DOI: 10.1111/tog.

12585 2019;21:169–75
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Smoking in pregnancy: pathophysiology of harm and

current evidence for monitoring and cessation
BA MB MRCPI, *
a b,c
Brendan P McDonnell Carmen Regan MD FRCPI MRCOG
a
Bernard Stuart Fellow in Perinatal Ultrasound, Coombe Women and Infants University Hospital, Dublin 8, Ireland
b
Consultant Obstetrician and Subspecialist in Maternal Fetal Medicine, Coombe Women and Infants University Hospital, Dublin 8, Ireland
c
Senior Lecturer, Royal College of Surgeons, Dublin 2, Ireland
*Correspondence: Brendan P McDonnell. Email: bmcdonnell@rcsi.ie

Accepted on 27 December 2018.

Key content
 Smoking in pregnancy is a risk factor for miscarriage, stillbirth,
placental abruption, preterm birth, low birthweight and neonatal
morbidity and mortality.
 The adverse effects of cigarette smoke are primarily driven by
carbon monoxide, tar and nicotine.
 Psychosocial interventions are effective in helping women to quit
smoking during pregnancy.
 There is weak evidence that nicotine replacement therapy (NRT)
with behavioural support can improve cessation rates
in pregnancy.
 Electronic cigarettes are more popular among smokers, but
evidence of their safety and effectiveness in pregnancy are lacking.
Learning objectives

To understand the pathophysiology of harm from
cigarette smoking.
 To describe the role of exhaled carbon monoxide testing among
pregnant women.
 To review the evidence on the safety and use of NRT and electronic
cigarettes as methods of cessation.
Keywords: carbon monoxide monitoring / electronic cigarettes /
nicotine replacement therapy / pregnancy / smoking

Please cite this paper as: McDonnell BP, Regan C. Smoking in pregnancy: pathophysiology of harm and current evidence for monitoring and cessation.
The Obstetrician & Gynaecologist. 2019;21:169–75. https://doi.org/10.1111/tog.12585

younger, be unemployed, have low educational attainment,

Introduction
Cigarette smoking in pregnancy has an adverse impact on
maternal and fetal health; smoking cessation is advocated to
eliminate this risk factor and improve pregnancy outcome.
Smoking has long been associated with increased rates of
miscarriage, stillbirth, placental abruption, preterm birth and
low birthweight.1 Emerging evidence suggests that in utero
exposure to smoking has long-term neonatal adverse
outcomes such as impaired neurological development,
endocrine dysfunction and oncogenesis. These continue to
manifest into early and late childhood with a higher
incidence of sudden infant death syndrome, attention
deficit hyperactivity disorder, poor academic performance
in school and future smoking in adulthood.2–4
In England, the prevalence of smoking at the time of
delivery has steadily declined from 15.1% in 2006/07 to 10.4%
in the first quarter of 2018, with a target of 6% or less by
2022.5 Smoking strongly correlates with lower socio-
economic status and is a major cause of the health and life
expectancy inequalities encountered by women from deprived
backgrounds. Pregnant smokers are more likely to be
have a lack of social support and have increased incidence of
mental illness.6 Women experiencing depression are four
times more likely to smoke than other women, and this
presents a challenge to smoking cessation services.7
The pathophysiology of harm from
smoking
Cigarette smoke is a complex, heterogeneous mixture of
more than 4000 compounds, including nicotine, carbon
monoxide, carcinogens and heavy metals. In pregnancy,
cigarette smoke negatively impacts the fetus globally –
restricting the supply of oxygen and nutrients, altering its
growth and affecting the development of organs such as the
brain and lungs.8
Carbon monoxide
Carbon monoxide is a colourless and odourless gas produced
by the combustion of tobacco. The quantity of carbon
monoxide entering the system is influenced by the type of
tobacco product smoked and the depth and frequency of

ª 2019 Royal College of Obstetricians and Gynaecologists 169

 Smoking in pregnancy
inhalation.9 Tobacco smoke is approximately 45 000 parts
per million (ppm) carbon monoxide, a concentration of
4.5% by volume. Absorbed carbon monoxide rapidly binds
to haemoglobin, forming carboxyhaemoglobin, where each
iron atom binds a molecule of carbon monoxide at the
expense of a molecule of oxygen. A smoker is exposed to
400–500 ppm carbon monoxide over the time taken to
smoke a cigarette, producing a baseline carboxyhaemoglobin
of 4% (range 3–8%). This is in contrast with non-smokers,
who have an average 1% carboxyhaemoglobin in their blood.
Heavy smokers may have a carboxyhaemoglobin level of up
to 15%.9 As the concentration of carbon monoxide increases,
there is a left shift of the oxygen–haemoglobin dissociation
curve, reflecting the greater affinity of haemoglobin for
carbon monoxide. This left shift impairs oxygen delivery to
the myometrium and fetoplacental unit.10 Chronic exposure
to carbon monoxide through sources other than smoking –
for example air pollution – is also associated with fetal
growth restriction and preterm birth.11,12
Tar
Tar is the combusted particulate matter contained in
cigarette smoke which forms a residue on the skin, mucous
membranes and lungs of smokers. Tar damages the
respiratory tract by mechanical and biochemical
mechanisms. It contains the majority of carcinogenic
compounds, such as polycyclic aromatic hydrocarbons,
aromatic amines and nitrosamines. These compounds
interfere with biochemical pathways and macromolecules,
leading to a pro-inflammatory state with widespread
oxidative damage.13 The fetotoxic and teratogenic nature of
these compounds has been established in animal studies,8 but
little research has been performed on their effects on the
human fetus. The heavy metal cadmium, contained in
cigarette smoke, is known to accumulate in the placenta
and has been associated with fetal growth restriction.14 The
effect of other compounds and the many additives to
cigarettes remains unclear.
Nicotine
Nicotine is an addictive alkaloid derived from tobacco and is
a potent stimulant of the parasympathetic nervous system. It
readily crosses the placenta and has a direct effect on the fetus
and the placental vasculature, in addition to its effect on the
maternal circulation.15 Nicotine has been classed as a neuro-
teratogen and is known to bind nicotinic acetylcholine
receptors in the fetal brain, disrupting neurotransmitter
function and altering normal brain development.16 These
developmental insults are thought to lead to the cognitive,
emotional and behavioural problems seen in children
of smokers, such as attention deficit hyperactivity disorder
and learning disabilities.17 Additionally, exposure to
nicotine during fetal development is thought to increase
170
the later likelihood of addictive behaviours, including
smoking itself.8
Carbon monoxide monitoring in pregnancy
The National Institute for Health and Care Excellence18
recommends that all pregnant women be asked about their
smoking status at their maternity booking visit and at regular
intervals during their pregnancy and puerperium. It also
recommends biochemical screening of all pregnant women
via exhaled carbon monoxide. This identifies non-disclosing
smokers who can be referred on an ‘opt-out’ basis for
smoking cessation support. Referring all women with a
positive exhaled carbon monoxide reading results in larger
numbers accessing help and support, although it does not
necessarily result in higher numbers of biochemically verified
quitters.19–21
Currently in the UK, a midwife or health support worker
administers the exhaled carbon monoxide test to women
presenting for their booking appointment. The test is
explained in advance and the result interpreted by the
midwife or health support worker and explained to the
patient. All current smokers, occasional smokers and smokers
who have quit in the previous 2 weeks are referred to their
local NHS Stop Smoking Services on an opt-out basis.
Women with high exhaled carbon monoxide levels (>4 ppm)
who deny smoking are referred to NHS Stop Smoking
Services for advice on second-hand smoking and smoke-free
homes.18 Rarer causes of a high carbon monoxide reading in
the absence of smoking are exposure to carbon monoxide
through faulty gas appliances, air pollution and
lactose intolerance.
Non-disclosure of smoking status during pregnancy
prevents women from accessing appropriate smoking
cessation support and can lead to significant
underestimation of smoking prevalence. This non-
disclosure can be a result of recall bias, whereby the
woman is unable to accurately recall exposure, or of
unwillingness to disclose smoking status because of the
negative social perception of smoking in pregnancy.22,23
A high carbon monoxide reading may help to motivate
some women to stop smoking as a form of feedback
intervention, with the subsequent referral to NHS Stop
Smoking Services acting as a ‘final push’ for cessation. In a
similar manner, a normal carbon monoxide reading is an
encouraging finding appreciated by women undergoing a
cessation attempt.21
Before the introduction of carbon monoxide screening,
concerns had been expressed about the impact of discussing
smoking status on the relationship between the midwife and
the woman. Some suggested midwives prioritised a good
relationship with the patient over provision of smoking
cessation advice.24 In the setting of a booking visit, there were
ª 2019 Royal College of Obstetricians and Gynaecologists

concerns about having sufficient time and resources for
carbon monoxide screening and smoking cessation advice,
especially when dealing with other issues such as alcohol use
and domestic violence.24,25 However, since the introduction
of carbon monoxide screening, midwives report favourable
views towards providing smoking cessation advice and see it
as integral to their role, with high motivation levels
expressed.26 Health support workers have found universal
carbon monoxide screening easy to implement and well
received by women, with screening now seen as part of the
daily routine.21
Smoking cessation during pregnancy
The cessation rate in pregnancy is much higher than that of
the general population, with between 27% and 47% of
smokers quitting within the first trimester.27 Many women
report quitting spontaneously when pregnancy is confirmed,
often within the first few days.28 Factors associated with
spontaneous cessation include living in a household with a
non-smoking partner, smoking fewer cigarettes per day, a
previously successful quit attempt and more awareness of the
negative consequences of smoking.6,29,30 Women who quit in
early pregnancy are more likely to maintain cessation than
are those who quit later.31
Prospective longitudinal data suggest there is little change
in smoking status from the second trimester onwards, and in
fact intention to quit falls as the pregnancy progresses and in
the postpartum period.29 Nonetheless, women may be
planning to quit at any time during pregnancy and
therefore smoking status and motivation to quit should be
re-addressed at each visit.
Postpartum relapse
Unfortunately, there is a high rate of relapse, with many women
smoking again before the end of pregnancy and in the early
postnatal period.29,31,32 Less than a third of spontaneous
quitters in pregnancy remain abstinent 1 year postpartum.33
Women who are single, who are parous, who have a partner or
household member who smokes, those with high depression
scores, and those with a heavier smoking habit prepregnancy
are most likely to relapse in the postpartum period.32–34
Breastfeeding mothers are less likely to relapse.32 Behavioural
interventions are generally unsuccessful in preventing long-
term postpartum relapse. Incentive-based therapies, while
effective in the short term, are associated with relapse once the
incentive is withdrawn.35 In non-pregnant women, bupropion
and nicotine replacement therapy (NRT) individually have
shown promising results in preventing relapse after an initial
period of abstinence.36 However, there are no clinical trials
using pharmacological agents specifically to prevent
postpartum relapse, and such treatments should be used with
ª 2019 Royal College of Obstetricians and Gynaecologists
McDonnell and Regan
caution in breastfeeding mothers because of a lack of
safety data.37
Psychosocial interventions
Psychosocial interventions such as counselling, feedback and
provision of incentives are effective at achieving cessation in
pregnancy. Moreover, psychosocial interventions reduce the
incidence of low birthweight and neonatal intensive care unit
admission.6 Such interventions are seen as positive by most
women, with evidence of an improved sense of wellbeing
without negative physical or psychological consequences.
All healthcare professionals should be comfortable in
asking about smoking status and providing basic smoking
cessation advice to their patients. Successful interventions
for smoking cessation begin with the identification of
smokers, giving clear advice to quit, and provision of
assistance for a cessation attempt. A useful strategy is to use
the five As approach to smoking cessation interventions
(Box 1).38
Meta-analysis of counselling interventions has shown most
to be effective in achieving cessation in late pregnancy,
particularly when used in conjunction with other therapies,
or when tailored to the individual woman. However, it is
unclear which type of counselling (cognitive behavioural
therapy, motivational interviewing, psychotherapy or other)
is most effective.
Feedback interventions consist of providing women with
individual measurements of tobacco use (such as salivary or
urinary cotinine or exhaled carbon monoxide) and
information on fetal status in relation to smoking.
Feedback has been shown to be effective when provided
with other interventions such as counselling.6
Financial incentives have been shown to improve smoking
cessation rates during pregnancy, but their use is
controversial.39 Health education alone, social support from
Box 1. The five As for brief smoking cessation interventions38
Ask: Identify and document tobacco use status for every woman at
every visit. Ask about previous quit attempts.
Advise: In a clear, strong, and personalised manner, urge every smoker
to quit.
Assess: Determine willingness to quit. Asking a readiness score can be
a useful way of assessing readiness to quit, e.g. ‘on a scale of 1 to 10
how ready are you to quit smoking?’.
Assist: For the woman willing to make a quit attempt, refer to in-
house smoking cessation services or a local NHS Stop Smoking Service.
Discuss methods of cessation including counselling and the use of
nicotine replacement therapy.
Arrange: Schedule follow-up contact, usually a week after the quit
date. If the woman has quit, congratulate them and discuss any
obstacles and how to overcome them. For those still smoking, revisit
the five As and encourage to set a new quit date.
171
 Smoking in pregnancy

no intention on
changing behaviour

fall back into aware a problem

old patterns of exists but with
behaviour no commitment
to action

learn from each relapse

sustained change; intent on taking

new behaviour action to address
replaces old the problem

of behaviour

Figure 1. The Transtheoretical Model of Intentional Behaviour Change. Adapted from Pacheco.40

a family member or peer, or exercise interventions are of less
certain benefit as a means of cessation.6
It is important to recognise that some women are not
prepared to stop smoking in pregnancy. The Transtheoretical
Model of Intentional Behaviour Change can provide a useful
starting point for the categorisation of the pregnant
smoker (Figure 1).40,41
Nicotine replacement therapy
NRT seeks to replace cigarette smoking, with its harmful tar,
carbon monoxide and other compounds, with clean nicotine
delivered in a safe manner. The dose of NRT is gradually
reduced until a user can stop the therapy without excessive
psychological or physiological withdrawal symptoms.18
Nicotine undergoes first pass metabolism in the liver,
limiting its oral bioavailability. NRT is therefore delivered
via mucosal or transdermal routes. Available forms of NRT
include transdermal patches, lozenges, chewing gum, oral
sprays, microtabs and inhalers.42 Transdermal patches deliver
nicotine slowly over the course of a day, in contrast with the
other products that are faster acting and aim to counter acute
cravings. Accelerated metabolism of nicotine in pregnancy
results in lower serum concentrations of nicotine and its
metabolite cotinine, making sufficient dosage of NRT an
issue in a pregnant population.43 Additionally, use of NRT
does not lead to the high serum levels of nicotine rapidly
achieved by smokers.
The use of NRT is a proven method of smoking cessation
in non-pregnant adults, with an increase of 50–60% in

172 ª 2019 Royal College of Obstetricians and Gynaecologists


cessation rate, regardless of the setting.42 The evidence
suggests that NRT use in pregnancy does not influence
pregnancy outcomes such as birthweight or preterm labour.
Occasional mild adverse effects are encountered with patches,
such as skin irritation and headaches, but in general NRT is
well tolerated. Clinical trials have not detected an increase in
serious adverse events either during pregnancy or in the
neonatal period. Two-year-old children born to users of NRT
were more likely to survive without a developmental
impairment than were those born to women who smoked
and used placebo NRT.42,44,45 Therefore, NRT use in
pregnancy may improve developmental outcomes for the
offspring of smokers.
Most trials of NRT use in pregnancy have used it as an
adjunct to behavioural support, with fewer comparing it
alone with placebo. There is weak evidence that NRT with
behavioural support can improve cessation rates in
pregnancy.43 A 2018 Cochrane meta-analysis on NRT
found a significantly higher rate of cessation at the end of
pregnancy, but with no effect on postpartum cessation.42 The
National Institute for Health and Care Excellence18 and the
Royal College of Obstetricians and Gynaecologists
recommend the use of NRT in pregnancy as an adjunct to
a smoking cessation attempt in those who have not quit with
a psychosocial intervention alone.
Electronic cigarettes
Electronic cigarettes use a battery-powered element to heat
a solution of water, propylene glycol or glycerine, nicotine
and flavourings. This solution becomes aerosolised and is
inhaled by the user. Electronic cigarette use results in a
rapid rise of serum nicotine levels, reaching higher values
than those achieved by NRT. The use of electronic
cigarettes mimics the behavioural and psychosocial
aspects of conventional cigarette smoking, without the
associated harm. Electronic cigarettes do not contain
tobacco and do not combust their contents. They
therefore do not contain the carbon monoxide and tar
found in cigarette smoke.46 Electronic cigarettes have been
regulated by UK and European Union law since 2016, with
the aim of standardising their form, content and
marketing. New-generation electronic cigarettes emit
minimal carcinogens, such as aldehydes, when tested
under conditions that mimic real use.47. Other purported
negative health effects appear to be minimal, and in studies
to date, they have not been associated with serious adverse
events in short-term to medium-term follow-up.8 It is
estimated that electronic cigarettes have a theoretical harm
reduction of 95% compared with smoking cigarettes,
however, this estimate is not based on real-world use and
the true risks or benefits of electronic cigarette use are still
unknown.9 Additionally, longitudinal data on safety and
ª 2019 Royal College of Obstetricians and Gynaecologists
McDonnell and Regan
the effects on pulmonary and cardiovascular health
are lacking.
Approximately 5.5% of the adult population in England
use electronic cigarettes, with their use increasing year on
year. The decline in the prevalence of cigarette smoking has
been mirrored with a rise in electronic cigarette use among
adults. There are currently approximately 2.6 million
electronic cigarette users in Great Britain, compared with
9 million tobacco smokers. The most frequently cited reasons
for using electronic cigarettes are health, wanting to cut
down, and wanting to quit smoking. The majority of
electronic cigarette users consider them safer than
cigarettes.46 Concerns have been raised that electronic
cigarettes may re-normalise smoking or perhaps lead to
non-smokers taking up smoking through a ‘gateway drug’
effect. However, almost all electronic cigarette users are
current or ex-smokers, with ‘never-smoker’ users of
electronic cigarettes accounting for only 0.2% of total users.
It is noteworthy that electronic cigarettes are the most
common smoking cessation aid used in the UK today.46
Studies of electronic cigarettes as a method of cessation are
heterogeneous, due to the constantly changing nature of the
technology. There have been no trials of electronic cigarettes
for smoking cessation compared with the recommended
regimen of behavioural support and NRT/medication.
Clinical trials of electronic cigarettes for smoking cessation
in non-pregnant adults have demonstrated their effectiveness
in reduction in cigarette consumption and smoking cessation
compared with placebo alone.50–52 There is also evidence that
electronic cigarette use can encourage smoking cessation even
in smokers who do not want to quit.
The National Centre for Smoking Cessation and Training
recommends that smoking cessation services be open to
electronic cigarette use among non-pregnant smokers,
particularly those who have tried to quit with other
methods and failed. Multi-sessional behavioural support is
recommended to improve their chances of quitting.
There is a lack of safety data on the use of electronic
cigarettes in pregnancy, and their effectiveness for smoking
cessation in pregnancy has not been established.43 There are
no randomised controlled trials of electronic cigarette use for
cessation in pregnancy and no published observational data
on obstetric outcomes in pregnant users of electronic
cigarettes. Women perceive electronic cigarettes as useful
aids for reducing cigarette consumption and achieving
cessation, while being less harmful than conventional
cigarettes.53 In the limited research conducted to date,
many pregnant electronic cigarette users report dual use of
electronic cigarettes and cigarettes. One US study54 found
that over half of pregnant women entering a smoking
cessation trial had previously used electronic cigarettes, with
these women reporting a higher cigarette consumption
prepregnancy and more failed quit attempts. Fourteen
173
 Smoking in pregnancy
percent of women entering the trial were actively using
electronic cigarettes in pregnancy and had similar
characteristics, leading the authors to conclude that women
who find it more difficult to quit smoking are more likely to
use electronic cigarettes. In the UK, ‘Helping pregnant
smokers quit’ is a National Institute for Health Research
multicentre randomised controlled trial currently recruiting
pregnant smokers for a clinical trial comparing electronic
cigarettes versus usual care (behavioural support and NRT),
with the results expected in 2021.
Conclusion
Smoking in pregnancy is a major preventable risk factor for
maternal and neonatal morbidity. Maternal smoking rates are
declining, with a higher proportion of continued cigarette
smoking encountered in lower socio-economic groups. The
harm from cigarette smoking is primarily from carbon
monoxide and tar, which contribute to the complications
seen during pregnancy. Nicotine alters fetal brain
development and contributes to behavioural disorders in
the offspring of smokers.
Smoking cessation in pregnancy is a key part of the NHS
England initiative Saving Babies’ Lives, a care bundle for
reducing stillbirths, and all healthcare professionals should be
comfortable with providing smoking cessation advice.
The relatively high smoking cessation rate in pregnancy is
tempered by a high rate of relapse in the postnatal period, with
less than one-third of spontaneous quitters remaining
abstinent at 1 year postpartum. There is weak evidence that
NRT with behavioural support can improve cessation rates in
pregnancy, but with no effect on postpartum cessation.
The use of electronic cigarettes is becoming more
common, as women perceive them to be less harmful than
cigarettes. However, there is a lack of safety and efficacy data
on their use in pregnancy, and no data on obstetric outcomes
in pregnant users.
Further research is needed on pregnancy-specific cessation
methods – for example, use of higher-dose NRT, electronic
cigarettes or pharmacotherapy – as well as methods of
preventing postpartum relapse. More data are also needed on
outcomes in pregnant users of electronic cigarettes. Clinical
trials for new methods of smoking cessation should consider
the inclusion of pregnant women, because they are a group
particularly at risk from continued smoking.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
BPM researched and wrote the article; CR critically revised
and edited the article. Both authors approved the
final version.
174
Supporting Information
Additional supporting information may be found in the
online version of this article at http://wileyonlinelibrary.com/
journal/tog
Infographic S1. Smoking in pregnancy.
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37 Hale TW, editor. Medications and Mother's Milk; a manual of lactational
pharmacology. 18th ed. Springer Publishing Company, LLC; 2019.
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38 Smoking Cessation During Pregnancy. ACOG Committee Opinion Number
721. The American College of Obstetricians and Gynecologists, Washington
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39 Cahill K, Hartmann-Boyce J, Perera R. Incentives for smoking cessation.
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40 Pacheco I. The Stages of Change (Prochaska & Diclemente). 2012. [http://soc
ialworktech.com/2012/01/09/stages-of-change-prochaska-diclemente/]
41 Prochaska JO, DiClemente CC. Stages and processes of self-change of
smoking: toward an integrative model of change. J Consult Clin Psychol
1983;51:390–5.
42 Hartmann-Boyce J, Chepkin S, Ye W, Bullen C, Lancaster T. Nicotine
replacement therapy versus control for smoking cessation. Cochrane
Database Syst Rev 2018;5:CD000146.
43 Coleman T, Chamberlain C, Davey M-A, Cooper SE, Leonardi-Bee J.
Pharmacological interventions for promoting smoking cessation during
pregnancy. Cochrane Database Syst Rev 2015;12:CD010078.
44 Coleman T, Cooper S, Thornton JG, Grainge MJ, Watts K, Britton J, et al. A
randomized trial of nicotine-replacement therapy patches in pregnancy. N
Engl J Med 2012;67:387–8.
45 Cooper S, Lewis S, Thornton JG, Marlow N, Watts K, Britton J, et al. The
SNAP trial: A randomised placebo-controlled trial of nicotine replacement
therapy in pregnancy - Clinical effectiveness and safety until 2 years after
delivery, with economic evaluation. Health Technol Assess (Rockv)
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46 McNeill A, Brose LLS, Calder R, Hitchman SC, Hajek P, McRobbie H. E-
cigarettes: an evidence update. A report commissioned by Public Health
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Aldehyde levels in e-cigarette aerosol: Findings from a replication study
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2018;111:64–70.
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Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev
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Estimating the harms of nicotine-containing products using the MCDA
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Electronic cigarettes for smoking cessation: a randomised controlled trial.
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 DOI: 10.1111/tog.12588 2019;21:185–92
The Obstetrician & Gynaecologist
Reviews
http://onlinetog.org

Preventing adhesions in laparoscopic surgery: the role of

anti-adhesion agents
MBBS MA MRCOG, *
a, b c,d
Mehrnoosh Aref-Adib Timothy Phan BBmed , Alexandre Ades MBBS MD PhD FRANZCOG
a
Fellow in Laparoscopy, Agora Centre for Women’s Health, Epworth Hospital, Richmond, Melbourne, Victoria, Australia
b
Doctor of Medicine student, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria 3052, Australia
c
Senior Lecturer, University of Melbourne, Parkville, Melbourne, 3052, Victoria, Australia
d
Consultant Obstetrician & Gynaecologist, Royal Women’s Hospital and Agora Centre for Women’s Health, Melbourne, Victoria 3052,
Australia
*Correspondence: Mehrnoosh Aref-Adib. Email: mezaref@yahoo.co.uk

Accepted on 14 January 2019.

Key content  To identify which anti-adhesive agents are currently available in

 Surgical injury causes the release of cytokines, growth factors, cell
adhesion molecules and histamine, creating an inflammatory
response, which can lead to adhesion formation in the
peritoneal cavity.
 Compared with open surgery, laparoscopy reduces the risk of
adhesion formation, but the risk is not completely eliminated.
 Adhesion formation is multifactorial and depends on patient
healing, surgical technique and equipment factors.
 Adhesions after gynaecological surgery can have long-term
consequences including small bowel obstruction, chronic pelvic
pain, deep dyspareunia and female subfertility.
 There are a variety of anti-adhesion agents with different
properties available for use in laparoscopic surgery.
clinical practice.
 To understand the mechanism by which adhesion prevention
agents work.
 To review the effectiveness and cost implications of anti-
adhesive agents.
Ethical issues
 Given the extra cost of anti-adhesive agents, and the limited
information regarding their efficacy, should surgeons be using
them in laparoscopic gynaecological surgery?
 Is the use of anti-adhesion agents complementary or detrimental to
meticulous surgical technique?
Keywords: laparoscopy / prevention and control / tissue adhesions

Learning objectives
 To review the pathophysiology of adhesion formation after
laparoscopic surgery.

