the balance of risks of bleeding and thrombosis should be discussed in consultation
with a haematologist with expertise in thrombosis and bleeding in pregnancy.
Risk factors for VTE
Score Tick Pre-existing risk factors
4 Previous VTE (except a single event related to major surgery)
3 Previous VTE provoked by major surgery
3 Known high-risk thrombophilia
3 Medical comorbidities e.g. cancer, heart failure; active systemic
lupus erythematosus, inflammatory polyarthropathy or
inflammatory bowel disease; nephrotic syndrome; type I
diabetes mellitus with nephropathy; sickle cell disease; current
intravenous drug user
1 Family history of unprovoked or estrogen-related VTE in first-
degree relative
1a Known low-risk thrombophilia (no VTE)
1 Age (> 35 years)
1 or 2b Obesity
1 Parity ≥ 3
1 Smoker
1 Gross varicose veins
Obstetric risk factors
1 Pre-eclampsia in current pregnancy
1 ART/IVF (antenatal only)
1 Multiple pregnancy
2 Caesarean section in labour
1 Elective caesarean section
1 Mid-cavity or rotational operative delivery
1 Prolonged labour (> 24 hours)
1 PPH (> 1 litre or transfusion)
1 Preterm birth < 37+0 weeks in current pregnancy
1 Stillbirth in current pregnancy
Transient risk factors
3 Any surgical procedure in pregnancy or puerperium except
immediate repair of the perineum, e.g. appendicectomy,
postpartum sterilisation
3 Hyperemesis
4 OHSS (first trimester only)
1 Current systemic infection
1 Immobility, dehydration
TOTAL

484
485
486
Appendix IV: Summary of guideline for thromboprophylaxis in women with previous VTE and/or
thrombophilia (also see Appendix I)
Recommend antenatal high-dose LMWH
and at least 6 weeks’ postnatal LMWH or
until switched back to oral anticoagulant
therapy
These women require specialist
management by experts in haemostasis
and pregnancy
Recommend antenatal and 6 weeks’
postnatal prophylactic LMWH
Refer to local expert Consider antenatal
LMWH Recommend postnatal
prophylactic LMWH for 6 weeks
Consider antenatal LMWH (but not
routinely recommended) Recommend
LMWH from 28 weeks of gestation and 6
weeks’ postnatal prophylactic LMWH
Consider as a risk factor and score
appropriately (see Appendix III)
Recommend 10 days’ if other risk factor
postpartum (or 6 weeks’ if significant
family history) postnatal prophylactic
LMWH
Previous VTE on long-term oral Very high risk
anticoagulant therapy
Antithrombin deficiency
Antiphospholipid syndrome with previous
VTE
Any previous VTE (except a single VTE High risk
related to major surgery)
Asymptomatic high-risk thrombophilia Intermediate risk
homozygous factor V Leiden/compound
heterozygote Protein C or S deficiency
Single previous VTE associated with
major surgery without thrombophilia,
family history or other risk factors
Asymptomatic low-risk thrombophilia Low risk
(prothrombin gene mutation or factor V
Leiden)

Table 3. Suggested thromboprophylactic doses for antenatal and postnatal LMWH

Tinzaparin (75 u/kg/day) Dalteparin Enoxaparin Weight
3500 units daily 2500 units daily 20 mg daily < 50 kg
4500 units daily 5000 units daily 40 mg daily 50–90 kg
7000 units daily* 7500 units daily 60 mg daily* 91–130 kg
9000 units daily* 10 000 units daily 80 mg daily* 131–170 kg
75 u/kg/day* 75 u/kg/day 0.6 mg/kg/day* > 170 kg
4500 units 12 hourly 5000 units 12 hourly 40 mg 12 hourly High prophylactic dose for
women weighing 50–90 kg

487
THE ACUTE MANAGEMENT OF THROMBOSIS AND EMBOLISM
DURING PREGNANCY AND THE PUERPERIUM
Introduction and background
 The subjective clinical assessment of PE and DVT in pregnancy is unreliable,
and only a minority of women will have a diagnosis confirmed objectively
 The prevalence of ultimately diagnosed PE in pregnant women with suspected
PE is 2-6%
 The majority of women with VTE in pregnancy have clinical symptoms
 DVT – leg pain and swelling (usually unilateral), lower abdominal pain
(extension of thrombus into pelvic vessels and/or development of collateral
circulation)
 PE – dyspnoea, chest pain, haemoptysis and collapse
 Low grade pyrexia and leucocytosis can occur with VTE

Diagnosis of acute VTE

 Any woman with symptoms and/or signs suggestive of VTE should have
objective testing performed expeditiously and treatment with LMWH given until
the diagnosis is excluded by objective testing, unless treatment is strongly
contraindicated
 If DVT remains untreated 15-24% of these patients will develop PE
 PE during pregnancy may be fatal in almost 15% of patients, and in 66% of
these, death will occur within 30mins of the embolic event
 Hospitals should have an agreed protocol for the objective diagnosis of
suspected VTE during pregnancy – this may involve obstetricians, radiologists,
physicians and haematologists
Compression duplex ultrasound should be undertaken where there is clinical
suspicion of DVT
 If ultrasound is negative and there is low level of clinical suspicion,
anticoagulant treatment can be discontinued
 If ultrasound is negative and there is a high level of clinical suspicion,
anticoagulant treatment can be discontinued but the ultrasound should be
repeated on days 3 and 7
 If repeat testing is negative, no further treatment is required
 If repeat testing confirms the presence of DVT, anticoagulant treatment
should be recommenced and continued
 The sensitivity of serial compression ultrasonography with Doppler imaging was
94.1%, the NPV was 99.5% and negative likelihood ratio 0.068
 When iliac vein thrombosis is suspected (back and buttock pain and swelling
of the entire limb), Doppler of the iliac vein, magnetic resonance venography
or conventional contrast venography may be considered

