OXFOR D M EDIC AL PU B LIC ATION S
Oxford Handbook of Obstetrics and Gynaecology
Published and forthcoming Oxford Handbooks Oxford Handbook for the Foundation Programme 5e Oxford Handbook of Acute Medicine 4e Oxford Handbook of Anaesthesia 5e Oxford Handbook of Cardiology 2e Oxford Handbook of Clinical and Healthcare Research Oxford Handbook of Clinical and Laboratory Investigation 4e Oxford Handbook of Clinical Dentistry 7e Oxford Handbook of Clinical Diagnosis 3e Oxford Handbook of Clinical Examination and Practical Skills 2e Oxford Handbook of Clinical Haematology 4e Oxford Handbook of Clinical Immunology and Allergy 4e Oxford Handbook of Clinical Medicine – Mini Edition 10e Oxford Handbook of Clinical Medicine 10e Oxford Handbook of Clinical Pathology 2e Oxford Handbook of Clinical Pharmacy 3e Oxford Handbook of Clinical Specialties 11e Oxford Handbook of Clinical Surgery 5e Oxford Handbook of Complementary Medicine Oxford Handbook of Critical Care 3e Oxford Handbook of Dental Patient Care Oxford Handbook of Dialysis 4e Oxford Handbook of Emergency Medicine 5e Oxford Handbook of Endocrinology and Diabetes 4e Oxford Handbook of ENT and Head and Neck Surgery 3e Oxford Handbook of Epidemiology for Clinicians Oxford Handbook of Expedition and Wilderness Medicine 2e Oxford Handbook of Forensic Medicine Oxford Handbook of Gastroenterology & Hepatology 3e Oxford Handbook of General Practice 5e Oxford Handbook of Genetics Oxford Handbook of Genitourinary Medicine, HIV, and Sexual Health 3e Oxford Handbook of Geriatric Medicine 3e Oxford Handbook of Head and Neck Anatomy Oxford Handbook of Infectious Diseases and Microbiology 2e Oxford Handbook of Integrated Dental Biosciences 2e Oxford Handbook of Humanitarian Medicine Oxford Handbook of Key Clinical Evidence 2e Oxford Handbook of Medical Dermatology 2e Oxford Handbook of Medical Ethics and Law
Oxford Handbook of Medical Imaging Oxford Handbook of Medical Sciences 3e Oxford Handbook for Medical School Oxford Handbook of Medical Statistics 2e Oxford Handbook of Neonatology 2e Oxford Handbook of Nephrology and Hypertension 2e Oxford Handbook of Neurology 2e Oxford Handbook of Nutrition and Dietetics 3e Oxford Handbook of Obstetrics and Gynaecology 4e Oxford Handbook of Occupational Health 3e Oxford Handbook of Oncology 4e Oxford Handbook of Operative Surgery 3e Oxford Handbook of Ophthalmology 4e Oxford Handbook of Oral and Maxillofacial Surgery 2e Oxford Handbook of Orthopaedics and Trauma Oxford Handbook of Paediatrics 3e Oxford Handbook of Pain Management Oxford Handbook of Palliative Care 3e Oxford Handbook of Practical Drug Therapy 2e Oxford Handbook of Pre-Hospital Care 2e Oxford Handbook of Psychiatry 4e Oxford Handbook of Public Health Practice 4e Oxford Handbook of Rehabilitation Medicine 3e Oxford Handbook of Respiratory Medicine 4e Oxford Handbook of Rheumatology 4e Oxford Handbook of Sleep Medicine Oxford Handbook of Sport and Exercise Medicine 2e Oxford Handbook of Tropical Medicine 5e Oxford Handbook of Urology 4e
OXFORD HANDBOOK OF
Obstetrics and Gynaecology FOURTH EDITION
edited by Sally Collins Consultant Obstetrician and Subspecialist in Maternal and Fetal Medicine, John Radcliffe Hospital, Oxford, and Professor of Obstetrics, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
Sabaratnam Arulkumaran Professor of Obstetrics and Gynaecology, University of Nicosia Medical School, Cyprus, Professor Emeritus, St George’s, University of London, and Visiting Professor, Imperial College London, London, UK
Kevin Hayes Consultant Obstetrician and Gynaecologist, St George’s University Hospital NHS Foundation Trust, London, UK
Kirana Arambage Consultant Gynaecologist, John Radcliffe Hospital, Oxford, and Honorary Senior Clinical Lecturer, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
Lawrence Impey Consultant Obstetrician and Subspecialist in Maternal and Fetal Medicine, John Radcliffe Hospital, Oxford, UK
Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 2023 The moral rights of the authors have been asserted First Edition published 2005 Second Edition published 2008 Third Edition published 2013 Fourth Edition published 2023 Impression: All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 98 Madison Avenue, New York, NY 006, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2022941170 ISBN 978–0–9–883867–8 DOI: 0.093/med/978098838678.00.000 Printed and bound in China by C&C Offset Printing Co., Ltd. Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.
Contents Preface vii Acknowledgements ix Symbols and abbreviations xi Contributors xvii Normal pregnancy 2 Pregnancy complications 3 Fetal medicine 4 Infectious diseases in pregnancy 5 Medical disorders in pregnancy 6 Labour and delivery 7 Obstetric anaesthesia 8 Neonatal resuscitation 9 Postnatal care 0 Obstetric emergencies Maternal and perinatal mortality 2 Benign and malignant tumours in pregnancy 3 Substance misuse and psychiatric disorders 4 Gynaecological anatomy and development 5 Normal menstruation and its disorders 6 Early pregnancy problems 7 Genital tract infections and pelvic pain 8 Subfertility and reproductive medicine 9 Sexual assault 20 Contraception 2 Menopause
47 03 59 25 297 36 373 383 407 439 475 499 529 573 597 625 65 695 703 723
22 Urogynaecology 23 Benign and malignant gynaecological conditions 24 Miscellaneous gynaecology Index 99
74 777 889
Preface Since the previous edition of the Oxford Handbook of Obstetrics and Gynaecology there has been significant growth within the specialty, with new reports and guidelines that have changed the approaches involved in delivering the best-quality care for patients. In writing and developing this new edition, we have taken the latest evidence-based practice as well as our own clinical experience to help those of you who are embarking on the challenging yet rewarding field of obstetrics and gynaecology. We are grateful to our past and present contributors, who have given both their time and expertise in writing and updating this Handbook, as well as to our readers. We hope that the information, which we have tried to present in a digestible format, will prove useful to you on the wards as well as at your desk. Where possible, we have tried to align our chapters with the Royal College of Obstetricians and Gynaecologists curriculum, but we have also included clinical tips gleaned from our practical experience. Please do let us know any suggestions or criticism related to the content of the book, and we will make every effort to improve the delivery of the content even more in the next edition. Sally Collins Sabaratnam Arulkumaran Kevin Hayes Kirana Arambage Lawrence Impey April 2022
Acknowledgements We would like to thank all our second and third edition authors on whose sterling work this latest edition is built. We would also like to thank the doctors of all grades who anonymously reviewed some of the text, providing valuable feedback and further fine-tuning of the finished manuscript. To conform to the Oxford Handbook style and to avoid overlap and repetition, some contributions have been considerably edited and we thank all our authors for their understanding. We are most grateful to Prof. Basky Thilaganathan for providing many of the ultrasound images and Ms Penny Trotter for the colposcopy pictures. We cannot fail to mention the marvellous team at Oxford University Press including Elizabeth Reeve, Helen Liepman, and Caroline Smith, but especially Sylvia Warren without whose incredible patience, kindness, and expert guidance this fourth edition would not have happened. Last, but definitely not least, we would like to thank our partners and families who continue to remain so patient and supportive throughout this project, especially Berni O’Connor, ‘for doing all the real work on the home front’ and David, Lexi, and Bea Reynard ‘for all their love and support throughout M’s mad projects’.
Symbols and abbreviations H warning 2 important 3 differential diagnosis controversial E cross-reference M website z video ° primary 2° secondary i increased d decreased l leading to ± with or without ~ approximately +ve positive −ve negative 5-FU 5-fluorouracil ABG arterial blood gases ACE angiotensin converting enzyme ACEI angiotensin converting enzyme inhibitor ACTH adrenocorticotropic hormone ADH antidiuretic hormone AF atrial fibrillation AFI amniotic fluid index AFLP acute fatty liver of pregnancy AFP alpha-fetoprotein AIS androgen insensitivity syndrome ALP alkaline phosphatase ALT alanine transaminase AMH anti-Müllerian hormone ANA antinuclear antibodies APH antepartum haemorrhage APS antiphospholipid syndrome AREDF absent/reversed end- diastolic flow ARM artificial rupture of membranes ASD atrial septal defect AST aspartate aminotransferase AVM arteriovenous malformation BASHH British Association for Sexual Health and HIV
BCG bd BEP
bacillus Calmette–Guérin twice daily bleomycin, etoposide, and cisplatin βhCG beta-human chorionic gonadotropin BMD bone mineral density BMI body mass index BOT borderline ovarian tumour BP blood pressure BPD biparietal diameter BRCA breast cancer gene BSO bilateral salpingo-oophorectomy BV bacterial vaginosis CA cancer antigen CAH congenital adrenal hyperplasia CAIS complete androgen insensitivity syndrome CAP chest/abdomen/pelvis cART combination antiretroviral therapy CBAVD congenital bilateral absence of the vas deferens CD Caesarean delivery CEA carcinoembryonic antigen CF cystic fibrosis CGIN cervical glandular intraepithelial neoplasia CI confidence interval CIN cervical intraepithelial neoplasia CMV cytomegalovirus CNS central nervous system CNST Clinical Negligence Scheme for Trusts CO2 carbon dioxide COCP combined oral contraceptive pill COVID-9 coronavirus disease 209 CP cerebral palsy CPAP continuous positive airway pressure CPP chronic pelvic pain
Symbols and abbreviations CPR
cerebroplacental ratio or cardiopulmonary resuscitation CRL crown–rump length CRP C-reactive protein CS Caesarean section CSF cerebrospinal fluid CT computed tomography CTG cardiotocography CTPA computed tomography pulmonary angiogram CVS chorionic villus sampling CXR chest X-ray DC dichorionic DCDA dichorionic and diamniotic DES diethylstilbestrol DHEAS dehydroepiandrosterone sulphate DIC disseminated intravascular coagulation DSD disorder of sex development DUB dysfunctional uterine bleeding dVIN differentiated vulval intraepithelial neoplasia EBL estimated blood loss EBRT external beam radiotherapy ECG electrocardiography/ electrocardiogram ECV external cephalic version EDD expected date of delivery EFW estimated fetal weight EP ectopic pregnancy EPAU early pregnancy assessment unit ESR erythrocyte sedimentation rate ET endometrial thickness ETT endotracheal tube EUA examination under anaesthetic FBC full blood count FBS fetal blood sampling FDA Food and Drug Administration FF fetal fraction FFP fresh frozen plasma FGM female genital mutilation FGR fetal growth restriction FH fetal heart FHR fetal heart rate FIGO International Federation of Gynaecology and Obstetrics FL femur length
FM FPR FSD FSH FVS GA GABA GAD GAS GBS GDM GFR GMC GnRH
fetal movements false-positive rate female sexual dysfunction follicle-stimulating hormone fetal varicella syndrome general anaesthesia gamma-aminobutyric acid generalized anxiety disorder group A Streptococcus group B Streptococcus gestational diabetes mellitus glomerular filtration rate General Medical Council gonadotropin-releasing hormone GP general practitioner GTD gestational trophoblastic disease GTN gestational trophoblastic neoplasia GTT glucose tolerance test GUM genitourinary medicine Hb haemoglobin HbA adult haemoglobin HbAc glycated haemoglobin HBeAg hepatitis B e antigen HbF fetal haemoglobin HBsAg hepatitis B surface antigen HBV hepatitis B virus HC head circumference hCG human chorionic gonadotropin HELLP haemolysis, elevated liver enzymes, and low platelets HFEA Human Fertilization and Embryology Authority HG high-grade serous ovarian carcinoma HIV human immunodeficiency virus HLA human leucocyte antigen HMB heavy menstrual bleeding HPO hypothalamic–p ituitary–o varian HPV human papillomavirus hrHPV high-risk human papillomavirus HRT hormone replacement therapy HSG hysterosalpingography HSV herpes simplex virus HVS high vaginal swab HyCoSy hysterosalpingo contrast sonography
Symbols and abbreviations IBD ICD-
inflammatory bowel disease International Classification of Diseases, th Revision ICD-MM International Classification of Diseases for Maternal Mortality ICG indocyanine green ICP intrahepatic cholestasis of pregnancy ICSI intracytoplasmic sperm injection IDS interval debulking surgery Ig immunoglobulin IHC immunohistochemistry IM intramuscular IMB intermenstrual bleeding IOL induction of labour IUCD intrauterine contraceptive device IUD intrauterine death IUI intrauterine insemination IUP intrauterine pregnancy IUS intrauterine system IV intravenous IVF in vitro fertilization IVU intravenous urography JVP jugular venous pressure LARC long-acting reversible contraceptive LDH lactate dehydrogenase LFT liver function test LGSOC low-grade serous ovarian carcinoma LH luteinizing hormone LLETZ large loop excision of transformation zone LMP last menstrual period LMWH low-molecular-weight heparin LN lymph node LNG levonorgestrel LVS low vaginal swab MBRRACE-UK Mothers and Babies: Reducing Risk through Audits and Confidential Enquiry across the UK MC monochorionic MCA middle cerebral artery MCDA monochorionic and diamniotic
mean corpuscular haemoglobin concentration MCMA monochorionic and monoamniotic MCV mean corpuscular volume MDT multidisciplinary team MEA microwave endometrial ablation Mg magnesium MMR measles, mumps, and rubella or mismatch repair MPA medroxyprogesterone acetate MRI magnetic resonance imaging MRKH Mayer–Rokitansky–Küster– Hauser MSAF meconium-stained amniotic fluid MSU midstream sample of urine MTCT mother-to-child transmission NAAT nucleic acid amplification test NEC necrotizing enterocolitis NHSCSP NHS Cervical Screening Programme NHSLA National Health Service Litigation Authority NICE National Institute for Health and Care Excellence NIPT non-invasive prenatal testing NPV negative predictive value NSAID non-steroidal anti- inflammatory drug NT nuchal translucency NTD neural tube defect OA occipito-anterior OAB overactive bladder od once daily OGTT oral glucose tolerance test OHSS ovarian hyperstimulation syndrome OL occipito-lateral OP occipito-posterior PAIS partial androgen insensitivity syndrome PAPP-A pregnancy-associated plasma protein-A PAS placenta accreta spectrum PCB postcoital bleeding PCOS polycystic ovary syndrome PCR protein:creatinine ratio or polymerase chain reaction PE pulmonary embolism
Symbols and abbreviations PEFR peak expiratory flow rate PEP postexposure prophylaxis PET pre-eclampsia toxaemia PG prostaglandin PGE prostaglandin E PGE2 prostaglandin E2 PID pelvic inflammatory disease PlGF placental growth factor PMB postmenopausal bleeding PMRT Perinatal Mortality Review Tool PMS premenstrual syndrome PO per os (by mouth) POF premature ovarian failure POMB/ACE cisplatin, vincristine, methotrexate, bleomycin, dactinomycin, cyclophosphamide, and etoposide POP progestogen-only pill PPH postpartum haemorrhage PPROM preterm prelabour rupture of membranes PPV positive predictive value PROM prelabour rupture of membranes PSV peak systolic velocity PUL pregnancy of unknown location PV per vaginam Q ventilation qds four times daily RCOG Royal College of Obstetricians and Gynaecologists RCT randomized controlled trial Rh rhesus RID relative infant dose RMI risk of malignancy index ROM rupture of membranes RR rate ratio or relative risk RRBSO risk-reducing bilateral salpingo-oophorectomy RUQ right upper quadrant SARC sexual assault referral centre SARS severe acute respiratory syndrome SC subcutaneous SFH symphysis fundal height sFlt- soluble FM-like tyrosine kinase SGA small for gestational age
SHBG SLE SLN SLNB SMM
sex hormone-binding globulin systemic lupus erythematosus sentinel lymph node sentinel lymph node biopsy surgical management of miscarriage SNRI serotonin and norepinephrine reuptake inhibitor SROM spontaneous rupture of membranes SSRI selective serotonin reuptake inhibitor STI sexually transmitted infection STIC serous tubal intraepithelial carcinoma T3 triiodothyronine T4 thyroxine TAS transabdominal scan TB tuberculosis Tc technetium tds three times daily TENS transcutaneous electrical nerve stimulation TFT thyroid function test TNF tumour necrosis factor TOP termination of pregnancy TSH thyroid-stimulating hormone TTP thrombotic thrombocytopenic purpura TTTS twin-to-twin transfusion syndrome TV transvaginal TVS transvaginal scan TVT tension-free vaginal tape U&E urea and electrolytes UKFOCSS UK Familial Ovarian Cancer Screening Study UN United Nations UPSI unprotected sexual intercourse USI urodynamic stress incontinence USS ultrasound scan UTI urinary tract infection uVIN usual-type vulval intraepithelial neoplasia V/Q ventilation/perfusion VBAC vaginal birth after Caesarean VDRL Venereal Disease Research Laboratory test VE vaginal examination