Please cite this paper as: Aref-Adib M, Phan T, Ades A. Preventing adhesions in laparoscopic surgery: the role of anti-adhesion agents. The Obstetrician &
Gynaecologist. 2019;21:185–92. https://doi.org/10.1111/tog.12588

pelvic surgery performed in Scotland, the readmission rate

Introduction
The development of peritoneal adhesions following surgery is
a complication that can have a significant impact on patients
and the wider healthcare system. It is estimated that
adhesions may develop in up to 90% of patients
undergoing major abdominal surgery and 55–100% of
women undergoing pelvic surgery.1
Adhesions may occur following either open or
laparoscopic surgery. Although most patients are
asymptomatic, adhesions can be associated with significant
morbidity including small bowel obstruction, chronic pelvic
pain, deep dyspareunia and female subfertility.2 In addition,
adhesions may increase the risk of complications during
subsequent surgery, including problems relating to difficult
abdominal access, increased blood loss and increased
duration of surgery.3–5 In a large study of gynaecological
related to adhesions was 13.9%.6
Quantifying the cost of adhesion-related problems is
difficult. In the USA, where litigation rates are high and the
costs of health care great, the estimated yearly costs of
managing adhesion-related complications exceed $2 billion.7
In the UK, in a study from 2002, it was estimated that the
direct cost of readmissions related to adhesions in the first
year after lower abdominal surgery is £24.2 million, which
increases to £95.2 million 10 years after the initial surgery.8
Therefore, minimising the formation of adhesions during
gynaecological surgery is paramount.
In the first instance, the prevention of surgical adhesions
relies on meticulous surgical technique, further enhanced
with the use of a minimally invasive surgical approach where
possible. Despite these important steps, a significant risk of
adhesion formation remains. A variety of additional

ª 2019 Royal College of Obstetricians and Gynaecologists 185

 Adhesion prevention in laparoscopic surgery
approaches have been used in the past: from agents to
prevent fibrin formation (sodium citrate and anticoagulants),
to fibrinolytic agents such as streptokinase and the insertion
of inert silicones at the time of surgery.9 Several novel anti-
adhesive agents have been developed, which are proposed to
be safe and effective adjuncts to good surgical technique.
This article describes the pathophysiology of adhesion
formation after surgery, presenting a summary of the main
anti-adhesive agents available in the market, an overview of
the current studies on their effectiveness and an evaluation of
the cost implications of their use in the healthcare system.
Pathophysiology
Adhesion formation is multifactorial and depends on patient
healing (peritoneal repair), surgical technique and
equipment factors.
The inciting event for adhesion formation is injury to the
peritoneal mesothelium, which initiates a peritoneal repair
response. Subsequently, the development of adhesions
depends on the balance between fibrin deposition and
degradation (fibrinolysis) that begins within hours of
surgery.9 Factors that favour the deposition of fibrin over
its degradation will lead to the development of a bridging
fibrinous mass between adjacent peritoneal surfaces.
Specifically, the organisation of fibrin into adhesions is
potentiated by two risk factors associated with surgical injury:
inflammation and tissue ischaemia.9
At a biomolecular level, this injury causes damaged tissues
to release cytokines, growth factors, cell adhesion molecules
and histamine, which mediate a local inflammatory response
that promotes fibrin deposition.10 This inflammatory reaction
involves processes such as coagulation and the recruitment of
leucocytes (macrophages and neutrophils) and
fibroblasts.11,12 In particular, macrophages are involved in
the recruitment of adjacent mesothelial cells and fibroblasts,
which migrate to the site of peritoneal injury and re-
epithelialise the injured peritoneal surface over 3–5 days.10
Figure 1 illustrates the pathway of adhesion formation.
Adhesion formation also occurs within this 3–5-day
window, which has clinical implications for the efficacy of
anti-adhesion agents that must also be active over
this period.10
Furthermore, contamination of the peritoneal cavity with
materials such as sutures, talcum powder, starch, faeces or
bacteria may induce further inflammation, which inhibits
fibrinolysis and increases the likelihood of adhesion formation.
Therefore, minimising tissue injury and preventing post-
operative infection and peritoneal contamination is important
for preventing adhesions after laparoscopic surgery.13
Tissue damage associated with ischaemia also promotes
the formation of peritoneal adhesions as a maladaptive
response. The inflammatory response to injury develops to
186
revascularise areas of relative ischaemia following surgical
procedures that may have disrupted tissue vasculature, such
as fulguration, ligation or crushing.2
Adhesion prevention methods
Measures for preventing adhesion development may include
minimising injury, preventing coagulation of serous exudate,
introducing a physical barrier between peritoneal surfaces
and inhibiting the cellular response to tissue injury
(fibroblasts and macrophages).10
Adhesion prevention measures can thus be classified into
meticulous surgical technique, physical barrier agents (liquid
or solid) and pharmacological agents. Figure 2 summarises
the measures available for adhesion prevention.
Meticulous surgical technique
Best practice surgical technique is the gold standard measure
against adhesion development. The principles of meticulous
surgical technique include tissue handling minimisation and
prevention of thermal injury, optimised haemostasis,
maintaining a moist surgical field, strict infection control and
avoiding contamination through copious irrigation and
unnecessary foreign material use (such as talcum powder).10,14
Laparoscopy versus laparotomy
Minimal access techniques should be chosen over laparotomy
wherever possible as a method of reducing adhesion
formation. Laparoscopy involves smaller abdominal
incisions, less handling of peritoneal tissues and reduced
exposure to foreign materials.15 Hence, laparoscopy
ultimately reduces the rate of adhesions over open
surgery.16–19 Buletti et al.20 showed significantly lower
adhesion rates at second-look laparoscopy when directly
comparing laparotomy and laparoscopy. Despite this,
laparoscopy does not guarantee complete adhesion
prevention, especially in conditions that are at high risk of
adhesion formation, such as endometriosis or chronic pelvic
inflammatory disease.10 There is also evidence that, despite
reducing de novo adhesions, laparoscopy may not reduce
adhesion reformation.20 In contrast, animal studies have
suggested that perhaps a carbon dioxide pneumoperitoneum
may in fact cause peritoneal inflammation and thus it has
been suggested that a combination of a low temperature,
humidified gas mixture of carbon dioxide, nitrous oxide and
oxygen is the best way to reduce this.20
Physical barrier agents
Physical barrier agents are inert materials that exert their
anti-adhesive effects by separating opposing injured
ª 2019 Royal College of Obstetricians and Gynaecologists
 Aref-Adib et al.

Figure 1. Pathophysiology of adhesion formation.

epithelialisation to prevent adhesion formation. In

Anti-adhesive addition, each agent is present temporarily by virtue of
measures
absorption, resorption, degradation or surgical removal.10
Although many physical barrier agents have been
developed, only a few are used regularly in clinical practice.
Meticulous Physical barrier Pharmacological
Barrier agents can be subdivided into solid or liquid barrier
surgical technique agents agents agents. Generally, solid barrier agents are used more
frequently in open surgery, while liquid or gel barriers are
favoured in laparoscopy. Figure 3 demonstrates the
classification and types of physical barrier agents available.
Solid Liquid/gel

Oxidised regenerated cellulose (Gynecare

Figure 2. Classification of anti-adhesive measures.
peritoneal surfaces during tissue healing.10 In particular,
barrier agents act to separate peritoneal surfaces for longer
than 3 days during the peak time of mesothelial re-
InterceedTM – Johnson & Johnson, Somerville, NJ)
Oxidised regenerated cellulose (ORC) is an absorbable
synthetic sheet that can be applied directly on to damaged
peritoneum, thus acting as a mechanical barrier (Figure 4).
The sheet may be cut as required, allowing for its use in

ª 2019 Royal College of Obstetricians and Gynaecologists 187

 Adhesion prevention in laparoscopic surgery
Physical barrier
agents
Solid
Oxidised Hyaluronate and
regenerated cellulose (Gore-Tex) carboxymethylcellulose
(Interceed)
Figure 3. Classification and types of physical barrier agents.
laparoscopic and open surgery.21,22 On application, the ORC
sheet transforms into a gel that coats the peritoneal surface
and is completely absorbed within 2 weeks.23 Importantly,
optimal haemostasis must be achieved before the application
of the ORC sheet, as the mixture of blood with ORC
increases fibrin deposition and may increase the formation of
adhesions.24 ORC was trialled in the USA for patients at high
risk of developing postoperative adhesions after gynaecologic
pelvic laparotomy.10 However, it is often used in laparoscopic
surgery.25 No adverse effects have been reported with the use
of ORC.2
Numerous randomised controlled trials (RCTs) have been
conducted comparing the use of ORC versus no barrier
agent. In a meta-analysis of 12 RCTs, ORC used in
laparoscopy was associated with a reduced incidence (odds
ratio [OR] 0.30, 95% confidence interval [CI] 0.12–0.79) and
recurrence (OR 0.19, 95% CI 0.09–0.42) of adhesions when
compared with no barrier treatment.26 In addition, a pooled
estimate of three trials comparing ORC with no barrier agent
found that ORC significantly reduced the risk of adhesions
(relative risk [RR] 0.51, 95% CI 0.31–0.86).27
Figure 4. Gynecare InterceedTM – Oxidised regenerated cellulose.
Reproduced with permission of Ethicon US, LLC.
188
Liquid/gel
Hyaluronic acid PEG-based liquid Icodextrin solution
gel barriers precursors (ADEPT)
(Intergel/Hyalobarrier) (SprayGel/Coseal)
Polytetrafluoroethylene (Gore-Tex – W.L. Gore &
Associates, Inc., Flagstaff, AZ, USA)
Polytetrafluoroethylene (PTFE) is a flexible non-absorbable
membrane that must be sutured on to peritoneal surfaces and
requires a secondary surgical procedure for its removal
(Figure 5).2 Therefore, the need for suturing and subsequent
removal renders PTFE an undesirable anti-adhesive agent. In
particular, the requirement of suturing the PTFE into place
may lead to surgical delays, especially in laparoscopic
surgery.2
To date, the use of PTFE physical barriers has only been
evaluated in the context of open surgery and there is no
evidence for its use in laparoscopic surgery.
Chemically modified sodium hyaluronate–
carboxymethylcellulose (Seprafilm – Genzyme
Corporation, Cambridge, MA, USA)
Hyaluronic acid is an anionic linear polysaccharide
composed of sodium D-glucuronate and N-acetyl-D-
glucosamine. Hyaluronic acid sheets are absorbable
membranes composed of two synthetic polysaccharides:
Figure 5. Gore-Tex – Polytetrafluoroethylene. Reproduced with
permission of W.L. Gore & Associates, Inc.
ª 2019 Royal College of Obstetricians and Gynaecologists

chemically modified sodium hyaluronate and
carboxymethylcellulose. Within 24–48 hours of application,
the membrane becomes a gelatinous barrier that prevents the
juxtaposition of damaged peritoneal tissues and is absorbed
within 7 days.2
The effectiveness of hyaluronic acid sheets has mostly been
demonstrated in non-gynaecological surgery. In terms of
gynaecological surgery, one RCT of 127 patients evaluated
the efficacy of hyaluronic acid sheets in open myomectomy
compared with no treatment.26 The results concluded that
the intervention group experienced a reduction in the
incidence, extent and severity of adhesion formation at
second-look laparoscopy compared with no treatment.
However, a Cochrane systematic review in 200826 criticised
the statistical analyses used in the study, and the results
should be interpreted with caution. No adverse effects have
been reported with the use of hyaluronic acid sheets.2
Currently, hyaluronic acid sheets are indicated for patients
at high risk of developing adhesions after abdominal or pelvic
laparotomy in the USA.10 The membrane is brittle and tends
to break when manipulated, making it unsuitable for
laparoscopic application.2 However, hyaluronic acid sheets
can be used in laparoscopy by creating a solution of Seprafilm
mixed with normal saline and then flushing the solution
through one of the laparoscopic ports using a catheter
(Figure 6).2 The solution coats the peritoneal surface with a
gelatinous membrane which prevents adhesions from other
surfaces. Despite this, there has been insufficient evidence to
support the use of hyaluronic acid sheets in laparoscopy
using this method.2
Figure 6. Seprafilm – Chemically modified sodium hyaluronate–
carboxymethylcellulose. Reproduced from Haensig et al.,41 with
permission of Dovepress.
ª 2019 Royal College of Obstetricians and Gynaecologists
Aref-Adib et al.
Figure 7. Hyalobarrier – Hyaluronic acid gel barriers. Reproduced
with permission of Anika Therapeutics, Inc.
Hyaluronic acid liquid barriers (Hyalobarrier –
Anika Therapeutics, Bedford, MA, USA)
Hyaluronic acid also exists in the form of gel barriers, which
have been found to be effective in both laparoscopy and open
surgery (Figure 7). A meta-analysis of four RCTs comparing
hyaluronic acid liquid barriers with placebo demonstrated
that the use of hyaluronic acid agents may decrease adhesion
formation (OR 0.31, 95% CI 0.19–0.51).29 In addition, a
subsequent meta-analysis of five RCTs showed a significant
reduction in intraperitoneal adhesions after laparoscopic
surgery (OR 0.25, 95% CI 0.09–0.63) and in intrauterine
adhesions after hysteroscopic surgery (OR 0.41, 95% CI
0.217–0.766) with the use of auto cross-linked
hyaluronan gel.30
Polyethylene glycol (PEG)-based liquid adhesion
barrier (SprayGel – Confluent Surgical Inc.,
Waltham, MA, USA) (Coseal sealant – Baxter
Healthcare Corporation, Deerfield, IL, USA)
The polyethylene glycol (PEG) adhesion barrier is a synthetic
hydrogel that is sprayed on to target tissues to form a
gelatinous barrier that remains intact for 5–7 days before
being absorbed from the peritoneal cavity after 30 days.31
Coseal is well known as an effective anti-adhesive agent in the
context of cardiothoracic surgery but is currently being
trialled as an anti-adhesive in gynaecological surgery.32
The evidence regarding the efficacy of PEG adhesion
barriers in the setting of laparoscopy and open surgery is
conflicting. A meta-analysis of three RCTs in 2012
demonstrated a significant reduction in the incidence of
adhesion development with the use of PEG-based barriers in
fertility-conserving laparoscopic gynaecological surgery
(OR 0.27, 95% CI 0.11–0.67).33 However, a 2014 systematic
review of four trials showed no significant difference in the
incidence of adhesion formation in laparoscopic and open
procedures when comparing PEG-based barriers with no
189
 Adhesion prevention in laparoscopic surgery
treatment, although adhesion scores were lower in those who
received PEG.27
Icodextrin solution (ADEPT – Baxter Healthcare
Corporation, Deerfield, IL, USA)
Icodextrin solution is used as an iso-osmolar surgical irrigant and
is composed of a 4% alpha-1,4 glucose polymer solution that
persists on peritoneal surfaces. A fluid reservoir of the icodextrin
solution is left in the peritoneal cavity after surgery and is slowly
absorbed via the lymphatic system over a period of 4 days.34
Therefore, the solution acts to separate injured serosal surfaces
during the period of peritoneal healing (Figure 8).
Evidence for 4% icodextrin solution in laparoscopic
surgery remains conflicted. However, it is the only agent in
the USA approved by the Food and Drug Administration for
preventing peritoneal adhesions in gynaecologic laparoscopy.
In a US trial involving laparoscopic adhesiolysis in 402 patients,
the use of 4% icodextrin solution led to a 9.8% reduction in
the incidence of adhesion development compared with
controls on second-look laparoscopy.34 However, a meta-
analysis of four RCTs comparing icodextrin with no
treatment or Hartmann’s solution showed that icodextrin
decreased the incidence of small bowel obstruction (2%
versus 11%), but did not reduce adhesion formation or the
need for reoperation for adhesive bowel obstruction (RR
0.33, 95% CI 0.03–3.11).27 There have been case studies
concerning possible extravasation of ADEPT, resulting in
return to theatre but the authors of one article suggest that
these cases can be managed conservatively and the occurrence
reduced by meticulous suturing at the port sites.35
Another interesting hypothesis that requires further
research is that to separate the peritoneal surfaces, organs
may be required to float within the solution. A small study by
Carpenter et al.36 demonstrated that ovaries did not float in
Figure 8. ADEPT – Icodextrin solution. Reproduced with permission
of Baxter Australia Inc and Enso Creative Communications.
190
the commonly used solutions for hydrofloatation, and the
authors concluded that it would be unlikely that these
solutions would prevent re-adherence of ovaries to the pelvic
side wall after endometriosis surgery.
Table 1 gives a summary of the anti-adhesion agents
discussed.
Pharmacological agents
Corticosteroids
Given that adhesion formation involves inflammation,
corticosteroids have been trialled to dampen the post-
surgical inflammatory response to prevent adhesions.
However, the use of corticosteroids as an anti-adhesive
agent is not supported by current evidence. A meta-analysis
of five RCTs that investigated the efficacy of steroids in
preventing adhesions following open gynaecological surgery
demonstrated a failure to reduce adhesion formation or
improve pregnancy rates.29
Heparin
Heparin has not been shown to be useful in adhesion
prevention. In a study by Reid et al.37 adding heparin to
oxidised regenerated cellulose did not confer any benefit in
postoperative adhesion formation.
Complications associated with adhesion
barriers
A 2016 study by Tulandi et al.38 reviewed the use of adhesion
barriers in myomectomy or hysterectomy and the
complications in the immediate postoperative period. The
authors looked at laparoscopy and laparotomy, with the most
commonly used adhesion barriers being sodium hyaluronate–
carboxymethylcellulose and oxidised regenerated cellulose.
Adhesion barriers were only used in 1.9% of the cases
reviewed, suggesting that most gynaecologists did not perceive
the importance of postoperative adhesion. The review
concluded that the use of an adhesion barrier was not
without complications of ileus and possible bowel obstruction
(more so in the laparotomy group), but the incidence of these
complications was low.
Cost implications
Postoperative adhesions impose a considerable economic
burden on healthcare systems worldwide. In particular,
complications related to adhesions increase surgical workload
and hospital expenditure and divert funds away from other
healthcare services.8 However, the widespread introduction of
anti-adhesive agents would also incur significant costs for
healthcare systems, including the cost of the agent and the
increase in operative time required for its use.
ª 2019 Royal College of Obstetricians and Gynaecologists
 Aref-Adib et al.

Table 1. Summary of anti-adhesive barrier methods

Type of Mechanism of Countries approved

barrier Trade name Cost per unit action Evidence
Europe# US

Oxidised Interceed £125 to £200* Solid sheet transforms Meta-analysis of 12 RCTs – reduced Yes Yes (Open)
regenerated into gel to coat incidence (OR 0.30) and recurrence
cellulose peritoneum of adhesions (OR 0.19)
Meta-analysis of 3 trials – reduced risk
of adhesions (RR 0.51)
PFTE Gore-Tex – Non-absorbable solid Limited gynaecological evidence in Yes No
membrane sutured laparoscopic surgery
on to peritoneum
Hyaluronic acid Seprafilm £170* Sheets form gelatinous Limited gynaecological evidence RCT Yes Yes (Open)
sheets solid barrier on of 127 patients – reduced incidence,
peritoneum extent and severity of adhesions

Hyaluronic acid Hyalobarrier £124 per Highly viscous gel Meta-analysis of 4 RCTs – reduced Yes No
gel 10 ml** coats peritoneum adhesions (OR 0.31)
Meta-analysis of 5 RCTs – reduced
adhesions in laparoscopy (OR 0.25)
and in hysteroscopy (OR 0.41)
PEG-based SprayGel £115 per 2 ml Sprayed on to Conflicting evidence Yes No
liquid barrier Coseal (Coseal)* peritoneal surfaces to Meta-analysis of 3 RCTs – reduced
form gel barrier incidence of adhesions (OR 0.27)
Systematic review of 4 trials failed to
show difference in adhesion formation
Icodextrin ADEPT £140 per Solution reservoir left Conflicting evidence RCT of 402 Yes Yes (Lap)
solution 1500 ml* in peritoneal cavity to patients – reduced adhesions by
separate peritoneal 9.8%
surfaces Meta-analysis of 4 RCTs – no
reduction in adhesions

*Price as per company and conversion from US dollars to pounds December 2017. **Price as per company and conversion from Euros to pounds
December 2017. #Approved in at least one country.
Lap = laparoscopy; Open = open surgery; PEG = polyethylene glycol; PFTE = polytetrafluoroethylene; RCT = randomised controlled trial.

Studies on the cost-effectiveness of anti-adhesives are
limited and most cost analyses were performed more than
10 years ago. In 2007 a study investigating cost-
effectiveness involving financial modelling over a 10-year
period between 1986 and 1995 found that anti-adhesives
costing up to €130 and with 25% efficacy could save €40
million.39 A study in 2011, which was financially modelled
based on the ‘payment by results’ system in England,
showed that the implementation of effective anti-adhesive
agents costing approximately £110 per product, which
results in a 25% reduction in adhesion prevalence, could
have made approximately £700,000 in cost savings for the
NHS during 2004–2008.40 Despite these estimated cost
benefits, not many anti-adhesive agents currently available
demonstrate this level of clinical efficacy or fall within this
price range.
Conclusion
Optimised adhesion prevention has the potential to
significantly reduce healthcare costs and patient morbidity
following laparoscopic abdominal or pelvic surgery.
Currently, the gold-standard anti-adhesive measure is
meticulous surgical technique, which should be adopted by
all surgeons. At present, liquid anti-adhesive agents are easier
to use than solid agents in laparoscopic surgery, with
4% icodextrin solution the only liquid anti-adhesive agent
recommended under US guidelines.
Overall, the evidence for the efficacy of anti-adhesive
agents in laparoscopic procedures is limited, which has
prevented their widespread uptake in gynaecological
surgery. In particular, evidence for improved clinical
outcomes, such as the incidence of chronic pelvic pain,
infertility and bowel obstruction, is lacking. It must be
noted, however, that there is difficulty in producing level A
evidence. Second-look operations are invasive and the
alternative of ultrasound to detect adhesions requires
significant expertise with a limited sensitivity
and specificity.
Further investigation is required to evaluate the long-term
clinical outcomes associated with the use of anti-adhesive
agents. Additional high-quality cost–benefit analyses are

ª 2019 Royal College of Obstetricians and Gynaecologists 191

 Adhesion prevention in laparoscopic surgery

required before the routine use of anti-adhesive agents can be 20 Bulletti C, Polli V, Negrini V, Giacomucci E, Flamigni C. Adhesion formation
after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 1996;3
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on-gynecare-interceed-absorbable-adhesion-barrier-10-bx-x_pid-54844.
There are no conflicts of interest. html].
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Contribution to authorship 2019. [https://www.ethicon.com/na/products/uterine-and-pelvic-surgery/ab
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MA-A instigated and wrote the article; TP researched and r].
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authors approved the final version. Gynecol Surv 2004;59(5):360–7.
24 DeCherney AH, diZerega GS. Clinical problem of intraperitoneal postsurgical
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27 Ten Broek RPG, Stommel MWJ, Strik C, van Laarhoven C, Keus F, van Goor H.
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28 Diamond MP. Reduction of adhesions after uterine myomectomy by
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3 ten Broek RP, Schreinemacher MH, Jilesen AP, Bouvy N, Bleichrodt RP, van
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29 Metwally M, Watson A, Lilford R, Vandekerckhove P. Fluid and
4 ten Broek RP, Strik C, Issa Y, Bleichrodt RP, van Goor H. Adhesiolysis-related
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30 Mais V, Cirronis MG, Peiretti M, Ferrucci G, Cossu E, Melis GB. Efficacy of
Schaapveld M, Van Goor H. Morbidity and mortality of inadvertent
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enterotomy during adhesiotomy. Br J Surg 2000;87(4):467–71.
hysteroscopy: a systematic review and meta-analysis of randomized
6 Lower AM, Hawthorn RJ, Clark D, Boyd JH, Finlayson AR, Knight AD, et al.
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Adhesion-related readmissions following gynaecological laparoscopy or
31 Ahmad G, Mackie FL, Iles DA, O'Flynn H, Dias S, Metwally M, et al. Fluid and
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7 Sikirica V, Bapat B, Candrilli SD, Davis KL, Wilson M, Johns A. The inpatient
32 Patel S, Yadav A. Prevention of adhesion in laparoscopic gynaecological
burden of abdominal and gynecological adhesiolysis in the US. BMC Surg
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2011;11:13.
33 ten Broek RP, Kok-Krant N, Verhoeve HR, van Goor H, Bakkum EA. Efficacy
8 Wilson MS, Menzies D, Knight AD, Crowe AM. Demonstrating the clinical
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11 Attard JA, MacLean AR. Adhesive small bowel obstruction: epidemiology,
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36 Carpenter TT, Kent A. Ovaries do not float. Gynecol Surg 2004;1(4):263–4.
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37 Reid RL, Hahn PM, Spence JE, Tulandi T, Yuzpe AA, Wiseman DM. A
Foreign material in postoperative adhesions. Ann Surg 1996;223(3):242–8.
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38 Tulandi T, Closon F, Czuzoj-Shulman N, Abenhaim H. Adhesion barrier use
15 Hull TL, Joyce MR, Geisler DP, Coffey JC. Adhesions after laparoscopic and
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complications. Obstet Gynecol 2016;127(1):23–8.
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39 Wilson MS. Practicalities and costs of adhesions. Colorectal Dis 2007;9
16 Sch€afer M, Kr€ahenb€ uhl L, B€
uchler MW. Comparison of adhesion formation
(Suppl 2):60–5.
in open and laparoscopic surgery. Dig Surg 1998;15(2):148–52.
40 Cheong Y, Sadek K, Watson A, Metwally M, Li TC. Adhesion reduction
17 Polymeneas G, Theodosopoulos T, Stamatiadis A, Kourias E. A comparative
agents in gynaecological procedures: can NHS afford it? An economic cost
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cholecystectomy. Surg Endosc 2001;15(1):41–3.
41 Haensig M, Mohr FW, Rastan AJ. Bioresorbable adhesion barrier for
18 Levrant SG, Bieber EJ, Barnes RB. Anterior abdominal wall adhesions after
reducing the severity of postoperative cardiac adhesions: Focus on REPEL-CV
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192 ª 2019 Royal College of Obstetricians and Gynaecologists