488
 Women presenting with symptoms and signs of an acute PE should have an
ECG and chest X-ray performed (ABG is of limited diagnostic value)
 ECG can be abnormal in 41% of women with acute PE
 T Wave inversion – 21%
 S1Q3T3 pattern – 15%
 Right bundle branch block – 18% during pregnancy, 4.2% in the puerperium
 CXR may identify other pulmonary disease such as pneumonia, pneumothorax or
lobar collapse
 Abnormal features due to PE include: atelectasis, effusion, focal opacities,
regional oligaemia or pulmonary oedema
 Women with suspected PE and symptoms and signs of DVT should have
bilateral compression duplex ultrasound performed
 If this confirms DVT then no further investigation is necessary and treatment for
VTE should continue (limits radiation dose to mother and fetus)
 Women with suspected PE without signs and symptoms of DVT should have a
V/Q scan or CTPA performed
 When the chest X-ray is abnormal, CTPA should be performed in preference to a
V/Q scan
 Alternative or repeat testing should be carried out where V/Q scan or CTPA is
normal but the clinical suspicion of PE remains, with anticoagulant treatment
continuing until PE is excluded definitively
 CTPA more readily available, lower radiation to fetus, can identify other pathology
(pneumonia 5-7%, pulmonary oedema 2-6%, and rarely aortic dissection)
 Women with suspected PE should be advised that, compared with CTPA, V/Q
scanning may carry a slightly increased risk of childhood cancer but is associated
with a lower risk of maternal breast cancer; in both situations the absolute risk is
very small
 The ventilation component of the V/Q scan can be omitted thereby minimising
the radiation dose for the fetus
 With both techniques the doses are well below accepted thresholds for
teratogenicity, fetal death and fetal growth restriction
 CTPA carries a relatively high radiation dose to mother‟s breast tissue which is
associated with an increased risk of breast cancer
 The dose is 20-100 times greater than for V/Q scan
 Dependent on breast size, technique used and maternal age – risk of cancer
greater in younger women
 Breast tissue is especially sensitive to radiation exposure during pregnancy
because of hormonally induced increased glandular activity
 The breast doses can be reduced by 20-40% by using bismuth shields placed
over the breasts
 There is a theoretical risk of neonatal hypothyroidism in babies exposed in utero
to iodinated contrast medium – not been shown in studies
 Women should be involved in the decision to undergo either test, where possible,
and informed consent should ideally be obtained

489
 D-dimer testing should not be performed in the investigation of acute VTE in
pregnancy
 There is a progressive rise in D-dimer levels with advancing gestation,
becoming „abnormal‟ at term and in the postnatal period, in healthy women
 It is increased further in multiple pregnancies, post C-section and major PPH
and pre-eclampsia
 A negative D-dimer is inadequate to exclude PE in pregnancy
 There is no evidence to support the use of pre-test probability assessment
(Wells score) in the management of acute VTE in pregnancy
Baseline blood investigations
 Blood should be taken for full blood count, coagulation screen, urea and
electrolytes, and liver function tests prior to anticoagulant therapy
 Performing a thrombophilia screen is not recommended
 In the non-pregnant, the presence of thrombophilia does not alter
management of acute VTE
 In pregnancy protein C, protein S and anti-thrombin levels may fall, as well as
an acquired activated protein C resistance (approx. 40% of pregnancies)
Initial anticoagulant treatment of VTE in pregnancy

491
 In clinically suspected DVT/PE, treatment with LMWH should be commenced
immediately until the diagnosis is excluded by objective testing, unless treatment
is strongly contraindicated
 Does not cross the placenta
 Not associated with increased risk of PPH
 Reduced risk of heparin induced thrombocytopenia (HIT)
 Reduced risk of osteoporosis
 LMWH should be given in doses titrated against the woman‟s booking or early
pregnancy weight
 There should be clear local guidelines for dosage
 Lower doses should be used if creatinine clearance less than 20 - 30ml/minute
 Routine measurement of peak anti-Xa activity is not recommended except in
women at extremes of body weight (<50kg and 90kg or more) or with other
complicating factors – renal impairment or recurrent VTE
 Routine platelet count monitoring should not be carried out
 Obstetric patients who are postoperative and receiving UFH should have platelet
count monitoring performed every 2-3 days from days 4 – 14 or until heparin is
stopped
 Collapsed, shocked women who are pregnant or in the puerperium should be
assessed by a team of experienced clinicians including the on-call consultant
obstetrician
 CPR should be performed in the left lateral position
 Aperi-mortem caesarean section should be performed by 5 minutes if
resuscitation is unsuccessful and the pregnancy is more than 20/40
 Women should be managed on an individual basis regarding: IV UFH,
thrombolytic therapy or thoracotomy and surgical embolectomy
 Management should involve a multidisciplinary team including senior physicians,
obstetricians and radiologists
 Intravenous UFH is the preferred, initial treatment in massive PE with
cardiovascular compromise
 The on-call medical team should be contacted immediately, urgent portable
echocardiogram or CTPA within 1 hour of presentation should be arranged.

491
  If massive PE is confirmed, or in extreme circumstances prior to confirmation,
immediate thrombolysis should be considered

ADDITIONAL THERAPIES
 In the initial management of DVT, the leg should be elevated and a graduated
elastic compression stocking applied to reduce oedema, mobilisation should be
encouraged
 Consideration should be given to the use of temporary inferior vena cava filter
(IVC) in the peripartum period for patients with iliac vein VTE to reduce the risk
of PE or in patients with proven DVT and who have recurrent PE despite
adequate anticoagulation
 Main complications of IVC filters are migration, increased risk of lower limb
DVT and caval thrombosis, and rarely, infection

MAINTENANCE TREATMENT OF VTE

 Treatment with therapeutic doses of subcutaneous LMWH should be employed
during the remainder of the pregnancy and for at least 6 weeks postnatally and
until at least 3 months of treatment has been given in total
 Women should be taught to self-inject LMWH and arrangements made to allow
safe disposal of needles and syringes. Outpatient follow-up should include
clinical assessment and advice with monitoring of blood platelets and peak anti-
Xa levels if appropriate (0.5-1.2 u/ml, 3 hours post-injection)
 Pregnant women who develop HIT or have heparin allergy and require
continuing anticoagulant therapy should be managed with an alternative
anticoagulant (e.g. danaparoid) under specialist advice
 Because of their adverse effects on the fetus, vitamin K antagonists, such as
warfarin, should not be used for antenatal VTE treatment
 Consideration should be given to the use of newer anticoagulants
(fondaparinux, argatroban or r-hirudin) in women who are unable to tolerate
heparin or danaparoid and who require continuing anticoagulant therapy
 NOACs should be avoided in the antenatal period

ANTICOAGULANT THERAPY DURING LABOUR AND DELIVERY

 When VTE occurs at term, consideration should be given to the use of IV
unfractionated heparin
 Women on LMWH for maintenance therapy should be advised not to inject any
further heparin once in established labour
 LMWH should be discontinued 24 hours prior to a planned delivery
 Subcutaneous unfractionated heparin should be discontinued 12 hours before
planned delivery
 Intravenous unfractionated heparin should be discontinued 6 hours before
planned delivery
 Regional anaesthetic should not be undertaken until at least 24 hours after the
last dose of therapeutic LMWH