Symbols and abbreviations VEGF VIN VRIII VSCC VSD
vascular endothelial growth factor vulval intraepithelial neoplasia variable rate intravenous insulin infusion vulvar squamous cell carcinoma ventricular septal defect
VTE vWF VZIG WCC WHO WLE
venous thromboembolism von Willebrand factor varicella zoster immunoglobulin white cell count World Health Organization wide local excision
Contributors Editors Sally Collins Consultant Obstetrician and Subspecialist in Maternal and Fetal Medicine, John Radcliffe Hospital, Oxford, and Professor of Obstetrics, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK Sabaratnam Arulkumaran Professor of Obstetrics and Gynaecology, University of Nicosia Medical School, Cyprus, Professor Emeritus, St George’s, University of London, and Professor, Imperial College London, London, UK
Kevin Hayes Consultant Obstetrician and Gynaecologist, St George’s University Hospital NHS Foundation Trust, London, UK Kirana Arambage Consultant Gynaecologist, John Radcliffe Hospital, Oxford, and Honorary Senior Clinical Lecturer, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK Lawrence Impey Consultant Obstetrician and Subspecialist in Maternal and Fetal Medicine, John Radcliffe Hospital, Oxford, UK
Contributors to the fourth edition W. Catarina Ang Consultant Gynaecologist, Royal Women’s Hospital, Parkville, VIC, Australia Chapter 2: Menopause Ilyas Arshad Consultant Gynaecologist, Liverpool University Hospitals NHS Trust, Liverpool, UK Chapter 20: Contraception
Christian Becker Associate Professor, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, and Honorary Consultant Gynaecologist, Subspecialist in Reproductive Medicine and Surgery, John Radcliffe Hospital, Oxford, UK Chapter 8: Subfertility and reproductive medicine
Charlotte Bennett Consultant Neonatologist, Oxford University Hospitals NHS Foundation Trust, Oxford, UK Chapter 8: Neonatal resuscitation
Rumana Islam Consultant Gynaecologist, Barts Health NHS Trust, London, UK Chapter 8: Subfertility and reproductive medicine
Abigail Brempah Specialty Trainee in Obstetrics and Gynaecology, Lewisham and Greenwich NHS Trust, London, UK Chapter 4: Gynaecological anatomy and development; Chapter 5: Normal menstruation and its disorders; Chapter 6: Early pregnancy problems; and Chapter 24: Miscellaneous gynaecology
Helen Jefferis Consultant Gynaecologist/ Urogynaecologist, John Radcliffe Hospital, Oxford, UK Chapter 22: Urogynaecology
Sarah Coleridge Subspeciality Trainee in Gynaecological Oncology, Nottingham University Hospitals Trust, Nottingham, UK Chapter 23: Benign and malignant gynaecological conditions Ruth Curry Consultant Obstetrician and Subspecialist in Maternal and Fetal Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK Chapter 2: Benign and malignant tumours in pregnancy Charlotte Frise Consultant Obstetric Physician, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK, and Lead Consultant Obstetric Physician for NW London Chapter 5: Medical disorders in pregnancy Suni Halder Consultant Obstetric Anaesthetist, Oxford University Hospitals NHS Foundation Trust, Oxford, UK Chapter 7: Obstetric anaesthesia
Shamitha Kathurusinghe Consultant Gynaecologist, Royal Women’s Hospital, Parkville, VIC, Australia Chapter 2: Menopause Bryn Kemp Consultant Obstetrician and Maternal Medicine Lead, Royal Berkshire NHS Foundation Trust, Reading, UK Chapter : Maternal and perinatal mortality Kimmee Khan Specialty Trainee in Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, London, UK Chapter 4: Gynaecological anatomy and development; Chapter 5: Normal menstruation and its disorders; Chapter 6: Early pregnancy problems; Chapter 9: Sexual assault; and Chapter 24: Miscellaneous gynaecology Vicky Minns Specialty Trainee in Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, London, UK Chapter 4: Gynaecological anatomy and development; Chapter 5: Normal menstruation and its disorders; Chapter 6: Early pregnancy problems; and Chapter 24: Miscellaneous gynaecology
Jo Morrison Consultant Gynaecological Oncologist, Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton, UK Chapter 23: Benign and malignant gynaecological conditions Sanyal Patel Consultant Obstetrician and Gynaecologist, Milton Keynes University Hospital, Milton Keynes, UK Chapter 4: Infectious diseases in pregnancy Pathiraja Pubudu Consultant Gynaecologist/ Gynaecological Oncologist, Addenbrooke’s Hospital, Cambridge, UK Chapter 7: Genital tract infections and pelvic pain Jane Reavey Senior Registrar, John Radcliffe Hospital, Oxford, UK Chapter 7: Genital tract infections and pelvic pain Fevzi Shakir Consultant Gynaecologist, Royal Free Hospital, London, UK Chapter 20: Contraception
Jasmine Tay Consultant Obstetrician and Subspecialist in Maternal Fetal Medicine, Queen Charlotte’s Hospital, Imperial College NHS Trust, London, UK Chapter 5: Medical disorders in pregnancy Katy Vincent Associate Professor, Senior Fellow in Pain in Women and Honorary Consultant Gynaecologist, Nuffield Department of Women’s and Reproductive Health, University of Oxford, John Radcliffe Hospital, Oxford, UK Chapter 7: Genital tract infections and pelvic pain Dilip Visvanathan Consultant Gynaecologist, Barts Health NHS Trust, London, UK Chapter 7: Genital tract infections and pelvic pain Michael Yousif Consultant in Liaison Psychiatry, West Middlesex University Hospital, London, UK Chapter 3: Substance misuse and psychiatric disorders
Contributors to the second and third editions Miss Karolina Afors St George’s Hospital, London, UK
Mrs Rebecca Black John Radcliffe Hospital, Oxford, UK
Dr Christian Becker John Radcliffe Hospital, Oxford, UK
Dr Shabana Bora St George’s Hospital, London, UK
Dr Amy Bennett Department of Genitourinary Medicine, Oxford University Hospitals, NHS Trust, Oxford, UK
Dr Brian Brady John Radcliffe Hospital, Oxford, UK Mr Paul Bulmer St George’s Hospital, London, UK
Mr Edwin Chandraharan St George’s Hospital, London, UK
Dr Emma Kirk St George’s Hospital, London, UK
Dr Noan-Minh Chau Specialist Registrar Rotation in Medical Oncology, London Deanery, UK
Dr Samatha Low Royal Berkshire Hospital, Reading, UK
Dr Mellisa Damodaram Queen Charlotte’s and Chelsea Hospital, London, UK Miss Claudine Domoney Chelsea and Westminster Hospital, London, UK Dr Stergios K. Doumouchtsis St George’s Hospital, London, UK Dr Suzy Elniel Chelsea and Westminster Hospital, London, UK Dr Cleave W. J. Gass St George’s Hospital, London, UK Dr Ingrid Granne John Radcliffe Hospital, Oxford, UK Miss Catherine Greenwood John Radcliffe Hospital, Oxford, UK Mr Manish Gupta John Radcliffe Hospital, Oxford, UK Miss Pauline Hurley John Radcliffe Hospital, Oxford, UK Dr Nia Jones Queens Medical Centre, Nottingham, UK Miss Brenda Kelly John Radcliffe Hospital, Oxford, UK Dr Nigel Kennea St George’s Hospital, London, UK Dr Andy Kent St George’s Hospital, London, UK Dr Su-Yen Khong John Radcliffe Hospital, Oxford, UK
Dr Jo Morrison Musgrove Park Hospital, Taunton, UK Dr Neelanjana Mukhopadhaya St George’s Hospital, London, UK Dr Faizah Mukri Specialist Registrar Rotation, London Deanery, UK Dr Santosh Pattnayak St George’s Hospital, London, UK Dr Natalia Price John Radcliffe Hospital, Oxford, UK Dr Aysha Qureshi Royal United Hospital, Bath, UK Dr Devanna Rajeswari St George’s Hospital, London, UK Dr Gowri Ramanathan St George’s Hospital, London, UK Dr Margaret Rees John Radcliffe Hospital, Oxford, UK Dr Jackie Sherrard Department of Genitourinary Medicine, Oxford University Hospitals NHS Trust, Oxford, UK Dr Lisa Story John Radcliffe Hospital, Oxford, UK Ms Louise Strawbridge University College London, London, UK Mr Alex Swanton Royal Berkshire Hospital, Reading, UK Dr Linda Tan St George’s Hospital, London, UK
Dr Katy Vincent John Radcliffe Hospital, Oxford, UK Miss Cara Williams University College London Hospital, UK Dr Niraj Yanamandra St Peter’s Hospital, Chertsey, UK
Normal pregnancy Obstetric history: current pregnancy 2 Obstetric history: other relevant features 4 Obstetric physical examination 6 Engagement of the fetal head 8 Female pelvis 0 Diameters of the female pelvis 2 Fetal head 4 Diameters and presenting parts of the fetal head 6 Placenta: early development 8 Placenta: later development 9 Placenta: circulation 20 Placenta: essential functions 22 Physiology of pregnancy: endocrine 24 Physiology of pregnancy: haemodynamics 26 Physiology of pregnancy: cardiorespiratory 27 Physiology of pregnancy: genital tract and breast 28 Physiology of pregnancy: other changes 30 Preparing for pregnancy 3 Supplements and lifestyle advice 32 General health check 34 Diagnosis of pregnancy 36 Dating of pregnancy 37 Ultrasound assessment of fetal growth 38 Booking visit 40 Antenatal care: planning 42 Antenatal care: routine blood tests 44 Antenatal care: specific blood tests 45 Antenatal care: preparing for delivery 46
Obstetric history: current pregnancy Obstetric history taking has many features in common with most other sections of medicine, along with certain areas specific to the specialty. The basic framework can be easily learned; however, competence requires good clinical knowledge and a lot of practice. As obstetrics often requires intimate examination and discussion of sensitive information, it is important to ensure privacy, and to demonstrate respect and confidentiality. It is important to offer a health professional as a chaperone. Translation may be required and it is best to have an official translator as a family member, especially the husband/partner, translating may not divulge or may distort certain information. It is also important to ask about domestic violence when the mother is alone and offer help if appropriate. A carefully obtained history taken in a logical sequence avoids inadvertent omission of important details, and guides the examination to follow.
Current pregnancy Much of this information will be contained in the patient’s ‘hand-held’ notes: • Name. • Age. • Occupation. • Relationship status. • Gravidity (i.e. number of pregnancies, including the current one). • Parity (i.e. number of births beyond 24wks gestation). The expected date of delivery (EDD) can be calculated from the last menstrual period (LMP) using Naegele’s rule (add yr and 7 days to the LMP and subtract 3mths), most often done with an obstetric calendar (‘wheel’). Enquire about details that may affect the validity of the patient’s EDD as calculated from her LMP including: • Long cycles. • Irregular periods. • Recent use of the combined oral contraceptive pill (COCP). 2 Dating scans between 8 and 3wks are more reliable than LMP and should be used to provide an EDD where possible. Enquire about the current pregnancy, including: • General health (tiredness, malaise, and other non-specific symptoms). • If >20wks, enquire about fetal movements (FM). • General details of pregnancy to date (previous admissions and current problems). • Results of all antenatal (AN) blood tests—routine and specific. • Results of anomaly and other scans (details of results can be cross- checked with the notes). • If she is postnatal: • labour and delivery • history of the postnatal period.
Obstetric history: current pregnancy
An obstetric history Should include: • Current pregnancy details. • Past obstetric history. • Past gynaecological history. • Past medical and surgical history. • Drug history and allergies. • Social history, including: • recreational drug use • domestic violence • psychiatric illness especially in the postnatal period. • Family history especially with regard to: • multiple pregnancy • diabetes • hypertension • chromosomal or congenital malformations.
Gravidity and parity explained The terminology used is gravida x, para a+b: • x is the total number of pregnancies (including this one). • a is the number of births beyond 24wks gestation. • b is the number of miscarriages or termination of pregnancies before 24wks gestation. Example A woman who is pregnant for the 4th time with normal delivery at term, termination at 9wks, and miscarriage at 6wks would be gravida 4, para +2.
Obstetric history: other relevant features 2 History often repeats itself, so previous AN, intrapartum, or postpartum complications should influence the management of this pregnancy.
Past obstetric history includes: • Details of all previous pregnancies (including miscarriages and terminations). • Length of gestation. • Date and place of delivery. • Onset of labour (including details of induction of labour). • Mode of delivery. • Sex and birth weight. • Fetal and neonatal life. • Clear details of any complications or adverse outcomes (such as shoulder dystocia, postpartum haemorrhage, or stillbirth).
Past gynaecological/medical/surgical history • • • • •
Method of contraception before conception. Previous gynaecological conditions/procedures. Cervical smear history. Medical conditions, such as hypertension, epilepsy, or diabetes. Details of any consultations with other physicians (neurologist or endocrinologist, psychiatrists). • Involvement of any multidisciplinary teams (MDTs). • Details of any previous surgery.
Drug and allergy history • Current medications. • Medications taken at any time during the pregnancy. • Any allergies and their severity (anaphylaxis or a rash?).
Family history Any history of hereditary illnesses or congenital defects is important and is required to ensure adequate counselling and screening is offered. • Familial disorders such as thrombophilias. • Previously affected pregnancies with any chromosomal or genetic disorders, hypertensive disorders, early pregnancy loss, or preterm delivery. • Consanguinity.
Social history • Smoking. • History of drug or alcohol abuse (E Chapter 3). • Plans for breast-feeding. • Social aspects, such as plans for childcare arrangements. • Domestic violence screening.
Obstetric history: other relevant features
Obstetric physical examination At initial visit, a complete physical examination should be undertaken.
Abdominal examination: inspection • Note the apparent size of the abdominal distension. • Note any asymmetry. • FM. • Cutaneous signs of pregnancy: • linea nigra (dark pigmented line stretching from the xiphisternum through the umbilicus to the suprapubic area) • striae gravidarum (recent stretch marks are purplish in colour) • striae albicans (old stretch marks are silvery-white) • flattening/eversion of umbilicus (due to i intra-abdominal pressure). • Superficial veins (alternative paths of venous drainage due to pressure on the inferior vena cava by a gravid uterus). • Surgical scars (a low Pfannenstiel incision may be obscured by pubic hair, and laparoscopy scars hidden within the umbilicus).
Abdominal examination: palpation • Symphysis fundal height (SFH): • palpated 20wks. • Estimation of number of fetuses: multiple fetal poles. • Fetal lie (relationship of longitudinal axis of fetus to that of the uterus): • longitudinal—fetal head or breech palpable over pelvic inlet • oblique—the head or breech is palpable in the iliac fossa and nothing felt in the lower uterus • transverse—fetal poles felt in flanks and nothing above the brim. • Presentation (part of the fetus overlying the pelvic brim): • cephalic (this could be vertex, face, or brow presentations determined vaginally) • breech • other (shoulder, compound). • Amniotic fluid volume: • i tense abdomen with fetal parts not easily palpated • d compact abdomen with fetal parts easily palpable. Auscultation of the fetal heart The fetal heart (FH) is best heard at the anterior shoulder of the fetus: • A Doppler ultrasound device (Sonicaid) from about 2wks gestation. • A fetal stethoscope (Pinard) from about 24wks gestation. • In a breech presentation it is often heard at, or above, the level of the maternal umbilicus. • Rate and the rhythm of the FH should be determined over min. • The recent National Institute for Health and Care Excellence (NICE) guidelines raise the need for routine fetal heart rate (FHR) auscultation in the presence of FM; but mothers enjoy listening to the FH.