 DOI: 10.1111/tog.12575
The Obstetrician & Gynaecologist
http://onlinetog.org
A guide to indications, components and interpretation of
urodynamic investigations
a b
Annika Taithongchai MRCOG , Abdul H Sultan
a
Specialty Trainee in Obstetrics and Gynaecology, Urogynaecology Department, Croydon University Hospital, London CR7 7YE, UK
b
Consultant Urogynaecologist, Urogynaecology Department, Croydon University Hospital, CR7 7YE, London, UK
*Correspondence: Ranee Thakar. Email: ranee.thakar@nhs.net
Accepted on 30 August 2018.
Key content
 Indications for urodynamic investigations include
urinary tract symptoms such as urge incontinence, stress
urinary incontinence (SUI) and neurological
urinary incontinence.
 Components of urodynamic testing include a physical
assessment along with representative uroflowmetry with post-
void residual (PVR), transurethral cystometry and a pressure-
flow study.
 It is important for clinicians to understand key physiological
measurements and parameters of lower urinary
tract function.
 There are many factors to consider when interpreting results from
urodynamic investigations, and it is vital for documentation to be
accurate and methodical.
Please cite this paper as: Taithongchai A, Sultan AH, Thakar R. A guide to indications, components and interpretation of urodynamic investigations.
The Obstetrician & Gynaecologist 2019;21:193–202. https://doi.org/10.1111/tog.12575
Introduction
The International Continence Society (ICS) first defined the
term ‘urodynamic studies’ in 1988. The definition has since
evolved to become urodynamic observations, which are made
during a variety of investigations to objectively assess the
function or dysfunction of the lower urinary tract (LUT).
These observations include measurements of physiological
parameters of bladder filling and voiding.1 Writers of the
2016 ICS publication Good urodynamic practices (ICS-
GUP2016) have suggested that the term ‘urodynamics’
should include all measurements that assess the function
and dysfunction of the LUT by any appropriate method,
including cystometry and pressure-flow studies.2
A prerequisite to undertaking any urodynamic investigation
is the formulation of a clear diagnostic question. Only then can
accurate interpretation of the results have any meaning. In
addition, an appreciation of the physiology of the LUT, physics
of the measurements being taken, practical experience with the
equipment and understanding of quality control are also vital.2
ICS-GUP2016 describes the set of standard investigations for
urodynamics to be used as an adjunct to aid management of a
ª 2019 Royal College of Obstetricians and Gynaecologists
2019;21:193–202
Review
MD FRCOG*
,b
MD FRCOG, Ranee Thakar
Learning objectives
 To understand the key indications and components of urodynamics
and how to define a clear question prior to starting investigations.
 To learn accepted physiological parameters for lower urinary tract
functions and apply these to a concise method of interpreting
urodynamic results.
 To acknowledge the limitations of an investigation when attempting
to reproduce pathology in an artificial environment.
Ethical issues
 Should all women undergoing an incontinence procedure have
urodynamic investigations?
 Who to believe – the patient or the test?
Keywords: cystometry / incontinence investigations / lower urinary
tract / pressure flow / urodynamics / uroflow
patient’s symptoms. They should only ever be performed after
taking a comprehensive history, including a medication list,
urinalysis, clinical examination and completed bladder diary,
as well as a valid bother score and quality of life questionnaires.
Physical assessment should include an abdominal and pelvic
examination assessing for prolapse, vaginal wall or pelvic
masses, genital atrophy, pelvic muscle quality and contractility,
urinary leakage with straining and focused neurological
examination.2 These are basic requirements of the ICS
standard urodynamics protocol (ICS-SUP), in conjunction
with the following components:
 representative uroflowmetry with post-void residual (PVR)
 transurethral cystometry
 pressure-flow study.
When the three tests above are performed in the patient’s
preferred or most usual position (either seated or standing, if
possible) then the patient is reported to have had an ICS
standard urodynamic test (ICS-SUT).2
The initial bladder diary is a useful, non-invasive method
of obtaining objective information on fluid intake, episodes
of incontinence and urgency, pad usage and timings of
193
 Understanding urodynamics
volumes voided. All patients presenting with LUT symptoms
(LUTS) should complete this diary. The International
Consultation on Incontinence (ICI) recommends a 3-day
frequency-voiding chart for accurate assessment,3 although
currently there is no clear evidence of optimal duration of
data collection.
Indications
Urodynamic observations are performed to confirm or refute
a diagnosis and identify all factors contributing to the causes
of the LUTS. They can help to ensure the correct
management is pursued – particularly if prior conservative
and/or surgical treatments have failed. They can also capture
information that may not present as symptoms in the patient,
such as concurrent detrusor overactivity or voiding
dysfunction, which may aid the surgeon in appropriate
preoperative counselling and guide patient expectations. In
turn, this may pre-empt potential postoperative outcomes,
such as the development of urinary urgency or voiding
dysfunction. They may also play a part in surveillance or
research programmes.4
The clinician must formulate a clear diagnostic question
that they expect the urodynamic observations to answer,
leading to a change in patient management. The National
Institute for Health and Care Excellence (NICE) and the
International Consultation on Incontinence for Urodynamic
Testing (ICI-UDT) offer some guidance. Both recommend
urodynamics for overactive bladder symptoms and urge-
predominant mixed urinary incontinence, but only after
failure of initial conservative treatment and prior to
considering surgery. NICE, however, does not recommend
urodynamic observations prior to primary surgical treatment
for pure stress urinary incontinence (SUI) or stress-
predominant mixed urinary incontinence, diagnosed by
clinical history and demonstrated at examination.5,6
Table 1 summarises the recommendations made by NICE
and ICI-UDT in different types of continence.
Despite the available guidance, there is still debate as to
whether urodynamic observations are routinely required
prior to surgery for pure SUI. This is because some studies
have revealed that patients with mixed incontinence
symptoms have a poorer surgical outcome than those with
pure SUI. Currently, however, there is no evidence confirming
that preoperative urodynamics in patients with pure SUI,
which accounts for 5% of tertiary unit incontinence cases, will
affect surgical outcomes or their further management.7 The
VALUE study was a randomised trial performed by Nager
et al.,8 in which women whose predominant symptom was
SUI were randomised to undergo urodynamic observations or
clinical assessment alone, prior to undergoing surgical mid-
urethral tape treatment. Other than differentiating between
mixed and pure SUI, the investigators found no difference in
194
surgical outcomes between those who underwent urodynamic
observations and those who did not.8 This study has been
criticised over whether the findings are applicable to daily
clinical practice or if they are appropriate for other types of
stress incontinence procedure.
With the current medicolegal climate surrounding tape
procedures for urinary incontinence, it is imperative that
clinicians have an objective diagnosis of SUI prior to surgery.
Potentially, urodynamic observations may mean that some
women avoid unnecessary surgical intervention, techniques
can be adjusted intraoperatively and patients can be given
appropriate preoperative counselling to manage their
expectations.4,7
Elderly patients should not be considered differently from
younger patients simply because of their age. However,
with potentially multiple contributory factors, clinicians
skilled in the care of elderly patients should be involved
before any invasive investigations are performed.9
Consent
To obtain the most useful results, it is important to recognise
that urodynamic observations aim to reproduce
pathophysiology and symptoms in an artificial setting. The
situation can involve significant anxiety, embarrassment and
discomfort for the patient. Individuals with depression,
anxiety or painful bladder syndrome have been found to
experience the most discomfort and apprehension.10 Much
more reliable results can be obtained if the clinician is
sensitive and treats the patient with respect, allowing privacy
and adequate time. To optimise the patient’s experience, it is
advisable to provide written information to explain the tests
before their arrival, so they know what to expect. There is
conflicting evidence, however, on the best written
information to provide, because the patient may find it
difficult to understand and increased information does not
necessarily reduce patient anxiety. An ICS Standard
Information leaflet for urodynamics is available.2
The International Consultation on Incontinence
Committee on Dynamic Testing (ICI-CDT) recommends
discussing with patients the imperfect or lack of predictive
value of urodynamic observations on their ‘chance of cure’
following surgery, as well as the unreliability in predicting
adverse outcomes of surgery.5 The clinician must therefore
appreciate the patient’s goal for investigation and treatment
and manage these expectations. It must also be clear to the
patient that there is no therapeutic effect. This is an
important component of the consenting process.
When urodynamic observations are performed in children,
the clinician must acknowledge any social influences, physical
demands and psychological stresses of the situation that may
modify the child’s behaviour and hence might alter the
observation outcomes.9
ª 2019 Royal College of Obstetricians and Gynaecologists
 Taithongchai et al.

Table 1. When to perform urodynamic investigations6,9,21

NICE recommendations ICI-UDT recommendations

Urge Before surgical treatment After failed conservative measures

incontinence Not to quantify detrusor overactivity before or after
treatment

SUI Not recommended if pure SUI has been diagnosed based on history Before surgical treatment
and examination, unless there is a suggestion of voiding dysfunction, After failed treatment
anterior compartment prolapse or previous surgical management (Before and) after experimental treatments

Neurological Offer video urodynamics for those at substantial risk of renal All relevant patients with urinary dysfunction suggestive
urinary complications (e.g. spina bifida, spinal cord injury or anorectal of neurological pathophysiology; initially and during
incontinence abnormalities) follow-up
Before any surgical treatment To be done in dedicated, specialised and multidisciplinary
centres

Children with No guidance Only after pragmatic management and treatment

urinary Before invasive treatment
incontinence After failed treatment
(Before and) after experimental treatments

Frail elderly with No guidance Only after initial conservative management

urinary Before invasive treatment
incontinence After failed treatment

NICE = National Institute for Health and Care Excellence; ICI-UDT = International Consultation on Incontinence for Urodynamic Testing; SUI = stress
urinary incontinence.

following urodynamic observations, but not of symptomatic

Preparation
The ICI-CDT has developed evidence-based guidelines for
urodynamic testing, which outline the equipment
recommended, the necessary training required and methods
of performing the tests.5 It is recommended that centres
make their own decisions about individual accreditation and
recertification requirements; however, the United Kingdom
Continence Society has set out minimum standards for
training and offers criteria for accreditation for those trained
outside of these standards.11 Ensuring the use of up-to-date
standards and careful training of examiners will reduce inter-
practice and inter-observer variation in results.2
While it has previously been usual practice to stop anti-
muscarinics prior to urodynamic observation, the latest
recommendation suggests that the clinician’s decision as to
whether or not to stop any medication before performing
urodynamic observations should depend on local guidelines
or standards.2 It is therefore important that current
medications for an overactive bladder are clearly
documented in the report.
Prior to commencing, the urine dipstick must be checked
for infection or haematuria. If there is evidence of a urinary
tract infection (UTI), then the test should be postponed until
the infection is treated.12 There is a risk of UTI when
undergoing urodynamic observations. A review of nine
randomised controlled trials showed that prophylactic
antibiotics reduce the risk of bacteriuria and haematuria
UTI. Therefore, the potential benefits of routine prophylactic
antibiotics do not outweigh the potential clinical and
financial implications and are therefore not routinely
prescribed.13 Aseptic conditions, however, should be
maintained when performing all invasive components of
urodynamic observations.
If there is any evidence of prolapse then this should be
reduced using a pessary, speculum or finger.2
Components of urodynamic testing
Uroflowmetry
Uroflowmetry is a simple, non-invasive and relatively
inexpensive test. It allows objective and quantitative
information to be gathered as a first-line screening test.
The patient is asked to void by relaxing, not straining, while
sitting on a commode over a rotating disc flowmeter or
weight-transducer flowmeter. The volume of urine passed per
unit time can be assessed in millilitres per second (ml/s),
giving a maximum flow rate and volume voided that can be
displayed graphically. PVR urine volume measurement can
then be done sonographically or with a catheter;2 this is the
remaining intravesical fluid volume after completed voiding.
ICS recommends that these three measurements should be
reported as a minimum, with the patient in their preferred
position (sitting or standing) and ensuring the patient had a
representative void.2

ª 2019 Royal College of Obstetricians and Gynaecologists 195

 Understanding urodynamics
The shape of the flow curve obtained can then be analysed
to provide insight into whether the patient is emptying their
bladder normally and possible causes of their symptoms.
Voiding dysfunction can be attributed to (a) detrusor
contractility dysfunction, (b) urethral dysfunction or (c)
bladder outflow resistance.
A normal flow is bell-shaped: a rapid upstroke, a curve
with continuous flow, a clear maximum flow rate (Qmax)
and a quick decline to end cleanly. The ‘bell’ or ‘arc’ is rarely
symmetrical (Figure 1). Large population studies have shown
normal Qmax in women to be 20–36 ml/s. Non-pathological
Figure 1. Uroflowmetry showing the typical bell shaped curved (top
line) seen with normal flow with a voided volume of 250 ml (bottom
line).
Table 2. Patterns of uroflowmetry with descriptions14
Qmax Description
Several peaks in Qmax (ml/s) Caused by repeated Valsalva manoeuvres/
straining, leading to fluctuating and
intermittent stream
Reduced Qmax A rapid upstroke but with reduced Qmax,
giving a plateau shape
Very high Qmax A rapid upstroke and downstroke
196
explanations for Qmax below normal are low voided volume
(<150 ml), overfilling of the bladder (>550 ml), an inhibited
patient, or calibration or recording problems. Artefacts can
lead to overestimation of Qmax, which may be caused by the
stream wandering on the spinning disc of the flowmeter.14
Table 2 summarises the different patterns of flow on
uroflowmetry and their causes.
‘Suprapubic tapping’ is a phenomenon that may be seen in
patients with neurological disease. The suprapubic area is
tapped to achieve a short bladder contraction and is
combined with straining to achieve partial emptying of the
bladder. It is commonly associated with high PVR.
A PVR of less than 100 ml is not regarded as clinically
significant in asymptomatic patients. A high PVR may be
secondary to detrusor under-activity caused by anticholinergic
medication, detrusor failure or bladder outlet obstruction.14
Cystometry
Cystometry is a test to assess the bladder’s storage ability. It
involves artificially and continuously filling the bladder with fluid
via a single-lumen or double-lumen catheter to measure the
pressure within the bladder or intravesical pressure (Pves)
(normal values 5–50 cm H2O). Rectal placement of a fully fluid-
filled open or punctured balloon catheter is used to measure the
pressure surrounding the bladder or abdominal pressure (Pabd)
(normal values 5–50 cm H2O).5 ICS recommends placement of
the abdominal pressure catheter in the vagina or a stoma as an
alternative, if rectal catheter placement is impossible.2
Measurement of the forces in the bladder wall, or detrusor
pressure (Pdet), is then achieved by subtracting the abdominal
pressure from the intravesical pressure (Pdet = Pves – Pabd)
(normal values 5 to 15 cm H2O).5
ICS-GUP2016 suggests that the standard thin (5–7F)
transurethral double-lumen or triple-lumen catheter is used
for bladder filling and pressure recordings. The pressure
Possible causes Uroflow shape
Bladder outflow obstruction
Unsustained detrusor contraction
A urethral stricture
External urethral compression or bladder
outflow obstruction (e.g. with prolapse,
following continence surgery, failure
of bladder neck relaxation)
Acontractile detrusor
Possible detrusor over-activity
High-speed squirting to overcome an obstruction
ª 2019 Royal College of Obstetricians and Gynaecologists

systems available can utilise fluid-filled, solid-state or air-filled
catheters. Standard cystometry is with a fluid-filled system
with external transducers at the reference level of the upper
edge of the symphysis pubis. The fluid type and temperature,
filling method and rate, catheter size, pressure recording
technique and the patient’s position should all be recorded.
Cysto-urethrometry can also be performed by continuously
measuring urethral pressure during cystometry.2
Initial resting pressures of Pves and Pabd are recorded at the
beginning of cystometry. The bladder is then continuously
filled with normal saline solution at room temperature. The
non-physiological rate at which this is done has not been
specified; however, ICS-GUP2016 suggests filling at a rate
(ml/min) of 10% of the maximum voided volume.
Patients with detrusor overactivity may need a slower rate of
10 ml/min.2 Physiological filling of the bladder is 1–2 ml/
min.3 It is important to obtain a balance between a filling rate
that is slow enough to mimic a representative bladder filling
and fast enough to complete the cystometry efficiently.2
The patient’s perceived sensations should be annotated on
the cystometrogram after careful explanation as to when to
report them2 (see Figure 2):
 First sensation of bladder filling (FSF) – the moment the
patient feels that their bladder is no longer empty.
Figure 2. Normal cystogram with a filling and voiding phase. Cg = cough; FD = first desire to void; ND = normal desire to void; SD = strong desire to
void; Pves = vesical pressure; Pabd = abdominal pressure; Pdet = detrusor pressure; MCC = maximum cystometric capacity; VD = void.
ª 2019 Royal College of Obstetricians and Gynaecologists
Taithongchai et al.
 First desire to void (FD) – the moment that normally tells
the patient to go to the toilet, without any hurry, at the
next convenient moment.
 Strong desire to void (equal to maximum cystometric
capacity) (SD) – the moment the patient – without any
pain or fear of losing urine – will not postpone the voiding
and will visit the nearest toilet.
 Feeling of urgency, fear of leaking or pain or any
other symptom.
During bladder filling, the patient is asked to cough every
minute to assess recording quality. This should produce an
acute and equal rise in Pabd and Pves, with little or no rise in
Pdet. Provocation manoeuvres to elicit the patient’s
symptoms are performed throughout the test. These may
include heel-bouncing, jogging, listening to running water,
washing hands, coughing or refilling the bladder in various
positions or with a cooled medium at a faster rate. These are
then annotated on the cystometrogram.14
Bladder compliance describes the association between rise
in bladder volume and change in Pdet. This is calculated
from the change in Pdet from an empty bladder up to the
maximum cytometric capacity. In particular, it can suggest
the presence of a neurological condition (if increased) or
prior radiotherapy damage (if reduced).15
197
 Understanding urodynamics

Figure 3. Filling and voiding cystogram showing unprovoked rises in detrusor pressure (blue arrows) associated with the sensations of urgency (FD
and SD) suggestive of detrusor overactivity. Cg = cough; FD = first desire to void; ND = normal desire to void; SD = strong desire to void;
Pves = vesical pressure; Pabd = abdominal pressure; Pdet = detrusor pressure; MCC = maximum cystometric capacity; VD = void.

With normal detrusor function, there will be no change in
Pdet throughout filling, despite provocation. Although
urodynamic observations can depict detrusor dysfunction,
ICI-CDT recommends that neither the cause (neurogenic or
idiopathic) nor the severity of detrusor overactivity is
diagnosed from cystometry alone5 (see Figure 3). Table 3
provides a summary of cystogram interpretations for
detrusor function.
Urodynamic stress incontinence is urinary leakage seen
during filling, in the presence of raised abdominal pressure
during the urodynamic stress test butin the absence of a detrusor
contraction.1 The cystogram of patients with urodynamic

Table 3. Detrusor findings on cystogram14

Detrusor feature Characteristics

Low or poor detrusor compliance e.g. post-radiotherapy Steep rise in detrusor pressure during filling that persists after filling
is stopped. Usually <30 ml/cm H2O. Associated with reduced bladder capacity.

High detrusor compliance e.g. neurological causes Generally, compliance will be >100 ml/cm H2O and can have capacities of > 1 L.
Poor detrusor accommodation Rise in detrusor pressure during filling, but the pressure falls to normal when
filling is stopped.

DO (Figure 3) Phasic – waves of detrusor contractions that may or may not

i.e. involuntary detrusor contractions be associated with incontinence.
during filling phase – can be spontaneous Terminal – single involuntary detrusor contraction at cystometric
or provoked (amplitudes >15 cm H2O) capacity resulting in incontinence, usually bladder emptying.
NB: not all detrusor contractions may cause Cough-associated DO – onset of DO is immediately following cough pressure peak
symptoms and therefore may not be clinically significant
In a patient with normal sensation, then urgency
is likely to be experienced just before the leak

DO = detrusor overactivity.

198 ª 2019 Royal College of Obstetricians and Gynaecologists


stress incontinence will therefore appear normal, with the
diagnosis being confirmed by seeing leakage during coughing or
another provocation method, with no associated detrusor
contraction. This should then be annotated on the cystogram.
Urodynamic artefacts
Urodynamic artefacts are spurious or inaccurate
measurements that can lead to the failure of reproduction
of symptoms and false-negative or false-positive findings.
Initial quality checks of the equipment and set-up with
calibrations are vital. Continuous checking and
contemporaneous correction of the calibration, pressure
transmissions, catheter patency and locations, and patient
positioning throughout the procedure are required to ensure
a reliable and useful investigation.16
During uroflowmetry, artefacts can particularly arise with
patient movement or rapid abdominal straining. Privacy can
help to reduce this, as can checking with the patient that they
had a representative void. During cystometry, artefacts often
occur as a result of equipment set-up, patient positioning or
catheter properties (Figure 4). Cough pressure peaks should
be seen throughout the study, identifying good subtraction
between the pressure lines and hence allowing for correction of
many artefacts, as well as zeroing transducers to atmospheric
pressure and expulsion of any air bubbles. This is the same for
Figure 4. Cystometry demonstrating an artefact caused by pump vibrations seen as small oscillations in the Pves line (red arrows). Cg = cough;
FD = first desire to void; ND = normal desire to void; SD = strong desire to void; MCC = maximum cystometric capacity; VD = void; Pves = vesical
pressure; Pabd = abdominal pressure; Pdet = detrusor pressure.
ª 2019 Royal College of Obstetricians and Gynaecologists
Taithongchai et al.
pressure flow studies, in which many artefacts are caused by
displaced pressure transducers, which can be picked up with
coughing before and after voiding and therefore corrected.14
Table 4 shows the common artefacts seen during urodynamic
observations and suggested remedies for them.
Interpreting the report
The amount of information produced from any urodynamic
study can be daunting to interpret and use in a meaningful
way. The clinician should incorporate the whole clinical
history, indication for the test and the bladder diary,
particularly when making management recommendations.
Automated systems are available to summate the findings;
however, the user should be able to check the outcomes,
change any values required and understand which findings to
ignore in interpretation. With the current media attention on
tape and mesh surgery, the systematic documentation of
urodynamic reporting is even more vital from a medicolegal
stand point. It is important to be methodical, to ensure the
correct information is retrieved and to avoid being distracted
by one overwhelming feature that may cause subtle but
essential findings to be missed. Comments on the technical
quality and representativeness of the results to the patient’s
symptoms should also be included. ICS GUP2016 provides a
standard report template that can be used.2
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 Understanding urodynamics
Table 4. Common artefacts and suggested remedies2,14,21
Artefact Effect on cystogram
Movement or tube High frequency, short duration spikes in
knock Pdet  in Pabd and Pves
Patient position Lasting change in Pves and Pabd of equal
change magnitude
Expelled vesical or Sudden drop in Pves or Pabd (usually
rectal catheter <0 cm H2O)
Not to be mistaken with a less drastic
drop in Pabd at voiding caused by pelvic
muscle relaxation
Catheter flush An abrupt large increase in a single
pressure trace lasting a few seconds,
which suddenly normalises
Line open to syringe Repeated line flushes do not restore a
good response to a cough signal
Empty bladder Response of the intravesical catheter to a
pressure transmission test is poor when
the bladder volume is low
Empty rectal catheter Deterioration in abdominal pressure
transmission during filling or voiding
Poor cough response One cough spike is visibly smaller than
others
Poor response to live Little or no live signal is observed on the
signal or dead signal trace and on Pdet, despite a satisfactory
cough test
Rectal contractions Temporary phasic increases in Pabd
without change in Pves, resulting in
negative deflections of Pdet
Pump vibrations Stable frequency oscillations of small but
(Figure 4) constant amplitude
Pdet = detrusor pressure; Pabd = abdominal pressure; Pves = vesical pressure.
Box 1 lists key factors to consider when approaching any
urodynamic investigation17 (Figure 2).
What to do if the test does not answer your
question
Sometimes the results of the urodynamic observations do not
correspond with the patient’s symptoms, and the
urodynamic question has been insufficiently answered. In
such cases, it is important to ensure no artefacts have caused
200
Cause Remedy
Knocking of one or both tubes Adjust tube position
Ignore these spikes on interpretation
Change in patient position from Move the transducers to the level of
supine to standing the symphisis pubis after any
If the pressure increase is temporary position change and check
then it may be because of patient transmission pressure
straining
Catheter is expelled from the patient Recatheterise and repeat the test
often because of voiding/valsalva
Water being pushed through the Check for good pressure transmission
transducer to remove any air after flushing
Ignore the sudden pressure change
when interpreting
The syringe is inadvertently still Set the taps correctly and repeat the
connected to the water line cough test to ensure good pressure
transmission
Catheter may be touching the bladder Fill the bladder with a further 50 ml
wall so pressure changes within the and test again
cavity cannot be registered
Reduced water in the rectal balloon Refill the balloon and retest
causing it to fail to connect
effectively with the rectal wall
Air bubble in the line, reducing the Flush the line
pressure transmission from patient to
transducer
Air bubble in the line Inspect there is no interference on the
May be the pump or patient affected line and stop the pump
disrupting the affected line Flush the line
Rectal contractions of which the Do not include in interpretation
patient may or may not be aware
Filling line touching the pressure Switch the pump on and off and
connecting tube with the pump on ensure tubing not in contact with
each other
spurious misleading results. ICS-GUP2016 suggests
immediately repeating a test if the findings cannot be
explained by the patient’s symptoms and signs.2
Once it has been concluded that the initial urodynamic
investigations are reliable, it is necessary to decide whether
further investigations are required. Specialist supplementary
tests that can be performed after conventional urodynamic
observations, if the diagnosis is still unclear, include:2
 pad test
 videocystometry (NICE recommended6)
ª 2019 Royal College of Obstetricians and Gynaecologists