492
 
LMWH should not be given for 4 hours after spinal, or after the epidural catheter
has been removed – this should not be removed within 12 hours of the most
recent injection
 A thromboprophylactic dose of LMWH should be given 4 hours postoperatively
and the treatment dose recommenced 8-12 hours later
 In patients receiving therapeutic doses of LMWH, wound drains should be
considered at caesarean section and the skin incision should be closed with
interrupted sutures to allow drainage of any haematoma
 Incidence of wound haematoma – 9.1%
 Any woman who is considered to be high risk of haemorrhage should be
managed with IV UFH until the risk factors for haemorrhage have resolved
How should massive life-threatening PTE in pregnancy be managed?
 Intravenous unfractionated heparin is the preferred treatment in massive PTE with
cardiovascular compromise.
 urgent portable echocardiogram or CTPA within 1 hour of presentation should be
arranged.
 If massive PTE is confirmed or, in extreme circumstances prior to confirmation,
immediate thrombolysis should be considered.
 Management should involve a multidisciplinary resuscitation team including senior
physicians, obstetricians and radiologists.
 loading dose of 80 units/kg, followed by a continuous intravenous infusion of 18
units/kg/hour
 if a woman has received thrombolysis, the loading dose of heparin should be
omitted and an infusion started at 18 units/kg/hour
 it is mandatory to measure activated partial thromboplastin time (APTT) 4–6
hours after the loading dose, 6 hours after any dose change and then at least
daily when in the therapeutic range(therapeutic target 1.5–2.5).
 APTT monitoring of unfractionated heparin is technically problematic in late
pregnancy when an apparent heparin resistance occurs because of increased
fibrinogen and factor VIII This can lead to unnecessarily high doses of heparin
being used
 It may be useful to determine the anti-Xa level as a measure of heparin dose.

POSTNATAL ANTICOAGULATION
 Women should be offered a choice of LMWH or oral anticoagulant for postnatal
therapy after discussion about the need for regular blood tests for monitoring of
warfarin, particularly during the first 10 days of treatment
 Postpartum warfarin should be avoided until at least the 5th day and for longer in
women with increased risk of PPH

493
 Neither heparin or warfarin are contraindicated in breastfeeding
 Prolonged use of LMWH (>12 weeks) is associated with a significantly lower
chance of developing post-thrombotic syndrome
 Persistent leg swelling, pain, a feeling of heaviness, dependant cyanosis,
telangiectasis, chronic pigmentation, eczema, varicose veins, venous ulceration
 The role of compression stockings in the prevention of post thrombotic syndrome
is unclear
 Postnatal review for patients who develop VTE during pregnancy or the
puerperium should be at an obstetric medicine clinic or a joint obstetric
haematology clinic
 Thrombophilia testing should be performed once anticoagulant therapy has been
discontinued, only if the results would influence future management ,