Obstetric physical examination
General examination • Body mass index (BMI) calculated [weight (kg)/height (m)2]. 2 Pregnancy complications are i with a BMI 25. • Blood pressure (BP) measured in the semi-recumbent position (45° tilt). 2 Use an appropriate size cuff; too small a cuff gives a falsely i BP. • Auscultation of the heart and lungs: • flow murmurs are common and are not significant • cardiac murmurs may be detected for the st time. • Thyroid gland (exclude a goitre). • Breasts (exclude any lumps). • Varicose veins and skeletal abnormalities (kyphosis or scoliosis): pregnancy associated with i lumbar lordosis: i lower backache.
Normal uterine size • The uterus normally becomes palpable at 2wks gestation. • It reaches the level of the umbilicus at 20wks gestation. • It is at the xiphisternum at 36wks gestation.
Symphysis fundal height 2 The SFH detects ~40–60% of small for gestational age (SGA) fetuses. Uterine size is measured from the highest point of the fundus to the upper margin of the symphysis pubis (Fig. .). Appropriate growth is usually estimated to be the number of wks gestation in centimetres (at 30wks the SFH should be 30 ± 2cm): • ± 2cm from 20 until 36wks gestation. • ± 3cm between 36 and 40wks. • ± 4cm at 40wks.
40 weeks 36 weeks
22 weeks 16 weeks 12 weeks
Fig. . Typical fundal heights at various stages of pregnancy. Reproduced from Wyatt JP, Illingworth RN, Graham CA, et al. (eds) (2006). Oxford Handbook of Emergency Medicine. Oxford: OUP. By permission of Oxford University Press.
Engagement of the fetal head Conventionally, engagement or the passage of the maximal diameter of the presenting part beyond the pelvic inlet is estimated using the palm width of the five fingers of the hand (Fig. .2). If five fingers are needed to cover the head above the pelvic brim, it is five-fifths palpable, and if no head is palpable, it is zero-fifths palpable. • Normally, the fetus engages in an attitude of flexion in the larger transverse diameter of the pelvic inlet, unless the pelvis is very roomy where it may engage in any diameter (Fig. .3). • In nulliparous women, engagement usually (not in all) occurs beyond 37wks, but in multiparous women it may not occur until the onset of labour. • Rare causes of non-engagement should always be considered and investigated with an ultrasound scan (USS) (including placenta praevia and fetal abnormality). • In women of Afro-Caribbean origin, engagement may only occur at the onset or during the course of labour, even in nulliparous women due to the shape of the pelvic inlet.
Paulik’s grip This is a one-handed technique that uses a cupped right hand to grasp and assess the lower pole of the uterus (usually the fetal head). 2 This can be very uncomfortable and is not necessary if the head can be palpated using two hands.
Engagement • A head that is only two-fifths palpable is usually considered to be engaged (and therefore fixed in the pelvis; see Fig. .2). • Put simply, an easily palpable head is not engaged, whereas a head more difficult to palpate is more likely to be deeply engaged. 2 Care must be taken, as a breech presentation can sometimes be mistaken for a deeply engaged head.
Engagement of the fetal head
Pelvic cavity Completely above
None of head palpable
Sinciput Sinciput Sinciput Sinciput felt easily felt high felt Occiput Occiput Occiput Occiput not felt felt easily felt just felt
Fig. .2 Clinical estimation of descent of the fetal head and engagement. Occipitoposterior (OP)
Mother’s right side
Mother’s left side
Left occipitotransverse (ROT)
Right occipitotransverse (ROT)
LOA Occipitoanterior (OA) Front
Fig. .3 Fetal position. Reproduced from Collier J, Longmore M, et al. (2008). Oxford Handbook of Clinical Specialties, 8th edn. Oxford: OUP. By permission of Oxford University Press.
Female pelvis The bony ring of the pelvis is made up of two symmetrical innominate bones and the sacrum. Each innominate bone is made up of the ilium, ischium, and the pubis, which are joined anteriorly at the symphysis pubis and posteriorly to the sacrum at the sacroiliac joints. The female pelvis has evolved for giving birth, and differs from the male pelvis in the following ways: • The female pelvis is broader, and the bones more slender than those of the male. • The male pelvic brim is heart-shaped and widest towards the back, whereas the female pelvic brim is oval-shaped transversely and widest further forwards; the sacral promontory is less prominent. • The female pelvic cavity is more spacious and has a wider outlet than the male pelvis. • The subpubic angle is rounded in a female pelvis (like a Roman arch) and more acute in the male pelvis (like a Gothic arch).
Pelvic muscles and ligaments The pelvis gains its strength and stability through numerous muscles and ligaments. The inner aspect of the pelvic bones is covered by muscles. Above the pelvic brim are the iliacus and psoas muscles; the obturator internus and its fascia occupies the side walls; the posterior wall is covered by the pyriformis; and the levator ani and coccygeus, with their opposite counterparts, constitute the pelvic floor. Pelvic ring stability is provided by the following ligaments: • Sacrospinous ligament: extending from the lateral margin of the sacrum and coccyx to the ischial spine. • Sacrotuberous ligament: extending from the sacrum to the ischial tuberosity. • Iliolumbar ligament: extending from the lumbar spine to the iliac crest at the back of the pelvis. • Dorsal sacroiliac ligament: a heavy band passing from the ilium to the sacrum posterior to the sacroiliac joint. • Ventral sacroiliac ligament: bridging the sacroiliac joint anteriorly, and is an important stabilizing structure of the joint. • Inferior and superior pubic ligament: a band across the lower and upper part of the symphysis respectively, providing further strength to the joint. • Inguinal ligament: running from the anterior superior iliac spine of the ilium to the pubic tubercle of the pubic bone. • The remaining ligaments that surround the pelvis are ligaments that do not provide stabilization of the pelvis.
Pelvic boundaries The pelvis is divided by an oblique plane passing through the prominence of the sacrum, the arcuate and pectineal lines, and the upper margin of the symphysis pubis, into the greater and the lesser pelvis. The circumference of this plane is termed the pelvic brim. This pelvic brim separates the false pelvis above from the true pelvis below. The plane of the pelvis is at an angle of 55° to the horizontal.
Pelvic shapes There are four basic shapes of the female pelvis, as illustrated in Fig. .4. • Gynaecoid: the classical female pelvis with the inlet transversely oval and a roomier pelvic cavity. • Anthropoid: a long, narrow, and oval-shaped pelvis due to the assimilation of the sacral body to the fifth lumbar vertebra. • Android: the inlet is heart-shaped and the cavity is funnel-shaped with a contracted outlet. • Platypelloid: a wide pelvis flattened at the brim with the sacral promontory pushed forward.
Fig. .4 Basic shapes of the female pelvis. Reproduced from Abitbol M, Chervenak F, Ledger WJ. (996). Birth and human evolution: anatomical and obstetrical mechanics in primates. New York: Bergin & Garvey.
Diameters of the female pelvis The female bony pelvis is not distensible, and only very minor degrees of movement are possible at the symphysis pubis and the sacroiliac joints. Its dimensions are, hence, critical for normal childbirth. 2 The diameters of the female pelvis vary at different parts: • The true pelvis is bound anteriorly by the symphysis pubis (3.5cm long) and posteriorly by the sacrum (2cm long). • The superior circumference of the true pelvis is the pelvic inlet and the inferior circumference is the outlet (Fig. .5). • The true pelvis has four planes.
Plane of pelvic inlet • This is bound anteriorly by the upper border of the pubis, laterally by the iliopectineal line, and posteriorly by the sacral promontory. • The average transverse diameter is 3.5cm and the average anteroposterior diameter is cm (obstetric conjugate diameter) (transversely oblong). • It is not possible to measure these diameters clinically, and the only diameter at the pelvic inlet amenable to clinical assessment is the distance from the inferior margin of the pubic symphysis to the midpoint of the sacral promontory (the diagonal conjugate), which is ~.5cm greater than the obstetric conjugate diameter.
Plane of greatest pelvic dimensions/cavity • This is the roomiest part of the pelvis and has little clinical significance. • It is almost round in shape with an average transverse diameter of 3.5cm and an average anteroposterior diameter of 2.5cm.
Plane of least pelvic dimensions/mid-pelvis (circular in shape) • This is bound anteriorly by the apex of the pubic arch, laterally by the ischial spines, and posteriorly by the tip of the sacrum. • The interspinous diameter is the narrowest space in the pelvis (0cm) and represents the level at which impaction of the fetal head is most likely to occur.
Plane of pelvic outlet • This is bound anteriorly by the pubic arch, which should have a desired angle of >90°, posterolaterally by the sacrotuberous ligaments and ischial tuberosities, leading to the coccyx posteriorly (anteroposteriorly oblong). • The average intertuberous diameter is cm.
Diameters of the female pelvis
Assessment of ‘pelvic adequacy’ Examination of the pelvis before labour does not accurately discriminate between those who will achieve vaginal birth and those who will not. Even computed tomography (CT) or magnetic resonance imaging (MRI) scanning, together with USS of the fetal head, is not helpful, unless there is a gross abnormality, which will be evident from the history or gait. This is because of the dynamic nature of labour, when the head ‘moulds’ (d the head circumference by a few centimetres) and the joints of the pelvis can move, i the pelvic dimensions slightly. The ideal female pelvis has the following features: • Oval brim. • Shallow cavity. • Non-prominent ischial spines. • Curved sacrum with large sciatic notches (>90°). • Sacrospinous ligament >3.5cm long. • Rounded subpubic arch (>90°). • Intertuberous distance of at least 0cm. • Diagonal conjugate diameter of at least 2cm.
Fig. .5 Median sagittal section of the female pelvis showing the pelvic inlet and outlet. Reproduced from Collier J, Longmore M, et al. (2008). Oxford Handbook of Clinical Specialties, 8th edn. Oxford: OUP. By permission of Oxford University Press.
Fetal head Anatomy of the fetal skull The fetal cranium is made up of five main bones, two parietal bones, two frontal bones, and the occipital bone. These are held together by membranous areas called sutures, which permit movement during birth (Fig. .6). • Coronal suture: separates the frontal bones from the parietal bones. • Sagittal suture: separates the two parietal bones. • Lambdoid suture: separates the occipital bone from the parietal bones. • Frontal suture: separates the two frontal bones. 2 When two or more sutures meet, there is an irregular membranous area between them called a fontanelle (Fig. .6): • Anterior fontanelle or bregma: is a diamond-shaped space at the junction of the coronal and sagittal sutures; this measures about 3cm in anteroposterior and transverse diameters, and usually ossifies at ~8mths after birth. • Posterior fontanelle or lambda: is a smaller triangular area that lies at the junction of the sagittal and lambdoid sutures. 2 The positions of the sutures and fontanelles play a very important role in identifying the position of the fetal head in labour.
Regions of the fetal head The fetal head has different regions assigned to help in the description of the presenting part felt during vaginal examination in labour. • Occiput: the bony prominence that lies behind the posterior fontanelle. • Vertex: the diamond-shaped area between the anterior and posterior fontanelles, and between the parietal eminences. • Bregma: the area around the anterior fontanelle. • Sinciput: the area in front of the anterior fontanelle, which is divided into the brow (between the bregma and the root of the nose) and the face (lying below the root of the nose and the supraorbital ridges).
Caput and moulding of the fetal head During labour, the dilating cervix may press firmly on the fetal scalp preventing venous blood and lymphatic fluid from flowing normally. This may result in a tissue swelling beneath the skin called caput succedaneum. It is soft and boggy to touch and usually disappears within 24h of birth. There is usually some alteration in the shape of the fetal head and a d in the head circumference in labour by a process of overlapping of the cranial bones (a d of up to 4cm is possible). This moulding is physiological and disappears a few hours after birth. The frontal bones can slip under the parietal bones and, in addition, one parietal bone can override the other and in turn slip under the occipital bone. The degree of moulding can be assessed vaginally: • No moulding: when the suture lines are separate. • + moulding: when the suture lines meet. • 2+ moulding: when the bones overlap but can be d with gentle digital pressure. • 3+ moulding: when the bones overlap and are irreducible with gentle digital pressure. 2 The presence of caput and moulding can play an important part in diagnosing obstructed labour. Posterior fontanelle ( λ)
Biparietal diameter 9.5cm Sagittal suture Anterior fontanelle (bregma) Fig. .6 Fontanelles, sagittal suture, and biparietal diameter. Reproduced from Collier J, Longmore M, et al. (2008). Oxford Handbook of Clinical Specialties, 8th edn. Oxford: OUP. By permission of Oxford University Press.
Diameters and presenting parts of the fetal head The region that presents in labour depends on the degree of flexion or deflexion of the fetal head on presentation to the maternal pelvis. The important diameters of the fetal head as well as the presenting parts are as described below (Fig. .7): • Suboccipitobregmatic diameter (9.5cm): • presentation of a well-flexed vertex • diameter extends from the middle of the bregma to the undersurface of the occipital bone where it joins the neck • fetal head circumference is smallest at this plane and measures 32cm. • Suboccipitofrontal diameter (0.5cm): • partially flexed vertex, with diameter extending from the prominent point of the mid-frontal bone to the undersurface of occipital bone where it joins the neck. • Occipitofrontal diameter (.5cm): • presentation of a deflexed head • diameter extends from the prominent point of the mid-frontal bone to the most prominent point on the occipital bone • fetal head circumference at this plane measures 34.5cm. • Mentovertical diameter (3cm): • brow presentation, with the diameter extending from the chin to the most prominent point of the mid-vertex • presents with the largest anteroposterior diameter. • Submentobregmatic diameter (9.5cm): • face presentation, with diameter extending from just behind chin to the middle of the bregma. 2 Other noteworthy diameters of the fetal head include: • Biparietal diameter (BPD, 9.5cm): • greatest transverse diameter of the head, extending from one parietal eminence to the other. • Bitemporal diameter (8cm): • greatest distance between two temporal eminences. • Bimastoid diameter (7.5cm): • distance between the tips of the two mastoid processes. E Malpresentations in labour: overview, p. 35.
Diameters and presenting parts of the fetal head
5 1 Suboccipitobregmatic 9.5cm flexed vertex presentation 2 Suboccipitofrontal 10.5cm partially deflexed vertex 3 Occipipitofrontal 11.5cm deflexed vertex 4 Mentovertical 13cm brow 5 Submentobregmatic 9.5cm face Fig. .7 Different presenting diameters of the fetal head. Reproduced from Collier J, Longmore M, Turmezei T, et al. (2008). Oxford Handbook of Clinical Specialties, 8th edn. Oxford: OUP. By permission of Oxford University Press.
Useful definitions when discussing the presenting part • Presentation is the lowermost part of the fetus presenting to the pelvis. In >95% of cases the vertex is the presenting part and is called normal presentation. Any other presentation (e.g. face, brow, breech, and shoulder) is called malpresentation. • Denominator is the most definable peripheral landmark of the presenting part, i.e. occiput for the vertex, mentum for the face, and sacrum for the breech presentation. • Position of the presenting part is the relationship of the denominator to the fixed points of the maternal pelvis, i.e. sacrum posteriorly, pubic symphysis anteriorly, sacro-iliac joints posterolaterally, and ileo- pectineal eminences anterolaterally. • Station is the relationship of the most prominent leading part of the presenting part to the ischial spines expressed as ±,2,3cm. 2 In the vertex presentation, >90% present in the occipito-anterior position, i.e. the occiput is in the anterior half of the pelvis and is called the normal position. If the occiput is pointing laterally or is in the posterior half of the pelvis, it is called malposition and is associated with deflexed head presenting a larger anteroposterior diameter of the vertex (.5cm) and, hence, difficulties with progress of labour (E Fig. .3).