Box 1. Key factors to consider when approaching urodynamic
investigation
1. Calibration – is the subtraction adequate?
 Baseline abdominal pressure (Pabd), vesical pressure (Pves) and
detrusor pressure (Pdet) should be within normal range before
commencing filling and checked each minute as the patient is
asked to cough.
 Filling and storage phase – assess involuntary detrusor activity,
bladder compliance, sensation, continence and capacity.
2. Pdet – pressure rise >15 cm H2O – yes or no?
 If there is a rise in Pdet, what is the pattern of rise?
 May be provoked or unprovoked rise in detrusor pressure that is
abnormal and would correlate with overactive bladder (Figure 3).
 Sensations noted?
 May be associated with sensations of urgency which would
correlate with overactive bladder.
3. Evidence of leak with provocation, with no rise in Pdet?
 Suggestive of stress incontinence.
4. Capacity – Normal, increased or reduced?
 Voiding phase – assess contractility of the bladder, emptying of
the bladder, co-ordination and any evidence of voiding
obstruction.
5. Voiding (Vmax) – is this normal?
 Pattern of void?
 May indicate bladder outflow obstruction or detrusor contractility
dysfunction.
6. Overall summary with diagnosis and management recommendations.
Figure 5. Bladder diverticula seen on video urodynamic observation.
Outpouchings of the normally smooth bladder wall are delineated
with the contrast medium.
ª 2019 Royal College of Obstetricians and Gynaecologists
Taithongchai et al.
 ambulatory urodynamics (NICE recommended6)
 urethral pressure profile tests.
Pad test
Pad tests can be performed to detect and quantify severity of
urine loss if urodynamic observations are not accepted by the
patient or have not produced results explaining their symptoms.
They will not, however, give a diagnostic cause for the urinary
incontinence. A short-term test over 1 hour involves wearing a
pre-weighed pad and instruction to exercise for 30 minutes.
Before and after weights of the pad determine the amount of
leakage and are most accurate if based on a fixed bladder volume.
A positive test is a weight gain of more than 1 g. The long-term
test, usually performed over 24–48 hours at home, allows women
to go about their normal activities wearing the pre-weighed pad
and correlates well with symptoms. The pad is changed every
4–6 hours and is either weighed immediately or stored in
an airtight bag for later weighing. A weight gain of more than
1.3 g is a positive result.18
Videocystometry
Videocystometry is performed using iodine-based contrast
rather than normal saline solution to allow X-ray or
ultrasound imaging or cine-loops of the LUT. The use of
contrast medium and possible X-rays means that this test
carries inherent risks of contrast allergy or anaphylaxis, as
well as radiation exposure; therefore, it is not done routinely.
It allows visualisation of the functional anatomy of the LUT.
This can lead to a more comprehensive assessment in
children, suspected multifactorial aetiologies or in patients
with neurogenic bladder. In particular, it can identify
vesicoureteric reflux during filling or voiding, as well as
correlating with SUI. It also allows detrusor sphincter
dyssynergia, bladder or urethral diverticula (see Figure 5),
or fistulae and bladder herniation to be visualised.14
Ambulatory urodynamic monitoring
Ambulatory testing can be useful if conventional urodynamic
observations fail to reproduce or explain a patient’s
symptoms because it allows physiological filling of the
bladder and privacy during voiding. It often takes place
outside of the artificial laboratory surroundings and allows
the day-to-day activities that may provoke incontinence in
the patient to be reproduced.19
Urethral function tests
Urethral function can be assessed during filling cystometry
and voiding. ICI-CDT does not recommend that these are
performed in isolation to assess patients because of the poor
sensitivity and specificity of these measurements.5
Urethral pressure profilometry assesses the urethral ability
to maintain a closed bladder outlet.5 It records absolute
201
 Understanding urodynamics
urethral length, functional urethral length, maximum
urethral pressure and maximum urethral closure pressure.
A catheter is placed in the urethra and withdrawn along the
length of the urethra. The measurements produce a graph of
the intraluminal pressure along the length of the urethra.14
The clinical relevance of urethral function tests, urethral
pressure profilometry or other urethral pressure
measurements is not yet clear because they have been
shown to have significant test–retest variation. It is therefore
recommended to only perform these tests in addition to the
standard urodynamic observations, if deemed necessary.5
Conclusion
Urodynamic observations can be a critical component of the
investigation of some patients who complain of LUTS. They
should, however, only ever be performed in the correct
patients and in conjunction with basic procedures, such as
taking a comprehensive history, examination, quality of life
questionnaires and completion of a bladder diary. There
must always be a clear question to answer to avoid
submitting the patient to an unnecessary invasive and
potentially embarrassing test. Paramount to this process is
ensuring that artefacts are minimised so that the correct
answers are obtained for the patient and the clinician will
know what to do next if more information is required
following inconclusive urodynamic observations.
Disclosure of interests
RT is the president of the International Urogynaecology
Association and on RCOG Council.
Contribution to authorship
AT instigated, researched and wrote the article. RT and AHS
researched and edited the article. All authors read and
approved the final version of the manuscript.
References
1 Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U. The
standardisation of terminology of lower urinary tract function: report from
the Standardisation Sub-Committee of the International Continence Society.
Neurourol Urodyn 2002;21:167–78.
2 Rosier P, Scheafer W, Lose G, Goldman H, Guralnick M, Eustice S, et al.
International Continence Society good urodynamic practices and terms
2016: urodynamics, uroflowmetry, cystometry, and pressure-flow study.
Neurourol Urodyn 2016;9999:1–18.
3 Abrams P, Cardozo L, Wagg A, Wein A. Incontinence. 6th ed. Bristol:
International Continence Society; 2017.
4 Bing MH, Gimbel H, Greisen S, Paulsen LB, Soerensen HC, Lose G. Clinical
risk factors and urodynamic predictors prior to surgical treatment for stress
urinary incontinence: a narrative review. Int Urogynecol J 2015;26:
175–85.
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5 Rosier P, GaJewski J, Sand P, Szabo L, Capewell A, Hosker G. Executive
summary: The International Consultation on Incontinence 2008 –
Committee on: “Dynamic Testing”; for Urinary Incontinence and for Fecal
Incontinence. Part 1: Innovations in urodynamic techniques and urodynamic
testing for signs and symptoms of urinary incontinence in female patients.
Neurourol Urodyn 2010;29:140–5.
6 National Institute for Health and Care Excellence (NICE) Urinary incontinence
and pelvic organ prolapse in women: management. Clinical guideline
[NG123]. London: NICE; 2019. [https://www.nice.org.uk/guidance/ng123].
7 Agur W, Housami F, Drake M, Abrams P. Could the National Institute for
Health and Clinical Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome from stress
incontinence surgery? BJU Int 2009;103:635–9.
8 Nager C, Brubaker L, Litman H, Zyczynski H, Edward Varner R, Amundsen C,
et al. A randomized trial of urodynamic testing before stress-incontinence
surgery. N Engl J Med 2012;366:1987–97.
9 Rosier P, Szabo L, Capewell A, Gajewski J, Sand P, Hosker G. Executive
Summary: The International Consultation on Incontinence 2008 –
Committee on: “Dynamic Testing”. Part 2: Urodynamic testing in male
patients with symptoms of urinary incontinence, in patients with relevant
neurological abnormalities, and in children and in frail elderly with
symptoms of urinary incontinence. Neurourol Urodyn 2010;29:146–52.
10 Yeung J, Eschenbacher M, Pauls R. Pain and embarrassment associated with
urodynamic testing in women. Int Urogynecol J 2014;25:645–50.
11 Association for Continence Advice, British Association of Paediatric
Urologists, British Association of Urological Nurses, British Association of
Urological Surgeons, British Society of Urogynaecology, Chartered Society of
Physiotherapists, et al. Joint statement on minimum standards for
urodynamic practice in the UK. London: United Kingdom Continence
Society; 2009[http://www.ukcs.uk.net/wp-content/uploads/2015/12/polic
y_document_joint_statement_ud_practice.pdf].
12 Preston A, O'Donnell T, Phillips C. Screening for urinary tract infections in
a gynaecological setting: validity and cost-effectiveness of reagent strips.
Br J Biomed Sci 1999;56:253–7.
13 Foon R, Toozs-Hobson P, Latthe P. Prophylactic antibiotics to reduce the risk
of urinary tract infections after urodynamic studies. Cochrane Database Syst
Rev 2012;(10):CD008224.
14 Thakar R, Toozs-Hobson P, Dolan L. Urodynamics illustrated. London: Royal
College of Obstetricians and Gynaecologists; 2011.
15 Cho SY, Yi JS, Oh SJ. The clinical significance of poor bladder compliance.
Neurourol Urodyn 2009;28:1010–4.
16 Gammie A, Clarkson B, Constantinou C, Damaser M, Drinnan M, Geleijnse
G, et al. International Continence Society guidelines on urodynamic
equipment performance. Neurourol Urodyn 2014;33:370–9.
17 Johnson KC, Rovner ES. The 9 “C's” of pressure-flow urodynamics. In:
Rovner ES, Koski ME, eds. Rapid and practical interpretation of urodynamics.
New York: Springer; 2015. pp. 27–33.
18 Krhut J, Zachoval R, Smith P, Rosier F, Valansky L, Martan A, et al. Pad
weight testing in the evaluation of urinary incontinence. Neurourol Urodyn
2014;33:507–10.
19 van Waalwick van Doorn E, Anders K, Khullar V, Kulseng-Hassen S, Pesce F,
Robertson A. Standardisation of ambulatory urodynamic reporting: report
of the Standardisation Sub-Committee of the International Continence
Society for Ambulatory Urodynamic Studies. Neurourol Urodyn
2000;19:113–25.
20 Gammie A, D'Ancona, Kuo H, Rosier P. ICS teaching module: artefacts in
urodynamic pressure traces (basic module). Neurourol Urodyn 2017;36:
35–7.
21 National Institute for Health and Care Excellence (NICE). Urinary
incontinence in neurological disease: assessment and management. Clinical
guideline CG148. London: NICE; 2018 [https://www.nice.org.uk/guidance/
cg148].
ª 2019 Royal College of Obstetricians and Gynaecologists
 DOI: 10.1111/tog.12573
The Obstetrician & Gynaecologist
http://onlinetog.org
Issues around vaginal vault closure
a,
Magdy Moustafa MB Bch MSc MD FRCOG FRCS PgD MSc, *
a
Consultant Obstetrician and Gynaecologist, Frimley Park Hospital, Frimley, Camberley, Surrey GU16 7UJ, UK
b
Lecturer in Obstetrics and Gynaecology, Cairo University, Giza 12613, Egypt
c
Clinical Fellow in Obstetrics and Gynaecology, Great Western Hospital, Marlborough Road, Swindon, Wiltshire SN3 6BB, UK
*Correspondence: Magdy Moustafa. Email: magdy_moustafa@live.co.uk
Accepted on 24 September 2018. Published online 26 June 2019.
Key content
 Vaginal cuff dehiscence (VCD), vault prolapse, vaginal cuff
granulation and infected vault haematoma are adverse events
following hysterectomy.
 There are several approaches to closing the vaginal cuff, each using
different techniques and sutures.
 Dehiscence of the vaginal cuff is more common with laparoscopic
hysterectomy. Techniques that minimise excessive use of
diathermy may reduce the risk of vault dehiscence.
 The incidence of post-hysterectomy vault prolapse is estimated to
be between 1.8% and 11.6%. McCall culdoplasty seems to be
effective in supporting the vaginal vault.
 Different techniques are used to minimise the development of
vault haematoma and granulation tissue.
Learning objectives
 To understand the different techniques used for vault closure
during hysterectomy.
Please cite this paper as: Moustafa M, Elnasharty M. Issues around vaginal vault closure. The Obstetrician & Gynaecologist 2019;21:203–8.
https://doi.org/10.1111/tog.12573
Introduction
Hysterectomy is one of the most commonly performed surgical
procedures in gynaecological practice. Various techniques
have been described for closing the vaginal vault to minimise
vaginal vault complications such as dehiscence, prolapse,
granulation tissue formation and infected vault haematoma.
There are several approaches to closing the vaginal cuff using
different techniques and different suture materials. This
review discusses these different approaches and reviews the
advantages and disadvantages of each technique.
Vaginal vault closure techniques
Abdominal hysterectomy
Currently, two surgical techniques have been described for
vaginal vault closure after total abdominal hysterectomy. The
first method is to leave the vaginal vault open, while suturing
the circumference of the vagina with a continuous locking
suture. However, the second method, complete closure of the
vaginal vault, is preferred because it is associated with better
ª 2019 Royal College of Obstetricians and Gynaecologists.
2019;21:203–8
Review
b,c
Mohamed Elnasharty MB Bch MSc MD MRCOG
 To understand the different surgical approaches used to reduce the
risk of vault dehiscence, vault prolapse and haematoma
after hysterectomy.
 To understand the post-operative care procedure that should be
followed after hysterectomy to minimise the risk of vaginal
vault complications.
Ethical issues
 Patients should be aware of the risk of vaginal vault dehiscence,
vault prolapse, haematoma and granulation tissue formation
after hysterectomy.
 Trainees should be well trained using simulators, be supervised
when performing laparoscopic vaginal vault closure and be made
aware that vaginal closure is another safe treatment option.
Keywords: vaginal vault / hysterectomy / closure / sutures / route
of surgery and techniques
healing and a lower risk of granulation tissue formation.1
Complete vaginal closure is initiated with a midline figure-of-
eight stitch, which can help in traction and haemostasis.
Then, both vaginal angles are transfixed with the suture
ligature, which attaches both uterosacral and cardinal
ligaments.2 While this technique is associated with reduced
blood loss and prevents any contamination of the peritoneal
cavity by the vaginal contents, it does cause the vaginal length
to be shortened.2
Vaginal hysterectomy
Closure of the vaginal cuff can be achieved with either a
vertical or horizontal technique, using interrupted, running
or running locking sutures. A running locking stitch may be
associated with better haemostasis. Although it is generally
the surgeon’s choice as to which technique is used, vertical
closure has been found to preserve the vaginal length better
than horizontal closure.3 One randomised controlled study
compared the closed cuff technique with an open vault
technique in which only a continuous, interlocking
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 Issues around vaginal vault closure
polyglycolic acid suture was used that incorporated the
uterosacral ligaments into the vault. No significant difference
was found between this technique and the traditional one.4
Laparoscopic hysterectomy
There are several techniques for closing the vaginal vault in
laparoscopic hysterectomy: vaginal or laparoscopic, continuous
or interrupted sutures, single or double layers, or knotted or
unknotted stitches. Laparoscopic knotting can use intracorporeal,
extracorporeal (Figure 1) or barbed sutures (Figure 2).5
In a prospective study, Jeung et al. (2010) found no
difference between the interrupted figure-of-eight technique
and the knotted double layer continuous technique.6 Shen
et al. (2002) compared three techniques for vaginal cuff
closure: single layer, double layers and open vaginal cuff
closure. They found no statistically significant difference in
terms of intraoperative or postoperative vaginal cuff
complications, apart from a lower incidence of granulation
tissue formation and vaginal discharge with the double layer
closure technique.7
Blikkendaal et al. (2012) found no statistically significant
difference between laparoscopic, single-layer, unknotted
running sutures and laparoscopic or vaginal, knotted,
interrupted sutures. They also found no difference in the
incidence of vaginal cuff dehiscence (VCD) with the use of
running polyglycolic acid sutures with clips.5
Laparoscopic closure of the vaginal cuff allows adequate
visualisation and more effective vaginal vault support by
incorporating the uterosacral ligament, and reduces the risk
of infection with greater vaginal length. However, there is an
increased risk of VCD compared with the vaginal
interrupted technique.8
Influence of suture material
Vaginal cuff closure is a complicated procedure because of
the risk of bacterial contamination and postoperative
granulation tissue formation. The ideal suture material
should prevent bacterial growth, produce minimal tissue
reaction and be absorbable but at the same time maintain
strength for the duration required for wound healing (about
2–4 weeks). The most common types of sutures used are
chromic catgut, multifilament polyglycolic acid sutures,
monofilament sutures and barbed sutures.8
Chromic catgut is associated with increased risk of
granulation tissue formation.9 Duckett and Patil (2012)
found an increased incidence of vaginal discharge, bleeding
and pain with the use of multifilament polyglycolic acid
(Vicryl) compared to polyglecaprone 25 (Monocryl).10
The barbed suture is a new class of knotless suture. Its
surface has barbs that penetrate the tissues and lock them in
place without needing to tie knots,11 so it is technically easier
to use and is thus associated with reduced operative times. It
allows more homogenous distribution of the tension
204
throughout the suture. Various studies have found that
barbed sutures give better results than other types of suture.
It has also been found that the bacterial adherence of barbed
sutures is similar to the standard monofilament suture but
lower than other types of suture material.12 In one report,
which described the use of barbed sutures in an operation to
remove a small bowel obstruction, the ileum was found to be
attached to the tail of the barbed suture 30 days later, causing
volvulus. It was therefore recommended that the tails of
barbed sutures should be kept short enough to avoid
such complications.13
Vaginal vault complications
Vaginal cuff dehiscence
VCD is the separation of the previously closed vaginal cuff
and is a rare but serious adverse event that can occur after
hysterectomy. It can lead to evisceration (i.e. prolapse) of the
abdominal contents, especially of the terminal ileum, which
can occur a few weeks or even years after hysterectomy.14,15
The incidence of VCD was found to be higher after
laparoscopic hysterectomy compared with abdominal or
vaginal routes (4.9%, 0.29% and 0.12%, respectively).16 VCD
is considered a surgical emergency. Red flag symptoms that
require immediate evaluation include vaginal bleeding,
vaginal discharge, pain and pressure.
Most researchers have hypothesised that the high incidence
of VCD after hysterectomy is either caused by the application
of electrosurgical thermal energy or by the suture techniques.
Laparoscopic colpotomies cause more tissue necrosis and
devascularisation.16 Three different forms of energy are used
for colpotomy: ultrasonic, monopolar and bipolar. In a
comparative study of the thermal damage caused by different
energy sources in the histological assessment of tissues in
swine, Gruber et al. (2011) concluded that ultrasonic energy
causes the least and bipolar energy causes the greatest
amount of tissue damage.17
The incidence of VCD is higher in laparoscopic
hysterectomy because advanced surgical and technical
suturing and knotting skills are required. Suture tension is
less reliable when using laparoscopic instruments compared
with open hysterectomies in which the surgeon uses their
hands. The magnifying effect of the scope can also lead to
insufficient amounts of tissue being sutured and excessive
electrocauterisation as a result of the magnification of small
vessels, which reduces the blood supply and subsequently
impedes the healing process.18
The type of suture material used also affects the incidence
of VCD. The use of early absorbable sutures is associated with
a higher incidence of VCD than when delayed absorbable
sutures are used (2.5% and 0.7%, respectively). This can be
justified by the fact that early absorbable sutures like those
made from polyglycolic acid can effectively support the
ª 2019 Royal College of Obstetricians and Gynaecologists.

wound for 3 weeks, while delayed absorbable sutures such as
those made from polydiaxone (PDS) are supportive for
6 weeks.19 Siedhoff et al. (2011) found a lower incidence of
VCD, granulation tissue formation, postoperative bleeding
and cellulitis when bidirectional barbed sutures were used.20
With barbed sutures, the average time to develop VCD was
approximately 73 days, but it was 29 days when polyglycolic
acid sutures were used. This difference can be attributed to
the fact that the relative tensile strength of barbed sutures
remains as high as 80% after 4 weeks, while polyglycolic acid
sutures have only 25% of their tensile strength remaining
after the same period of time.21 However, Stefano et al.
(2015) found no difference in the incidence of VCD between
polyglycolic acid sutures and bidirectional barbed sutures.22
Other studies have shown that certain surgical techniques
may reduce the risk of VCD; for example, incising the vaginal
Figure 1. Closure of the vaginal vault using extracorporeal sutures.
Figure 2. Closure of the vaginal vault using knotless barbed sutures.
ª 2019 Royal College of Obstetricians and Gynaecologists.
Moustafa and Elnasharty
cuff using a cutting mode set to monopolar current is
associated with less thermal spread, and using sutures rather
than electrocoagulation for haemostasis avoids excessive
coagulation. Closing the full thickness of the cuff with two
layers of PDS sutures placed at least 1 cm from the edge, and
the use of bidirectional barbed sutures, are also associated
with reduced VCD risk.14,20
Other factors that may contribute to the occurrence of
VCD include postoperative vault infection or haematoma,
post-menopausal state, use of radiotherapy, chronic
steroid use, chronic increase in intra-abdominal pressure,
obesity, diabetes, immunosuppression and early return to
sexual intercourse.15
Finally, VCD is a surgical emergency that requires
immediate intervention. Initial measures include adequate
hydration and empirical antibiotics. The patient should be
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 Issues around vaginal vault closure
kept in Trendelenburg’s position and the exposed bowel
should be kept moist during transfer to the operating
theatre.23 The American College of Obstetricians and
Gynecologists recommends copious lavage of the exposed
bowel, sufficient debridement of the separate edge before re-
suture, full-thickness interrupted sutures and approximation
of the VCD edge.24
Vaginal vault prolapse
Vaginal vault prolapse (VVP) is defined as descent of
the vaginal vault below a point that is 2 cm less than the
total vaginal length above the plane of the hymen.25 The
incidence of VVP is about 36 per 10 000.26
In attempts to reduce the risk of VVP, different techniques
have been described for prophylactic vaginal vault suspension
such as sacrospinous fixation, sacrotuberous ligament
fixation, McCall culdoplasty, Moschcowitz culdoplasty,
iliococcygeal fixation, Halban culdoplasty, endopelvic fascia
vault fixation, uterosacral ligament suspension, posterior
pelvic shelf colpopexy or simple peritoneal closure.27
However, the most commonly used procedures are sacrospinous
ligament fixation and uterosacral ligament suspension.
Prophylactic sacrospinous fixation is indicated after
vaginal hysterectomy in cases of uterine prolapse at stage 2
or greater.28However, use of this technique requires adequate
vaginal length and vault width to be able to reach the
sacrospinous ligament.29 The incidence of dyspareunia and
cystocele has been found to increase after sacrospinous
fixation, most probably because of changes to the vaginal
axis.27 Sacrospinous fixation is also associated with vascular
and nerve injuries (e.g. injuries to the sciatic, pudendal and
perirectal vessels).30
Several techniques have been described for using the
uterosacral ligament to support the vaginal vault. In McCall
culdoplasty, the uterosacral ligaments are brought to the
midline by a series of stitches, incorporating the peritoneal
pouch of Douglas and the posterior vaginal cuff to
obliterate the pouch of Douglas and support the
vaginal vault.31
The use of permanent sutures is not recommended during
vaginal hysterectomy because the knot remaining in the
vaginal cavity can cause partner irritation during intercourse.
Moreover, the midline deviation caused by the McCall
culdoplasty technique can result in pain or ureteral injury.32
A modification of the technique has been described in which
purse-string sutures are used to close the pouch of Douglas,
with intraperitoneal hitching of the uterosacral ligaments.
Since this does not involve the cardinal ligaments, it keeps
the ureter away from the stitch.30
Other modifications using different stitches and different
fixation points have also been described.
In Moschcowitz culdoplasty, purse-string sutures are used
to close the pelvic peritoneum, incorporating both the
206
anterior and posterior peritoneum and the uterosacral
ligaments to close the pouch of Douglas.33
The Halban culdoplasty, which is used to prevent
enterocele formation, involves placement of vertical purse-
string sutures between the uterosacral ligaments to shorten
them. However, it has no role in the prevention or treatment
of VVP.34
Uterosacral ligament suspension can be done abdominally,
vaginally or laparoscopically. The incidence of ureteric injury
associated with uterosacral ligament suspension can be up to
11%, especially when performed vaginally. An extraperitoneal
approach for uterosacral ligament fixation was associated
with lower incidence of ureteric injury.27
No technique has yet been found to be superior over
another for the prevention of VVP. Two cohort studies
showed that McCall culdoplasty is more effective than
Moschcowitz culdoplasty or simple peritoneal closure for
maintaining vault support for up to 3 years after surgery.32,35.
Some studies have also showed that McCall culdoplasty gives
better anatomical and functional results, with improved
overall patient sexual satisfaction.30 In terms of prolapse
recurrence and patient satisfaction, other studies found no
difference between McCall culdoplasty and ligament
suspension procedures.36
Maintaining the cervix may improve sexual and urinary
functions after hysterectomy. In 2012, a systematic review
found no difference in urinary, bowel or sexual functions
with subtotal hysterectomy. Another review, conducted in
2015, concluded that subtotal hysterectomy did not protect
against urinary incontinence or pelvic organ prolapse.37,38
The Royal College of Obstetricians and Gynaecologists
does not recommend subtotal hysterectomy for the
prevention of post-hysterectomy vault prolapse (PHVP).39
Robinson et al. (2017) described the role of sacro-
colpopexy in the treatment of PHVP, which has a success
rate of 78–100%. It carries the risk of cystotomy, ureteric
injuries, enterotomy and injury of the presacral veins.
Depending on the type of mesh used, there is also the
risk of mesh erosions. A higher risk has been associated
with polyethylene terephthalate (Mersilene) compared with
polypropylene (Prolene).40
The intrafascial technique for total abdominal hysterectomy
has the advantage of supporting the vaginal vault. It preserves
the complex anatomic relationships between the endopelvic
fascia and the vagina by maintaining attachment of the
uterosacral ligament and incorporating it into the vaginal
cuff closure. It also maintains the length and axis of the vagina.
However, intrafascial hysterectomy is only indicated for the
treatment of benign disease.41
Vaginal vault haematoma
Vaginal vault haematoma is more common after vaginal
hysterectomy and has an incidence of between 25% and 59%.
ª 2019 Royal College of Obstetricians and Gynaecologists.