494
VENOUS THROMBOEMBOLISM AND HORMONE REPLACEMENT THERAPY
Introduction
 there is an increased relative risk of VTE in women on estrogen-containing HRT.
 On the available evidence, risk of VTE may relate only to oral and not to
transdermal HRT.
 There are more than 50 (HRT) preparations.
Types of oestrogen-based HRT:
 Oestrogen alone in hysterectomized women.
 Oestrogen plus progestogen in nonhysterectomized women:
 Oestrogen and cyclical progestogen in perimenopausal women.
 Contineous combined oestrogen-progestogen(no bleed HRT) in postmenopausal
women.
 Routes of administration of oestrogen:
 Oral
 Transdermal
 Subcutaneous.
 Vaginal.
Routes of administration of progestogen:
 Oral
 Transdermal
 Intrauterine (levonorgestrel.)
Oestrogen:
 Include estradiol, estrone, and estriol.
 Chemically synthesized from soya beans.
 2types, stratified and conjugated equine oestrogens.
Progestogen:
 Chemically synthesized from plant sources.
2types:
 71-hydroxyprogesterone
 Dydrogesterone
 Medroxy progesterone acetate.
 71-northesterone derivatives:
 Northesterone.
 lvonorgestrel.
Other hormones used at the menopause:
 Tibolone.
 Testosterone.
Side effects of systemic HRT:
 Oestrogen related:
 Headaches.
 Breast tenderness or enlargement.
 Fluid retention.
 Bloating, nausea, dyspepsia.
 Leg cramps.
 Progestogen-related:
 Headaches, migraine, moode swings and depression.
 Acne.
495
  Breast tenderness or enlargement.
 Lower abdominal pain.
Combined HRT:
 Irregular breakthrough bleeding.
Benefits of HRT:
 Decreased Vasomotor symptoms (hot flushes).
 Decreased Urogenital symptoms and improved sexuality.
 Decreased risk of osteoporosis.
 Decreased risk of colorectal cancer.
Risks of HRT:
 Increased risk of breast cancer, more with combined HRT.
 Increased risk of endometrial cancer with unopposed oestrogen, no risk with
combined HRT.
 Increased risk of VTE.
 Increased risk of gallbladder disease
What are the changes in coagulation factors associated with HRT?
 The mechanism whereby oral HRT provokes an increased risk of VTE is unclear.
 by the menopause, with increases in a number of coagulation factors which are
known to be associated with vascular risk.
 There is an overall enhancement of fibrinolytic potential in those taking
HRT(reduction in fibrinogen and a reasonably decrease in plasminogen activator
inhibitor-1 levels.
 HRT may reduce factor VII levels.
 By contrast, oral HRT also reduces plasma levels of the natural anticoagulant
protein S.
 HRT is associated with acquired activated protein C resistence(APCR). Inherited
APCR is associated with factor V Leiden (FVL) mutation
 the oral preparations of HRT undergo first-pass hepatic metabolism and therefore
have a greater effect on factors produced by the liver than transdermal
preparations, which avoid the first-pass effect.
How should VTE risk be approached when HRT is being considered?
 All women commencing HRT should be counseled about the risk of VTE and the
signs and symptoms of VTE.
 All women should be advised to access medical help rapidly if they suspect a
thrombosis.
 there is some evidence that different HRT preparations may result in different VTE
risks.
 transdermal therapy carries a lower risk of VTE than oral therapy, but the numbers
studied have been small.
 six studies all show non-significant risks associated with transdermal preparations
Do HRT type and duration influence VTE risk?
 The risks of VTE in association with HRT may be influenced by the type of
preparation and the duration.
 There is a greater risk in the 1st year of use than in subsequent years.
 no evidence of continuing risk on stopping HRT.
 there is a substantially lesser risk with transdermal compared with oral
preparations.
 the overall VTE risk with combination preparations may be influenced by the type of
progestogen used.
496
The influence of estrogen type:
 The risk of VTE may be less with esterified estrogens compared with conjugated
equine estrogen.
 there is still evidence of a significant VTE risk with both types of estrogen.
The effect of combination HRT:
 There may be a greater risk of VTE with combination therapy and definitive
information on individual estrogen types is still lacking.
 However, the results to date suggest that therapy with estrogen alone is associated
with a significant VTE risk.
The influence of progestogen type:
 Comparing a combined preparations containing micronised progesterone,
pregnane derivatives (dydrogesterone, medrogestone, chlormadinone acetate,
cyproterone acetate and MPA) and norpregnane derivatives (nomegestrol acetate
and promegestone.)
 micronised progesterone and pregnane derivatives may carry a lower thrombotic
risk compared with norpregnane derivatives.
 These data need to be confirmed in further studies ,specific data also required on
the VTE risk associated with newer progestogens such as drospirenone.
VTE relationship to estrogen dose:
 There is some evidence that the effect of estrogen therapy may be dose related.
 no significant VTE risk associated with doses of oral estrogen of around 0.3 mg.
 a higher VTE risk with estrogen doses of ~1.25 mg or more.
Transdermal preparations:
 Transdermal preparations are associated with a substantially lower risk of VTE than
oral preparations.
Duration of therapy:
 The risk of VTE is highest in the 1st year of HRT use(specially in the first 6 months).
 no evidence of continuing risk on stopping HRT.
Past use of HRT:
 no significant pooled VTE risk with those who had used oral estrogen HRT in the
past.
What is the role of screening for heritable thrombophilia when assessing the VTE risk
associated with HRT?
 Universal screening of women for thrombophilic defects before prescribing or
before continuing the prescription of HRT is inappropriate.(costly)
 The absolute risk of VTE with HRT is, however, low.
 In women without a personal history of VTE but with a high-risk thrombophilic trait
(such as deficiency of antithrombin, protein C or protein S) that has been identified
through screening because of a symptomatic family member, oral HRT should be
avoided and specialist advice sought. evidence indicates around an overall eight-
fold increase in riskof VTE.
 An assessment of other risk factors for VTE should be made .
 In the presence of multiple risk factors, HRT should be avoided.
How should HRT be managed in those with a previous VTE?
 A personal history of thrombosis is a contraindication to oral HRT.(a five-fold higher
risk of recurrent VTE(
 If it is considered that quality of life is so severely affected that the benefits of HRT
outweigh the risks, a transdermal preparation should be used.
How should HRT be managed in those who develop VTE while receiving HRT?
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  It is recommended that, when a woman who is on HRT develops a VTE, HRT
should be discontinued.
 If it is considered desirable that a woman should continue HRT after a VTE has
occurred on therapy, she should be referred to a clinician with special expertise in
managing women at increased thrombotic risk requiring HRT.
 As further VTE may be prevented by anticoagulation, consideration can be given to
postponing the withdrawal of HRT until the woman is due to stop anticoagulant
therapy for her VTE.
What other risk factors should be considered when assessing the risk of VTE associated
with HRT?
 Before commencing HRT, any personal or family history of VTE should be
assessed.
 A history of VTE in a first-degree relative (i.e. parent, sibling or offspring) is a
relative contraindication to HRT, alternatives to oral HRT should be suggested.
 If HRT is considered desirable, transdermal preparations are associated with a
significantly lower risk of venous thrombosis.
 HRT should be avoided in women with multiple pre-existing risk factors for VTE.

What other assessments should be considered in those presenting with VTE?

 In women over 50 years of age with a history of VTE within the previous year, a full
clinical history and examination are warranted to detect underlying disease.
 The need for any additional investigations should be determined by the clinical
assessment.
 VTE may be precipitated by an underlying malignancy or connective tissue disease,
so it is important to consider such diagnoses when assessing women with recent
(particularly unprovoked) VTE.
How should HRT be managed in those requiring surgery?
 Each woman requires an individual assessment of the risks and benefits of
stopping HRT before elective surgery.
 the British National Formulary and the National Institute for Health and Clinical
Excellence advise women to consider stopping HRT 4 weeks before elective
surgery.
 HRT may not need to be stopped before surgery provided that appropriate
thromboprophylaxis is used.

498
VTE AND HORMONAL CONTRACEPTION
Do combined hormonal methods of contraception increase the risk of VTE?
 The relative risk of venous thromboembolism is increased with all combined
contraceptives.
 The relative risk of venous thromboembolism increases in the first few months after
initiating combined hormonal contraceptives.
 This risk reduces with increasing duration of use but it remains above the background
risk until the combined hormonal contraceptive is stopped.
 Although much of the data on VTE risk and combined hormonal contraception is based
on studies of oral methods the risk of VTE is considered to be the same for all hormonal
contraceptive methods regardless of the mode of administration
Combined oral contraception:
 combined oral contraceptives containing gestodene or desogestrel (third-generation pills)
had a two-fold increase in the risk of VTE compared with those containing norethisterone
or levonorgestrel (second-generation pills.(
 for women using combined oral contraceptives containing desogestrel or gestodene
reducing the ethinylestradiol dose to 20 micrograms reduced the VTE risk by 18%.
 A more recent Europe-wide surveillance study (EURAS) found a two-fold increase in the
relative risk of VTE with combined oral contraceptive use compared with non-use.
 No difference in risk was identified between any brand of combined oral contraceptive,
regardless of the progestogen (including those containing drospirenone.(
Cyproterone acetate-containing combined oral contraception:
 Used as second-line treatment for severe acne or moderate to severe hirsuitism.
 There is some evidence that the use of this contraceptive is associated with a four-fold
increase in the risk of VTE
 Risk table for combined oral contraceptive (COC) users and the risk of venous
thromboembolism (Committee on Safety of Medicine data from 1999).