Placenta: early development The placenta is the organ responsible for providing endocrine secretions and selective transfer of substances to and from the fetus. It serves as an interface between the mother and developing fetus. Understanding the development of the placenta is important, as it is the placental trophoblasts that are critical for a successful pregnancy.
Embryological development • After fertilization, the zygote enters the uterus in 3–5 days and continues to divide to become the blastocyst. • Implantation of the blastocyst starts on day 7 and is finished by day : • the inner cell mass of the blastocyst forms the embryo, yolk sac, and amniotic cavity • the trophoblast forms the future placenta, chorion, and extraembryonic mesoderm. • When the blastocyst embeds into the decidua, trophoblastic cells differentiate and the embryo becomes surrounded by two layers of trophoblasts: • the inner mononuclear cytotrophoblast • the outer multinucleated syncytiotrophoblast. • The invading trophoblast penetrates endometrial blood vessels forming inter-trophoblastic maternal blood-filled sinuses (lacunar spaces). • Trophoblastic cells advance as early or primitive villi, each consisting of cytotrophoblast surrounded by the syncytium. • These villi mature into 2° and 3° villi, and the mesodermal core develops to form fetal blood vessels (completed by day 2). • On days 6–7, the surface of the blastocyst is covered by branching villi which are best developed at the embryonic pole: the chorion here is known as chorionic frondosum; the future placenta develops from this area. • Simultaneously, the lacunar spaces become confluent with one another and, by wks 3–4, form a multilocular receptacle lined by syncytium and filled with maternal blood: this becomes the future intervillous space. • With further growth of the embryo, the decidua capsularis becomes thinner, and both villi and the lacunar spaces in the decidua are obliterated, converting the chorion into chorionic levae. • The villi in the chorionic frondosum show exuberant division and subdivision, and with the accompanying proliferation of the decidua basalis, the future placenta is formed. • This process starts at 6wks and the definitive numbers of stem villi are established by 2wks.
Placenta: later development
Placenta: later development • Placental growth continues to term. • Until wk 6, the placenta grows both in thickness and circumference due to growth of the chorionic villi with accompanying expansion of the intervillous space. • After 6wks, growth occurs mainly circumferentially.
Placental villi • Functional units of the placenta. • There are ~60 stem villi in human placenta with each cotyledon containing 3–4 major stem villi. • Despite their close proximity (0.025mm), there is no mixing of maternal and fetal blood. • Placental barrier is made of outer syncytiotrophoblast, which is in direct contact with maternal blood, the cytotrophoblast layer, basement membrane, stroma containing mesenchymal cells, and the endothelium and basement membrane of fetal blood vessels.
The placenta at term • Circular, diameter 5–20cm, thickness ~2.5cm at the centre. • Weight ~500g (ratio of fetal:placental weight at term is about 6:). • Occupies ~30% of the uterine wall at term and has two surfaces. Fetal surface • Covered by a smooth, glistening amnion with the umbilical cord usually attached at or near its centre. • Branches of the umbilical blood vessels are visible beneath amnion as they radiate from the insertion of the cord. • Amnion can be peeled off from underlying chorion, except at insertion of cord. Maternal surface • Rough and spongy appearance, divided into several velvety bumps called cotyledons (5–20) by septa arising from the maternal tissues. • Each cotyledon may be supplied by its own spiral artery. • Numerous small greyish spots may be visible on the maternal surface representing calcium deposition in degenerated areas. Umbilical cord • Vascular cable that connects the fetus to the placenta. • Varies from 30 to 90cm long, covered by amniotic epithelium. • Contains two umbilical arteries and one umbilical vein embedded into the Wharton’s jelly. • Arteries carry deoxygenated blood from fetus to placenta and the oxygenated blood returns to fetus via the umbilical vein. • In a full-term fetus, blood flow in the cord is ~350mL/min.
Placenta: circulation The placental circulation consists of two distinctly different systems—the uteroplacental circulation and the fetoplacental circulation.
Uteroplacental circulation • Uteroplacental circulation is the maternal blood circulating through the intervillous space (Table .). • Intervillous blood flow at term is estimated to be 500–600mL/min, and blood in the intervillous space is replaced 3–4 times/min. • Pressure and concentration gradients between fetal capillaries and intervillous space favours placental transfer of oxygen and other nutrients to the fetus. Arterial system • Spiral arteries respond to the i demand of blood supply to the placental bed by becoming low-pressure, high-flow vessels. • They become tortuous, dilated, and less elastic by trophoblastic invasion, which starts early in pregnancy and occurs in two stages: • in st trimester, the decidual segments of the spiral arterioles are structurally modified • in 2nd trimester, 2nd wave of trophoblastic invasion occurs, resulting in invasion of myometrial segments of spiral arteries. 2 Failure of this physiological change, particularly 2nd wave of trophoblastic invasion, is implicated in development of pre-eclampsia and fetal growth restriction. Venous system • Blood entering the intervillous space from the spiral artery becomes dispersed to reach the chorionic plate and gradually the basal plate, being facilitated by mild movements of villi and uterine contractions. • From basal plate, uterine veins drain the deoxygenated blood. • Venous drainage only occurs during uterine relaxation. • Spiral arteries are perpendicular and veins are parallel to uterine wall, making large volumes of blood available for exchange at the intervillous space even though the rate of flow is d during contraction, i.e. the veins are blocked for a longer time to allow pooling of blood in the retroplacental area.
Fetoplacental circulation (See Table .2.) • Two umbilical arteries carry deoxygenated blood from the fetus and enter the chorionic plate underneath the amnion. • Arteries divide into small branches and enter the stem of the chorionic villi, where further division to arterioles and capillaries occurs. • The blood then flows to the corresponding venous channel and subsequently to the umbilical vein. • Maternal and fetal bloodstreams flow side by side, in opposite directions, facilitating exchange between mother and fetus.
Placenta: circulation Table . Haemodynamics of uteroplacental circulation Volume of blood in the intervillous space
Blood flow in the intervillous space
Pressure changes in the intervillous space Height of uterine contraction
Pressure in the spiral artery
Pressure in the uterine veins
Table .2 Haemodynamics of fetoplacental circulation Fetal blood flow through placenta
Pressure In the umbilical artery
In the umbilical vein
Oxygen saturation and partial pressure of oxygen In the umbilical artery
In the umbilical vein
Placenta: essential functions The placenta is directly responsible for mediating and/or modulating the maternal environment necessary for normal fetal development.
The placenta as an endocrine organ As an active endocrine organ, the placenta produces a number of hormones, growth factors, and cytokines. The production of human chorionic gonadotropin (hCG), oestrogens, and progesterone by the placenta is vital for the maintenance of pregnancy. Human chorionic gonadotropin • ° produced by syncytiotrophoblasts. • Detected from 6 days after fertilization: • forms basis of modern pregnancy testing. • Concentrations reach a peak at 0–2wks gestation, then plateau for remainder of the pregnancy.
The placenta as a barrier The placenta acts as a barrier for the fetus against pathogens and the maternal immune system. Infection The placenta forms an effective barrier against most maternal blood-borne bacterial infections. However, some important organisms, such as syphilis, parvovirus, hepatitis B and C, rubella, Zika, human immunodeficiency virus (HIV), and cytomegalovirus (CMV), can cross it and infect the fetus during pregnancy. Although rare, there are cases of coronavirus transmission via the placenta as shown by placental inflammation and neonatal viraemia. Drugs Many drugs administered to the mother will pass across the placenta into the fetus; exceptions include low-molecular-weight heparin (LMWH). Some drugs may have little effect on the fetus and be considered ‘safe’ (e.g. paracetamol), but others (e.g. warfarin) may significantly affect development, structure, and function of the fetus—a process known as teratogenesis. Recently, a hormonal pregnancy testing drug, Primodos, used decades ago, has been incriminated in the causation of terminal limb reduction malformation. This is similar to thalidomide which was prescribed for vomiting in early pregnancy and caused phocomelia. Neither drug is used in pregnancy today. Before prescribing any drug to a pregnant woman, it is the prescriber’s obligation to ensure its benefit outweighs any risks to the pregnancy. (E Common drugs: safety and usage, inside front and back covers.)
Placenta: essential functions
Principal functions of the placenta • To anchor the fetus and establish the fetoplacental unit. • To act as an organ for gaseous exchange. • Endocrine organ to bring the needed changes in pregnancy. • Transfer of substances to and from the fetus. • Barrier against infection.
Placental transfer Although the placenta acts as a barrier to most substances, it allows exchange of gases, transfer of fetal nutrition, and removal of waste products in a highly effective manner. Speed of exchange and concentration of substance exchanged depend upon: • Concentration of the substance on each side of the placenta. • Molecular size. • Lipid solubility. • Ionization. • Placental surface area. • Maternofetal blood flow. A low-molecular-weight lipid-soluble substance with a high concentration gradient across the placenta, for example, will be transferred quickly to the fetus. Actual transfer occurs by simple diffusion, facilitated diffusion, active transport, and/or endocytosis (Table .3). Table .3 Transfer mechanisms across the placenta for common anabolites and catabolites Substance
Direction of transfer
Simple and facilitated diffusion
To and from fetus
To and from fetus
Urea and creatinine
Physiology of pregnancy: endocrine Physiological and anatomical changes occur during the course of pregnancy to provide a suitable environment for the growth and development of the fetus. Early changes are due, in part, to metabolic demands brought on by the fetus, placenta, and uterus, and, in part, to i levels of pregnancy hormones, particularly those of progesterone and oestrogen. Later changes are more anatomical in nature and are caused by mechanical pressure from the expanding uterus.
Endocrine changes Progesterone i throughout pregnancy • Synthesized by the corpus luteum until 35 days and by the placenta thereafter. • Progesterone promotes smooth muscle relaxation (gut, ureters, uterus) and raises body temperature. • It is the principal hormone that prevents preterm labour and is now i administered to prevent preterm labour. Oestrogens—mainly oestradiol (90%) • i Breast and nipple growth, and pigmentation of the areola. • Promote uterine blood flow, myometrial growth, cervical softening. • i Sensitivity and expression of myometrial oxytocin receptors. • i Water retention and protein synthesis. Human placental lactogen (hPL) • Has a structure and function similar to growth hormone. • Modifies maternal metabolism to i the energy supply to the fetus. • i Insulin secretion, but d insulin’s peripheral effect (liberating maternal fatty acids and sparing glucose enabling it to be diverted to the fetus).
The pituitary gland in pregnancy • Enlarges mainly due to changes in the anterior lobe. • Prolactin levels i substantially, probably due to oestrogen stimulation of the lactotrophs. • Gonadotropin secretion is inhibited, while plasma adrenocorticotropic hormone (ACTH) levels i. • Maternal plasma cortisone output i, but the unbound levels remain constant. • The posterior pituitary releases oxytocin principally during the st stage of labour and during suckling.
Physiology of pregnancy: endocrine
Effect of pregnancy on the thyroid • The maternal thyroid gland enlarges due to i demand in pregnancy. • i Renal clearance of iodine results in a relative iodide deficiency. • The thyroid responds by tripling its iodide uptake from the blood, which results in follicular enlargement. • Thyroid-binding globulin (TBG) is doubled by the end of the st trimester due to high oestrogen levels. • As a result, total T3 (triiodothyronine) and T4 (thyroxine) levels rise early in pregnancy, then d to remain within normal non- pregnant range. • Thyroid-stimulating hormone (TSH) may d slightly in early pregnancy, but tends to remain within the normal range. • T3 and T4 cross the placental barrier in very small amounts. 2 Iodine, antithyroid drugs, and long-acting thyroid stimulator (LATS) or antibodies associated with Graves’ disease can cross the placenta and affect the fetal thyroid function, which starts as early as 2wks.
Physiology of pregnancy: haemodynamics Plasma volume • i By 0–5% at 6–2wks of gestation. • Expands rapidly until 30–34wks. • Total gain at term ~00–600mL (total plasma volume of 4700– 5200mL, a 30–50% i from the non-pregnant state). • Acute excessive weight gain is commonly due to oedema.
Red cell volume (or red cell mass) • i From 400 to 640mL at term (i 8%). • With iron and folate supplements, an i of 30% has been reported. 2 The discrepancy between the rate of i of plasma volume and that of red cell mass results in a relative haemodilution or ‘physiological anaemia’ with the haemoglobin (Hb) concentration, haematocrit, and red cell counts all d (particularly in the 2nd trimester). 2 Mean corpuscular Hb concentration remains constant.
Total white cell count • i Mainly due to the i in neutrophil polymorphonuclear leucocytes, which peaks at 32wks. • A further massive neutrophilia occurs during labour. • Eosinophils, basophils, and monocytes remain relatively constant, but there is a profound d in eosinophils during labour, being virtually absent at delivery. • Although lymphocyte count and the number of B and T cells remain constant, lymphocyte function and cell-mediated immunity are profoundly depressed, giving rise to lowered resistance to viral infections.
Platelets • d Slightly during pregnancy. • Platelet function is unchanged.
Clotting factors • Pregnancy is a hypercoagulable state. • Most clotting factors i, especially fibrinogen. 2 Erythrocyte sedimentation rate (ESR) levels can also be elevated up to 4-fold in pregnancy.
PHYSIOLOGY OF PREGNANCY: CARDIORESPIRATORY
Physiology of pregnancy: cardiorespiratory Cardiovascular changes Major changes occur in the cardiovascular system in pregnancy; the most significant of these changes occur within the st 2wks. • Cardiac output i from 5 to 6.5L/min by i stroke volume (0%) and pulse rate (~5 beats/min). • During labour, contractions may i cardiac output by 2L/min, probably due to injection of blood from the intervillous space. • With progressive enlargement of the uterus, the heart and diaphragm are displaced upwards. • The heart enlarges and i in volume by 70–80mL due to i diastolic filling and muscle hypertrophy. 2 Pregnancy may proceed normally even when the mother has an artificial cardiac pacemaker, with compensation occurring mainly from i stroke volume.
Blood pressure in pregnancy • Peripheral resistance d by nearly 50% (probably due to the i production of vasodilator prostaglandins). • BP (most noticeably diastolic) d mid-pregnancy by 0–20mmHg and i to non-pregnant levels by term. • Profound d can occur late in pregnancy when lying supine, due to compression of the inferior vena cava leading to d venous return and d cardiac output (supine hypotension syndrome). • Aortic compression may also occur causing a difference between brachial and femoral pressures giving a pressure difference of 0–5% from the supine to the lateral position. • The balance of vasoconstrictor and vasodilator factors regulating peripheral resistance may be the basis of BP regulation in pregnancy and implicated in pregnancy-induced hypertension. • Vasodilatation and hypotension also stimulate renin–angiotensin release, which plays a part in BP regulation.
Respiratory system changes • The level of the diaphragm rises in pregnancy and the intercostal angle i from 68° in early pregnancy to 03° in late pregnancy: breathing becomes more diaphragmatic than costal. • Tidal volume i ~40% (500–700mL) due to effect of progesterone. • Inspiratory capacity (tidal volume plus inspiratory reserve volume) i progressively in late pregnancy. • Respiratory rate changes slightly, hence the resting pregnant woman i ventilation by breathing more deeply and not more frequently. • Breathlessness is common in pregnancy as maternal partial pressure of carbon dioxide (pCO2) is set lower to allow the fetus to offload CO2.
Physiology of pregnancy: genital tract and breast Uterus • Undergoes a 0-fold i in weight to 000g at term. • Muscle hypertrophy occurs up to 20wks, after which stretching of the muscle fibres occurs. • Uterine blood flow has been shown to i from ~50mL/min at 0wks to 500–700mL/min at term. • The uterine and ovarian arteries and branches of the superior vesical arteries undergo massive hypertrophy. • The uterus is divided functionally and morphologically into three sections: • Cervix. • Isthmus (which later develops into the lower segment). • Body of the uterus (corpus uteri). Cervix • d In cervical collagen towards term enables its dilatation. • Hypertrophy of cervical glands leads to the production of profuse cervical mucus, and the formation of a thick mucus plug or operculum that acts as a barrier to infection. • Vaginal discharge i due to cervical ectopy (proliferation of columnar epithelium into vaginal portion of the cervix) and cell desquamation. Uterine body • i In size, shape, position, and consistency. • Uterine cavity expands from 4 to 4000mL.