Haematoma may occur as a result of postoperative bleeding
during vaginal hysterectomy. In most cases, haematoma is
asymptomatic, but it may occasionally result in prolonged
hospital admission, pyrexia, anaemia, secondary haemorrhage,
blood transfusion, pelvic discomfort or secondary surgery for
haematoma evacuation.42
Interventions to reduce the risk of vault haematoma
include adequate haemostasis, use of antibiotics and proper
surgical techniques. The traditional hysterectomy technique
is to close the peritoneum and the vaginal vault separately;
however, this creates a potential space haematoma
formation. The aims of closing the vaginal vault are to
extra-peritonealise the vascular pedicles, maintain support
of the vault and ensure adequate haemostasis. Wood et al.
(1997) proposed that suturing the edges of the peritoneum
to the vault of the vagina up to the uterosacral ligaments may
reduce the risk of haematoma formation.43
Miskry and Magos (2001) described a mass closure
technique to reduce the risk of haematoma formation.44 This
technique involves mass closure of the full thickness of the
anterior vaginal epithelium, the anterior peritoneum, medial
aspect of the right round ligament and uterosacral pedicles,
then the posterior peritoneum and posterior vaginal
epithelium. An additional stitch is then taken laterally
through the vaginal epithelium to emerge near to the original
point of entry, before being tied. The same steps are repeated on
the left side. Two other figure-of-eight stitches are taken
medially to the angle sutures. The medial bite into the posterior
peritoneum is placed high to decrease the risk of enterocele.
This technique is easier, faster, has no intraoperative
complications and is effective in preventing VVP.44
Morris et al. (2001) described another technique in which
the peritoneum remains attached to the posterior vaginal
skin.42 In this technique, the cervix is incised in a ‘V’ shaped
incision and suturing starts vertically from the posterior
vaginal wall. The incidence of vault haematoma in this study
was 1.7%.42
Recently, studies have shown that use of a bipolar vessel
sealing system is associated with a lower risk of vault
haematoma.45 However, no proven benefit was identified for
routine vault drainage.46
Vaginal vault granulation
Vaginal vault granulation is a common complication
following abdominal hysterectomy. In most cases, it is
benign and tends to regress spontaneously over a few
months. However, it may be symptomatic, causing copious
vaginal discharge, bleeding and sometimes infection. Surgical
technique and the type of suture material used are the most
common contributing factors.1
The closed cuff technique, in which healing occurs by
primary intention, has been associated with reduced risk of
granulation tissue formation compared with the open cuff
ª 2019 Royal College of Obstetricians and Gynaecologists.
Moustafa and Elnasharty
technique, in which healing occurs by secondary intention.
Several studies concluded that the perioperative use of
antibiotics and the choice of suture material can help to
reduce the risk of such complications.1
Management of vaginal vault granulation usually involves
2–3 additional outpatient clinic visits for cauterisation, silver
nitrate application or cryotherapy. Admission to the hospital
for diathermy under anaesthesia may be required.1
Post-hysterectomy prolapse of the fallopian tube is an
uncommon complication that is often confused with vault
granulation tissue. Diagnosis should be considered if the
lesion at the vaginal vault does not respond to conservative
management. In such rare conditions, a biopsy of the area
can be performed to confirm tubal epithelium. Treatment is
mainly surgical, as the surrounding vaginal epithelium is
incised and widely undermined and the tube is removed.47
Postoperative care
Currently, there are no documented, evidence-based measures
that can help to reduce the risk of vault complications.
However, the most commonly recommended measures are to
avoid lifting heavy objects to reduce the risk of vault prolapse
and to avoid sexual intercourse for the first 3 months after
laparoscopic hysterectomy.
Conclusion
Closure of the vaginal vault is associated with possible
complications. Patients should be well informed before
undergoing such a procedure and advised of the
postoperative care that will be required. Although patient
characteristics and early sexual coitus are known to predispose
to complications, choice of surgical technique remains the
most important contributing factor.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
MM instigated and edited the article. ME researched and
wrote the article. Both authors read and approved the final
version of the manuscript.
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3 Cavkaytar S, Mahmut MK, Topcu HO, Aksakal OS, Doganay M. Effects of
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hysterectomy using various energy sources in swine: a histopathologic
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18 Uccella S, Ghezzi F, Mariani A, Cromi A, Bogani G, Serati M, et al. Vaginal
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19 Agdi M, Al-Ghafri W, Antolin R, Arrington J, O’Kelley K, Thomson AJ, et al.
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20 Siedhoff MT, Yunker AC, Steege JF. Decreased incidence of vaginal cuff
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21 Drudi L, Press JZ, Lau S, Gotlieb R, How J, Eniu I, et al. Vaginal vault
dehiscence after robotic hysterectomy for gynecologic cancers: search for
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22 Bogliolo S, Musacchi V, Dominoni M, Cassani C, Gaggero CR, De Silvestri A,
et al. Barbed suture in minimally invasive hysterectomy: a systematic review
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23 Matthews CA, Kenton K. Treatment of vaginal cuff evisceration. Obstet
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24 Jareemit N, Parkpinyo N, Chayachinda C, Sophontanarak P,
Yiengpruksawan A. Vaginal cuff dehiscence with small bowel evisceration
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25 Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The
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27 Dwyer PL, Fatton B. Bilateral extraperitoneal uterosacral suspension: a new
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28 Cruikshank SH. Preventing post hysterectomy vaginal vault prolapse and
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29 Randall CL, Nichols DH. Surgical treatment of vaginal inversion.
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30 Chene G, Tardieu AS, Savary D, Krief M, Boda C, Anton-Bousquet MC, et al.
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31 McCall ML. Posterior culdeplasty: surgical correction of enterocele during
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35 Montella JM, Morrill MY. Effectiveness of the McCall culdeplasty in
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36 Colombo M, Milani R. Sacrospinous ligament fixation and modified McCall
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37 Lethaby A, Mukhopadhyay A, Naik R. Total versus subtotal hysterectomy for
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vault at vaginal hysterectomy. BJOG 2001;108:1295–7.
45 Hefni MA, Bhaumik J, El-Toukhy T, Kho P, Wong I, Abdel-Razik T, et al.
Safety and efficacy of using the Ligasure vessel sealing system for securing
the pedicles in vaginal hysterectomy: randomised controlled trial. BJOG
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46 Dua A, Galimberti A, Subramaniam M, Popli G, Radley S. The effects of vault
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ª 2019 Royal College of Obstetricians and Gynaecologists.
 DOI: 10.1111/tog.12574
The Obstetrician & Gynaecologist
http://onlinetog.org
A review of acupuncture in obstetrics and gynaecology
Faisal Karim MBBS BSc (Hons),a,* James Dilley MBChB MRCOG,b Elaine Cheung MBBS BSc (Hons) CoBC (Acupuncture) MRCOGc
a
ST1 in Obstetrics and Gynaecology, King’s College Hospital, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
b
Registrar in Obstetrics and Gynaecology, King’s College Hospital, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
c
Consultant Obstetrician and Gynaecologist, Royal Free London NHS Foundation Trust (Barnet site), London NW3 2QG, UK
*Correspondence: Faisal Karim. Email: faiskarim@outlook.com
Accepted on 10 December 2018. Published online 25 June 2019.
Key content
 Acupuncture is an ancient form of medicine involving sensory
stimulation via needle insertion.
 In the UK, Western medical acupuncture (WMA), an adaptation
of traditional Chinese approach, is used in varying
circumstances, including in obstetrics and
gynaecology.
 Outcome studies have demonstrated that acupuncture can be
effective in pain management, fertility and obstetrics (during
pregnancy, intrapartum and postpartum).
 Acupuncture is safe and has a very low risk of adverse
incidents if carried out by trained and accredited
practitioners.
Please cite this paper as: Karim F, Dilley J, Cheung E. A review of acupuncture in obstetrics and gynaecology. The Obstetrician & Gynaecologist 2019;21:209–14.
https://doi.org/10.1111/tog.12574
Introduction
Acupuncture is an ancient form of medicine that is
approximately 3000 years old. A key part of traditional
Chinese medicine, it is also increasingly popular in the
Western world, with an estimated 4 million sessions
provided annually.1
The term ‘acupuncture’ is derived from the Latin acus (a
needle) and puncture (a puncture).2 In traditional Chinese
medicine, it is believed that stimulating specific points on the
surface of the body affects the functioning of organs; a line,
known as the meridian, links the points pertaining to each
organ. Energy, or Qi (the Chinese term for life energy), passes
through the body via different meridians. Pain and/or disease
subsequently occurs when the flow of Qi is disrupted.4
Acupuncture points, which map the whole body, lie along
these meridians. Normally 4–6 needles are inserted
simultaneously, with the depth of insertion dependent on the
body position. This is designed to redirect the flow of Qi to
influence the body’s healing response and restore harmony.4
Western medical acupuncture (WMA) is an adaptation of
the traditional Chinese approach, involving evidence-based
medicine and knowledge of anatomy and physiology. WMA
does not adhere to the traditional circulation of Qi and is the
main form of acupuncture practised in Western countries.5
ª 2019 Royal College of Obstetricians and Gynaecologists
2019;21:209–14
Review
Learning objectives
 To understand that there is a different but complementary option
available when treatment success is not achieved with Western
medicine and that women may opt for acupuncture over more
recognised treatment options.
 To be aware that studies have shown that acupuncture can be a
beneficial treatment, but most studies are non-randomised.
Ethical issues
 Women should be given information about all suitable treatments,
including acupuncture, to make an informed choice.
Keywords: acupuncture / alternative medicine / assisted
conception / complementary medicine / dysmenorrhoea
The primary therapeutic effects of needle insertion at the
acupuncture points are achieved via stimulation of the
sensory nervous system. It can also have local effects, such as
the release of neuropeptides and increase in local blood flow.6
Clinical effects differ depending on tissue level (skin or
muscle) and the type and amount of stimulation provided by
inserting the needle. The selection of specific points is also
based upon the nerve supply of the condition in question.5
As acupuncture is regarded as a form of sensory
stimulation, it can be difficult to ascertain the appropriate
dose of stimulation for each condition. Since the dose
depends on each individual’s nervous system, it would be
problematic to use a similar dose across different trials,
although there is a lack of data on this means. Hence, trials
may have been conducted in a suboptimal fashion.7
Another problem with acupuncture trials is that inserting a
needle at a non-classical site will inevitably create some form
of nervous stimulation. Often, placebo or sham acupuncture
involves inserting a needle at classical sites but at a different
tissue level to the intervention needles, or at non-standard
acupuncture points.5 Since both placebo and intervention
needles will cause sensory stimulation, it is difficult to
accurately assess the effectiveness of the treatment
acupuncture. For this reason, sham or placebo acupuncture
cannot truly be defined as an inert placebo.
209
 Acupuncture in obstetrics and gynaecology
Acupuncture in obstetrics and gynaecology
Acupuncture is increasingly offered as an adjunct therapy to
conventional treatment. In obstetrics, no adverse fetal effects
have been noted when using acupuncture, although data are
limited thus far. When used for relief of gynaecological
conditions, no long-term side effects have been noted beyond
the initial pain of needle insertion. Acupuncture is not
known to have any teratogenic side effects and avoids the
ingestion of medication. This may be why some women
prefer this option during and outside of pregnancy.4,5
Breech
Breech presentation occurs in 3–4% of term pregnancies.8 In
Western countries, it has become more common to deliver
breech babies by caesarean section because this carries a
lower infant morbidity and mortality risk than planned
vaginal breech delivery.9 External cephalic version (ECV),
where the fetus is manually rotated from a breech to a
cephalic presentation through the mother’s abdominal wall,
is a safe and effective way to reduce the requirement for a
caesarean section when attempted after 36 weeks of
gestation.10,11 There is, however, a risk of fetal distress,
abdominal pain and bruising, and failure of the procedure,
which is why women may seek an alternative to ECV.
Moxibustion, which involves burning the herb mugwort,
can be used to attempt to adjust breech to cephalic
presentations. It is applied to the acupuncture point
Bladder 67 (BL67, Zhiyin), located at the tip of the fifth
toe, at between 28 and 37 weeks of gestation.12,13 Treatment
lasts for 15–20 minutes and is repeated up to 10 times per
day, for up to 10 days. Currently, there is no consensus on
the best treatment pattern.13 It has been suggested that the
longwave infrared radiation produced by burning the moxa
sticks induces maternal hormone production, resulting in
fetal activity and uterine contraction.14 Side effects including
blisters, burns and burning sensations have been noted in
8.5% of women who used this,15 and the unpleasant burning
odour has also been noted.11 Moxibustion trials have
reported no harm to the fetus.
In a 2012 Cochrane review, Coyle et al.11 found that,
compared with the use of acupuncture, moxibustion reduced
the number of non-cephalic presentations at birth. They also
found that, compared with no treatment, moxibustion
combined with acupuncture reduced the number of
non-cephalic presentations at birth and the caesarean
section rate. The quality of evidence was deemed moderate,
with clinical heterogeneity and differing levels of
statistical heterogeneity.
Subsequently, a 2014 randomised controlled trial (RCT) by
Coulon et al.15 showed no benefit of moxibustion and
acupuncture in correcting breech presentation at term
compared with a placebo treatment, which was an
210
inactivated laser. There is, therefore, some evidence to
indicate that moxibustion and acupuncture can correct
breech presentation at term, but further evidence is
required to confirm this.
During labour
Pain during labour has been described as the most severe
pain that one can experience. It is caused by uterine
contractions, cervical dilatation and stretching of the
vaginal and pelvic floor.16 In China, acupuncture has been
used as analgesia during labour for centuries.17
In a 2011 Cochrane review, Smith et al.18 concluded that
acupuncture is beneficial for reducing pain in labour,
increases maternal satisfaction and reduces the requirement
for pharmacological analgesia. More data and further trials
are required to be able to make a clinical recommendation.
A 2010 review by Cho et al.19 revealed that although
acupuncture does seem to reduce the requirement for other
forms of analgesia compared with conventional analgesia, the
evidence is weak. Compared with placebo acupuncture or
conventional analgesia, acupuncture does not seem to
provide more effective pain relief.17–19
None of the studies discussed so far have noted any adverse
side effects or harmful outcomes. The use of acupuncture in
labour shows a trend for a reduced requirement for analgesia
(including use of epidural) and can also increase maternal
satisfaction with the analgesia provided during labour.
Further studies are needed, but this evidence suggests that
acupuncture is a valid choice that may help women to
manage their pain in labour. Guidelines published in 2014 by
the National Institute for Health and Care Excellence
(NICE)20 indicate that acupuncture will not be offered, but
if the woman requests it, it can be used during labour.
Induction of labour
Induction of labour may be required if warranted by
concerns for the safety of the mother, her baby, or both.
Traditionally, it involves mechanical (e.g. membrane
sweeping, artificial rupture of membranes, balloon insertion
into the uterus) or pharmacological (synthetic oxytocin or
prostaglandin) methods.21
A 2017 Cochrane review by Smith et al.21 concluded that
there was no evidence to suggest that using acupuncture (or
acupressure, which involves applying physical pressure to
acupuncture points) reduced the caesarean section rate.
However, where acupuncture was used, there was a greater
change in the Bishop’s score22 and cervical dilatation23
compared with usual (mechanical or pharmacological)
methods. No difference was noted between acupuncture
and placebo/sham acupuncture.24 Furthermore, electro-
acupuncture (acupuncture involving passing a small electric
current between sited needles) reduced the caesarean section
rate compared with usual care, but there was no difference
ª 2019 Royal College of Obstetricians and Gynaecologists

between placebo and electro-acupuncture.21 Although the
2008 NICE guidelines25 state that there is insufficient
evidence to warrant the use of acupuncture for induction
of labour, the woman may use it if she wishes.
Available data suggest that acupuncture does not reduce
the caesarean section rate, but may improve the readiness of
the cervix for labour. No known adverse effects were reported
in the use of acupuncture. Further research is required,
especially to assess how acupuncture affects cervical
readiness. To make an informed decision regarding their
care, women should be informed that acupuncture may have
a similar effect to conventional treatment methods.
Hyperemesis gravidarum
Nausea and vomiting occur in 50–80% of pregnancies.
Hyperemesis gravidarum is a severe form of pregnancy-
related sickness that affects 0.3–1.0% of pregnancies.26 The
definition of hyperemesis gravidarum varies, but generally
includes severe, protracted nausea, weight loss of >5% of
pre-pregnancy weight, electrolyte imbalances, starvation
(ketonuria) and exclusion of other diagnoses.27 In 90% of
affected pregnancies, hyperemesis gravidarum usually
commences between the fourth and seventh weeks of
gestation, peaks around the ninth week and resolves by the
20th week.26,28
In a 2016 Cochrane review by Beolig et al.,28 it was shown that
fewer women who undergo acupuncture require additional
antiemetic medication compared with those receiving a placebo.
However, comparing acupuncture with metoclopramide, there
was no difference in the rate of reduction of nausea and vomiting
experienced. Acupuncture had no effect on preterm birth,
stillbirth, miscarriage or neonatal death.
Although they used small sample populations, other studies
have shown that acupuncture can reduce hyperemesis
gravidarum, in addition to intravenous rehydration.29
Therefore, it appears reasonable to offer acupuncture as a
complementary treatment to resolve hyperemesis gravidarum
or/and reduce medication usage, but further studies are
required to improve the quality of the evidence available.
Dysmenorrhoea
Dysmenorrhoea, or period pain, describes painful cramps of
uterine origin. Primary dysmenorrhoea describes pain that
starts within the first 3 years of menarche, in women
<26 years of age, with no known organic cause. Primary
dysmenorrhoea is typically characterised by cramp-like and
colic-like spasms in the suprapubic region, peaking within
the first few days of menstruation. It is also associated with
diarrhoea, vomiting, back pain and headaches.30 It is the
most common cause of pain in young women, with
estimated prevalence rates ranging from 16.1–81%.31
There is limited evidence to suggest that acupuncture is
more effective than placebo acupuncture for the treatment of
ª 2019 Royal College of Obstetricians and Gynaecologists
Karim et al.
dysmenorrhoea, with women who were followed up for up to
1 year. There is, however, evidence to indicate that
acupuncture is more effective than non-steroidal anti-
inflammatory drugs (NSAIDs) at reducing menstrual pain
and improving quality of life and is less likely to cause adverse
events. Therefore, for women who are offered the use of
NSAIDS, or for whom NSAIDs are effective but cause adverse
effects, acupuncture may be suggested as a complementary
therapy as it may have a similar, if not better, outcome.
Differences in the styles of acupuncture used, reported
outcomes and follow-up outcomes, and the risk of bias and
statistical heterogeneity mean that further trials are required to
assess the value of acupuncture in treating primary
dysmenorrhoea and provide a more conclusive outcome.32
Secondary dysmenorrhoea is generally caused by problems
with the reproductive system. It tends to start later in life
than primary dysmenorrhoea and worsens over time.
Conditions such as endometriosis and fibroids can cause
secondary dysmenorrhoea.33
Endometriosis occurs when tissue from the lining of the
uterus is found abnormally outside of the uterus – most
commonly in the pelvic or abdominal cavity. The most
common symptom is dysmenorrhoea, although other
symptoms can include dyschezia, dyspareunia and
subfertility. Normal fluctuations in hormones cause the
endometrial lining of the uterus to break down at the end of
each menstrual cycle. However, in endometriosis, the
abnormally ectopic endometrial lining also breaks down,
resulting in bleeding. The reasons why this should cause pain
are unclear, but it is potentially caused by the fact that the
ectopic bleeding tissue cannot be removed as menstrual
outflow, subsequently causing inflammation of the sites.33–35
Endometriosis is the third leading reason for gynaecological
hospitalisation and hysterectomy in the USA and affects
women’s quality of life. Medical pain management is
frequently inadequate, and although surgical intervention
may be curative, its associated risks mean that it may not be a
viable option.34,35 A 2011 review by Zhu et al. demonstrated
that there is insufficient evidence to support the effectiveness of
acupuncture in relieving the pain of endometriosis.35 One
study of auricular acupuncture36 demonstrated a reduction in
pain compared with those receiving Chinese herbal medicine.
Nevertheless, the small sample size, lack of randomisation and
difficulty in determining the ways in which outcomes were
assessed means that further research is required to fully explore
the effect of acupuncture in endometriosis.
Assisted conception
Approximately one in seven couples in industrialised
countries experience subfertility and seek help to
conceive.37 Medical help includes assisted reproductive
technologies, such as controlled ovarian stimulation with or
without intrauterine insemination and in vitro fertilisation.38
211
 Acupuncture in obstetrics and gynaecology

The high failure rate of assisted conception methods means
that other therapies, including acupuncture, are being
considered.
In women who had acupuncture on or around the day of
embryo transfer, there was an increase in the live-birth rate
compared with control individuals who received usual care.
No benefit of acupuncture was seen when compared with
placebo/sham acupuncture. This might be associated with the
study quality38 or the fact that placebo acupuncture is not an
inert control.
Taking all the evidence together, acupuncture does not
seem to improve the clinical pregnancy rate or live-birth rate,
whether performed at the time of transvaginal oocyte
retrieval or around the time of embryo transfer during
in vitro fertilisation, but there was also no evidence that
acupuncture increases the rate of miscarriage.38,39 However,
there is a lack of standardisation of the acupuncture points
utilised between studies, and controls often included placebo/
sham acupuncture, which might elicit an effect.
Urinary incontinence
Urinary incontinence can be classified as stress urinary
incontinence (SUI), urgency urinary incontinence or mixed
urinary incontinence.40 SUI is the unintentional loss of urine
on physical exertion, coughing or sneezing. This is caused by
increased intra-abdominal pressure resulting in the bladder
pressure being greater than urethral resistance.40 Urgency
urinary incontinence is secondary to alterations in the
nervous system, resulting in muscle hypersensitivity and
reduced effectiveness of smooth muscle relaxation. Mixed
urinary incontinence is a combination of SUI and urgency
urinary incontinence.41
The results of several trials have suggested that acupuncture
is beneficial to those experiencing urinary incontinence
because it reduces the number of incontinence episodes.
Acupuncture may also have a similar effect to anticholinergic
therapy and improves quality of life by reducing symptoms.42
For SUI specifically, when compared with pharmaceutical
treatment (midrodine), acupuncture appeared to improve
symptoms, but there was no statistical difference in the cure
rate.43 Nonetheless, there is insufficient data to make a firm
conclusion. As such, in both instances, further high quality
RCTs are required to assess how acupuncture affects
urinary incontinence.
Polycystic ovary syndrome
Polycystic ovary syndrome (PCOS) is characterised by
oligomenorrhoea, infertility (often caused by failure to
ovulate) and hirsutism (secondary to excessive androgen
production). It is also associated with metabolic disorders
such as diabetes mellitus,44 and is potentially associated with
an alteration in the autonomic nervous system – specifically
increased sympathetic nervous activity.45 Based on the 2003
Rotterdam criteria,46 PCOS is diagnosed when two of
the three following criteria are met: polycystic ovaries,
oligoovulation or anovulation, and hyperandrogenaemia
(and excluding other causes of hyperandrogenaemia).46 The
prevalence rate of PCOS varies between studies, potentially

Table 1. Recommendations for the use of acupuncture in obstetrics and gynaecology

Condition Acupuncture successful? Recommendation

Correcting breech Moxibustion with acupuncture more successful when compared with no Further research required
presentation treatment

Pain in labour Can be beneficial in reducing pain in labour Further research required, NICE
guidelines state it can be used

Induction of labour Improves cervical readiness for labour but does not reduce caesarean section rate Further research required, NICE
guidelines state it can be used but
insufficient evidence available

Hyperemesis gravidarum Complementary treatment reduces medication usage Further research required

Primary dysmenorrhoea More effective than non-steroidal anti-inflammatory drugs Further research required

Secondary dysmenorrhoea Auricular acupuncture may be effective Further research required

Assisted conception Lack of evidence to suggest it improves the pregnancy rate or live birth rate Further research required

Urinary incontinence May reduce number of incontinence episodes and improve symptoms in stress Further research required
urinary incontinence

Polycystic ovarian syndrome May increase level of ovulation Further research required

Premenstrual syndrome Acupuncture and acupressure may reduce symptoms Further research required

NICE = National Institute for Health and Care Excellence.

212 ª 2019 Royal College of Obstetricians and Gynaecologists


because different definitions are used for diagnosis, but it is
usually estimated as affecting 4–12% in women in their
reproductive years.47
A 2016 Cochrane study44 highlighted that none of the
studies reviewed assessed whether acupuncture in PCOS
affected the live birth rate. Not all studies evaluated whether
acupuncture altered the levels of ovulation although, in some
instances, ovulation levels increased with acupuncture. There
was also insufficient data on adverse events.
In a 2009 study by Manneras et al.,45 which used rats
induced with PCOS, electro-acupuncture increased ovulation
and, they concluded, may help to control the action of the
sympathetic nervous system. Exercise had a similar effect, but
to a lesser degree. This could help explain why acupuncture
has a positive effect in patients suffering from PCOS who
wish to conceive.
There is evidence that acupuncture is effective in PCOS, in
particular for increasing ovulation levels, but further RCTs
with standardised recruiting criteria and outcomes are
required.
Premenstrual syndrome
Premenstrual syndrome (PMS) is a clinical syndrome
encompassing many different symptoms that interfere with
women’s lives. It generally starts 5–11 days prior to
menstruation and stops at the start of menstruation or
shortly after menstruation has begun. Symptoms may be
behavioural (fatigue, dizziness, overeating), psychological
(irritability, anger, depression) and/or physical (headaches,
breast tenderness, abdominal pain, muscle and joint pain).
Commonly, symptoms are mild, but approximately
20–30%48 of women experience severe symptoms that
significantly affect activities of daily living.49,50
A 2018 Cochrane review50 concluded that both
acupuncture and acupressure may reduce PMS symptoms
when compared with a sham acupuncture control. More
specifically, acupuncture can decrease the physical and
psychological mood-related symptoms of PMS. No known
adverse effects were reported in the use of acupuncture or
acupressure. However, treatment was not compared with
recommended therapies for PMS, such as selective serotonin
re-uptake inhibitors, which makes it difficult to quantify
benefit. Further research is required using adequate blinding
and comparator groups reflecting current best practice.
Conclusion
There are no data to conclude that the use of acupuncture
(whether during or outside of pregnancy) has any adverse
effects; therefore it may be used as a complementary and/or
replacement therapy if the patient wishes. There is some
evidence to suggest that acupuncture may be beneficial in
correcting breech presentation, improving cervical readiness
ª 2019 Royal College of Obstetricians and Gynaecologists
Karim et al.
for labour, reducing pain in labour and reducing medication
usage in hyperemesis gravidarum. It may also be used for
symptom relief in primary dysmenorrhoea, urinary
incontinence and PMS, while increasing ovulation in PCOS
(summarised in Table 1).
Further research is required in all areas to assess the
effectiveness of acupuncture. When reviewing the evidence, it
is important to be aware that sham or placebo acupuncture
cannot be considered an inert placebo. Consequently, it is
associated with considerable effects, especially when compared
with no treatment control groups.51 In view of this, using sham
acupuncture as the control group makes it difficult to assess the
true effectiveness of the acupuncture intervention.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
JD instigated and edited the article. FK researched and wrote
the article. EC edited the article. All authors read and
approved the final version of the manuscript.
Acknowledgements
With thanks to Nick Dalton-Brewer of King’s Fertility for his
insight into acupuncture used on a daily basis.
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22 Harper TC, Coeytaux RR, Chen W, Campbell K, Kaufman JS, Moise KJ, et al.
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23 Smith CA, Crowther CA, Collins CT, Coyle ME. Acupuncture to induce labor:
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26 Miller F. Nausea and vomiting in pregnancy: the problem of perception—is
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28 Neri I, Allais G, Schiapparelli P, Blasi I, Benedetto C, Facchinetti F.
Acupuncture versus pharmacological approach to reduce Hyperemesis
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29 Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ
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30 Latthe P, Latthe M, Say L, G€ ulmezoglu M, Khan KS. WHO systematic review
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36 Boivin J, Bunting L, Collins JA, Nygren KG. International estimates of
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39 Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An
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41 Sun-Ho P, Su-Ryan H, Oh-Jun K, Young-Min A, Byung-Cheol Lee, Se-Young
A. Acupuncture for the treatment of urinary incontinence: a review of
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42 Wang Y, Zhishun L, Peng W, Zhao J, Liu B. Acupuncture for stress
urinary incontinence in adults. Cochrane Database Syst Rev 2013;(7):
CD009408.
43 Lim CED, Ng RWC, Xu K, Cheng NCL, Xue CCL, Liu JP, et al. Acupuncture for
polycystic ovarian syndrome. Cochrane Database Syst Rev 2016;(5):
CD007689.
44 Manneras L, Cajander S, Lonn M, Stener-Victorin E. Acupuncture and
exercise restore adipose tissue expression of sympathetic markers and
improve ovarian morphology in rats with dihydrotestosterone-induced
PCOS. Am J Physiol Regul Integr Comp Physiol 2009;296:R1124–31.
45 The Rotterdam ESHERE/ASRM-sponsored PCOS consensus workshop
group. Revised 2003 consensus on diagnostic criteria and long term health
risks related to polycystic ovary syndrome (PCOS). Hum Reprod
2004;19:41–7.
46 Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale H,
Futterweit W, et al. The Androgen Excess and PCOS Society criteria for the
polycystic ovary syndrome: the complete task force report. Fertil Steril
2009;91:456–88.
47 Borenstein J, Chiou CF, Dean B, Wong J, Wade S. Estimating direct and
indirect costs of premenstrual syndrome. J Occup Environ Med
2005;47:26–33.
48 Dickerson LM, Mazyck PJ, Hunter MH. Premenstrual syndrome. Am Fam
Physician 2004;57:1743–52.
49 Armour M, Ee CC, Hao J, Wilson TM, Yao SS, Smith CA. Acupuncture and
acupressure for premenstrual syndrome. Cochrane Database Syst Rev 2018;
(8):CD005290.
50 Linde K, Niemann K, Meissner K. Are sham acupuncture interventions
more effective than (other) placebos? A re-analysis of data from the
Cochrane Review on placebo effects. Forsch Komplementmed
2010;17:259–64.
ª 2019 Royal College of Obstetricians and Gynaecologists
 DOI: 10.1111/tog.12596 2019;21:215–8
The Obstetrician & Gynaecologist
CPD
http://onlinetog.org

CPD questions for volume 21 issue 3

CPD credits can be claimed for the following questions passive smoking in the absence of other
online via the TOG CPD submission system in the RCOG causes. ThFh
CPD ePortfolio. You must be a registered CPD participant of
With regard to smoking cessation in pregnancy,
the RCOG CPD programme (available in the UK and
8. women are less likely to succeed than are non-
worldwide) in order to submit your answers.
pregnant women. ThFh
Participants can claim 2 credits per set of questions if at
9. women should be asked to cut down rather
least 70% of questions have been answered correctly. CPD
than stop, to prevent withdrawal effects on
participants are advised to consider whether the articles are
the fetus. ThFh
still relevant for their CPD, in particular if there are more
10. nicotine replacement therapy in the form of
recent articles on the same topic available and if clinical
patches is recommended for use for no more
guidelines have been updated since publication.
than 16 hours per day. ThFh
Please direct all questions or problems to the CPD Office.
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Tel: +44(0) 20 7772 6307 or email: cpd@rcog.org.uk
12. carbon monoxide screening in pregnant
The blue symbol denotes which source the questions refer to
women applies only to smokers and those who
including the RCOG journals, TOG and BJOG, and RCOG
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guidance, such as Green-top Guidelines (GTGs) and Scientific
13. urinary cotinine is a metabolite of
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RCOG Members, Fellows Registered Trainees and
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Associates have full access to TOG content via the TOG
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Regarding interventions for smoking cessation during
pregnancy,
TOG Smoking in pregnancy:
15. incentive-based interventions are useful for
pathophysiology of harm and current
achieving cessation. ThFh
evidence for monitoring and cessation
16. 50% of spontaneous quitters in pregnancy
Smoking in pregnancy is associated with, remain abstinent 1 year postpartum. ThFh
1. placental abruption. ThFh
Electronic cigarettes,
2. an increased incidence of smoking in offspring. T h F h
17. combust a solution of water, propylene glycol
With regard to the contents of cigarette smoke and or glycerine, nicotine and flavourings. ThFh
smoking, 18. are the most used smoking cessation aid in
3. cigarette smoke consists primarily of carbon the UK. ThFh
dioxide, tar and water vapour. ThFh 19. quickly deliver a high serum
4. tar is the combusted particulate matter contained nicotine concentration. ThFh
within cigarette smoke that forms a residue on the 20. lack the behavioural and psychosocial aspects
skin, mucous membranes and lungs of smokers. T h F h of conventional cigarette smoking. ThFh
5. nicotine is a neuro-teratogen linked to
childhood behavioural disorders and attention
deficit hyperactivity disorder. ThFh TOG Multiple sclerosis and pregnancy
6. increased carbon monoxide concentration leads
to a right shift in the oxygen–haemoglobin With regard to multiple sclerosis (MS),
dissociation curve. ThFh 1. it is a B cell-mediated autoimmune disease. ThFh
7. carbon monoxide levels of 4 parts per million 2. it is two to three times more common in
are indicative of smoking or exposure to women than men. ThFh