 Risk table for combined oral contraceptive (COC) users and the risk of venous
thromboembolism (EURAS data from 2007)

Duration of use

499
 The risk of VTE is highest in the 4 months following initiation of combined hormonal
contraception.
 The risk reduces and remains stable thereafter and remains higher than that of non-
users until the contraceptive is stopped
Do progestogen-only methods of contraception increase the risk of venous
thromboembolism?
 Progestogen-only pills, injectable, implants progestogen-only emergency contraception
(levonorgestrel 1.5 mg)and the levonorgestrel-releasing intrauterine system do not
appear to be associated with an increased risk of venous thromboembolism.
What conditions which may increase the risk factors of VTE?
Definitions of UK Medical Eligibility Criteria categories for contraceptive use:

 A clinical history should identify any conditions which fall within the categories 3 or 4 for
use of hormonal contraception.
 Since progestogen-only methods do not increase the risk of VTE most of the risk
assessment relates to combined contraceptive use.
Current or previous VTE:
 Women with current venous thromboembolism or previous venous thromboembolism
should be advised against the use of combined hormonal contraception as this poses an
unacceptable health risk. (UKMEC 4, unacceptable health risk).
 For women with current venous thromboembolism on anticoagulants or previous venous
thromboembolism the use of progestogen-only contraception is safe outweighs any risks.
(UKMEC 2).
 Although there is a small risk of haematoma with use of progestogen-only implant or
injectable in women using anticoagulants, the risk is small.
 The levonorgestrel intrauterine system can be used to manage menorrhagia associated
with anticoagulant use.
Family history:
 The use of combined hormonal contraception by women with a family history of VTE in a
first-degree relative aged under the age of 45 years is not recommended. the risks
outweigh the benefits(UKMEC 3).
 Progestogen-onlymethods may be used regardless of family history.
Known thrombogenic mutations:
 For women with a known thrombogenic mutation the use of combined hormonal
contraception poses an unacceptable health risk (UKMEC 4).
 Women with reduced levels of naturally occurring anticoagulant (anti-thrombin III, protein
C orprotein S) or factor V Leiden who use combined oral contraceptives have up to a
five-fold increase the risk of VTE with combined oral contraceptive use.
 Women with factor V Leiden can have up to a 35-fold increase in the risk of VTE with
combined oral contraceptive use.
 Progestogen-only methods do not increase the risk of VTE and these methods can be
used without further increasing the risk of VTE.
Post-pregnancy use:
511
 For women who are postpartum and not breastfeeding, combined hormonal
contraception (pill, patch or vaginal ring) should not be initiated before day 21
postpartum(fibrinolytic factors have not returned to their Prepregnancy state).
 the risks of using combined hormonal contraception before day 21 postpartum usually
outweigh the benefits (UKMEC 3).
 progestogen-only methods can be started any time postpartum as they do not pose an
increased risk.
 All hormonal contraception can be safely initiated immediately following a first- or
second-trimester termination of pregnancy.
Smoking:
 For women aged over 35 years who are current smokers or who have stopped smoking
less than 1 year ago, the use of combined hormonal contraception is not
recommended(UKMEC 3 for women who light smoker UKMEC 4 for women heavy
smoker).
 Most data on smoking and thrombosis relate to arterial rather than venous thrombosis
(myocardial infarction).
 The use of combined hormonal contraception in heavy smokers (more than 15
cigarettes/day)appears to increase the risk 20 fold.
 The risks of stroke, myocardial infarction and VTE increase with increasing age and
mortality from cigarette smoking increases from age 35 years.
Obesity:
 For women with a body mass index of 35 kg/m or greater, the risks of combined
hormonal contraception may outweigh the benefits.
 Combined oral contraceptive users who are obese have a five to-eight fold increased risk
of VTE.
 obesity I (BMI 30.0–34.9 kg/m²), the benefits of using combined hormonal contraception
generally outweigh the risks (UKMEC 2).
 obesity II (BMI 35.0–39.9 kg/m²) and obesity III (BMI 40 kg/m² or more) the risks of
combined hormonal contraception may outweigh the benefits (UKMEC 3).
 Progestogen-only contraception may be used safely regardless of weight.
Surgery and other conditions leading to immobilisation:
 Combined hormonal contraception should be discontinued and an alternative estrogen-
free method used at least 4 weeks before major elective surgery where immobilisation is
expected(UKMEC 4).
 does not need to be discontinued before minor surgery without immobilisation(UKMEC
2).
 progestogen-only methods does not increase the risk of VTE and does not need to be
discontinued before surgery.
Other conditions which may predispose to venous thromboembolism:
 Women with inflammatory bowel disease are not at an inherent increase in risk of VTE
and should be offered the same contraceptive choices as other women.
 In women who are immobilised owing to disease exacerbation or major surgery,
however, stopping combined hormonal contraception and providing an alternative
method of contraception is recommended.
 Women with varicose veins(UKMEC category 1 unrestricted use) and superficial
thrombophlebitis(UKMEC category 2) are not at an increased risk of VTE and can use
any method of contraception.
 In Sickle-cell disease comparing hormonal (combined and progestogen-only) and barrier
contraception showed no significant difference in haemostatic variables.
 There is a reduction in painful sickle-cell crises with use of a progestogen-only Injectable.
 Use of combined hormonal contraception by women with SLE and positive
antiphospholipid antibodies poses an unacceptable health risk (UKMEC 4).
511
 A UKMEC category 3 is given for use of progestogen-only methods of contraception for
women with SLE and positive or unknown antiphospholipid antibodies
Is screening for thrombophilia recommended before prescribing hormonal
contraception?
 Routine thrombophilia screening prior to hormonal contraceptive use is not
recommended.
 Most episodes of VTE occur in women who do not have a thrombogenic mutation.