Vagina • A rich venous vascular network in connective tissue surrounds vaginal walls with blood and gives rise to slightly bluish appearance. • High oestrogen levels stimulate glycogen synthesis and deposition: • action of lactobacilli on glycogen in vaginal cells produces lactic acid • lactic acid lowers the vaginal pH to keep the vagina relatively free from any bacterial pathogens.
Physiology of pregnancy: genital tract and breast
Breast changes in pregnancy • The lactiferous ducts and alveoli develop and grow under the stimulus of oestrogen, progesterone, and prolactin. • From 3–4mths of pregnancy, colostrum (thick, glossy, protein-rich fluid) can be expressed from the breast. • Prolactin stimulates the cells of the alveoli to secrete milk: • effect is blocked during pregnancy by the peripheral action of oestrogen and progesterone • shortly after delivery the sudden d in these hormones enables prolactin to act uninhibited on the breast, and lactation begins. • Suckling further stimulates prolactin and oxytocin release: • oxytocin stimulates contraction of the myoepithelial cells to cause ejection of milk.
Physiology of pregnancy: other changes Urinary tract Various anatomical and physiological changes occur in pregnancy: • Kidney size i by about cm in length. • Marked dilatation of the calyces, renal pelvis, and ureter from st trimester. • Vesicoureteric reflux occurs sporadically: a combination of reflux and ureteric dilatation leads to urinary stasis and i incidence of infection. • Although bladder muscle relaxes in pregnancy, residual urine is not normally present after micturition. • Uric acid clearance i from 2 to 20mmol/mL, causing d in plasma uric acid levels: as pregnancy progresses, the filtered load of uric acid i, while the excretion remains constant, resulting in plasma levels returning to non-pregnant values. • Renal blood flow i by 30–50% in the st trimester, in line with the i in cardiac output that occurs, and remains elevated: • results in i glomerular filtration rate (GFR) and effective renal plasma flow, causing a d in plasma levels of urea and creatinine • plays an important role in the variable glycosuria (due to exceeding the tubular maximum of absorption caused by more volume filtered) and urinary frequency that occurs in pregnancy. H Creatinine within the normal range for non-pregnant women may indicate renal impairment in pregnancy.
Alimentary system • d Tone of oesophageal sphincter and displacement through the diaphragm due to i abdominal pressure causes reflux oesophagitis (heartburn). • Gastric mobility is low and gastric secretion is d, resulting in delayed gastric emptying. • Gut motility is generally d, and with possible i sodium and water absorption in the large bowel, there is a tendency to constipation.
Skin • Pigmentation in linear nigra, nipple, and areola or chloasma (brown patches of pigmentation seen especially on the face). • Palmar erythema and spider naevi are also common. • Incidence of striae varies in different populations: • represents the effect of disruption of collagen fibres in the subcuticular zone • probably related to the effect of i production of adrenocortical hormones, as well as to the actual stress in the skin associated with relatively rapid expansion of the abdomen.
Preparing for pregnancy
Preparing for pregnancy A woman’s body undergoes significant changes in pregnancy, with the developing fetus making i demands. Preparation for pregnancy should begin before conception, as fetal development begins from the 3rd wk after the LMP. Damaging effects (e.g. exposure to drugs) may occur before the woman is even aware she is pregnant. Being as fit and healthy as possible before conception maximizes chances of a healthy pregnancy, but not all poor obstetric outcomes can be avoided. Pre-pregnancy counselling by a specialist team is recommended where specific risks and diseases are identified.
Specific risks for older mothers • Advanced maternal age is a risk factor for adverse outcome. • A woman >35yrs old has a d chance of conceiving: • this rate of decline drops very quickly by 40yrs. • Age also carries an i risk of chromosomal abnormalities in the baby (most common abnormality being trisomy 2). • Older mothers are more likely to develop complications in pregnancy, e.g. pre-eclampsia and diabetes mellitus.
Exercise and stress • Moderate exercise should be encouraged, as it improves a woman’s cardiovascular and muscular fitness. • Women should be reassured that beginning or continuing a moderate course of exercise during pregnancy is not associated with adverse outcome. • Best exercises are low-impact aerobics, swimming, brisk walking, and jogging. • Contact and high-impact and vigorous racquet sports that may involve the risk of abdominal trauma should be avoided. • Exercise is also associated with higher self-esteem and confidence. • Relaxation and avoiding stress should be encouraged when planning for pregnancy. H Scuba diving may result in fetal birth defects and fetal decompression disease and, therefore, is not recommended.
Stopping contraception • There is no delay in return to fertility after stopping the pill or having the coil removed. • Women using contraceptive injection may experience a delay of several months. • It is often recommended that women wait 3mths after stopping the pill before trying to conceive.
Supplements and lifestyle advice Supplements Folic acid Only vitamin supplement that is recommended for use before pregnancy and up to 2wks gestation for women who are otherwise eating a healthy balanced diet. Iron • Routine supplementation is not necessary and should be only prescribed when medically indicated: • may be considered routine in areas where incidence of iron- deficiency anaemia is high. • The amount of elemental iron in an adult female is 5g: • she will need mg/day before menstrual age • 2mg/day during reproductive age • 3mg/day during pregnancy. Calcium Supplementation may be necessary if intake of calcium is low; however, the ideal is i calcium by dietary intake. Iodine Deficiency is endemic in some parts of the world, and can cause cretinism and neonatal hypothyroidism. Supplementation with iodized salt or oil should be considered. Zinc Low serum levels have been associated with an i risk of preterm labour and growth restriction, but i intake from dietary sources, such as milk and dairy products, should be sufficient. Vitamin A H Vitamin A supplementation (intake >700 micrograms/day) might be teratogenic and should be avoided, as should consumption of products high in vitamin A, such as liver and pâté.
Alcohol, smoking, and recreational drugs Excessive alcohol intake has been conclusively shown to cause fetal malformations. The exact threshold of alcohol that will cause malformation in the fetus has not been established. H Avoid alcohol or limit consumption to 30) or underweight (BMI 25IU/L • can confirm pregnancy within wk of a missed period.
Dating of pregnancy
Dating of pregnancy Menstrual history • The st day of the LMP may be used to calculate the gestational age and the EDD (E Obstetric history: current pregnancy, p. 2), but this may be inaccurate as: • many women may not be certain of their LMP • ovulation does not always occur on day 4 and the proliferative phase may vary in shorter or longer menstrual cycles. • The EDD can be calculated using Naegele’s formula (E Obstetric history: current pregnancy, p. 2). • About 40% of women will deliver within 5 days of the EDD and about 2/3 within 0 days. H –42% of gestational age estimates from LMP may be inaccurate. 2 Pregnancies resulting from in vitro fertilization (IVF) can be dated using the day of embryo transfer.
Dating ultrasound scan • Between 8 and 3wks USS provides the most accurate measure of gestational age and, where possible, should be used to calculate EDD. • Before 8wks it is unreliable due to the small size of the gestation sac and fetal pole. • After 3wks other factors may affect fetal growth; therefore, although an estimate can be made using BPD and femur length (FL), it may be unreliable.
Crown–rump length Crown–rump length (CRL; Fig. .8) is used to calculate gestation between 8 and 3wks. It is measured from one fetal pole to the other along its longitudinal axis in a straight line.
Fig. .8 Ultrasound image of a 2wk fetus measuring the CRL.
Ultrasound assessment of fetal growth Any clinical suspicion that the fetus may be small or large for gestational age should be followed by a formal ultrasound assessment of fetal growth and amount of amniotic fluid (liquor volume). The measurements used are given in Fig. .9:
Biparietal diameter and head circumference • The anatomical landmarks used to ensure the accuracy and reproducibility of the measurement are a midline falx, the thalami symmetrically positioned on either side of the falx, the visualization of the cavum septum pellucidum at /3 the fronto-occipital distance, and the lateral ventricles with their anterior and posterior horns identifiable. • The calipers are placed between the leading edge of the proximal and distal skull bones (BPD) and circumferentially around the head (HC).
Abdominal circumference • The abdominal circumference (AC) is the single most important measurement in assessing fetal size and growth. • It is measured where the image of the stomach and the portal vein is visualized in a tangential section.
Femur length By convention, measurement of the FL is considered accurate only when the image shows two blunted ends. H FL can be underestimated if the correct plane is not obtained. E Fetal growth restriction: definitions, p. 44.
Uterus measurement anomalies The uterus may measure small for dates because of: • Wrong dates. • Oligohydramnios. • Fetal growth restriction. • Presenting part deep in the pelvis. • Abnormal lie of the fetus. The uterus may measure large for dates because of: • Wrong dates. • Macrosomia. • Polyhydramnios. • Multiple pregnancy. • Presence of fibroids.
Ultrasound assessment of fetal growth
Fig. .9 Ultrasound measurement of biparietal diameter (top), abdominal circumference (middle), and femur length (bottom).
Booking visit The needs of each pregnant woman should be assessed at the st appointment and a plan of care made for her pregnancy. This should be reassessed at each appointment as new problems can arise at any time. Many women in the UK have ‘shared obstetric care’ whereby the woman’s GP and community midwife undertake most of the obstetric care, with a limited number of visits to the hospital. Routine involvement of an obstetrician in the care of an uncomplicated pregnancy does not appear to improve perinatal outcomes compared with involving obstetricians when complications arise. There should be continuity of care throughout the AN period and this should be provided by a small group of carers with whom the woman feels comfortable. The environment in which AN appointments take place should enable women to discuss sensitive issues, such as domestic violence, sexual abuse, psychiatric illness, and illicit drug use. Women should be given the information needed to choose between giving birth at home, in a midwifery-led unit, or in hospital. Booking should ideally be early in pregnancy (before 2wks) in order to take full advantage of AN care. However, many women are seen for the st time in the 2nd trimester. H Children born to very late bookers or unbooked women have a higher risk of perinatal mortality (4–5×) and morbidity, with an attendant i in maternal morbidity and mortality.
Booking visit: history A comprehensive history should be elicited (E Obstetric history: current pregnancy, p. 2) and a full physical examination undertaken (E Obstetric physical examination, p. 6). • Risk factors from past history should be highlighted. • It is essential to obtain past obstetric notes if this information may change the management. • History of inheritable diseases in close relatives should be sought, and history of migration and travel may identify risk for diseases such as haemoglobinopathies, some forms of hepatitis, and HIV. • Histories of alcohol abuse, smoking, and addictive drug use are useful behavioural markers of potential risks (e.g. fetal abnormalities, impaired fetal growth, preterm labour, and neonatal drug withdrawal problems). • It is important to identify women at risk of postnatal depression: • women should be asked about previous and family history of psychiatric disorders, and social problems including domestic violence and previous self-harm • women at risk should have psychiatric care and social support. • Advice and support should be given on healthy lifestyles (including diet and exercise), pregnancy care services available, maternity benefits, and sufficient information to enable informed decision-making following screening tests.
1st contact with healthcare professionals Ensure the woman is given information on: • Folic acid supplementation. • Low-dose aspirin if meets criteria. • Lifestyle advice. • AN screening. • Booking appointment. Booking appointment (usually with a midwife in the UK) • Identify high-risk women who need additional care. • Calculate BMI. • Measure BP. • Dipstick test urine (protein, glucose, blood, etc.). • Check an ultrasound appointment has been made for confirmation of viability, gestational age, and aneuploidy screening (if desired). • Take blood tests for: • haemoglobinopathies • rubella • Venereal Disease Research Laboratory (VDRL) test • HIV • hepatitis B virus • red cell allo-antibodies • Hb for anaemia. • Give information on: • AN classes • pregnancy care pathway • nutrition, diet, and vitamin supplementation • maternity benefits • how baby develops.
Antenatal care: planning The basic aims of AN care are: • To provide evidence-based information and support to women and their partners, to enable them to make informed decisions regarding their care. • To advise on minor problems and symptoms of pregnancy. • To assess maternal and fetal risk factors at the onset of pregnancy. • To facilitate provision of prenatal screening and subsequent management of any abnormalities detected. • To monitor fetal and maternal well-being throughout pregnancy and screen for commonly occurring complications (most notably BP and urine check at every visit to detect signs of developing pre-eclampsia and diabetes). • To determine timing and mode of delivery when complications arise or if pregnancy continues after the EDD. 2 The needs of each pregnant woman should be assessed at each appointment as new problems can arise at any stage in pregnancy. H Urine should be dipstick tested and BP measured at every AN visit.
Screening for chromosomal and structural abnormalities • Ideally, screening should be offered to all women at the time of booking. • Detailed, unbiased, written information should be provided about the conditions being screened for, types of test available, and the implications of the results. H It is important for a woman to understand that a negative result in any screening test does not guarantee that her baby does not have that or another abnormality. For full details on current UK screening E Prenatal diagnosis: overview, p. 04.
Antenatal care: planning
Antenatal appointment schedule A schedule of AN appointments and what needs to be done at each visit has been described in the recent NICE antenatal care guidelines and is summarized below. 6wks • Discuss screening results. • Investigate if Hb level 30). • Glycosuria on more than one occasion. • Polyhydramnios. • Large for gestational age fetus in current pregnancy.
Antenatal care: preparing for delivery • In the early 3rd trimester, women are seen monthly and, at each visit, BP, urinalysis, and fundal height measurement, as well as enquiry about maternal well-being and fetal activity, are recorded. • FBC and antibody screen is repeated at 28 and 34wks gestation, and Rh –ve women are offered anti-D prophylaxis at these times. • From 36wks onwards, fetal presentation as well as growth are assessed, and an ultrasound assessment performed if indicated. • Preparation for labour and delivery should be discussed. • The final routine visit between 40 and 4wks includes discussions on induction of labour after 4wks gestation. • In women who wish to avoid induction, the risks of prolonging pregnancy should be discussed and a plan for i fetal surveillance with cardiotocography (CTG) and ultrasound assessment of fetal growth and liquor volume can be made.
Pregnancy complications Minor symptoms of pregnancy: gastrointestinal 48 Minor symptoms of pregnancy: musculoskeletal and vascular 49 Minor symptoms of pregnancy: genitourinary and others 50 Antepartum haemorrhage: overview 51 Antepartum haemorrhage: assessment 52 Antepartum haemorrhage: management 54 Placental abruption 55 Blood pressure in pregnancy: physiology 56 Blood pressure in pregnancy: hypertension 58 Pre-eclampsia: overview 60 Pre-eclampsia: clinical features and investigations 62 Pre-eclampsia: management 63 Severe pre-eclampsia: management 64 Eclampsia and haemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome 66 Multiple pregnancy: overview 68 Multiple pregnancy: types 70 Multiple pregnancy: antenatal care 72 Monochorionic, diamniotic twins 74 Multiple pregnancy: labour 76 Breech presentation: overview 78 External cephalic version 80 Breech presentation: delivery 82 Transverse, oblique, and unstable lie 84 Abdominal pain in pregnancy: pregnancy related (24wks) 88 Abdominal pain in pregnancy: bowel related 90 Abdominal pain in pregnancy: other causes 92 Preterm labour: overview 94 Preterm labour: prevention and prediction 96 Preterm prelabour rupture of membranes: overview 97 Preterm prelabour rupture of membranes: management 98 Prolonged pregnancy: overview 100 Prolonged pregnancy: management 102
Minor symptoms of pregnancy: gastrointestinal Minor symptoms of pregnancy are mostly related to hormonal, physiological, and i weight-bearing aspects of pregnancy. Although usually mild and self-limiting, some women may experience severe symptoms, which can affect their ability to cope with activities of daily living (E Further reading).
Nausea and vomiting (morning sickness) • Most common complaint, especially in the 1st trimester: • Nausea: 80–85% • Vomiting: 52%. • Believed to be caused by hormones of pregnancy especially hCG. • i In multiple and molar pregnancies. • May be severe enough to warrant hospital admission—hyperemesis gravidarum (E Hyperemesis gravidarum, p. 622). • Not usually associated with poor pregnancy outcome. • Tends to resolve spontaneously by 16–20wks. Management • Lifestyle modification (e.g. eat small meals, i fluid intake) acupressure (P6). • Antiemetics (prochlorperazine, promethazine, metoclopramide, ondansetron).