ª 2019 Royal College of Obstetricians and Gynaecologists 215

 CPD
3. the HLA-DRB1*1501 allele is present in most
genetically susceptible individuals.
4. most patients are diagnosed with relapsing
remitting MS (RRMS) followed by primary
progressive MS (PPMS).
5. the risk of developing MS is four-fold higher
in monozygotic compared with dizygotic
twins.
Considering MS and pregnancy,
6. pregnancy adversely affects MS with long-term
progression of the disease.
7. exacerbations during pregnancy can be well
differentiated from pregnancy symptoms.
8. lactational amenorrhoea due to exclusive
breastfeeding reduces the risk of postpartum
relapse by three-fold.
Regarding the effects of MS on pregnancy,
9. there is no increased risk of
congenital malformations.
10. affected women are at increased risk of having
small-for-gestational-age infants.
11. smoking cessation has beneficial effects on
disease progression.
Regarding medications used to treat MS and their effect on
reproduction and pregnancy,
12. fingolomid is associated with reduced ovarian
reserve and amenorrhoea.
13. methotrexate should be discontinued for at
least 6 months prior to conception.
14. interferon-ß and glatiramer acetate can be
safely continued up until conception.
15. natalizumab crosses the placenta and can
cause fetal haematological abnormalities.
16. steroids and immunoglobulins are safe to
use during pregnancy to treat MS
relapse.
17. it is safe to recommence disease-modifying
treatment while breastfeeding.
With regard to delivery in women with MS,
18. most women with MS will need a
caesarean delivery.
19. parenteral hydrocortisone should be given
during labour to women taking steroids close
to delivery.
20. epidural anaesthesia is safe and does not lead
to disease progression.
216
TOG Preventing adhesions in laparoscopic
ThFh
surgery: the role of anti-adhesion agents
Peritoneal adhesions are,
ThFh 1. estimated to develop in less than 50% of
women undergoing pelvic surgery. ThFh
2. associated with significant patient morbidity
ThFh such as female subfertility. ThFh
3. estimated to contribute to more than
$2 billion in healthcare costs in the USA. ThFh
ThFh With regard to the pathophysiology of peritoneal adhesion
formation,
ThFh 4. surgical technique is a factor that contributes to
adhesion formation. ThFh
5. the extent of acute inflammation in the
ThFh abdominal peritoneum is a risk factor for post-
surgical adhesion formation. ThFh
6. white blood cells and fibroblasts re-epithelialise
injured peritoneal surfaces over a period of
ThFh
5–7 days. ThFh
7. factors which inhibit fibrinolysis, such as
ThFh
bacterial infection, decrease the likelihood of
peritoneal adhesion formation. ThFh
ThFh
8. acute tissue ischaemia caused by surgery is a
risk factor for post-surgical adhesion formation. T h F h
With regard to anti-adhesive agents,
9. physical barrier agents act by separating injured
ThFh
peritoneal surfaces during tissue healing. ThFh
10. once applied to peritoneal surfaces, these
ThFh
agents remain permanently in the abdomen
and pelvis. ThFh
ThFh
11. oxidised regenerated cellulose sheets
(Interceed) have been shown to have no effect
ThFh
on the incidence of adhesion development
compared with no barrier treatment. ThFh
12. an undesirable characteristic of
ThFh
polytetrafluoroethylene (Gore-Tex) is that it
requires suturing onto peritoneal surfaces and
ThFh
subsequent surgical removal. ThFh
13. solid hyaluronic acid sheet (Seprafilm)
barriers are suitable for laparoscopic use. ThFh
ThFh
When considering liquid and pharmacological
anti-adhesive agents,
14. liquid hyaluronic acid barriers (Intergel/
ThFh
Hyalobarrier) have been demonstrated to
reduce the development of intraperitoneal
ThFh
adhesions after laparoscopic surgery. ThFh
15. current evidence suggests that polyethylene
glycol-based liquid barriers (Spraygel/Coseal)
decrease the incidence of adhesion formation
ª 2019 Royal College of Obstetricians and Gynaecologists

in laparoscopic procedures compared with
no treatment.
16. 4% icodextrin solution (ADEPT) is the only
agent in the United States that the FDA has
approved for preventing peritoneal adhesions
after gynaecologic laparoscopic surgery.
17. 4% icodextrin solution (ADEPT) has been
demonstrated to reduce the incidence of
adhesion development compared with untreated
controls following laparoscopic adhesiolysis.
18. systemic administration of corticosteroids has
been demonstrated to prevent adhesions
following laparoscopic surgery.
With regard to peritoneal adhesions,
19. heparin has been shown to be useful in
adhesion prevention.
20. the readmission rate related to adhesions after
pelvic surgery is around 20%.
TOG A guide to indications, components
and interpretation of urodynamic
investigations
With regard to the International Continence Society Good
Urodynamic Practices 2016 (ICS-GUP2016),
1. standard urodynamic testing consists of history,
examination, bladder diary, post-void residual
and uroflowmetry.
2. standard urodynamic protocol should be
performed in the supine position.
3. a filling rate of 10% of the maximum voided
volume is suggested during cystometry.
Concerning incontinence surgery,
4. a randomised trial has shown benefit from
performing urodynamic investigations for
women prior to incontinence surgery.
5. there is evidence that urodynamics prior to
incontinence surgery will affect the outcome.
With regard to uroflowmetry,
6. a rapid upstroke to a reduced maximum flow
rate (Qmax) that then remains plateaued may
suggest a urethral stricture or bladder
outflow obstruction.
7. high speed squirting of urine has been shown to
give rise to a very high Qmax.
8. in asymptomatic patients, a post-void residual
of less than 100ml should not be considered
clinically significant.
9. detrusor overactivity with anticholinergics is a
recognised cause of a low post-void residual.
ª 2019 Royal College of Obstetricians and Gynaecologists
CPD
With regard to cystometry,
ThFh 10. the normal intravesical pressure (Pves) values
range from 5 to 50 cm H2O. ThFh
11. the patient is asked to cough every minute to
assess recording quality. ThFh
ThFh 12. if rectal catheter placement is impossible, then
placement of the abdominal pressure catheter
in the vagina or a stoma is an alternative. ThFh
13. the external transducers during cystometry
ThFh should be placed at a reference level below the
lower edge of the symphysis pubis. ThFh
14. detrusor pressure (Pdet) is calculated by
ThFh subtracting the abdominal pressure (Pabd)
from the vesical pressure (Pves). ThFh
At urodynamic testing,
ThFh 15. stress urinary incontinence will be clearly
demonstrated with a rise in detrusor pressure
ThFh with coughing. ThFh
16. it is possible to define the severity of
detrusor overactivity. ThFh
17. not all detrusor contractions cause symptoms
and therefore may not be clinically significant. ThFh
Regarding supplementary tests,
18. short-term pad tests involve the patient wearing
pads for 24 hours and weighing each pad every
6 hours. ThFh
19. videocystometry allows visualisation of the
ThFh functional anatomy of the lower urinary tract. T h F h
20. the National Institute for Health and Care
ThFh Excellence (NICE) advises considering
ambulatory urodynamics or pad tests if the
ThFh diagnosis remains unclear after
conventional urodynamics. ThFh
TOG Issues around vaginal vault closure
ThFh
With regard to abdominal hysterectomy,
ThFh 1. complete closure of the vagina results in greater
granulation tissue formation. ThFh
2. vaginal length is preserved with the closed
cuff technique. ThFh
3. subtotal hysterectomy does not protect
against urinary incontinence or pelvic
ThFh
organ prolapse. ThFh
ThFh With regard to closure of the vault at vaginal hysterectomy,
4. the horizontal approach better preserves the
vaginal length than the vertical approach. ThFh
ThFh 5. the open vault technique achieves
better outcomes than the closed cuff
ThFh technique. ThFh
217
 CPD

With regard to closure of the vault at laparoscopic 2. it stimulates the sensory nervous system. ThFh
hysterectomy, 3. it has been shown to increase the local
6. adhesive bowel obstruction is a complication of blood flow. ThFh
using barbed sutures. ThFh 4. its effects differ depending on the depth
7. this risk of vault cuff dehiscence is similar if the of stimulation. ThFh
closure is either vaginal or laparoscopic. ThFh 5. it is not known to have any teratogenic
side effects. ThFh
With regard to vaginal cuff dehiscence,
6. it permits needles to be placed at certain pre-
8. it is more common after laparoscopic
determined points only. ThFh
hysterectomy than after vaginal hysterectomy. ThFh
7. it can be combined with other forms of
9. studies have shown that bipolar energy causes
traditional Chinese medicine. ThFh
the least tissue damage. ThFh
10. when early absorbable sutures are used, the Moxibustion treatments for breech presentation of
incidence is about 10%. ThFh the fetus,
11. after 3 weeks, the tensile strength of barbed 8. involve the burning of a herb. ThFh
suture is about 25%. ThFh 9. have an established treatment pattern. ThFh
12. it is a surgical emergency that requires
With regard to the use of acupuncture in induction of
immediate intervention. ThFh
labour,
With regard to vaginal vault prolapse, 10. it is associated with a greater change in the
13. it is defined as descent of the vaginal vault Bishop’s score compared with
below a point that is 2 cm less than the total traditional methods. ThFh
vaginal length above the plane of hymen. ThFh 11. it reduces caesarean section rates. ThFh
14. the incidence of rectocele increases after
Regarding the use of acupuncture in pregnancy,
sacrospinous fixation (SSF). ThFh
12. it prevents the requirement for anti-emetics
15. SSF is associated with obturator nerve injuries. ThFh
in hyperemesis. ThFh
16. uterosacral ligament fixation is associated with
an approximately 11% risk of ureteric injury. ThFh With regard to acupuncture in gynaecological pathologies,
13. it has been shown in some studies to improve
With regard to vault haematoma,
quality of life in primary dysmenorrhoea when
17. routine vault drainage reduces the risk of
compared with non-steroidal anti-
vault haematoma. ThFh
inflammatory drugs. ThFh
18. dissecting the peritoneum from the posterior
14. it is not recognised as a recommended
vaginal wall increases the risk of haematoma. ThFh
treatment in endometriosis. ThFh
With regard to vault granulation tissue, 15. there is some evidence to suggest that using it
19. it occurs more commonly after in urinary incontinence improves quality
vaginal hysterectomy. ThFh of life. ThFh
20. antibiotics are the main treatment for vault 16. it increases the live-birth rate in women
granulation tissue. ThFh with PCOS. ThFh
17. sham or placebo types have the same effect as
no treatment control groups in studies. ThFh
TOG A review of acupuncture in obstetrics
In assisted conception, acupuncture,
and gynaecology
18. does not improve the clinical pregnancy rate. T h F h
With regard to Western medical acupuncture, 19. has been proven to increase the live-birth rate. T h F h
1. it is designed to affect the flow of Qi. ThFh 20. has increased the rate of miscarriage. ThFh

218 ª 2019 Royal College of Obstetricians and Gynaecologists

 DOI: 10.1111/tog.12591 2019;21:219
The Obstetrician & Gynaecologist
http://onlinetog.org
Please note that letters and emails to
the editor should be no more than
500 words with a maximum of five
references.
Re: Vaginal estrogen deficiency
Dear Editor
As Khanjani and Panay have stated, vaginal estrogen
deficiency can have a profound effect on quality of life.1 It
also frequently complicates other vulvovaginal disorders.2 It
is a subject that I have had a very long interest in because I
was fortunate to be taught cytology in order to write and
subsequently publish my gynaecology commentary for the
MRCOG.3 I have made good use of that teaching and have
performed vaginal cytology, where applicable, more or less
ever since, using the relatively simple technique described in
The Vulva & Vagina Manual.4 I consider the maturation
index the gold standard to diagnose vaginal estrogen
deficiency. I recently analysed 1000 consecutive stained
vaginal smears obtained from patients complaining of
discharge and/or pruritus/vulvodynia and/or dyspareunia
and as a means of assessing treatment response in my private
practice between 2014 and 2018. Atrophy without significant
inflammatory changes was diagnosed in 15% of the smears,
and atrophic vaginitis was diagnosed in another 4%.
Regarding treatment, I use only systemic estrogen
replacement in almost all women with symptomatic vaginal
atrophy unless they are lactating or have a history of recent
breast or endometrial cancer. I gave up using vaginal estrogen
in otherwise healthy women over a decade ago because I had
to manage too many women in whom it had not worked, or
worked too well, predisposing them to candidiasis.5 Contact
dermatitis may also complicate its prolonged use.
Furthermore, these patients were missing out on the side
ª 2019 Royal College of Obstetricians and Gynaecologists
Letters and emails
benefits of systemic estrogen replacement, particularly the
prevention of loss of bone mineral density. Addressing the
numerous fears that abound regarding systemic estrogen
replacement, I say to my patients “Modern menopausal
hormone replacement, done correctly, does nothing but
replace what nature has taken away, whereas the untreated
menopause is a potentially nasty disease”.
Our patients would benefit from increased emphasis on
training in the use of the microscope as above in women with
vulvovaginal complaints, not only those with suspected
urogenital atrophy.
Graeme Dennerstein FRCOG FRANZCOG
Past Director of Dermogynaecology Clinic, Melbourne University
Department of Obstetrics and Gynaecology,Mercy Hospital for Women,
Melbourne, Australia
References
1 Khanjani S, Panay N. Vaginal estrogen deficiency. TOG 2019;1:37–42.
2 Dennerstein G and Harding T. What Makes Vulvovaginal Disease Difficult to
Manage? Poster presentation, RCOG World Congress Cape Town, South
Africa, March 2017.
3 Dennerstein G. The cytology of the vulva. J. Obstet. Gynaec. Brit. Cwlth
1968;75:603–609.
4 Dennerstein G, Scurry J, Brenan J, et al. The Vulva & Vagina Manual.
Melbourne: Gynederm Publishing; 2005. p. 17–20.
5 Dennerstein G and Ellis DH. Oestrogen, glycogen and vaginal candidiasis.
ANZJOG. 2001;41(3):326–8.
Authors' reply
The original authors were invited to respond but chose not to
at this time.
219

DOI: 10.1111/tog.12587
2019;21:220–1
The Obstetrician & Gynaecologist
http://onlinetog.org
APP REVIEW
Figure 1
Aim: Th is app gives free access
to thousands of real medical
cases across 185 specialties
worldwide. It allows the user
to share cases, recognise rare
conditions in their patients and
get feedback from specialists.
Operating system: Android
and iOS 10.0 or later, compatible
with iPhone, iPad, iPod touch.
Usability: The app has features
such as ‘case of the week’ and
alerts for cases in your chosen
specialty. It is easy to use and
to send messages to other
professionals. Registration is
quick and easy (professional
verification requires an
institutional email address).
Cases are pictorial, e.g. an
image of a rash or an ECG with
a short history, allowing users
to comment on diagnosis and
treatment.
Recommend to colleagues/
patients? Yes, to colleagues as
a learning resource. Note that
not all cases are necessarily
presented with the ‘correct’
diagnosis – instead the app
should be used as a platform
to seek opinions (some cases
are posed as multiple choice
questions).
Cost: Free
Reviewer: Cathy Malone
MRCOG, ST7 in O&G, Antrim
Area Hospital, Antrim BT41 2RL,
Northern Ireland
TOG rating:
220
TOG ratings ★★★★★
BOOK REVIEW
Eponyms and Names in Obstetrics and Gynaecology, 3rd edition
Author: Thomas F. Baskett
ISBN 9781108421706 / Hardback / 521 pages / £99.99 / Cambridge University Press
The new title of this successful book of biographies gives little hint of the magic inside. The first two
editions, published in 1996 and 2008, were called On the Shoulders of Giants, but when Cambridge
took over RCOG Press in 2013, other books had appeared under that name. Hence the prosaic ex-
subtitle for the third edition – the last, says its author.
Tom Baskett, a Belfast graduate and Professor Emeritus of obstetrics and gynaecology in Dalhousie,
is an award-winning historian who knows how to engage his readers. His preface quotes fellow
Canadian Marshall McLuhan: “Anyone who tries to make a distinction between education and
entertainment doesn’t know the first thing about either”. I wish I’d heard that years ago.
But there’s more here than a new title and preface. There are many new pictures and names.
Michael Robson and Charles Rodeck from our own era enter just ahead of fellow newbie
Eucharius Rösslin from the 16th century. Kurt Semm now snuggles down beside Ignac
Semmelweiss. Alphabetical order makes it easy to fi nd what you’re looking for, but the
juxtapositions make it hard to put the book down again.
Midwives past and present have been added along with pioneers of oral contraception. Existing
entries have been expanded, and the huge bibliography shows how much research the author has
done in libraries over the past 30 years. Eat your heart out, Wikipedia. This book is a masterpiece.
Reviewer: James Drife MD FRCOG FRCPEd FRCSEd FCOGSA FFSRH, Emeritus Professor of
Obstetrics and Gynaecology, Leeds, UK
TOG rating:
BOOK REVIEW
Obstetrics: Evidence-Based Algorithms, and Gynaecology: Evidence-Based Algorithms
Authors: Jyotsna Pundir and Arri Coomarasamy
ISBN 9781107618930 and 9781107480698 / 338 and 324 pages / 2016 /
Paperback / Cambridge University Press
There are very few easy-to-read textbooks in obstetrics and gynaecology, especially for those
more visually oriented. These two beautifully written books cover all the basics of general
obstetrics and gynaecology extensively through their combined 150 chapters, with topics ranging
from amniotic fluid abnormities to precocious puberty. Each chapter is laid out in the format of
a colour-coordinated flowchart, starting with prevalence and pathogenesis and fi nishing with
management options and a short note on ‘What not to do’.
Having completed the MRCOG exams years ago, I wish I had these books back then, as the
content is perfect for exam preparation. Each chapter is well organised, complete and most
importantly fun to read. With this book at hand during the stressful exam preparation
period, you can easily read through an otherwise boring topic before bedtime and retain the
material. Although the books comprehensively cover the topics through guidelines and latest
evidence, they should not be used to replace revision of latest guidelines, as no textbook should.
Nevertheless, some sections of the books include essential material for the exam that are poorly
covered by guidelines and other textbooks. Examples include the sections on infections in
pregnancy, reproductive medicine, sexually transmitted diseases and gynaecological oncology.
It was such a pleasure for me to have the chance to review these magnificently constructed books.
I highly recommend them to all trainees in obstetrics and gynaecology, in the UK and beyond.
Reviewer: Jane Ding BMBCh MPhil PhD MRCOG, ST6 Trainee, Queen’s Hospital, Rom Valley
Way, Romford RM7 0AG, UK
TOG rating:
© 2019 Royal College of Obstetricians and Gynaecologists
TOG Ratings ★★★★★
BOOK REVIEW
Medicolegal Issues in Obstetrics & Gynaecology
Editors: Swati Jha and Emma Ferriman
ISBN 9783319786834 / eBook / 387 pages / £79.50 / Springer International Publishing
This is an extremely interesting, informative and practical book about current clinical
management in obstetrics and gynaecology (O&G), the clinical risks associated with each area
within the specialty and the ensuing harm – litigation – that may ultimately occur.
It is comprehensive, as it covers most specialist areas in O&G and is 387 pages in length, but being
Write for
composed of 70 chapters, it is easy to dip in and out of the sections relevant to the reader’s own
specific interest. TOG ratings
I felt the introductory chapters were particularly interesting in terms of understanding the legal
process, which is appropriate given the medicolegal focus of the book. I would consider the
chapters including ‘Why Doctors get Sued’, ‘Consent After Montgomery’, ‘Leading Cases’ (with
an explanation and summary of the legal processes and arguments, including liability, breach
of duty and causation that underlie litigation), ‘The Claim journey’, ‘GMC’ and ‘The Coroner’s
Court’ very valuable for all clinicians in our specialty to read in order to gain an understanding
of how the legal and medical worlds merge in this process of litigation. Rather than ignoring it, Have you recently read a
understanding the process makes risk management more relevant. book or used an app, website
One of the book’s major strengths is that the clinical chapters are written by experienced clinicians or e-learning resource to
and experts in their fields, who combine experience and common sense to provide insights into
the current standard management of certain conditions, focusing on where the risks lie and what
help your O&G practice?
can be done to reduce them. Most admit that there is no way to avoid bad outcomes and litigation
in every aspect of O&G but specify ways it can be minimised. I learnt a lot.
Those who practice obstetrics will be very aware of the issues of consent, team working and,
especially in emergencies, good documentation to improve outcomes and reduce litigation. The
Practical Obstetric Multi-Professional Training (PROMPT) and Managing Obstetric Emergencies Submit your review to
and Trauma (MOET) courses have highlighted these needs.
tog@rcog.org.uk
In contrast, having not been a gynaecologist for many years, I found that the gynaecology chapters
highlighted the challenges of benign gynaecology. Throughout the chapters the same messages to be considered for the
came through: next TOG ratings
• the requirement for detailed discussion of options, including medical management before
considering surgery
• the need to have appropriate surgical skills when undertaking surgery
• laparoscopic surgery carries more risks when not conducted well and is therefore subject to
more litigation ‡%RRNUHYLHZVZRUGV
• litigation occurs commonly when poor outcomes occur in low-risk procedures.
Gynaecological oncology, as expected with cancer, highlights the issues related to delay in
diagnosis. The cervical screening programme has been extremely successful, but early ovarian ‡:HEVLWHUHYLHZV
cancer remains a challenge, particularly so for GPs. Sequential screening is recommended to ZRUGV
enable some differentiation of nonspecific symptoms in order to determine who needs referral.
Each clinical chapter succinctly runs along the theme of:
‡$SSUHYLHZV ZRUGV
1) current evidence-based practice and standards
2) clinical governance issues including useful statistics for specific outcomes and risks
3) reasons for litigation
4) how to avoid litigation.
In addition, each chapter includes one or two clinical short case reports to illustrate the points and
highlights that where there is variation in practice, it is revealed by variation in outcomes. Summary
key points are at the end are helpful to summarise the main themes and to refer back to.
In conclusion, this book is an extremely useful summary update on current clinical management
across each area of O&G, and with the first section on the legal process related to litigation it
becomes an extremely useful, practical book to read and have access to. I found each chapter
simple to read with a pertinent message to reflect on.
Reviewer: Pippa Kyle MB ChB MD FRCOG FRANZCOG CMFM, Clinical Professor, University of
Otago and Subspecialist Maternal Fetal Medicine, Christchurch Women’s Hospital, New Zealand
TOG rating:
© 2019 Royal College of Obstetricians and Gynaecologists 221
 DOI: 10.1111/tog.12594 2019;21:223
The Obstetrician & Gynaecologist
http://onlinetog.org
UKOSS update
Maternal and perinatal outcomes in
pregnant women with BMI >50 kg/m2: An
international collaborative study1
 National studies examining pregnant women with body
mass index (BMI) ≥50 kg/m2 have been limited in their
ability to examine severe but rare maternal and
perinatal outcomes.
 The aim of this study was to combine information from a
UKOSS study of pregnant women with BMI ≥50 kg/m2 with
data from a similar cohort identified through the Australasian
Maternity Outcomes Surveillance System (AMOSS) to
examine the association between maternal BMI >50 kg/m2
during pregnancy and maternal and perinatal outcomes.
 A total of 932 pregnant women with BMI >50 kg/m2
(617 UKOSS, 315 AMOSS) were compared with 1232
pregnant women with BMI <50 kg/m2.
 Women with a BMI >50 kg/m2 during pregnancy had
significantly raised odds of preeclampsia/eclampsia (adjusted
odds ratio [aOR] 4.88, 95% confidence interval [CI]
3.11–7.65), caesarean birth (aOR 2.77, 95% CI 2.31–3.32),
induction of labour (aOR 2.45, 95% CI 2.00–2.99) or
post-caesarean wound infection (aOR 7.25, 95% CI
3.28–16.07), compared with women with a BMI <50 kg/m2.
 Infants born to women with a BMI >50 kg/m2 had raised
odds of macrosomia (aOR 8.05, 95% CI 4.70–13.78) and
of an Apgar score <7 at 5 minutes (aOR 2.03, 95% CI
1.13–3.6) compared with women with BMI <50 kg/m2,
after adjusting for gestational age at delivery.
 Twelve of the infants born to women in the extremely obese
cohort died in the early neonatal period or were stillborn.
 This study has shown that the combination of two national
cohorts identified using the same methodology increased
ª 2019 Royal College of Obstetricians and Gynaecologists
UKOSS update
the statistical power and precision to estimate the
incidence of maternal and perinatal outcomes in
extremely obese women.
 Extreme maternal obesity in both countries was associated
with increased odds of potentially preventable outcomes
such as wound infection, highlighting the need for a
proactive approach to management.
Marian Knight MA DPhil FFPH FRCP Edin FRCOG
a
Professor of Maternal and Child Population Health, National Perinatal
Epidemiology Unit, Nuffield Department of Population Health, University
of Oxford, Old Rd Campus, Oxford, OX3 7LF, UK
Email: marian.knight@npeu.ox.ac.uk
Reference
1 McCall SJ, Li Z, Kurinczuk JJ, Sullivan E, Knight M. Maternal and perinatal
outcomes in pregnant women with BMI >50: An international collaborative
study. PLoS One 2019;14:e0211278.
Acknowledgement
Thank you to all members who contributed information to
these studies.
Further information
Details of this and other UKOSS and AMOSS study results
can be obtained from the UKOSS website (http://www.npeu.
ox.ac.uk/ukoss/completed-surveillance) or the AMOSS
website (https://www.amoss.com.au/publications). If you
would like a reprint of any UKOSS publications please
contact ukoss@npeu.ox.ac.uk.
223
 DOI: 10.1111/tog.12597
The Obstetrician & Gynaecologist
2019;21:224
http://onlinetog.org
A night at the museum
James Drife MD FRCOG FRCPED FRCSED FCOGSA FFSRH
Emeritus Professor of Obstetrics and Gynaecology, Leeds, UK
The RCOG, like many Royal Colleges, has an interesting
museum, but unlike others we don’t make a big thing of it. In
fact, for the last few years we’ve kept it under the stairs. Will
it be housed in more splendid surroundings when we move
to Union Street? I hope so. Plans are already afoot for an
accessible cafe (the essential feature of any contemporary
museum) so we’re halfway there already.
Roll up! Roll up!
Museums are big business these days. Last year in London
nearly six million people visited the British Museum, while
north of the border the National Museums pipped
Edinburgh Castle as Scotland’s top visitor attraction. Part
of their allure, I suppose, is the fact that admission is free, but
there’s more to it than that. People can be fascinated by
history if it’s expertly presented, which is why so many
museums, including medical ones, are having makeovers.
The Royal College of Surgeons in Lincoln’s Inn Fields is
undergoing massive redevelopment and when it reopens, the
Hunterian Museum will occupy most of the ground floor. In the
meantime its collection of 50 000 specimens and instruments
can be browsed online at surgicat.rcseng.ac.uk. In Edinburgh,
Surgeons’ Hall has recently had a £4.5 million upgrade and now
houses three museums. Tourists with a taste for the macabre can
see dental equipment, tumours, surgically removed foreign
bodies and a book covered by the skin of Burke the murderer. Or
go on a walking tour entitled ‘Blood and guts’.
Our past and proud of it
If the public wants blood we can provide it, but I suspect this is
not the image the RCOG wants to project in these sensitive times.
After years of being criticised by everyone (except our patients)
for doing large numbers of hysterectomies and caesarean
sections, are we now embarrassed by our surgical past? And
even by our forceps, though they’ve saved the lives of countless
mothers and babies over the years. We no longer conduct
instrumental deliveries under a blanket like the Chamberlens,
but neither do we unwrap the forceps with a theatrical flourish
and wait for the birth partner to applaud. Or at least, not often.
Our specialty has a story of historic achievements, but how
to tell it? In Leeds in the 1990s I tried to help the Thackray
Medical Museum illustrate the spectacular fall in UK
224
And finally. . .
maternal mortality during my parents’ lifetime. I drew a
graph which a designer expanded and filled with little clay
models of pregnant tummies. The eye-catching torsos
grabbed visitors’ attention – so much so that they didn’t
notice my graph at all. Today the Thackray has closed for its
own costly makeover and his models are probably on eBay.
Museums Inc.
There’s a knack to using objects to tell stories and it’s not a job for
amateurs. Fortunately the RCOG museum now has a
professional curator. After Peter Basham moved here from the
Royal College of Physicians in 2016, retired Fellows like myself
slowly became aware that the museum world has moved into the
21st century. Last year the RCOG joined a network, London
MuseumsofHealthandMedicine(http://medicalmuseums.org),
whose 26 members range alphabetically from the Alexander
Fleming Laboratory Museum to the Worshipful Society of
Apothecaries. Our nearest neighbours when we move to
Southwark will be the Gordon Museum of Pathology (which
is not open to the public) and the Old Operating Theatre
Museum (which is).
How open do we want to be? At present the curator runs
guided tours on request and the majority of the 50 or so
groups each year are midwives (the RCOG now houses the
Royal College of Midwives’ collection). We obstetricians
probably feel that we don’t need to be guided around our
own treasures but perhaps we should give it a try. We might
learn a lot.
Hello, Dolly
Museums can inspire as well as inform. Recently I attended a gala
evening at the Royal Scottish Museum, which has just completed
an £80 million transformation from Victorian institution to
modern tourist attraction. Wandering past Lewis chessmen and
Sir Jackie Stewart’s racing car, I found myself face to face with
Dolly the Sheep, slowly rotating on a pedestal. I’d seen a sheep
before, but this time the wow factor kicked in. That nose! Those
eyeballs! That wool! All produced by the nucleus of a mammary
cell – gee whizz! I’ve always been amazed that two little cells can
create a baby, and Dolly reignited that sense of wonder. It’s the
kind of feeling that can make a blas
e teenager decide to study
reproductive biology, or perhaps even obstetrics.
ª 2019 Royal College of Obstetricians and Gynaecologists
 TOG
The Obstetrician & Gynaecologist
The journal for continuing professional development
from the RCOG
The CPD journal from the RCOG ISSN 1467-2561/1744-4667 (online)
http://onlinetog.org http://onlinetog.org