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THEMANAGEMENT OF VULVAL SKIN DISORDERS
Introduction and background
 1/5 of women have significant vulval symptoms.
 In the hospital setting, common causes are dermatitis, lichen simplex, vulval candidiasis,
lichen sclerosus and lichen planus.
 Lichen sclerosus accounts for 25% of the women seen in vulval clinics, with incidence as
1/ 300-1/1000 of all patients referred to dermatology departments.
What information needs to be included in history taking and examination when women
are referred to the gynaecology clinic with symptoms and/or signs of a vulval skin
disorder to aid investigation and management?
 A standard gynaecological history will not identify all relevant symptoms.
 The history taken from a women presenting with vulval symptoms needs to explore
symptoms at other skin sites, medical and drug history and family history.
 The history should include details of any personal or family history of autoimmune
conditions.
 Women with lichen sclerosus and erosive lichen planus are at increased risk of a
personal or family history of autoimmune disorders.
 The most common autoimmune conditions in women with lichen sclerosus are
thyroid disorders, alopecia areata, pernicious anaemia, type 1 diabetes and vitiligo.
 The reported prevalence of autoimmune conditions in first-degree relatives is around
30%.
 However, vesiculobullous autoimmune diseases at anogenital sites are uncommon.
 The history should include details of any personal or family history of atopic conditions
(hay fever, asthma, eczema).
 The history should include any symptoms of urinary or faecal incontinence.
 Women with vulval skin disorders require systematic examination of the anogenital
region and other skin and mucosal sites.
 It is important to systematically examine the vulva with adequate light and legs raised
into a modified lithotomy position.
 Colposcopy is not necessary.
 It is important to ask the woman to identify the symptomatic area.
 If VIN is suspected, it is important to examine other lower genital tract sites including
the vagina, cervix and perianal skin.
 It is important to examine the rest of body, including the mouth, for signs of lichen
planus and the scalp, elbows, knees and nails for psoriasis. Eczema may be seen at
any site.
Which investigations are useful in the investigation of a woman with a vulval skin
disorder?
 In the initial assessment of awoman with vulval symptoms, consider testing for thyroid
disease, diabetes and sexually transmitted infections if clinically indicated.
 Skin biopsy is not necessary when a diagnosis can be made on clinical examination.
 Biopsy is required if woman fails to respond to treatment or there is suspicion of VIN or
cancer
 Women suspected of having lichen sclerosus or lichen planus should be investigated for
other autoimmune conditions if there are clinical symptoms or signs.
 Serum ferritin should be checked in women with vulval dermatitis.
What is the role of skin patch testing in the investigation and management of women with vulval
dermatoses?
 Skin patch testing should be performed for women seen with vulval dermatitis.
513
  26–80% of women referred with vulval symptoms have at least one positive result on
patch testing. The most common relevant allergens are cosmetics, medicaments
and preservatives. Others include fragrances, preservatives in topical treatments,
rubber and textile dyes.Washing powder, fabric conditioners, sanitary towels or
panty liners and synthetic underwear may also be irritants.
How should lichen sclerosus and lichen planus be managed?
 Ultrapotent steroids are important in the management of women diagnosed with lichen
sclerosus and lichen planus.
 The patient and her general practitioner require clear advice on the management regime
 Corticosteroids have anti-inflammatory and immunosuppressive properties
 Clobetasol propionate is the most potent topical corticosteroid available.Women
under the age of 50 years had the highest response rates.
 Relapse is common: 84% of women experience a relapse within 4 years.
 Higher response rates are seen with longer regular use before returning to „as
required‟ use.
 Clobetasol propionate appears to be effective and safe in premenarchal girls.
 You should apply your clobestasol cream/ointment sparingly (this means half to one
finger tip) to the affected area(s).These are the areas where you notice
itch/discomfort or changes in the skin.Apply the cream:
1. once daily for 1 month
2. then on alternate days for 1 month
3. then twice a week for 1 month
4. then once a week for 1 month
5. then gradually reduce this until you can use it occasionally or not at all.
 Approximately 4–10%of women with anogenital lichen sclerosus will have symptoms that
do not improve with topical ultrapotent steroids (steroid-resistant disease).
 The recommended second-line treatment is topical tacrolimus under the supervision of a
specialist clinic.
 Tacrolimus and pimicrolimus belong to the class of immunosuppressant drugs known
as calcineurin inhibitors. Mainly reducing inflammation by suppressing T-lymphocyte
responses.maximal effects were seen after 10–24 weeks of treatment and 77% of
women had a full or partial response.
 Surgery and CO2 laser vaporisation are not recommended for the treatment of
symptoms of lichen sclerosus. However, these treatments have a role in restoring
function impaired by agglutination and adhesions such as urinary retention or narrowing
of the vaginal introitus that affect sexual function or body image.
8.How should VIN be managed?
 The gold standard for the treatment of VIN is local surgical excision.
 Simple vulvectomy and radical vulvectomy are inappropriate surgical treatments
owing to their adverse effects on sexual function and body image.
 Local excision is adequate with the same recurrence rates and provides a specimen
for histological diagnosis.
 Complete response rates are higher with excision than with ablative or medical
treatment techniques.
 The risk of recurrence is lower with surgical margins free from disease.
 Women undergoing surgical excision of VIN should have access to reconstructive
surgery.
 Primary closure following excision of small lesions of VIN can produce good results
without tension, scarring or disruption to normal anatomy.
 With larger lesions, multifocal lesions or certain anatomical sites, scarring and
tension can result in pain and psychosexual morbidity.
 Non-surgical treatments are accepted as an alternative to surgery, but women require
regular, long-term follow-up.
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  Topical imiquimod cream is licensed for the treatment of genital warts, but there is
15–81% clinical and histological response rate to the imiqimod regime used two to
three times per week. Adverse effects include pain, erythema and swelling and can
result in non-compliance.
 Cidofovir is also used in the treatment of genital warts and has shown clinical and
histological responses in women with VIN.
 Laser ablation has been shown to be effective in case series.Treatment failure rates
are in the order of 40%, but laser ablation is not suitable for hair-bearing skin owing
to the involvement of skin appendages
What non-specific measures and advice are useful in the control of vulval symptoms?
 A key part of management is general care of the vulval skin and avoidance of any
potential irritants that may worsen vulval irritation.
 Emollients are widely recognised as having a key role in protecting the skin and
restoring skin barrier function.
 Avoiding potential irritants that may worsen vulval symptoms.
 Avoiding soap and detergents and using soap substitutes can be soothing and
protective to the skin.
 It is important to enquire about over-the-counter preparations that may aggravate skin
conditions.
Do women with vulval skin disorders need to remain under long-term surveillance at
the gynaecology clinic?
 Women with VIN need to be seen on a regular basis for vulvoscopy or careful clinical
assessment and biopsy of any suspicious area.