Gastro-oesophageal reflux (heartburn) • Very common complaint at all stages of pregnancy: • 1st trimester—22%; 2nd trimester—39%; 3rd trimester—72%. • Progesterone relaxes oesophageal sphincter allowing gastric reflux, which gradually worsens with i intra-abdominal pressure from the growing fetus. Management • Lifestyle modification (e.g. sleep propped up, avoid spicy food). • Alginate preparations and simple antacids. • If severe, proton pump inhibitors (omeprazole).
Constipation • Common complaint that appears to d with gestation: • progesterone d smooth muscle tone, affecting bowel activity • often made worse by iron supplementation. Management • Lifestyle modification (e.g. i fruit, fibre, and water intake). • Fibre supplements. • Osmotic laxatives (lactulose).
Further reading NICE (2021). Antenatal care. NICE guideline [NG201]. M www.nice.org.uk/guidance/ng201
MINOR SYMPTOMS OF PREGNANCY
Minor symptoms of pregnancy: musculoskeletal and vascular Symphysis pubis dysfunction or pelvic girdle pain • Describes a collection of signs and symptoms producing pelvic pain. • Usually mild, but can present with severe and debilitating pain. • Incidence up to 10%. Management • Physiotherapy advice and support. • Simple analgesia. • Limit abduction of legs at delivery. • Caesarean delivery (CD) not indicated. (See M www.pelvicpartnership.org.uk.)
Backache and sciatica • Common complaint, attributed to hormonal softening of ligaments exacerbated by altered posture due to the weight of the uterus. • Prevalence estimated between 35% and 61%. • Neurological symptoms (sciatica) may occur. Management • Lifestyle modification (e.g. sleeping positions). • Alternative therapies including relaxation and massage. • Physiotherapy (e.g. back care classes) and simple analgesia.
Carpal tunnel syndrome • Occurs due to oedema compressing the median nerve in the wrist. • Usually resolves spontaneously after delivery. Management • Sleeping with hands over the side of the bed may help. • Wrist splints may be of benefit. • If evidence of neurological deficit, surgical referral indicated.
Haemorrhoids • Tend to occur in the 3rd trimester. • Incidence 8–30% of pregnant women. Management • Avoid constipation from early pregnancy. • Ice packs and digital reduction of prolapsed haemorrhoids. • Suppositories and topical agents for symptomatic relief. • If thrombosed, may require surgical referral.
Varicose veins • Common complaint, which i with gestation. Management • Regular exercise and compression hosiery. • Consider thromboprophylaxis if other risk factors are present.
Minor symptoms of pregnancy: genitourinary and others Urinary symptoms • Frequency in the 1st trimester results from i GFR and the uterus pressing against the bladder. • Stress incontinence may occur in the 3rd trimester as a result of pressure on the pelvic floor. 2 Urinary tract infections (UTIs) are common in pregnancy. Management • Screen for UTI (urine dipstick testing: nitrite analysis is best). • Avoid caffeine and fluid late at night.
Vaginal discharge • i Due to i blood flow to the vagina and cervix. • Should be white/clear and mucoid: • offensive, coloured, or itchy may indicate an infection • profuse and watery may indicate ruptured membranes. Management • Exclude ruptured membranes. • Exclude sexually transmitted infection (STI) and candidiasis (common in pregnancy). • Reassurance.
Itching and rashes • Skin changes and itching are common in pregnancy. • Rashes are usually self-limiting and not serious. Management • Full history and examination to exclude infectious causes (e.g. varicella (E Varicella zoster, p. 172) and intrahepatic cholestasis (E Intrahepatic cholestasis of pregnancy, p. 252). • Emollients and simple over-the-counter ‘anti-itch creams’. • Reassurance—most will resolve after delivery. • Referral to dermatologist if severe.
Other common minor symptoms of pregnancy • Breast enlargement and pain: helped with supportive underwear. • Mild breathlessness on exertion: important to exclude pulmonary embolus and anaemia. • Headaches: important to exclude pre-eclampsia or (rare) neurological cause. • Tiredness. • Insomnia. • Stretch marks. • Labile mood. • Calf cramps. • Braxton Hicks contractions.
Antepartum haemorrhage: overview
Antepartum haemorrhage: overview Antepartum haemorrhage (APH) is bleeding from the genital tract in pregnancy at ≥24wks gestation before onset of labour. Women with placenta praevia or placental abruption may present with typical symptoms and signs and with recognized risk factors. H However, there may be minimal or no per vaginam (PV) loss in a large abruption and an abruption is usually, but not always, painful.
Causes of antepartum haemorrhage • Unexplained (80%): usually marginal placental bleeds (i.e. minor placental abruptions). • Placenta praevia. • Placental abruption. • Others, including: • maternal: – incidental (cervical erosion/ectropion) – local infection of cervix/vagina – a ‘show’, usually light and pink or brown – genital tract tumours, particularly cervical carcinoma – varicosities – trauma. • fetal: vasa praevia. H There may be rapid and severe haemorrhage from a placenta praevia. H Most bleeding from an abruption is concealed.
Vasa praevia • This occurs when the fetal vessels run in membranes below the presenting fetal part, unsupported by placental tissue or umbilical cord. • Incidence of ruptured vasa praevia is 1:2500–2700. • May present with PV bleeding after rupture of fetal membranes followed by rapid fetal distress (from exsanguination). • Reported fetal mortality of rupture 33–100%. • Risk factors include: • low-l ying placenta • multiple pregnancy • IVF pregnancy • bilobed and especially succenturiate lobed placentas.
Antepartum haemorrhage: assessment Initial assessment Rapid assessment of maternal and fetal condition is a vital 1st step as it may prove to be an obstetric emergency.
History A basic clinical history should establish: • Gestational age. • Amount of bleeding (but don’t forget blood may be concealed). • Associated or initiating factors (coitus/trauma). • Abdominal pain. • Fetal movements. • Date of last smear. • Previous episodes of PV bleeding in this pregnancy. • Leakage of fluid PV. • Previous uterine surgery (including CD). • Smoking and use of illegal drugs (especially cocaine). • Blood group and Rh status (will she need anti-D?). • Previous obstetric history (placental abruption/fetal growth restriction (FGR), placenta praevia). • Position of placenta, if known from previous scan.
Maternal assessment This should include: • BP. • Pulse. • Other signs of haemodynamic compromise (e.g. peripheral vasoconstriction or central cyanosis). • Uterine palpation for size, hardness/contractions, tenderness, fetal lie, presenting part. H Remember, never perform a vaginal examination (VE) in presence of PV bleeding without 1st excluding a placenta praevia (‘No PV until no PP’). Once a placenta praevia is excluded, a speculum examination should be undertaken to assess degree of bleeding and possible local causes of bleeding (trauma, polyps, ectropion), and to determine if membranes are ruptured. A digital examination ascertains cervical changes indicative of labour.
Fetal assessment • Establish whether a FH can be heard. • Ensure that it is fetal and not maternal (remember, the mother may be very tachycardic). • If the FH is heard and gestation is estimated to be 26wks or more, FHR monitoring should be commenced.
Antepartum haemorrhage: assessment
Placenta praevia and low-lying placenta (See Fig. 2.1.) Definitions • Placenta praevia (formerly major or grade III–IV): the placenta is over the internal cervical os. • Low lying placenta (formerly minor or grade I–II): the placenta is within 20mm of the internal os. Incidence About 0.5% of pregnancies at term. Diagnosis Transvaginal USS is safe and is more accurate than transabdominal USS in locating the placenta, particularly if posterior. H Establish that there has been no previous CD (E Placenta accreta spectrum: overview, p. 138). Management • Consider admission in women with major placenta praevia who have bled. • Offer steroids if 24h. • Baby is more likely to be admitted to the special care baby unit: no evidence of a difference in eventual neonatal outcome (morbidity/ mortality) with expectant management of 2h after delivery to allow close observation of the baby. • Consider induction if not in labour by 24h. • Seek medical advice if any concerns regarding the baby’s well-being in the st 5 days of life (especially in the first 2h). Use of antibiotics is controversial. NICE does not recommend prophylactic antibiotics for either mother or baby in the absence of symptoms, even if her membranes have been ruptured for >24h. 2 In labour, regular maternal observations are essential to pick up signs of infection early. FHR monitoring should be carried out as it may be tachycardic in the presence of infection. H If there is clinical evidence of infection a full course of broad-spectrum IV antibiotic therapy should be started after blood cultures have been sent.
Prelabour rupture of membranes: management
PROM in known group B Streptococcus carriers (E Group B Streptococcus, p. 96.) GBS carriers (high risk) • Mothers should be regarded as high-risk carriers and offered intrapartum antibiotic prophylaxis (IAP) in labour if they: • had a previous baby affected by early-or late-onset GBS disease • had GBS bacteriuria in the current pregnancy. • Standard IAP is benzylpenicillin from the time admitted in labour until delivery. • cephalosporins can be used as an alternative • if allergic to penicillin, vancomycin is recommended. • Birth in a pool is not contraindicated if the mother is a carrier but IAP should be given. H Women with pyrexia >38°C should be given broad-spectrum antibiotics that will cover GBS. 75,000 women die of PPH each year. • Major cause of maternal deaths in the UK (often after CD). • Incidence is 2–% in the UK. • With a low BMI and/or low Hb, 35yrs. H The presence of any risk factors for PPH should lead to the woman being advised to deliver in an obstetric unit (facilities for blood transfusion and surgical management of PPH).
Intrapartum risk factors for PPH • IOL. • Prolonged st, 2nd, or 3rd stage. • Use of oxytocin. • Precipitate labour. • Vaginal operative delivery. • CD.
Labour and delivery
Home birth: overview Home birth can be safe for women screened as low risk, and emotionally satisfying for the mother and her family. For women identified as having risk factors, hospital delivery is safer. Debates about the safety of home births focus on risk of preventable perinatal morbidity and mortality, and on issues of screening and referral.
The numbers • Proportion of births at home fell from 80% in 930 to % in 990. • As a result of UK Government committee recommendation (993), stating that a full choice including home births should be offered, followed by ‘Maternity matters’, a Government white paper (2007), the UK home birth rate has i and is now ~2–3%. • Studies suggest that 0–4% of women would choose home birth if given the opportunity. • In some regions where there is difficulty in geographical accessibility to a hospital, the home birth rate could be ~0%. • In women booked for home births: • change to hospital care is nearly 29% • transfer in labour is ~5% in multiparae and ~30% in nulliparae • most of these transfers are for failure to progress or pain relief. • Risk of intrapartum fetal death in appropriately selected low-risk women is :000. • It is difficult to compare directly the perinatal mortality rates for home and hospital, as more complex deliveries occur in hospital. • Recent prospective study suggests a slight i in perinatal mortality with home births.
Discussion points when considering home birth • In the presence of obvious risk factors (hypertension, diabetes, placenta praevia), the advice must be to deliver in hospital. • If mother is low risk and wishes to have a home birth, she should be counselled appropriately with full information about the very slight i in perinatal mortality and possibility of transfer in labour. • If a risk arises before birth, the booking should be changed. • If risk is minimal, the lead professional in charge should offer the woman and her partner the opportunity to review their choice and respect their decision.
Reasons for women to choose home birth • Wish for a familiar setting where they feel relaxed and in control. • Fear of hospital setting. • To have a continuing relationship with a known midwife. • To be with more family members who provide support. • Previous home birth. • To avoid intervention.
Home birth: risks and GP involvement
Home birth: risks and GP involvement The potential risks of home birth are rare but should be discussed with the woman as part of her decision. These include: • Should a complication occur, transfer to hospital may be required. • Should there be a delay in transfer, response to acute complications, such as intrapartum fetal hypoxia or PPH, may be delayed, potentially l a worse outcome although such complications are rare. • The facilities for neonatal resuscitation will be limited but the midwife should be well trained in basic neonatal resuscitation. • Inadequate lighting and analgesia may make diagnosis of the extent of perineal tears difficult, necessitating transfer to hospital. Discussion of the risks and other factors, including type of pain relief available, will help the woman to make an informed choice. Clear documentation of these discussions in the antenatal period is essential for the mother not to regret her choice and for medico-legal reasons.
The role of the GP • The GP should be fully informed about the local options for place of birth and will then be able to provide the options to the woman in a clear, understandable, and balanced manner. • GPs who do not wish to provide care for home births should refer women to the community midwife or a GP who provides this care. • In case of any unfortunate event occurring with intrapartum care of a woman being looked after by her GP and if the case proceeds to a litigation, the GP would not be judged by the standards of a consultant obstetrician, but by those of a GP with similar skills and standing (the Bolam test). • The GP does not have to attend a home birth even when the woman has been accepted by the GP for full maternity care, unless asked to do so by the midwife. • The GP should provide support to the woman and midwife, help identify any deviations from normal course of labour, and arrange for hospital care. • Where the midwife feels that the GP is supportive, the likelihood of transfer to hospital is d. • In current practice, very few GPs offer care in labour and delivery services.
Further reading Bandolier. The GP’s guide to home birth. M www.bandolier.org.uk/band32/b32-8.html
Labour and delivery
Home birth: the evidence Meta- analysis of several methodologically sound observational studies comparing the outcomes of planned home births (irrespective of the eventual place of birth) with planned hospital births for women with similar characteristics showed that there was no i in maternal mortality. The rate is unlikely to be different as the maternal mortality is generally low, and good midwifery and ambulance services help to avoid such deaths, although occasional cases have been described. Home birth study in the UK showed: • Slightly i perinatal mortality, but when all studies in literature are considered there is little statistically significant difference. This is partly due to the complexity of such studies, some being retrospective or prospective descriptive. • In the home births group there were significantly fewer medical interventions (including in women transferred to hospital). • Fewer babies had low Apgar scores, neonatal respiratory problems, and instances of birth trauma with home births. Further RCTs are needed to resolve this controversy over relative safety of home and hospital births. Because maternal and perinatal mortality and morbidity are so low in low-risk pregnancies, to observe differences in these ° outcome measures large numbers need to be studied.
Home birth: general points GPs and midwives have the responsibility for creating the right circumstances for safe and satisfying home births. This means: • Selecting women without risk factors. • Establishing an infrastructure for safe obstetric care including: • hygiene during delivery • keeping the baby warm • care of the eyes. • Providing support and care during labour, delivery, and in immediate postnatal period. • Arrangements for transfer to hospital in the event of any unforeseen complication. • Care should be provided based on a prearranged protocol that provides guidance as to conduct of labour and what action needs to be taken should the woman need help.
Obstetric anaesthesia Pain relief in labour 362 Epidural analgesia: overview 364 Epidural analgesia: advantages and disadvantages 366 Anaesthetic techniques for Caesarean delivery: spinal 368 Anaesthetic techniques for Caesarean delivery: epidural 369 Anaesthetic techniques for Caesarean delivery: combined spinal epidural 370 Anaesthetic techniques for Caesarean delivery: general anaesthesia 371
Pain relief in labour Uterine contractions in labour are associated with pain. Professionals can help to reduce women’s fears by giving precise, accurate, and relevant information antenatally including the types of analgesia available in their unit.
Ideal pain relief in labour Should • Provide good analgesia. • Be safe for the mother and baby. • Be predictable and constant in its effects. • Be reversible if necessary. • Be easy to administer. Should not • Interfere with uterine contractions. • Interfere with mobility.
Non-pharmacological methods • Education regarding what to expect may help reduce fear and the sense of loss of control. • A trusted companion present throughout labour and birth reduces the need for pain relief. • Warm bath, acupuncture, hypnosis, and homeopathy are also helpful. • Transcutaneous electrical nerve stimulation (TENS): • may help with short labour and postpone the need for stronger analgesia, but may not be adequate as labour advances.
Pharmacological methods Nitrous oxide (Entonox®) Entonox® is premixed nitrous oxide and oxygen as a 50:50 mixture. It is self- administered and has quick onset of action and a short half-life. Side effects can include feeling faint, nausea, and vomiting. Narcotic agents • Pethidine: administered at a dose of 50–150mg IM; onset of action is 15–20min. It lasts about 3–4h and can be repeated. It is usually given with an antiemetic. If given within 2h of delivery, it can cause neonatal respiratory depression and naloxone may be needed. • Diamorphine: may also be used at a dose of 2.5–5mg IM. There is controversy about the extent and timing of neonatal respiratory depression, but it may be up to 3–4h after the last dose. • Meptazinol: is an opioid that may cause less respiratory depression. The onset of action starts in 15min and lasts for about 2–7h.