Volume 21 Issue 3 2019

Contents

Editorial 203 Issues around vaginal vault closure

SBA Magdy Moustafa, Mohamed Elnasharty
159 Editorial
Kate Harding 209 A review of acupuncture in obstetrics and gynaecology
SBA Faisal Karim, James Dilley, Elaine Cheung

Editor's Pick
163 Spotlight on … primary care CPD
Nicola Mullin 215 CPD questions for volume 21 issue 3

Letters and emails

Commentary
219 Re: Vaginal estrogen deficiency
165 Duty of candour: the obstetrics and gynaecology perspective Graeme Dennerstein
Thomas G Gray, Swati Jha, Helen Bolton

220 TOG ratings

Reviews
169 Smoking in pregnancy: pathophysiology of harm and current
SBA evidence for monitoring and cessation 223 UKOSS update
Brendan P McDonnell, Carmen Regan
177 Multiple sclerosis and pregnancy And finally…
SBA Priya Kanagaraj, Nikos Evangelou, Dipanwita Kapoor
224 A night at the museum
185 Preventing adhesions in laparoscopic surgery: the role of anti- James Drife
SBA adhesion agents
Mehrnoosh Aref-Adib, Timothy Phan, Alexandre Ades
193 A guide to indications, components and interpretation of
SBA urodynamic investigations
Annika Taithongchai, Abdul H Sultan, Ranee Thakar
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The Obstetrician & Gynaecologist 10.1111/tog.12595 http://onlinetog.org Editorial

Editorial
One of the current aims of The Obstetrician &
Gynaecologist (TOG) is to extend our educational
influence to others who have a key role in maintaining
and improving the health of women. In this regard,
among the new Associate Editors who have joined the
Editorial Board in the past 12 months, we are delighted
to have welcomed Chantal Simon, who is a practising
GP and Medical Director for Enterprise and Professional
Development at the Royal College of General
Practitioners (RCGP). Our intention is to identify and
highlight TOG articles that might be of interest to
individuals who care for women but may not always
consider this journal to be the first place to look for
up-to-date information. We hope that our new link with
the RCGP will help to provide valuable insight in future
issues of TOG.
Having increased the size of the Editorial Board, I do
not anticipate any new vacancies arising in the near
future, but that does not exclude our readers from being
involved in TOG. We are always on the lookout for
interesting articles and always grateful to those who
volunteer their time to peer review our papers. Without
you we would not have a journal.
In this quarter’s journal, we have articles covering a
wide range of topics in obstetrics and gynaecology. Swati
Jha (another new member of our Board), Thomas Gray
and Helen Bolton have written an excellent article on
duty of candour. They discuss not only the obligations
we all have to explain clearly and honestly when things
have not gone as expected, but also the implications of
this on consent in light of the Montgomery ruling. I
strongly recommend this paper to all working in the UK,
and I am sure these principles are equally useful in other
healthcare environments.
Cigarette smoking has long been known to cause
harm to both the mother (with regard to her long-term
health) and the fetus (both in the short and long term).
There has been a recent focus on smoking rates in
pregnancy and the associated risk of stillbirth (with the
NHS target to halve the rate of stillbirth in England by
2025). McDonnell and Regan explain the Editorial Board
pathophysiology of the harm of cigarette smoking and Kate Harding FRCOG
Guy’s and St Thomas’ NHS Foundation
describe various strategies to help women to reduce Trust, London
tobacco use and hopefully quit. I hope that reading this George Attilakos MD MRCOG
University College London Hospitals NHS
article will give those of you who have previously been Foundation Trust, London
reluctant the confidence to prescribe nicotine Shagaf Bakour MD FRCOG
City Hospital, Birmingham
replacement therapy as recommended by the National Evelyn Ferguson
Institute for Health and Care Excellence. NHS Lanarkshire
In an excellent article by Karim, Dilley and Cheung, Kannamannadiar Jayaprakasan
Royal Derby Hospital, Derby
the use of acupuncture in our patients is thoroughly Swati Jha MD FRCOG
explored. For those who count themselves as sceptics, Sheffield Teaching Hospitals NHS
Foundation Trust, Sheffield
there would appear to be a substantial number of trials
Justin Konje FMCOG (Nig) FWACS MRCOG
in both pregnancy and general gynaecology showing University of Leicester, Leicester
(Lead CPD Editor)
benefit. I strongly recommend reading this article and
Bid Kumar FRCOG
reconsidering the lack of harm and the possible benefit Wrexham Maelor Hospital, Wrexham
acupuncture may bring your patients. Mohamed Mehasseb MD PhD MRCOG
Glasgow Royal Infirmary, Glasgow
We have two papers addressing surgical technique Jo Morrison BM BCh MA MRCOG DPhil (Oxon)
that I wish to bring to your attention: one on reducing Musgrove Park Hospital, Taunton
adhesions in laparoscopic surgery and the other on the Nicola Mullin MFFP FRCOG
Countess of Chester Hospital NHS
various techniques that can be used for vault closure at Foundation Trust, Chester
hysterectomy. For those of us who are referred women Surabhi Nanda MRCOG
Guy’s and St Thomas’ NHS Foundation Trust,
with stress incontinence and are unsure about who to London
refer for urodynamics, as well as what the women will be Nikoletta Panagiotopoulou MD MRCOG
Royal Victoria Hospital, Belfast
asked to do and how to interpret the results, the article Asha Shetty MD FRCOG
by Taithongchai et al. will be very helpful. Aberdeen Maternity Hospital, Aberdeen
Chantal Simon
A final reminder of the change in the continuing GP, Bournemouth
professional development (CPD) curriculum for the Thomas Tang MD MRCOG
RCOG that is coming in 2019. Although completing the Regional Fertility Centre, Royal Maternity
Hospital, Belfast
TOG multiple choice questions (MCQs) will no longer
Philip Toozs-Hobson
be mandatory, please don’t use this as an excuse to Birmingham Women’s and Children’s NHS
either read us less (as we hope our articles have always Foundation Trust, Birmingham
been read for their own sake) or stop doing the MCQs. Ephia Yasmin MRCOG
University College London Hospitals NHS
Many readers have told us over the years how they like Foundation Trust, London
to ‘prove’ they have read and learnt from the article by Wai Yoong MD FRCOG
doing the MCQ attached. We will continue to provide North Middlesex University Hospital, London
the resource as well as the single best answer questions, Bassel Wattar (Trainee Representative)
University of Warwick
which are available via RCOG eLearning.
Alison Richardson MBChB MRCOG PhD (Trainee
Representative)
Leeds Teaching Hospitals NHS Trust, Leeds
International Advisory Board

Richard Brown MBBS DFSRH FRCOG FACOG

McGill University Health Centre, Montreal,
Canada
Amr El-Shalakany MSc MD FRCOG
Ain Shams University Maternity Hospital,
Cairo, Egypt
Sebastian Gidlo€f
Stockholm South Hospital, Sweden
Carman Lai MRCOG FHKCOG FHKAM (O&G) Cert
RCOG (Maternal and Fetal Medicine)
Queen Mary Hospital, University of Hong
Kong, Hong Kong
Henry Murray MRCOG
Australia
N Rajamaheswari MD DGO MCh (Urology)
Director, Urogynaecology Research Center
Pvt Ltd, India
Editor-in-Chief Duru Shah MD FCPS FICS FICOG DGO DFP FICMCH
Jaslok Hospital, Sir Hurkinsondas Hospital
and Breach Candy Research Centers, India

Kate Harding David Shaker FRCSEd FRCOG FRANZCOG

University of Queensland, Rockhampton
Base Hospital and Mater Private Hospital,
Australia
Jason Waugh MRCOG (Emeritus Editor)
Auckland, New Zealand

ª 2019 Royal College of Obstetricians and Gynaecologists

 DOI: 10.1111/tog.12592
The Obstetrician & Gynaecologist
http://onlinetog.org
Spotlight on . . . primary care
Nicola Mullin FRCOG FFSRH Virgin Care, Chester, UK
Correspondence: Nicola Mullin. Email: nicolamullin@nhs.net
Links between the Royal College of Obstetricians and
Gynaecologists and the Royal College of General
Practitioners (RCGP) are well established, and the
Diploma of the Royal College of Obstetricians and
Gynaecologists (DRCOG) has been the examination for
generalists interested in obstetrics and gynaecology since
1949. Women’s health is a large component of primary care,
and the RCGP training curriculum includes a
comprehensive module on women’s health for which
articles from The Obstetrician and Gynaecologist (TOG)
provide timely, succinct information. TOG reviews and
infographics help with examination preparation and may
also be of interest to other members of the primary care
team, including specialist nurses, pharmacists and physician
associates. In each edition of TOG there are reviews with
great relevance to women’s health in primary care, and in
this Spotlight some have been selected to illustrate the range
of topics that have been covered.
Menstrual problems
General practitioners (GPs) encounter every kind of
menstrual dysfunction and the associated complex
conditions that accompany them, such as premenstrual
syndrome (PMS), polycystic ovary syndrome (PCOS),
endometriosis and irritable bowel syndrome: diagnostic
challenges abound. Prospective charting to identify core
and variant PMS or premenstrual dysphoric disorder was
advocated by Walsh et al., and their review indicated that
hormonal contraception carefully tailored to the individual
may also improve PMS symptoms (TOG 2015;17:99–104).
We were reminded that pelvic pain caused by endometriosis
and irritable bowel syndrome requires detailed history taking
and that women may be reassured that long-term laxatives
and antidiarrhoeal medication will not damage the bowel
(TOG 2016;18:9–16). Menstrual disorders in early
reproductive life were discussed in an early volume (TOG
2003;5:136–41), and non-menstrual bleeding in women
under 40 years of age was covered the following year (TOG
2004;6:153–8). The modern approach to uterine fibroids was
published in 2016 (TOG 2016;18:33–42), giving clear
information on the various treatment modalities. The
particular challenges of managing menstruation in women
ª 2019 Royal College of Obstetricians and Gynaecologists
2019;21:163–4
Editor's Pick
with learning and physical disabilities has been addressed,
and again the usefulness of contraceptive methods was
illustrated (TOG 2013;15:106–12).
Contraception
The majority of women in the UK obtain their method of
contraception free of charge on the National Health Service,
from their GP. GPs and specialist nurses are expected to be
knowledgeable about the benefits, risks, bleeding patterns
and management of side effects of contraception. A number
of reviews on hormonal contraception and long-acting
reversible contraception – injectables, implants and
intrauterine devices/systems – have been published. The
contraceptive needs of certain groups of women have been
covered in TOG: for young women under 16 (TOG 2008;10:
22–6), women with addictions (TOG 2014;16:269–71),
women with cardiac disease (TOG 2018;20:21–9), women
requiring postpartum contraception (TOG 2018;20:159–66)
and, very recently, trans individuals (TOG 2019;21:11–20).
Polycystic ovary syndrome and obesity
The developments in our understanding of the aetiology and
management of PCOS have been reviewed recently by Balen
and by Sagili and Chandrasekaran (TOG 2017;19:119–29 and
TOG 2018,20:245–52). Lifestyle, medical and surgical
approaches were discussed. GPs are ideally placed to help
women with personalised advice and support to help to tackle
obesity and increase the knowledge of reproductive and
metabolic consequences of PCOS. The 2009 article on
hirsutism in young women by Swingler et al. (TOG 2009;11:
101–7) remains a useful and practical guide for clinicians. The
primary care team may also be caring for women who are
pregnant after bariatric surgery (TOG 2013;15:37–43).
Reproductive health
Women with early pregnancy complications often present to
primary care practitioners for their initial management, and
TOG has published on ectopic pregnancy (TOG 2014;16:193–
8 and TOG 2017;19:13–20) and miscarriage (TOG 2007;9:
102–8). Fertility is a challenging subject, and women may
163
 Editor’s Pick
present with unplanned pregnancies or with subfertility,
requesting information about the causes, investigations and
treatment available to them. A generalist will find the reviews
in TOG cover topics such as an overview of assisted
reproductive technology and its potential complications
(TOG 2018;20:167–76 and TOG 2018;20:177–86) and
unexplained subfertility (TOG 2016;18:107–15). Young
women who have been treated for chlamydia trachomatis
may ask about its effect on their fertility, and TOG has
published an article on the place of tubal patency tests (TOG
2014;16:37–45).
Post-reproductive health
Women also need their GPs to be up-to-date with
perimenopausal contraception (TOG 2017;19:289–97),
hormone replacement therapy (HRT) (TOG 2014;16:20–8)
alternatives to HRT (TOG 2013;15:19–25), vulval disorders
(TOG 2017;19:307–15), sexual problems (TOG 2010;12:1–6)
and urinary problems (TOG 2011;13:98–106 and TOG
2014;16:169–77). The impact of obesity on the health of
women in midlife (TOG 2015;17:201–8) is a good summary
of the effect of obesity on hormonal profiles around the
perimenopause and the effect of obesity on menopausal
symptoms – a relevant topic, as women often believe weight
gain is caused by HRT.
164
Pregnancy
While generalists are not obstetricians, women and their
partners present with many questions about pregnancy-
related issues. TOG has published on the following topics and
common conditions affecting pregnancy: constipation (TOG
2015;17:111–5), headaches (TOG 2014;16:179–84), vitamin
supplementation (TOG 2012;14:175–8), asthma (TOG
2013;15:241–5), vaccinations (TOG 2015;17:257–63),
prescription drug use (TOG 2012;14:87–92), inflammatory
bowel disease (TOG 2016;18:205–12) and, very importantly,
postpartum psychosis (TOG 2013;15:145–50). This was first
covered in two parts in 2008 by Oates (TOG 2008;10:145–50
and TOG 2008;10:231–5). TOG reviews are not often written
by a GP, but in 2011 Barnie-Adshead co-authored a review
on severe nausea and vomiting in pregnancy (TOG 2011;13:
107–11). This problem may cause misery and disruption to a
woman and her family and requires a sympathetic and
knowledgeable approach. Other articles on more complex
obstetric topics are easily accessible for a rapid revision.
It is hoped that the topical infographics published
alongside select articles in each issue of TOG will also be
attractive to primary care staff and patients; all infographics
are freely availabe at onlinetog.org. A virtual issue of all TOG
articles applicable to primary care is also available
at onlinetog.org.
ª 2019 Royal College of Obstetricians and Gynaecologists
 DOI: 10.1111/tog.12586
The Obstetrician & Gynaecologist
http://onlinetog.org
Duty of candour: the obstetrics and gynaecology
perspective
Thomas G. Gray MRCOG MSc,
a
Swati Jha MD FRCOG
a
Subspecialty Trainee in Urogynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Level 4, Jessop Wing, Tree Root Walk,
Sheffield S10 2SF, UK
b
Consultant Gynaecologist, Subspecialist in Urogynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Level 4, Jessop Wing, Tree Root
Walk, Sheffield S10 2SF, UK
c
Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Box 242, Department of Gynaecological Oncology, Cambridge
CB2 0QQ, UK
*Correspondence: Swati Jha. Email: Swati.Jha@sth.nhs.uk
Accepted on 6 January 2019.
Introduction
The word candour describes a quality of being open and
honest. An ethical duty of candour (DoC) has always existed
and has been a cornerstone of medical practice but was not
always enforced in law. In 2015, the General Medical Council
(GMC) document Openness and honesty when things go
wrong: the professional duty of candour was published and sent
to doctors with a licence to practice1 This lays out the
responsibilities of individuals when things go wrong. DoC
has now become a legal requirement and is a contractual duty
imposed on all NHS organisations.
There are two types of DoC: statutory and professional.
Statutory DoC applies to organisations and all care providers
registered by the Care Quality Commission (CQC). In
contrast, professional DoC applies to individuals and is
defined as ‘a professional responsibility to be honest with
patients when things go wrong’. Although there is
considerable overlap, there are several key differences
between the two. In obstetrics and gynaecology, where the
cost of harm can be catastrophic, it is important that
clinicians appreciate the implications of DoC within their
practice. The aim of this article is to equip doctors working
within obstetrics and gynaecology with an understanding of
DoC, addressing current training gaps on this topic and
helping to support implementation into clinical practice,
especially around knowing when and how to appropriately
and correctly apologise to patients/relatives as per the
DoC guidance.
Rationale for the ‘disclosure gap’
NHS enquiries and studies assessing disclosure habits among
UK doctors have identified that there is failure to disclose
errors to patients in as many as 70–97% of cases.2,3 Reasons for
ª 2019 Royal College of Obstetricians and Gynaecologists
2019;21:165–8
Commentary
b,
* Helen Bolton DLM PhD MRCOG
c
non-disclosure include negligible perception of patient harm,
fear of litigation and fear of organisational reprisal.4 This is
pertinent in obstetrics and gynaecology, with current
workforce challenges and persistent issues around
undermining within the specialty. It can be psychologically
difficult for doctors to admit mistakes, partly because they have
a professional and personal commitment to help patients,5 but
also because they may fear the personal consequences. Some
doctors may feel paternalistic and will want to protect patients
from the effects that difficult information can have upon them.
Statutory duty of candour
Public enquiries into high-profile failings in NHS care have
been key drivers in the development of statutory DoC. The
Bristol Enquiry (2001)6 emphasised the need to be open
about mistakes and led to the establishment of the National
Patient Safety Agency. Following the Mid-Staffordshire NHS
Foundation Trust Public Enquiry, the Francis Report (2013)3
recommended a statutory DoC obligation to be imposed on
all healthcare providers and registered healthcare
practitioners. This became statute in November 2014,
mandating that all CQC-registered healthcare providers
must comply. In 2015, following the Morecambe Bay
Investigation, the Kirkup Report7 commended the
introduction of the DoC for all NHS professionals and
recommended that this should be extended to include the
involvement of patients and relatives in the investigation of
serious incidents. Scandals within maternity services in both
Mid Staffordshire3 and Morecambe Bay7 therefore had an
impact on DoC legislation.
Statutory DoC is a corporate, as opposed to professional,
obligation and applies when a threshold of moderate harm
(or worse) has been breached. The DoC guidance8 does not
clearly state what constitutes harm or distress, but the
165
 Duty of candour in O and G

National Patient Safety Agency, whose function is now

carried out by NHS Improvement, defined levels of harm as
low, moderate, severe and death9; the NHS now also uses
these terms to define levels of harm. It would seem logical
that any adverse event of moderate or greater severity, which
would usually trigger incident reporting, should be explained
to the patient and an apology given. The guidance states that
‘providers are not required by the regulation to inform a
person using the service when a “near miss” has occurred,
and the incident has resulted in no harm to that person’.8
‘Near misses’ are covered by professional DoC, with further
details below.
Guidance8 states that harm should be assessed in the
‘reasonable opinion of a healthcare professional’, with the
emphasis on being open if there is any doubt. Individual
clinicians should be encouraged to seek advice from
appropriate colleagues and their organisation’s managers in
cases where there is uncertainty. Doctors with management
roles must be responsible for ensuring systems for incident
reporting are in place and supported, as well as encouraging a
culture of openness and honesty. Once such an event has
arisen, the organisation must take the following steps:
 The patient should be informed of the incident, preferably
in person, as soon as reasonably practical. Patients must be
provided with a written account of the discussion, and
copies of correspondence must be kept by
the organisation.
 A full explanation should be given, including details of any
further investigations that will be carried out.
 An apology should be offered, and reasonable support
should be provided for the patient.
 Organisations must keep a written record of the
notification to the patient.
Examples of statutory DoC are given in Table 1.
Professional duty of candour
GMC guidance1 on professional DoC consists of two parts: the
first states the duties of doctors to their patients, and the
second concerns the duties of a doctor to the organisation they
work for, including their role in incident reporting.
Professional DoC applies whenever patients have suffered
harm or distress when something has gone wrong with their
care. There is no defined threshold of harm that needs to be
met for the duty to arise. For ‘near miss’ episodes (i.e. care has
gone wrong, but fortunately the patient came to no harm), the
GMC has advised clinicians to use their professional
judgement when deciding whether to tell patients about the
error,1 but, in reality, following professional DoC should
include telling patients when a near miss has occurred. When
there is uncertainty, it may be helpful to seek advice from
senior colleagues or a clinical director. The duties of the
healthcare professional for professional DoC include:
 Telling the patient (or, when appropriate, the patient’s
family or carer) when something has gone wrong.
 Apologising to the patient (or, when appropriate, the
patient’s advocate, carer or family).
 Offering an appropriate remedy or support to put matters
right where possible.
 Giving the patient a full explanation of the short and long-
term effects of what has happened.
Examples of professional DoC are given in Table 2.
Apologising
The DoC guidance8 gives specific details on how to make an
appropriate apology (Box 1), while making it clear that an
apology does not equate to admitting legal liability. The UK
Compensation Act (2006)12 also reassures clinicians that

Table 1. Examples of when statutory duty of candour should be

applied
Obstetrics
Injury to a baby during delivery,
requiring treatment or admission
to the special care baby unit
Obstetric anal sphincter injury
occurring during instrumental
delivery
Gynaecology
An intraoperative visceral injury
Delay in diagnosing ectopic
pregnancy because of
misinterpretation of levels of
human chorionic gonadotropin,
resulting in collapsed patient
and emergency surgery
Table 2. Examples of when professional duty of candour should be
applied
Obstetrics
Any abrasion to a baby during
caesarean delivery, requiring no
intervention
Stitch taken through rectum at
suturing of perineal tear
identified at per rectum exam,
requiring stitches to be taken
down and tear re-repaired
Gynaecology
Any tear to the cervix occurring
during surgical management of
miscarriage requiring suturing
Any diathermy burn to a patient's
skin at edge of incision during a
laparotomy

Delay in induction of labour Incorrect reporting of ultrasound Dural puncture during epidural Difficulty gaining entry at
resulting in intrauterine fetal findings in early pregnancy anaesthetic laparoscopy resulting in surgical
death emphysema and bruising