 Women who have been treated for VIN are at risk of intraepithelial neoplasia at other
sites. Colposcopy examination should be available at follow-up.
 There is no evidence that follow-up of women with lichen sclerosus needs to be hospital
based.
 Women with lichen sclerosus and lichen planus appear to have a lifetime risk of
developing invasive vulval cancer in the order of 2–4%.
 Estimating the risk of squamous cell cancer among women with vulval dermatoses is
difficult
 Women with lichen sclerosus and differentiated VIN are recognised as a high-risk
group and should be kept under specialist review.
 It has been suggested that women with genital lichen planus also have a risk of
vulval cancer; however, the number of case reports is too low to confirm if there is a
risk associated with this condition per se and best practice is to recommend self-
surveillance.
How should sexual problems associated with vulval skin disorders be identified and, if
identified, what is the most effective approach to their management?
 Women should be asked about the impact of their vulval disorder on sexual function and
appropriate advice and care should be available.
 Advice on sexual behaviour should include the importance of arousal and the use of
lubrication.
 Psychosexual counselling is a specialist service and referral should be available.
 It is also important to recognise that treatment of vulval disorders can have a
negative as well as a positive impact on sexual function.
What is the role of self-examination and what information should women be given on
this?
 Women with vulval symptoms should be encouraged to perform self-examination to
monitor their skin condition and any suspicious areas.
What training should general gynaecologists have in the management of vulval
disorders?
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 According to the RCOG core curriculum, obstetrics and gynaecology trainees must have
knowledge and experience of the management of common vulval disorders as a training
requirement.
What is the most effective model for care provision for the investigation and
management of women with vulval skin disorders?
 Women with complex or rare vulval skin disorders or who do not respond to standard
treatment should be seen at a specialist vulval clinic.
EXECUTIVE SUMMARY
 Pruritus vulvae and vulval pain are very common complaints and most women initially
self-medicate.
 Although it is often self-limiting, chronic vulval pruritus suggests an underlying vulval
dermatosis.
 Careful and systemic examination is fundamental to making a diagnosis.
 Skin biopsies are not always necessary but are essential if VIN or invasive disease is
suspected or if the condition does not respond to treatment.
 General care of vulval skin is a fundamental component of treatment.
 Avoidance of potential irritants will benefit most conditions.
 The mainstay of the management of lichen sclerosus is topical ultrapotent steroids.
 Women require clear advice on the appropriate treatment regimes.
 Women with VIN require a biopsy to confirm disease.
 Long-term surveillance is necessary, particularly when a medical or conservative
approach to management is taken.
 All gynaecological trainees require experience in the management of common skin
disorders, but a specialist service improves care for women by improving the accuracy of
diagnosis and the implementation of adequate and appropriate treatment.
VULVAL SKIN DISORDERS
Common vulval skin disorders
Lichen sclerosus
 Anogenital lichen sclerosus can present at any age,but is more commonly seen in
postmenopausal women.
 It causes severe pruritus,which may be worse at night.
 The whole vulval perianal area may be affected in a figure-of-eight distribution.
 Uncontrollable scratching may cause trauma with bleeding and skin splitting and
symptoms of discomfort,pain and dyspareunia.
 Lichen sclerosus is not linked to female hormone changes, contraceptives, hormone
replacement therapy or the menopause.
 Evidence suggests that it is an autoimmune condition, with around 40% of women with
lichen sclerosus having or going on to develop another autoimmune condition.
 Pruritus is related to active inflammation with erythema and keratinisation of the vulval
skin.
 Hyperkeratosis can be marked with thickened white skin.
 The skin is often atrophic, classically demonstrating subepithelial haemorrhages
(ecchymoses),and it may split easily.
 Continuing inflammation results in inflammatory adhesions.
 Often there is lateral fusion of the labia minora,which become adherent and eventually
are completely reabsorbed. Hood of the clitoris and its lateral margins may fuse, burying
the clitoris.
 Midline fusion can produce skin bridges at the fourchette and narrowing of the introitus.
 Occasionally, the labia minora fuse together medially,which also restricts the vaginal
opening and can cause difficulty with micturition and even urinary retention.
Lichen planus
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 Lichen planus is a common skin disease which may affect the skin anywhere on the
body.
 Lichen planus usually affects mucosal surfaces and is more commonly seen in oral
mucosa.
 Lichen planus presents with polygonal flat-topped violaceous purpuric plaques and
papules with a fine white reticular pattern (Wickham striae).
 However, in the mouth and genital region it can be erosive and is more commonly
associated with pain than with pruritus.
 Erosive lichen planus appears as a well demarcated, glazed erythema around the
introitus.
 The aetiology is unknown, but it may be an autoimmune condition.
 It can affect all ages and is not linked to hormonal status.
Lichen simplex chronic or chronic vulval dermatitis
 Women with sensitive skin, dermatitis or eczema can present with vulval
symptoms,which can result in lichen simplex chronic, a common inflammatory skin
condition.
 This presents with severe intractable pruritus, especially at night.Non-specific
inflammation often involves the labia majora but can extend to the mons pubis and inner
thighs.
 There may be erythema and swelling with discrete areas of thickening and
lichenification,especially with scratching.
 These symptoms can be exacerbated by chemical or contact dermatitis and are
sometimes linked to stress or low body iron stores.
 The mainstay of treatment is general care of the vulva, avoiding potential irritants and
use of emollients and soap substitutes.
 Antihistamines or antipruritics may be helpful, especially if sleep is disturbed.
 However, moderate or ultrapotent topical steroids may be necessary to break itch–
scratch cycle.
VIN
 VIN is divided into two types depending on its histopathological characteristics.
Usual type VIN
 Nearly all VIN is of usual type: warty, basaloid and mixed (warty and basaloid).
 Usual type VIN is more common in women aged 35–55.
 It is associated with HPV(especially HPV-16)intraepithelial neoplasia of cervix and
vagina, perianal, anal, natal cleft skin and mucosa, cigarette smoking and chronic
immunosuppression
 Clinically, it may be multifocal and multicentric.The appearance of usual type VIN varies
widely: red,white or pigmented;plaques,papules or patches; erosions,nodules,warty or
hyperkeratosis.
 Usual type VIN is associated with warty or basaloid squamous cell carcinoma.
Differentiated type VIN
 Differentiated type VIN is rarer than usual type and is seen in older women aged 55–85.
 Some cases are associated with lichen sclerosus.Differentiated typeVIN is not related to
HPV and does not appear to have a long intraepithelial stage.
 It is linked to keratinising squamous cell carcinomas of the vulva.
 Clinically, it tends to be unifocal in the form of an ulcer or plaque.The risk of progression
appears to be higher than in usual type VIN.
 The symptom of pruritus can be intractable, although the use of emollients or a mild
topical steroid may help.
 The gold standard for VIN is local surgical excision.Women undergo treatment of VIN to
relieve symptoms, to confirm histology and to exclude invasive disease.