Pain relief in labour
Intracutaneous sterile water for back pain in labour • Severe constant lower back pain occurs in ~30% of labouring women. • It is believed to be associated with the stretching of the lumbosacral nerve plexus and compression of the viscera. • It is often associated with an OP position. 2 The painful stimuli is not actually occurring in the lower back but is instead ‘referred’ there due to intercommunication in the dorsal horns of the spinal segments between the afferent fibres from the lumbosacral plexus and viscera, and the Aδ afferent fibres of the dermatomes of the lower back. • Where epidural analgesia is not available, the pain can lead to an extremely distressing, potentially traumatic, birth experience. • Intracutaneous sterile water, administered into the skin bordering the Michaelis rhomboid has been demonstrated to be effective in reducing this back pain.
Pudendal nerve block and local perineal infiltration • Pudendal nerve block is used for operative vaginal delivery and is performed by the obstetrician: • lidocaine (lignocaine) is injected 1–2cm medially, and below the right and left ischial spines • this is done transvaginally with a specially designed pudendal needle. • Local anaesthetic such as lidocaine is infiltrated in the perineum before performing an episiotomy at the time of delivery, or before suturing tears and episiotomies.
Epidural analgesia: overview Safe and effective analgesia for labour is still something that is not available for the vast majority of women in the world today. Although the provision of epidural analgesia during labour has been one of the greatest advances in the care of women during this difficult and distressing time, it still carries a small, but definite complication rate.
Consent for analgesia in labour Women in labour present a particular group of patients in whom obtaining fully informed consent may be difficult because of a variety of factors such as pain, fatigue, or the effects of narcotic analgesia administered previously. Ideally, anaesthetists should try to explain the risks and benefits of epidural analgesia to women in the antenatal period.
Anatomy • The epidural space lies between the spinal dura and the vertebral canal (Fig. 7.1). • The superior margin is the foramen magnum, inferiorly the sacrococcygeal membrane. • Posteriorly lie the ligamentum flavum and the anterior surfaces of the laminae, anteriorly the posterior longitudinal ligament. • Within the epidural space lie the spinal nerve roots as well as the spinal arteries and extradural veins. • The usual distance between skin and the epidural space in the lumbar region in adults is ~4–5cm. 2 It is important to realize that the epidural space is continuous the whole way down the back. The lumbar region is chosen for the provision of labour analgesia as this is where the nerve roots involved in the production of pain during labour are found. • The pain of the first stage of labour is caused by uterine contractions and is referred by afferent Aδ and C fibres mainly to dermatomes T10– L1, and by distension of the perineum during the second stage of labour to S2–S4.
Epidural analgesia: overview
Epidural needle Epidural space Spinal needle
Posterior longitudinal ligament Subarachnoid space Dura
Ligamentum flavum Fig. 7.1 Subarachnoid and epidural spaces. Reproduced from Allman KG, McIndoe A, Wilson I. (2011). Oxford Handbook of Anaesthesia, 3rd edn. With permission from Oxford University Press.
Epidural analgesia: advantages and disadvantages Advantages • Effective analgesia in labour. • Reduced maternal catecholamine secretion (thought to benefit fetus). • Can be topped up for an operative delivery or any other complications, e.g. retained placenta or difficult perineal repair. • Can provide effective postoperative analgesia. • Can be used to aid BP control in pre-eclampsia.
Disadvantages • Failure to site, or a patchy, or incomplete block. • Hypotension from sympathetic blockade. • d mobility. • Tenderness over the insertion site. Complications • Inadvertent dural puncture: • incidence 40mmHg from normal). • Heart rate ≥30 beats/min. • Respiratory rate ≥25 breaths/min. • Needs O2 to keep SpO2 ≥92%. • Non-blanching rash/mottled/ashen/cyanotic. • Lactate ≥2 mmol/L.* • Not passed urine in 8h (1500mL. • Rapid treatment of the underlying cause. • Supportive therapy and monitoring. • Give 1g IV tranexamic acid.
Consequences of massive obstetric haemorrhage • Acute hypovolaemia. • Sudden and rapid cardiovascular decompensation. • If antenatal, fetal distress or death. • DIC. • Iatrogenic complications associated with fluid replacement and multiple blood transfusions. • Pulmonary oedema. • Adult respiratory distress syndrome. • Sheehan’s syndrome (hypopituitarism).
Massive obstetric haemorrhage: management
Disseminated intravascular coagulopathy The main cause of DIC is massive blood loss, but it can occur with other conditions such as amniotic fluid embolism. It occurs due to the depletion of fibrinogen, platelets, and coagulation factors that are consumed or lost with the blood. Infusions of replacement fluids further dilute the remaining coagulation factors and combined with hypotension-mediated endothelial injury may trigger DIC. The most useful tests to diagnose DIC are fibrinogen, partial thromboplastin time (PTT), and activated PTT (APTT). Early involvement of a senior haematologist is vital to advise on appropriate replacement of blood products. Blood products • FFP: contains all the clotting factors required. Ideally, 1U of FFP should be given with each unit of rapidly transfused blood. • Cryoprecipitate: contains more fibrinogen but lacks antithrombin III which is often depleted in massive obstetric haemorrhages. • Platelet concentrate: rarely indicated, but may be required if surgical intervention is planned. • Recombinant activated factor VII: used successfully in severe coagulopathy but is expensive and not always readily available. Adjuvant therapy • Consider tranexamic acid 1g IV.
Prevention of massive obstetric haemorrhage • Risk stratification. • Routine prophylaxis: • Vaginal birth: Syntometrine® (oxytocin and ergometrine) or oxytocin (if hypertensive or cardiac disease) • Caesarean birth: oxytocin 5IU IV and consider repeating. • Recognition and early and appropriate treatment of more minor haemorrhage.
Massive obstetric haemorrhage: resuscitation The most common situation is postnatal. In the ante-or intrapartum situation, the principles are the same but delivery of the fetus once the mother is stable is required. Resuscitative measures may need to occur at the same time as stopping the bleeding.
If EBL 1000mL or clinical signs of shock As above plus • Call anaesthetist. • Lie flat and keep warm. • Administer oxygen. • Check fibrinogen. • Give IV crystalloid (maximum 3.5L).
If EBL >1500mL and continuing: massive obstetric haemorrhage As above plus • Activate massive obstetric haemorrhage protocol, which includes: • 4U of blood and 4U of FFP • summon anaesthetic and obstetric consultant • porter on site for blood samples • scribe for timeline • alert to haematologist. • Administer blood and FFP in ratio of 1:1. • Avoid relying on HemoCue™ or point-of-care Hb estimations. • Give cryoprecipitate if >6U given or fibrinogen 30kg/m2) either before pregnancy or in early pregnancy. • Parity >4. • Gross varicose veins. • Paraplegia. • Sickle cell disease. • Inflammatory disorders, e.g. inflammatory bowel disease. • Medical disorders, e.g. nephrotic syndrome, cardiac diseases. • Myeloproliferative disorders, e.g. essential thrombocythaemia, polycythaemia vera. New-onset or transient risk factors • Ovarian hyperstimulation syndrome. • Hyperemesis. • Dehydration. • Long-haul travel. • Severe infection, e.g. pyelonephritis. • Immobility (>4 days’ bed rest). • Pre-eclampsia. • Prolonged labour. • Mid-cavity instrumental delivery. • Excessive blood loss. • Surgical procedure in pregnancy or puerperium, e.g. evacuation of retained products of conception, postpartum sterilization. • Immobility after delivery.
Further reading RCOG (2015). Reducing the risk of venous thromboembolism during pregnancy and the puerperium. Green-top guideline no. 37a. M www.rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf
Venous thromboembolism: prevention • LMWHs are the agents of choice for antenatal thromboprophylaxis. • They are as effective as unfractionated heparin in pregnancy, safer, and easier to monitor. • Monitoring anti-Xa levels is not usually required when using LMWH for thromboprophylaxis. 2 Women should be reassessed before, during, and after labour for risk factors for VTE using mandatory, often electronic, ‘scoresheets’. 2 An individual’s score will guide management. See Fig. 10.1 for an example of an antenatal assessment tool. See Fig. 10.2, p. 429, for an example of a postnatal assessment tool.
Thromboprophylaxis: other considerations • All women should undergo an assessment of risk factors for VTE in early pregnancy. • Repeat if they develop any other problems and after delivery. • Women with previous VTE should be screened for inherited and acquired thrombophilia, ideally before pregnancy. • Immobilization and dehydration should be avoided. • Antenatal thromboprophylaxis should begin as early as practical. • Postpartum prophylaxis should begin as soon as possible after delivery (with precautions after use of regional anaesthesia). • Excess blood loss and blood transfusion are risk factors for VTE, so thromboprophylaxis should be commenced or reinstituted as soon as the immediate risk of haemorrhage is d.
Further reading RCOG (2015). Reducing the risk of venous thromboembolism during pregnancy and the puerperium. Green-top guideline no. 37a. M www.rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf
Venous thromboembolism: prevention Any of: Previous VTE High-risk thrombophilia + no VTE Medical comorbidities, e.g. cancer; heart failure; active SLE, IBD or inflammatory polyarthropathy; nephrotic syndrome, type 1 DM with nephropathy, sickle cell disease, current IVDU Transient risk factors: OHSS (1st trimester only) Hospital admission Any surgical procedure, e.g. appendectomy Obesity (BMI ≥3035 Parity ≥3 Smoker Gross varicose veins Current pre-eclampsia Immobility, e.g. paraplegia, PGP Family history of unprovoked or oestrogenprovoked VTE in 1st-degree relative Low-risk thrombophilia Multiple pregnancy IVF/ART Transient risk factors: Dehydration/hyperemesis Current systemic infection Long-distance travel
HIGH RISK Antenatal prophylaxis with LMWH from 1st trimester
4+ risk factors
3+ risk factors
INTERMEDIATE RISK Prophylaxis from 28 wks
3 consider extending thromboprophylaxis with LMWH to 6wks
2+ risk factors
48h. • Doctors assessing pregnant women should be competent to perform a neurological examination, including assessing for neck stiffness and performing fundoscopy.
Care of women with neurological disorders
2 Recommendation 3: caring for pregnant women with epilepsy • GPs, 2° care providers, and commissioners should work together to ensure that women with epilepsy have access to appropriately specialized care, before, during, and after pregnancy. • Preconception counselling for women with epilepsy is widely advised, but is not always delivered effectively and should be robustly offered in all care settings on an opportunistic basis. • All antenatal services should identify a liaison epilepsy nurse to integrate into their routine antenatal service. • All women with a possible new diagnosis of epilepsy should be seen promptly by a specialist in epilepsy and the care of pregnant women with epilepsy should be shared between an epilepsy specialist or obstetric physician and an obstetrician. • The diagnosis of epilepsy per se is not an indication for planned CD or induction of labour. • Postpartum safety advice and strategies should be part of the antenatal and postnatal discussions with the mother alongside breastfeeding, seizure deterioration, and antiseizure medication intake. (See RCOG (206). Epilepsy in pregnancy. Green-top guideline no. 68. M www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg68/)
/12_first_proofs/first_proofs/xml_for_typesetting med-9780198838685-chapter-11.indd 459
Maternal and perinatal mortality
Care of women with sepsis E Puerperal sepsis: overview p. 386. • Sepsis deaths include those with sepsis originating from the genital tract, influenza, and sepsis from other causes (such as pneumonia). • This group of related conditions was responsible for 20 deaths in 205– 207 and 9 deaths in 204–206. • Although there was a significant and sustained d in influenza-related sepsis between 20–203 and 202–204, deaths from non-influenza related sepsis have continued to i. • See Table .8. Table .8 Deaths from sepsis Classification of care received (203–205)
Women who died, n (%)
Improvements in care which would have made no difference to outcome.
Improvements to care which would have made a difference to outcome
MBRRACE-UK messages for care • Toolkits provided by The UK Sepsis Trust can be used to identify and manage sepsis in pregnant and postpartum women. • The maternity-inpatient sepsis tool kit includes the following actions when sepsis is confirmed: • lactate measurement using venous blood gas analysis • microbiological sampling • early IV antimicrobial treatment. • Maternity units should have a local guideline that outlines their sepsis pathway, with information on antimicrobials and how to access advice from clinical microbiologists and critical care services. • Source control is essential—meaning that clinicians should not delay imaging as the basis for surgical or radiology-guided drainage of collections; removal of the source of infection may be required to improve the clinical situation of a woman with sepsis. • Prompt source control might include termination of pregnancy (in women who are preterm with chorioamnionitis), or induction of labour or CS once the baby has reached viability.
Further reading RCOG (202). Sepsis in pregnancy, bacterial. Green-top guideline no. 64a M www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg64a/ The UK Sepsis Trust M https://sepsistrust.org/
Care of women with sepsis
2 Recommendation 4: managing women with seasonal or pandemic influenza • The Department of Health/RCOG guideline on the investigation and management of pregnant women with seasonal or pandemic flu should be followed. • Early neuraminidase inhibitor treatment should be instigated for women with symptoms consistent with influenza, in line with national guidance. • The benefits of influenza vaccination to pregnant women should be promoted and pregnant women at any stage of pregnancy should be offered vaccination against seasonal and pandemic influenza with inactivated vaccine. (See UK Government. An nual flu programme. M www.gov.uk/governm ent/ collections/annual-flu-programme)
/12_first_proofs/first_proofs/xml_for_typesetting med-9780198838685-chapter-11.indd 461
Maternal and perinatal mortality
Perinatal mortality: an overview • Perinatal mortality refers to fetal deaths while pregnant (stillbirths after 24wks gestation) and those in the first 7 days of life (early neonatal mortality, UK). • Neonatal deaths include liveborn infants who die before 28 completed days after birth, and so include both early and late neonatal deaths. • UK surveillance, therefore, also reports an extended perinatal mortality rate comprising all stillbirths and neonatal deaths. • Since 986, perinatal morality has d from 9.6 per 000 births to 5.4 per 000 in 207 when there were 3686 perinatal deaths. • The Still-Birth (Definition) Act 992 modified the definition of a stillbirth by reducing the gestational age for babies included from 28 to 24wks.
Perinatal mortality: an overview
Perinatal mortality: definitions • Late fetal loss: a baby delivered between 22+0 and 23+6wks showing no signs of life, irrespective of when the death occurred. • Stillbirtha: a baby delivered at or after 24+0wks showing no signs of life, irrespective of when the death occurred. • Neonatal deathb: a liveborn baby (born at 20+0wks or later, or with a birthweight ≥400g where an accurate estimate of gestation is not available), who died before 28 completed days after birth. • Perinatal death: a stillbirth or early neonatal death. • Extended perinatal death: a stillbirth or neonatal death. • Termination of pregnancy: the deliberate ending of a pregnancy, normally carried out before the embryo or fetus is capable of independent life. • Perinatal mortality rate: stillbirths +early neonatal deaths per 000 total births. • Extended perinatal mortality rate: stillbirths +neonatal deaths per 000 total births. Stillbirths can be antepartum (birth before onset of care in labour) or intrapartum (birth after the onset of care in labour). b Early neonatal death (death before 7 completed days after birth) or late neonatal death (death after 7 but before 28 completed days after birth). a
/12_first_proofs/first_proofs/xml_for_typesetting med-9780198838685-chapter-11.indd 463
Maternal and perinatal mortality
UK confidential enquiry: perinatal deaths From 203, the programme has been managed by the MBRRACE-UK consortium who publish reports once a year.