166 ª 2019 Royal College of Obstetricians and Gynaecologists


Box 1. How you should apologise in line with professional duty of
candour guidance
Who should apologise: the lead or accountable clinician (usually the
consultant) should speak to the patient.
Timing of the apology: as soon as practicably possible, but ensuring
the patient can retain the information.
Who should be present: someone should be present to support the
patient. This may be a family member, carer or an advocate from the
healthcare team.
What you should tell the patient in the apology: all you know
and believe to be true about what went wrong and why and what the
likely consequences are going to be.
How you should apologise: considerately and in a personalised way.
Ideally use the words “I am sorry. . .”, as opposed to a more general
expression of regret about the incident on the organisation’s behalf.
How you should give information: in a way the patient, carers and
family can understand.
How you should record the apology: details of the apology should
be recorded in the notes.
offering an apology does not equate to an admission of blame
or negligence for harm that has occurred.
Obstetrics and gynaecology is a high-risk specialty,
receiving 15% of claims against hospital specialties and
accounting for 50% of the value of all claims.11 Therefore,
apologies that admit fault can create anxiety for professionals,
fearing that admission may increase the possibility of
financial claims or professional sanction. However, an
appropriate apology may instead prevent the issue
escalating into a formal complaint or legal action for
negligence. The DoC guidance8 also suggests that a fitness
to practice panel may view an apology as evidence of insight,
although few doctors working in obstetrics and gynaecology
are likely to find this reassuring.
Challenges posed by duty of candour
DoC guidance8 also deals with reporting incidents when
something has gone wrong with a patient’s care, so that
lessons can be learnt quickly and patients protected from
future harm. Obstetrics and gynaecology departments must
have a functional policy for reporting adverse events and near
misses and should support individuals reporting these. There
are many challenges for implementing the guidance laid out
by DoC, and these include funding, staffing levels in the
current climate and shifting long-held ingrained opinions
about the role of doctors and medical paternalism.
Candour and consent
Professional DoC mandates doctors to be open and honest with
patients at all times, not just when things go wrong. This
extends to making decisions together, and consequently
requires a candid approach to providing information before
beginning treatment or providing care. Patients must be fully
ª 2019 Royal College of Obstetricians and Gynaecologists
Gray et al.
informed about their care options, including risks and available
alternatives. This is in line with the principles laid out in the
Montgomery v Lanarkshire Healthboard ruling,10 which
clarified the standards required for informed consent. The
principles of explaining all options for treatment, including no
treatment, the pros and cons of each option and ensuring these
are underlined by written information, appropriate use of
decision aids, and ensuring all options are well documented in
the medical notes is essential for the practice of modern
obstetrics and gynaecology. Healthcare professionals must be
open about all reasonable treatment options for patients, even if
they are unable to provide a treatment within their
organisation. Although the Montgomery ruling requires
patients to be informed about alternatives, it does not
mandate the healthcare professional to provide all these
procedures. Rather, each clinician should be able to refer the
patient to another clinician who can potentially provide the
alternative procedures they are unable to provide themselves.
Maternity care presents unique challenges around consent,
especially in the delivery suite setting, where there may be only
one safe option for treatment and decisions need to be made
quickly. Many women find that pain and exhaustion affect
their ability to make decisions during labour,13 and therefore
‘best interests’ and paternalism around decision making can
still potentially dominate. A culture of only informing patients
in detail about normal birth in the antenatal period is
potentially harmful in this context, as women will not be able
to make informed decisions without appropriate information.
To mitigate this, improved antenatal education and individual
discussion of potential interventions in labour should equip
women to be better able to understand and make decisions
regarding their intrapartum care. This truly individualised
approach to all women may be challenging to provide with
current limited resources.
The challenges of consent in the light of DoC are also
pertinent in gynaecological practice, where patients should be
informed of all the surgical and non-surgical options
available to treat their condition. This will include the pros
and cons of each and the provision of detailed written
information, decision aids and time to make an informed,
shared decision. The recent concerns about the use of vaginal
mesh to treat incontinence in urogynaecology highlight the
importance of demonstrating that patients with such
conditions have detailed discussions about all surgical
alternatives and conservative management.
Conclusion
There is evidence that DoC guidance8 is still not reaching all
frontline staff, despite the high-profile introduction of the
guidance. Each obstetrics and gynaecology department
should ideally be providing information to staff about DoC
and ensuring that departmental procedures and guidelines
167
 Duty of candour in O and G
are in place to support staff with implementing DoC in day-
to-day practice.
In particular, there is currently a paucity of teaching and
training available on this subject, compared with other
communication skills for obstetricians and gynaecologists,
such as breaking bad news. Teaching rarely extends to
conducting the challenging conversations that are required
for disclosure of errors or mistakes. Education and practical
training may be beneficial in helping obstetricians and
gynaecologists implement the principles and practices into
their daily practice.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
TG researched the manuscript, SJ instigated the manuscript.
All authors wrote, edited and approved the final version of
the manuscript.
References
1 General Medical Council. Openness and honesty when things go wrong:
The professional duty of candour. 2015 [ http://www.gmc-uk.org/Joint_sta
tement_on_the_professional_duty_of_candour_FINAL.pdf_58140142.pdf].
168
2 Pham JC, Story JL, Hicks RW, Shore AD, Morlock LL, Cheung DS, et al.
National study on the frequency, types, causes, and consequences of
voluntarily reported emergency department medication errors. J Emerg Med
2011;40:485–92.
3 Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public
Enquiry. 2013 [http://webarchive.nationalarchives.gov.uk/
20150407084231/http://www.midstaffspublicinquiry.com/report].
4 White SM, Deacy N, Sudan S. Trainee anaesthetists’ attitudes to error, safety
and the law. Eur J Anaesthesiol 2009; 26:463–8.
5 Birks Y. Duty of candour and the disclosure of adverse events to patients and
families. Clin Risk 2014;20:19–23.
6 Department of Health. Learning from Bristol. 2001 [http://webarc
hive.nationalarchives.gov.uk/20090811143822/http://www.bristol-inquiry.
org.uk/final_report/the_report.pdf].
7 Kirkup B. The report of the Morecambe Bay Investigation. 2015 [https://asse
ts.publishing.service.gov.uk/government/uploads/system/uploads/attachme
nt_data/file/408480/47487_MBI_Accessible_v0.1.pdf].
8 Care Quality Commission. Health and Social Care Act 2008 (regulated activities).
Regulations 2014, regulation 20. [https://www.cqc.org.uk/guidance-providers/
regulations-enforcement/regulation-20-duty-candour#guidance].
9 National Patient Safety Agency. Seven Steps to patient safety. 2004 [https://
improvement.nhs.uk/resources/learning-from-patient-safety-incidents/].
10 The Supreme Court. (2015) Judgment: Montgomery (Appellant) v
Lanarkshire Health Board (Respondent) (Scotland). 2015 [https://
www.supremecourt.uk/cases/docs/ uksc-2013-0136-judgment.pdf].
11 NHS Resolution. Annual reports and accounts 2017/2018. 2018 [https://
resolution.nhs.uk/wp-content/uploads/2018/08/NHS-Resolution-Annual-Re
port-2017-2018.pdf]
12 Compensation Act 2006 (England and Wales). [www.legislation.gov.uk/
ukpga/2006/29/pdfs/ukpga_20060029_en.pdf].
13 Jackson G, Cox M. Consent on labour ward. Trends Anaesth Crit Care
2011;1:7–12.
ª 2019 Royal College of Obstetricians and Gynaecologists
 DOI: 10.1111/tog.12576
The Obstetrician & Gynaecologist
http://onlinetog.org
Multiple sclerosis and pregnancy
MBBS MRCOG, *
a,
Priya Kanagaraj Nikos Evangelou
a
Specialist registrar (ST7), Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
b
Clinical Associate Professor and Consultant Neurologist, Division of Clinical Neurosciences, Queen’s Medical Centre, University of Nottingham,
Nottingham NG7 2UH, UK
c
Consultant Obstetrician, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
*Correspondence: Priya Kanagaraj. Email: kanagarajpriya@yahoo.co.uk
Accepted on 26 November 2018.
Key content
 Multiple sclerosis (MS) is a chronic neurological disease that
manifests with clinical and subclinical attacks of central nervous
system demyelination.
 Women are at least twice as likely as men to develop MS, with a
mean age of onset of 30 years.
 Pregnancy has no adverse long-term effect on disease progression,
but it is associated with a higher relapse rate in the immediate
postpartum period.
 Pregnancy can worsen pre-existing urinary/bowel dysfunction and
motor problems.
 MS is not associated with significant obstetric or
neonatal complications.
Learning objectives
 To understand how to manage pregnant women with MS in the
multidisciplinary setting.
Please cite this paper as: Kanagaraj P, Evangelou N, Kapoor D. Multiple sclerosis and pregnancy. The Obstetrician & Gynaecologist. 2019;21:177–84. https://doi.
org/10.1111/tog.12576
Introduction
Multiple sclerosis (MS) is a chronic inflammatory,
demyelinating disorder of the central nervous system that is
characterised by neurological relapses and frequent
progressive neurological dysfunction and disability.
Multiple sclerosis is two to three times more common in
women1,2 than in men, with a mean age of onset of 30 years.
More than half of women with MS will develop the disease
during their reproductive years, making pregnancy issues
important for these patients.3 A population study by
Mackenzie et al. showed that 126 669 people in the UK
were living with MS in 2010 and the prevalence among
women was 285.8 per 100 000.1
Although the aetiology of MS is unknown, genetic
components seem to be important.4 It is difficult to
positively identify high-risk individuals using genetic
screening because most carriers with the HLA-DRB1*1501
allele5 are not in the genetically susceptible group.5 The
ª 2019 Royal College of Obstetricians and Gynaecologists
2019;21:177–84
Review
b c
FRCP DPhil (Oxon), Dipanwita Kapoor MBBS MRCOG
 To understand the importance of pre-pregnancy counselling for
women with MS who are on disease-modifying drugs.
 To understand the implications of pregnancy on MS symptoms
and their management.
 To be aware of the benefits of breastfeeding and the safety of
disease-modifying drugs and lactation.
Ethical issues
 In the absence of clear guidelines, should women ever be advised to
avoid pregnancy?
 Should women be offered in vitro fertilisation treatment, which is
known to increase disease relapse?
Keywords: breastfeeding / contraception / disease-modifying drug
therapy / multiple sclerosis / regional anaesthesia
lifetime risk of developing MS in the general population is
1 in 330. Around 80% of people with MS have an affected
family member. Data from a meta-analysis of familial risk
studies by O’Gorman et al. showed the risk of inheritance
with one affected parent to be 1 in 67, increasing to around
10% with one affected sibling and one affected parent. The
risk is highest – at around 20% – in monozygotic twins and
in children who have both parents affected. The risk is 5% in
dizygotic twins. The recurrence risk with one affected child is
2.7%.2,6 The remainder of risk is determined by
environmental or lifestyle risk factors such as viral infection
(e.g. Epstein–Barr virus), smoking and obesity.7
MS is categorised on the basis of three patterns of
progression and relapse: relapsing remitting MS (RRMS),
secondary progressive MS (SPMS) and primary progressive
MS (PPMS). Patients with SPMS can still have the occasional
relapse. Most patients (85%) are diagnosed with RRMS,
which is characterised by cycles of remission and relapse.
Over time, some people develop SPMS whereby relapse
177
 MS and pregnancy

MS was traditionally considered a T cell-mediated

Box 1. Clinical presentation of multiple sclerosis
Primary symptoms – a direct result of damage to the myelin
and nerve fibres in the central nervous system
Most common Least common
Fatigue Dysarthria,
dysphonia
Urinary incontinence or retention Dysphagia
Numbness, tingling/prickling Seizures
Loss of balance Tremors
Dizziness and vertigo Breathing
problems
Visual problems: optic neuritis (often the first Itching
symptoms in 20–30%), diplopia, blurring of vision, Headache
poor colour vision Hearing loss
Acute and chronic pain
Constipation or anal incontinence
Spasticity
Cognitive symptoms
Mood changes: significant clinical depression, mood
swings, irritability
Secondary symptoms – complications as a result of primary
symptoms
Recurrent urinary tract infections
Poor postural alignment and trunk control
Decreased bone density (and resulting increased risk of fracture),
shallow, inefficient breathing
becomes infrequent but their disabilities worsen. About
10–15% of people are diagnosed with PPMS, in which there
is a progressive worsening of the disability from disease onset,
with rare occurrences of relapse. The expanded disability
status scale (EDSS) is the most widely used scale to monitor
disease progression. This is a 20-point scale, ranging from
0 = ‘normal’ to 10 = ‘death caused by MS’, marked in 0.5
increments. MS can present with a wide range of symptoms,
as summarised in Box 1.
This article gives an overview of the course of the disease
during pregnancy, its impact on pregnancy and the safety of
medications used to treat MS during pregnancy
and breastfeeding.
Effect of pregnancy and breastfeeding
on MS
Women with MS appeared to have fewer relapses during
pregnancy,7–9 but relapse during the first 3–4 months
postpartum is not uncommon (20–30% of female
patients).10–12 The single best predictor for postpartum
relapse is the pre-pregnancy relapse rate.13,14 MS relapses
occur less often in parous women, and pregnancy after MS
onset is associated with a lower risk of progression.9,15 A
recent systematic review by McKay et al.7 confirmed that
pregnancy does not alter the risk of MS or long-
term progression.
autoimmune disease, although recently the role of B cells
has been widely recognised and is the basis of several new
drugs. During pregnancy, there is a shift from cell-mediated
immunity towards increased humoral immunity. Normal
pregnancy is associated with predominately T helper 2 (Th2)
cytokine response, with interleukin 10 (IL-10) produced by
the fetal–placental unit playing a major role in the
maintenance of pregnancy. IL-10 production is significantly
reduced at term, and this downregulation favours a pro-
inflammatory state around the time of labour. This antenatal
immunosuppression explains spontaneous remission of MS
during pregnancy and exacerbations during the
postpartum period.16
Pregnancy is associated with worsening of some symptoms
of MS, such as fatigue, back pain and bladder/bowel
problems. Pregnancy is also associated with a higher
incidence of urinary tract infection (UTI), especially in
women with a neurogenic bladder.17–19 Some women with
MS and existing mobility difficulties report a further
reduction in mobility and increased spasticity as the
pregnancy progresses, which is associated with increasing
weight and changes in the centre of gravity. Although many
of these symptoms are attributed to pregnancy, one must be
vigilant for symptoms that might suggest relapse. Most new
relapses involve different symptoms that have not presented
before, whereas most ‘pseudo relapses’ manifest as a flare-up
of all symptoms, sometimes with greater intensity. For
example, the development of painful visual loss (optic
neuritis) in a woman who had never experienced visual
symptoms before suggests a new relapse, whereas relapse is
not suggested in a woman with existing walking difficulties
who reports a worsening gait and greater fatigue. New
symptoms should be promptly reviewed by the neurologist.
Women must be reassured that there is no increased risk of
relapse with the use of regional anaesthesia, especially
epidural use.20,21
Several studies have found that breastfeeding has beneficial
effects on MS relapse.14,22–25 Exclusive breastfeeding for at
least the first 2 months postpartum has shown to reduce
relapse in the immediate postnatal period11,14,22,24 as it leads
to a distinct hormonal state in which luteinising hormone
(LH) and pulsatile gonadotrophin-releasing hormone
(GnRH) are suppressed and prolactin levels are high. This
results in anovulation, lactational amenorrhoea and a
reduction of tumour necrosis factor-alpha (TNF-a)-
producing CD4 cells. This immunological effect is believed
to reduce postpartum relapse by four-fold.14,26 A meta-
analysis by Papkoor et al. demonstrated that breastfeeding
halves the risk of MS relapse.25 However, the heterogeneity of
studies with a lack of differentiation between exclusive and
non-exclusive breastfeeding and the severity of disease was
not considered in reaching a consensus.

178 ª 2019 Royal College of Obstetricians and Gynaecologists


Effects of MS on pregnancy
Maternal effects
Although fertility is not affected by the disease per se, recent
evidence from a study by Th€ one et al. suggests that anti-
M€ ullerian hormone – the marker for ovarian reserve – is
significantly reduced in women with MS.27 However, MS is
associated with a higher frequency of voluntary childlessness
(22% versus 13% in women without MS) and many more
women with MS will choose to terminate their pregnancy
than those without the disease (20% versus 12%).28 Reasons
for voluntary childlessness and termination most often cited
in the published literature are disability or fear of disability,
fear of transmitting MS to offspring, fear of discontinuing
medications and discouragement from physicians. The
sexual dysfunction that is reportedly seen in 30–70% of
women with MS may also contribute to the rate of
voluntary childlessness in this population. In addition,
some older immunosuppressants used to treat MS, such as
mitoxantrone or cyclophosphamide (which are rarely used
in MS treatment currently), can have a negative effect
on fertility.
Reassuring results have been found in several studies that
have explored maternal outcomes in women with MS.29,30 A
large national database study of 7697 pregnancy outcomes in
women with MS showed a higher rate of antenatal
hospitalisation and caesarean delivery, when adjusted for
maternal age and race. However, they were unable to adjust
for other variables such as medication use, duration and
severity of underlying disease and parity.31 A small increase
in operative vaginal deliveries has been noted in women with
greater disability,26 which may be associated with worsening
neuromuscular weakness.
Fetal effects
There is evidence to suggest no major increase in adverse
outcomes in infants born to women with MS. The rate of
miscarriage, stillbirth and congenital abnormality are not
increased in women with MS.32 Several studies have shown no
increased risk of miscarriage in women with MS who are
exposed to disease-modifying therapies (DMTs).32–34 The risk
of congenital malformations of children born to women with
MS is comparable to that in the general population.35 This
effect was noted even in women exposed to some, but not all,
DMTs.33,36–38 Women with MS can be reassured that there is
no increased risk of stillbirth or perinatal mortality.17,18,39
A systematic review and meta-analysis by Finkelsztejn
et al.8 suggested a higher prevalence of prematurity and low
birthweight in children born to women with MS. There is a
small – albeit increased – risk of preterm delivery before
37 weeks of gestation in women with MS.17,18 An increased
rate of preterm delivery (8.3% versus 6.4%) was noted in
women with disease manifestation compared with women
ª 2019 Royal College of Obstetricians and Gynaecologists
Kanagaraj et al.
without symptoms (whether pre-diagnosis or in the early
stages of MS).39 Several studies have shown an increased risk
of fetal growth restriction (FGR) in women with MS.12,17,18,31
The risk of FGR is approximately 1.7 times higher than that
of the general obstetric population.31 This increased risk is
noted in women diagnosed with MS and was not observed in
women before the onset of MS.39
Safety of the use of MS medications during
pregnancy and breastfeeding
It used to be the case that all immunosuppressants and other
DMTs for MS were stopped prior to conception. However,
growing evidence from pregnancy registries suggests that
some DMTs, like glatiramer acetate and interferons, are
relatively safe to use during early pregnancy.40,41 The risk of
stopping DMTs must be discussed with patients during pre-
pregnancy counselling, usually by the neurologist and the MS
nurse who know the patient better. Although the overall risk
of a relapse is reduced in pregnancy, for some patients with
highly active disease who are taking DMTs, there is the risk of
a significant rebound of disease activity (within 3 months).
Therefore, there will be a small cohort of women who choose
to stay on their DMT, e.g. natalizumab, while pregnant, or –
alternatively – who re-start it early in the postpartum period
to reduce the risk of a significant postpartum relapse. Other
immunosuppressants and DMTs are contraindicated during
pregnancy and breastfeeding, either because of their negative
effects on the growing fetus or because of limited evidence
of safety.
Table 1 provides a summary of the safety of the use of MS
medications during pregnancy and breastfeeding to maintain
disease remission and treat acute flare.36,42–59 Definitions of
the US Food and Drug Administration (FDA) categories are
shown in Box 2.
Pre-pregnancy counselling
So far, no study has shown that pregnancy in MS is harmful,
therefore patients can be reassured that pregnancy does not
lead to disease progression. Usually, this is discussed with the
MS clinical team (neurologists and specialist nurses). When a
woman is planning a pregnancy, meeting with the obstetrics
team could also reduce the anxiety that is usually felt. For
both the patient and the multidisciplinary team, it is usually
helpful to summarise the illness and its treatment so far, and
to outline possible treatment plans in the event of a relapse
during pregnancy. This discussion should include the
importance of conceiving during remission and of good
disease control during pregnancy to reduce adverse
pregnancy outcomes. The impact of the disease on
pregnancy and vice versa and the safety of medications
used during pregnancy and breastfeeding should also be
179
 MS and pregnancy

Table 1. Safety of medications during pregnancy and breastfeeding

FDA
classification Pre-conception Pregnancy Breastfeeding Comments

Interferon-b C Stop after conception Contraindicated Contraindicated Does not cross the placental
barrier
No increased risk of congenital
abnormalities, spontaneous
miscarriage, SGA or preterm
delivery with early pregnancy
exposure42

Glatiramer acetate B Stop after conception Contraindicated Caution Does not cross the placental
barrier
No increased risk of congenital
abnormalities, spontaneous
miscarriage, SGA or preterm
delivery with early pregnancy
exposure43–45

Steroids C Possible Possible Possible Used to treat flare-ups

Increased association with
maternal hypertension,
gestational diabetes, SGA
infants, preterm rupture of
the membranes, preterm
delivery46
Can cause neonatal adrenal
suppression at higher doses
Give ‘stress dose’ at delivery

Natalizumab C Stop before conception Although some
Maintain effective
contraception for 2–3
additional months after
discontinuing drug
Contraindicated Crosses placenta after second
women are able to trimester and peaks during
discontinue third trimester
treatment before or Increased risk of SGA fetus
during pregnancy, No increased risk of
others with more spontaneous miscarriage or
severe disease may fetal malformations47,48
elect to continue Known to cause SGA fetus,47
treatment fetal haematological
abnormalities (anaemia/
thrombocytopenia)49

Teriflunomide X Stop before conception Contraindicated Contraindicated Teratogenic in animal studies

Recommend an accelerated but not in humans
elimination procedure with No increased risk of
oral cholestyramine spontaneous miscarriages
Maintain effective
contraception as long as
plasma concentration is
above 0.02 mg/l

50

Alemtuzumab C Stop before conception Contraindicated Contraindicated Does not cross placental
Maintain effective barrier until week 13
contraception for 4 months Embryo toxic in animal studies
after discontinuation No increased risks of
spontaneous miscarriage or
teratogenicity in human
studies51

180 ª 2019 Royal College of Obstetricians and Gynaecologists

 Kanagaraj et al.

Table 1. (Continued)

FDA
classification Pre-conception Pregnancy Breastfeeding Comments

Fingolomid C Stop before conception Contraindicated Contraindicated Crosses placental barrier

Maintain effective Teratogenic in animal studies
contraception for 2 months Increased risk of spontaneous
after discontinuation miscarriage rate (24% versus
15%) and higher rate of fetal
abnormalities52,53

Mitoxantrone D Stop before conception Contraindicated Contraindicated 28 Reduction of ovarian reserve

Maintain effective days of clearance and amenorrhoea54,55
contraception for 6 months Fetal growth restriction and
after discontinuation preterm delivery in animal
models

Methotrexate X Stop before conception Contraindicated Contraindicated Teratogenic and embryotoxic

Maintain effective Increased miscarriage and
contraception for 6 months congenital anomalies with
after discontinuation specific pattern56

Mycophenolatemofetil D Stop before conception Contraindicated Contraindicated Teratogenic

Maintain effective Increased miscarriage and
contraception for 6 weeks congenital anomalies with
after discontinuation specific pattern57

Dimethyl fumarate C Stop before conception Contraindicated Contraindicated Crosses placental barrier
Contraception could be No increased risk of
stopped rapidly as short miscarriage, fetal
half-life anomalies36

Cladribine D Stop before conception Contraindicated Contraindicated Very limited data

Maintain effective Teratogenic in animal studies
contraception for 6 months No increased miscarriage rate,
after discontinuation congenital malformation in
humans58

Ocreluzimab Not assigned Stop before conception Contraindicated Contraindicated Humanised monoclonal IgG
Women of childbearing (excreted in the milk of antibody targeted against
potential should use ocrelizumab-treated CD20+ B cells
contraception while monkeys but no data Crosses placental barrier
receiving treatment and for in humans) Very limited data – it is too
6 months after the last early to tell – only approved
infusion by NICE this autumn with a
warning against
pregnancies59

FDA = US Food and Drug Administration; NICE = National Institute for Health and Care Excellence; SGA = small-for-gestational-age.

discussed, because some DMTs are known to pose risks to the

newborn. It is also important to discuss the risk of stopping
DMTs during pre-conception counselling with the woman.
The fact that MS is not a hereditary disease and that the risk
of having children who may develop the disease is very small
should be reiterated during these consultations.2,6 Women
should be reassured that the risk of miscarriage, congenital
malformation and perinatal mortality is not affected by MS
per se. Women should be encouraged and supported to stop
smoking because – in addition to its deleterious effect in
pregnancy – cigarette smoking increases the risk of
disease progression.60
Management of MS during pregnancy
Antenatal
Although, overall, pregnancies in women with MS run
smoothly, it is important that they are managed in a
multidisciplinary setting involving a neurologist with an
interest in MS and pregnancy, an MS specialist nurse, an
obstetrician with expertise in MS, a general practitioner (GP)
and a community midwife. This will help to ensure that
women are given the correct advice.
As pregnancy-related symptoms mimic MS exacerbations,
extra vigilance is needed to assess these symptoms, as

ª 2019 Royal College of Obstetricians and Gynaecologists 181

 MS and pregnancy
Box 2. Summary of US Food and Drug Administration categories for
drug safety during pregnancy
A: Controlled studies in animals and women fail to show fetal risk
B: Either animal studies show no risk and no data in women, or animal
studies show an adverse effect that has not been confirmed in
controlled studies of women in their first trimester
C: No controlled studies available in women and either animal studies
not done or done and showed an adverse effect
D: Evidence of risk to the fetus but benefits may still outweigh this risk
X: Evidence of risk to the fetus and drug contraindicated in pregnancy
mentioned previously. Simple measures such as taking
frequent rest and avoiding stress may be helpful for women
with fatigue. A small dose of amitriptyline may be used to help
with neurogenic pain, and diazepam can improve spasticity to
some extent. Women with bladder symptoms and neurogenic
bladder must have monthly midstream urine samples taken
because of the increased risk of UTI in this cohort. Neurogenic
bladder symptoms may worsen, with an increased need for
intermittent self-catheterisation during pregnancy. Adequate
hydration, a high-fibre diet and occasional use of laxatives can
be considered in women who experience constipation.
Consider thromboprophylaxis with compression stockings
and low molecular weight heparin in women who have reduced
mobility or who are wheelchair-bound and have additional risk
factors;61 these patients should also be warned against falls and
may need increased physiotherapy. Anaesthetist review enables
women to discuss pain relief options during labour and
delivery. It is safe to use pethidine, nitrous oxide, a
transcutaneous electrical nerve stimulation machine and
regional anaesthesia during labour. Although there are
theoretical concerns about the use of spinal anaesthesia, to
date, no studies have found any detrimental effects of exposing
the demyelinated spinal cord to the neurotoxic effects of local
anaesthesia.62,63 Fetal scan surveillance in the third trimester
should be considered, given the increased risk of small-for-
gestational-age infants in these women.64
Relapse during pregnancy is more likely to occur during
the first and second trimesters. Use of magnetic resonance
imaging (MRI) to confirm a relapse and exclude other
pathologies is safe in all trimesters of pregnancy, but it is not
often deemed necessary. However, MRI with gadolinium
contrast should be avoided during pregnancy.65 Management
of acute flare-up usually involves oral or intravenously
administered corticosteroids. This is safe during pregnancy
and breastfeeding.66 Vigilance is required regarding maternal
hypertension and gestational diabetes with repeated courses
of steroids in pregnancy. Fetal growth scans during the third
trimester are also advised. It is very uncommon for women
with MS to be given steroids (prednisolone equivalence of
greater than 5 mg) for more than 4 weeks before giving birth,
182
but they will need additional oral doses or parenteral
hydrocortisone during delivery and in the immediate
postpartum period to lower the risk of acute adrenal crisis.67
Labour and delivery
Obstetric indications will guide the timing and mode of
delivery in women with MS. Vaginal delivery is considered
safe; however, planned caesarean section may be
considered in women with severe neurological problems.
Women with higher EDSS scores are more likely to require
induction of labour. Ensure the bladder is emptied
periodically during labour, and it is advisable to use an
indwelling urinary catheter with epidural anaesthesia.
Increased fatigue and maternal exhaustion may warrant
assisted delivery.
Postpartum and breastfeeding
It is recommended that the MS team formulates a postnatal
plan for women with MS in the late third trimester. This plan
should include vigilance for disease flare-ups, advice
regarding drug treatments and their implications on
breastfeeding, MS team contact numbers and follow-up
appointments. A written copy should be made available to
the woman, her GP and the obstetric team.
Women should be encouraged to breastfeed because of the
benefits to babies, although the full extent of the benefit of
exclusive breastfeeding in MS remains uncertain. However,
breastfeeding is contraindicated when they restart on a DMT
in the immediate postpartum period. Patients with very
active disease prior to pregnancy usually restart their MS
treatment immediately after delivery and choose not to
breastfeed. Women must be reassured that breastfeeding is
safe during steroid therapy. The British National Formulary
advises to breastfeed 4 hours post-administration to
minimise infant exposure.
Effective contraception is necessary to prevent unintended
pregnancies in women with MS, especially during active
disease, or if taking immunosuppressants for disease control
because many of them are teratogenic. Based on the current
evidence, most contraceptive methods are safe to take for
women with MS.68 It is important to consider the woman’s
level of disability, mobility and medication use when
choosing the best contraceptive choice.
MS and assisted reproductive techniques
Several studies have shown that the rate of relapse is
considerably higher following assisted reproductive
techniques (ART),69–71 and is significantly higher after
unsuccessful attempts and following GnRH agonist
protocols. The increased relapse rate tends to occur 3 months
following ART. Correale et al.70 prospectively followed 16
patients before and during an ART cycle. A seven-fold
ª 2019 Royal College of Obstetricians and Gynaecologists

increase in the risk of MS exacerbation was found, as well as a
nine-fold increase in the risk of enhanced disease activity on
MRI. Several factors contributed to the increased relapse rate,
such as immunological changes during ART, with increased
levels of pro-inflammatory cytokines and increased migration
of immune cells through the blood brain barrier, stress and
discontinuation of DMTs prior to ART.
Conclusion
Pre-pregnancy counselling and careful planning will allow
women with MS to have a favourable pregnancy outcome.
Women with MS should be reassured that pregnancy does
not appear to be harmful overall – and may even be
beneficial. For most patients with MS, pregnancy outcome is
not significantly different from that of the general
population, though some precautions may be required in
patients with advanced MS. Given the potential benefits,
breastfeeding should be encouraged during the postpartum
period, but women should be counselled that DMTs may
need to be commenced in the event of postpartum relapse.
Although there is an increase in the relapse rate with ART, it
is not contraindicated in women with MS.
Disclosure of interests
PK and DK have no conflicts of interest. NE served on
scientific advisory boards for Merck, Biogen, Roche and
Novartis and has received conference hospitality from Biogen
and Teva.
Contribution to authorship
PK contributed to literature searches and drafted the article
based on available evidence. DK and NE reviewed the
manuscript and provided their comments. All authors read
and approved the final version of the manuscript.
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