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 Local excision is adequate surgical treatment and allows a specimen to be taken for
histological diagnosis.
 Twelve to sixteen percent of women undergoing an excision have unrecognised invasion
and, if conservative or medical treatment is undertaken,care must be taken to ensure
adequate biopsy sampling to avoid unrecognised invasive disease.

Usual type VIN Differentiated type VIN

warty, basaloid and mixed (warty and
basaloid)
common in women aged 35–55 yrs
assot‟d with HPV (especially HPV-16),
intraepithelial neoplasia of the cervix and
vagina, perianal, anal and natal cleft skin and
mucosa, cigarette smoking and chronic
immunosuppression
rarer than usual type and is seen in older
women aged 55–85
not related to HPV and does not appear to
have a long intraepithelial stage.
linked to keratinising squamous cell
carcinomas of the vulva

may be multifocal and multicentric unifocal in the form of an ulcer or plaque

red, white or pigmented plaques, papules or

patches; erosions, nodules, warty or
hyperkeratosis

associated with warty or basaloid squamous linked to keratinising squamous cell

cell carcinoma carcinomas of the vulva

Vulval candidiasis
 Vulval candidiasis tends to present with irritation and soreness of the vulva and anus
rather than discharge.
 Diabetes, obesity and antibiotic use may be contributory.
 Vulval candidiasis may become chronic and a leading edge of inflammation with satellite
lesions extending out from the labia majora to the inner thighs or mons pubis.
 Prolonged topical antifungal therapy may be necessary to clear a skin infection with oral
or topical preparations.
Vulval psoriasis
 Psoriasis can involve the skin of the vulva but not vaginal mucosa.
 The appearance of vulval psoriasis differs from the typical scale of non-genital sites: it
often appears as smooth, non-scaly red or pink discrete lesions.
 Scratching may cause infection, dryness and skin thickening.
 Examination of other sites including nails and scalp may be helpful in making a
diagnosis.
 Emollients, soap substitutes, topical steroids and calcipotriene are useful for symptom
control, but cold tar preparations should not be used in genital sites.
Rare vulval skin disorders
Beçhet’s disease
 Bechet‟s disease is chronic multisystem disease characterised by recurrent oral and
genital ulcers
 In women, ulcers can involve the cervix, vulva or vagina.
 The ulcers are usually recurrent and painful and can leave scarring.
 Treatment to control flare-ups and reduce symptoms is based on topical or systemic
immunosuppressants.
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Extramammary Paget’s disease
 Extramammary Paget‟s disease of the vulva is a rare vulval condition seen in
postmenopausal women.
 The main symptom is pruritus.
 On examination, lesions have a florid eczematous appearance with lichenification,
erythema and excoriation.
 Extramammary Paget‟s disease can be associated with an underlying adenocarcinoma.
 The gastrointestinal and urinary tracts and the breasts should be checked.
 Surgical excision is recommended to exclude adenocarcinoma of a skin appendage.
 Photodynamic therapy and topical imiquimod have been used with some success.
 Despite obvious clinical features, surgical margins are difficult to achieve owing to
subclinical disease, and recurrence is common.
Plasma cell (Zoon’s) vulvitis
 Zoon‟s vulvitis is a rare benign chronic inflammatory condition of the vulva that presents
with symptoms of pruritus, burning, dyspareunia and dysuria.
 It usually presents in postmenopausal women.
 Zoon‟s vulvitis is diagnosed histologically and is characterised by dermal infiltration with
plasma cells, vessel dilatation and haemosiderrin deposition.
 The aetiology of this condition is unknown; one theory is that it is an autoimmune
disorder.
 There have been case reports favouring successful treatment with topical ultrapotent
steroids
4. Vulval Crohn’s disease
 Crohn‟s disease is a chronic inflammatory bowel disorder.
 It can involve the vulva by direct extension from involved bowel or „metastatic‟
granulomas.
 Rarely, it is seen without known bowel disease or preceding the presentation of bowel
disease.
 The vulva is often swollen and odematous with granulomas abscesses, draining sinuses
and ulceration.
 Surgery can result in sinus and fistula formation and tissue breakdown and therefore
should be avoided.
 Treatments include metronidazole and oral immunomodulators.
GENERAL CARE OF VULVAL SKIN
Most women with a vulval disorder will benefit from advice on general care of vulval skin and
avoidingpotential irritants.
 Washing with water only causes dry skin and makes itching worse.Use a soap substitute
to clean the vulval area.Use a small amount of the cream or ointment with water to wash
your skin.This will stop the skin from getting as dry and irritated as it would if you used
soap or water alone.The cream/ointment is safe to use frequently.
 Shower rather than bath and clean the vulval area only once a day.
 Avoid using sponges or flannels to wash the vulva. Instead,wash your vulva using
aqueous cream or another soap substitute with just your hand.
 Wear loose-fitting silk or cotton underwear. Wear loose-fitting trousers or skirts and
replace tights with stockings.At home, you may find it more comfortable to wear long
skirts without underwear. Sleep without underwear.
 Avoid fabric conditioners and biological washing powders.You may want to wash your
underwear separately in a non-biological washing powder/gel.
 avoid soaps, shower gel, scrubs, bubble baths, deodorants, baby wipes or douches in
vulval area

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 Some over-the-counter creams including baby or nappy creams, herbal creams (e.g. tea
tree oil, aloe vera) and „thrush‟ treatments may include possible irritants.
 Avoid wearing panty liners or sanitary towels on a regular basis.
 Avoid antiseptic (as a cream or added to bath water) in the vulval area.
 Wear white or light colours of underwear.Dark textile dyes (black, navy) may cause an
allergy;
 Avoid coloured toilet paper.
 Avoid wearing nail varnish on finger nails if you tend to scratch your skin.
Use of emollients to protect your skin
 Emollients can be used as moisturisers throughout the day.
 Using one of these moisturisers every day can help relieve symptoms. Even when you
do not have symptoms, using a moisturiser will protect the skin and can prevent flare-
ups.
 It is important to find the moisturiser that suits you best. If the first one you try does not
work well, it is well worth trying another one.
 If your skin is irritated, aqueous cream can be kept in the fridge and dabbed on to cool
and soothe the skin as often as you like.
EXAMPLE OF A PATIENT QUESTIONNAIRE
You have been referred to this clinic with a skin problem. It would be helpful if you could
complete this questionnaire before you are seen.This will help to identify any factors that
may be causing or aggravating your skin problem.This will be discussed with the doctor,but
you may want to add additional notes if you feel it will help you to remember any important
information.

The following questions relate to your own health.

Do you have any of the following conditions?

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