Methodology • MBRRACE-UK collects information on all late fetal losses, stillbirths, and neonatal deaths using an online data collection system. • Individual level information is also collected from all births in the UK to provide the denominator for calculating mortality rates. • Maps and tables are used to compare outcomes at a national level within the UK, as well at the level of healthcare providers and commissioners. • Crude mortality rates describe ‘what happened’ at the level of individual units of comparison, such as different regions or healthcare providers. However, individual ‘units of comparison’ are likely to serve populations where () the number of deaths is small in comparison to the UK as a whole, and (2) the distribution of risk within any population or subgroups will influence outcomes, irrespective of the quality of healthcare provided (e.g. due to areas of high socioeconomic deprivation). • See Fig. .5.
Outcomes reported • ‘Stabilized’ and ‘stabilized and adjusted’ rates are also reported to enable ‘fair comparisons’. • A stabilized rate allows for the effects of chance variation due to small numbers. A stabilized mortality rate will better reflect the ‘average’ mortality rate than the crude mortality rate. • Stabilized rates are then adjusted for important characteristics which are known to influence mortality rates, such as a baby’s ethnicity or sex, as well as gestational age at birth (for neonatal deaths). • Adjustment of stabilized rates is used to ensure that mortality estimates consider key characteristics that are known to i perinatal mortality rates. These data must be available at the individual level for all births within a population and are restricted to maternal age, maternal sociodemographic status (using her residence), the baby’s sex and ethnicity, their gestational age at birth, and lastly, whether they were from a multiple pregnancy. The adjustment process is unable to adjust for whether the mother smokes or her BMI. • Stabilized and adjusted rates provide important information on perinatal outcomes but cannot be considered as definitive measures of care quality within populations and between subgroups within a population. • This chapter summarizes the points highlighted by assessors in the 209 report and the outputs from confidential enquiries into antepartum and intrapartum stillbirths.
UK confidential enquiry: perinatal deaths
MBRRACE-UK stillbirths and LFLs
Total stillbirths and LFLs
ONS neonatal deaths
MBRRACE-UK neonatal deaths
Total neonatal deaths
Gestation 70% more likely to die in the neonatal period, RR .73 (95% CI .50–.98). • Babies born to mothers from the most deprived socioeconomic group were >70% more likely to be stillborn, RR =.72 (95% CI .6–.86); and ~60% more likely to die during the neonatal period, RR .57 (95% CI .4–.76).
Singleton pregnancies (203–207) • The extended perinatal mortality rate d by 2%—equivalent to 500 fewer deaths in 207. • The stillbirth rate d from 4.20 per 000 births to 3.73 per 000 and so there were 350 fewer stillbirths in 207. • The neonatal mortality rate d from .84 to .67 deaths per 000 live births—representing 50 fewer neonatal deaths. • Intrapartum stillbirths d substantially—from 89 (5.8%) in 204 to 5 (.4%) in 207. • Causes of stillbirths in singleton pregnancies—placental cause in ~33% although unknown cause reported in 35%.
Multiple pregnancies (203–207) • Stillbirths d by a quarter—9.03/000 to 6.99 /000 total births. • Neonatal deaths d by a third—8.0/000 to 5.45/000 live births. • Among twin pregnancies, when compared to singleton pregnancies: • stillbirth risk is .93× higher • neonatal mortality risk 3.53× higher • stillbirth and neonatal mortality risks i as maternal age d, as maternal social deprivation i; both risks are i in female versus male twins • stillbirth risk is lower in preterm twins for all gestational ages • neonatal mortality risk in twins is 56% at 28+0 to 3+6wks. • Causes of stillbirths in twins—placental cause in ~40% and congenital anomaly in ~0%. Key messages are shown in Fig. .6.
Further reading Frøen JF et al. (2009). Causes of death and associated causes (CODAC)—a classification system for perinatal deaths. BMC Pregnancy Childbirth. 9:22. M https://bmcpregnancychildbirth.biomedcentral.com/articles/0.86/47-2393-9-22
Perinatal deaths (207): surveillance data
Fig. .6 Perinatal deaths in 207: key messages from MBRRACE-UK (209).
/12_first_proofs/first_proofs/xml_for_typesetting med-9780198838685-chapter-11.indd 467
Maternal and perinatal mortality
The term, singleton, normally formed, antepartum stillbirth enquiry A confidential enquiry examining 85 cases of antepartum stillbirth at term in babies without congenital abnormalities was undertaken to examine why the stillbirth rate in the UK was higher than elsewhere in Europe (Table .9). Table .9 Term singleton intrapartum stillbirths—classification of care received (203) Baby, n (%)
Woman, n (%)
Improvements in care which would have made no difference to outcome.
Improvements to care which would have made a difference to outcome.
Messages for future care • Gestational diabetes: missed opportunities for screening were frequently identified. ≥ risk factor in >50% of women with only ~33% of women screened. • Fetal growth: national recommendations for growth monitoring not followed in nearly 2/3 of cases and /3 of stillbirths were in growth- restricted babies. d fetal movements reported to maternity units by women in ~50% of cases. Women should be aware of the importance of reporting d fetal movements because of its association with stillbirth. Organizations should provide care in accordance with national guidance.
2 Recommendation 5: screening for gestational diabetes
• Offer women with GDM in a previous pregnancy either: • early self-monitoring of blood glucose, or • 75g OGTT. • This should be performed as soon as possible after booking and repeated at 24–28wks if negative. • Offer women with ≥ of the following an OGTT at 24–28wks: • BMI >30kg/m2 • previous baby weighing ≥4.5kg • family history of diabetes (st-degree relative) • ethnic origin with a high prevalence of diabetes. (See NICE (205, updated 2020). Diabetes in pregnancy. M www.nice. org.uk/ guida nce/ ng3; NICE (202). Antenatal care. NICE guideline [NG20]. M www.nice.org.uk/guidance/ng20)
STILLBIRTH AT TERM ENQUIRY
2 Recommendation 6: risk assessment and surveillance of fetal growth • There is strong evidence suggesting that fetal growth restriction (FGR) is the biggest risk factor in stillbirth and is linked to placental dysfunction. • All women should have a risk assessment at booking to determine their risk of placental dysfunction and this should be used by clinicians to determine which growth surveillance pathway is appropriate. • There are challenges associated with diagnosing FGR—both in previous and current pregnancies. • FGR in a previous pregnancy includes ≥ of the following: • birthweight 6mths is recommended). • Some studies have suggested that the rupture risk is higher following laparoscopic than open myomectomy.
Uterine artery embolization • Pregnancy following uterine artery embolization has been shown to be associated with higher rates of miscarriage, CD, and PPH. • Abnormal placentation is also more common, with up to % of women developing PAS following uterine artery embolization.
Pregnancy after fibroid treatment
Benign and malignant tumours in pregnancy
Benign adnexal masses • Adnexal masses in pregnancy are common: • prevalence of 0.9–8.8% • often an incidental finding on routine pregnancy scans • usually benign. • Ovarian cysts ≥6cm occur in 0.5–2:000 pregnancies.
Imaging E Benign ovarian tumours: imaging, p. 784. Ultrasound • Features of malignancy are the same as in non-pregnant women. • Greyscale USS for diagnosis of ovarian malignancy: • sensitivity: 86–95% and specificity: 68–90% • st-line modality for evaluating adnexal masses • comparable to both CT and MRI. • The role of colour Doppler in pregnancy is less clear. MRI • Valuable for indeterminate masses due to its ability to: • characterize tissue composition • assess for metastasis. • Safe and preferable to CT as it avoids radiation exposure. The safety of gadolinium, which enhances the vascularity of malignant tissue on MRI, remains uncertain.
Serum tumour markers May be of limited value as normal pregnancy can affect levels. • Cancer antigen (CA)-25: • >80% with epithelial ovarian cancer will have i Ca-25 levels • also produced by the decidua, making interpretation challenging. • LDH: • i serum levels may be associated with dysgerminoma • pregnancy does not alter LDH, therefore it remains a useful marker. • AFP and hCG: • in the non-pregnant women may be i with germ cell tumours • both are i in normal pregnancy.
Benign adnexal masses
Screening tools in pregnancy Risk of Malignancy Index (RMI) • Limited use in pregnancy due to reliance on the serum tumour marker CA-25. International Ovarian Tumour Analysis (IOTA) tool • Uses standardized terminology to categorize ovarian masses on USS. Has not been evaluated in pregnancy. E Benign ovarian tumours: imaging, p. 784.
Clinically significant benign adnexal masses in pregnancy Gynaecological • Functional ovarian cysts including: • corpus luteal cysts • follicular cysts • haemorrhagic cysts. • Benign cystic teratoma. • Serous cystadenoma. • Mucinous cystadenoma. • Endometrioma. • Paraovarian cyst. • Hydrosalpinx. • Tubo-ovarian abscess. • Ectopic pregnancy. • Hyperstimulated ovaries. Non-g ynaecological • Appendix mass. • Mesenteric cyst. • Diverticular mass. • Pelvic kidney.
Benign and malignant tumours in pregnancy
Management of ovarian cysts • Around 75% of adnexal masses seen in pregnancy are simple ovarian cysts 20%) as higher risk of malignancy • cysts >0cm, which could cause obstruction in labour. H Acute complications should be managed as an acute surgical abdomen and treated surgically, regardless of the gestation. • Elective surgery should be at 6–20wks: • d risk of miscarriage • easier access to the pedicle. Laparoscopic approach is associated with i maternal outcomes with no i risk to the fetus. Laparoscopy versus laparotomy • Choice depends on: • skills of the surgeon • urgency of the procedure • risk of malignancy • size of the cyst. Size is controversial but risk of rupture i if cyst >7cm: E Benign ovarian tumours: management, p. 788. • Indeterminate masses or those with malignant features warrant: • further assessed with MRI • input from a specialist MDT in gynaecological oncology. E Ovarian cancer, p. 495.
Management of ovarian cysts
Complications of ovarian cysts in pregnancy These are the same as in the non-pregnant state. Torsion • Incidence in pregnancy is –5:0,000 pregnancies. • May be as high as 6% in women with ovarian hyperstimulation. • Most common in the st and early 2nd trimester. • May occur in the absence of an adnexal mass (i.e. in a normal-sized ovary). • Clinical presentation is similar to non-pregnant women. • Pregnant women are twice as likely to have recurrence. Cyst haemorrhage • May occur as a result of i vascularity. Malpresentation • Very large cysts may prevent engagement of the fetal head and predispose to malpresentation. • Very rarely may cause obstructed labour.
Further reading RCOG (20). Management of suspected ovarian masses in premenopausal women. Green-top guideline no. 62 M www.rcog.org.uk/globalassets/documents/guidelines/gtg_62.pdf
Benign and malignant tumours in pregnancy
Malignancy in pregnancy: overview • Rare, occurring in ~:000 pregnancies annually. • During the 204–206 triennium: • 04 women died during or up to yr after pregnancy from malignant disease in the UK and Ireland • 26 women died during or up to 6wks after the end of pregnancy • mortality rate of .04 per 00,000 maternities. • Most common malignancies in pregnancy are: • breast cancer • malignant melanoma • cervical cancer • lymphomas • leukaemias.
Diagnosis • Delays in diagnosis are not uncommon: • signs and symptoms may be attributed to normal physiological changes seen in pregnancy • may also be a reluctance to perform the necessary investigations due to concerns about their effects on the fetus.
Treatment • MDT input is essential to plan investigation and treatment which must be individualized taking into account: • gestation • tumour histology • staging • patient wishes. Surgery should not be delayed if it is clinically indicated. Radiotherapy • Radiotherapy is not routinely recommended during pregnancy and should be postponed until after birth where possible. • Oncological emergencies such as spinal cord compression and CNS metastases may justify its use during pregnancy: • at later gestations, delivery may be deemed more appropriate. Chemotherapy • Should ideally follow standard protocols for non-pregnant patients. • Cytotoxic chemotherapy should be avoided in the st trimester if possible. • If there is an urgent need to commence treatment in the st trimester then TOP should be offered. • Exposure in the 2nd and 3rd trimesters has been associated with FGR and serial growth scans are recommended.
Malignancy in pregnancy: overview
Key points H Repeated presentation with pain requiring opioid analgesia should be considered a ‘red flag’ and warrants a thorough assessment to establish the cause. H If a cancer diagnosis is suspected, investigations and treatment should proceed in the same manner and on the same timescale as for a non- pregnant woman. H Malignancy diagnosed within 6mths of becoming pregnant is an independent risk factor for VTE. Thrombosis, particularly if migratory or in an unusual location, should be fully investigated as it may be a presenting sign of cancer. E Care of women with breast cancer, p. 448.
Further reading MBRRACE-UK (208). Saving lives, improving mothers’ care. M www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20 Report%20208%20-%20Web%20Version.pdf
Benign and malignant tumours in pregnancy
Breast cancer Breast cancer is the most common malignancy seen in pregnancy, estimated to occur in :3000–0,000 pregnancies.
Presentation • Usually presents as a painless lump or thickening of the breast tissue. • Occasionally presents as a unilateral bloody nipple discharge. • Rare cases with erythema and breast induration: • ± a peau d’orange appearance of the skin.
Diagnosis • Should be referred for assessment using standard cancer referral pathways. • Investigations should follow the usual diagnostic protocols and not be withheld or delayed on account of the pregnancy.
Prognosis • Pregnancy associated with a poorer prognosis, possibly due to: • delays in diagnosis • less aggressive therapy due to potential risks to the fetus • physiological changes which worsen outcomes • or a combination of all three. • No evidence that TOP improves prognosis. E Care of women with breast cancer, p. 448.
Further reading NICE (205, updated 202). Suspected cancer: recognition and referral. NICE guideline [NG2]. M www.nice.org.uk/guidance/ng2
Management of breast cancer in pregnancy • Should be managed by an experienced MDT. Treatments Surgery • Surgery can be performed in all trimesters. • Reconstructive surgery should be delayed until after pregnancy: • prevents asymmetry resulting from pregnancy-related changes • avoids prolonged anaesthesia. • Sentinel node assessment using radioisotopes does not cause significant uterine radiation and can be performed if required. Radiotherapy • Radiotherapy delayed until after delivery unless to prevent either life-threatening or organ-threatening complications, e.g. spinal cord compression. • It can be performed with fetal shielding. Chemotherapy H Systemic therapy is contraindicated in the st trimester. • Can be performed from the 2nd trimester onwards. • Not associated with late miscarriage, growth restriction, or organ dysfunction in the fetus. • Anthracycline regimens can be used. • Taxanes lack safety data in pregnancy and are therefore reserved for high-risk (node +ve) or metastatic disease. Hormone/targeted therapy H Trastuzumab (Herceptin®) and tamoxifen are contraindicated in pregnancy and breastfeeding. Other medications • Antiemetics, e.g. dexamethasone and ondansetron, can be used. • Granulocyte colony-stimulating factor can be used in chemotherapy- related neutropenia. • VTE prophylaxis should be prescribed to all women with malignancy in pregnancy unless contraindications present. Delivery timing • At least 2wks after the last cycle of chemotherapy is advisable, to avoid issues with neutropenia at delivery. • Administration of steroids for fetal lung maturation as normal if preterm delivery is anticipated. • Granulocyte colony-stimulating factor may be useful prior to delivery. Lactation • No evidence that breastfeeding i chance of recurrence. • Lactation be more difficult depending on the surgical intervention that may have been performed. • In women with a recent diagnosis of breast cancer, chemotherapy plans will determine whether breastfeeding is advisable.
Benign and malignant tumours in pregnancy
Cervical cancer • Most common cancer of the genital tract presenting in pregnancy. • Estimated incidence –0:0,000 pregnancies. • Most cases diagnosed in the st two trimesters are early (≤stage IB). • NHS Cervical Screening Programme has significantly d: • incidence of invasive carcinoma of the cervix • mortality from cervical cancer. E Cervical screening, p. 804.
Presentation H Recurrent or unexpected bleeding in pregnancy should always be investigated with a speculum examination. • Pregnancy may result in significant morphological changes to the cervix including: • i in cervical volume • i in vascularity l a blueish tint • ectropion • inflammatory changes.
Diagnosis • Where clinically indicated, urgent referral should be made for colposcopic examination by an operator experienced in pregnancy. • Cervical smears are not recommended in pregnancy as decidual cells may be mistaken for atypia. • Visible lesions should be sampled via punch biopsy: • carries an i risk of bleeding due to the i cervical vascularity • does not i the risk of pregnancy loss. • Cone biopsy and large loop excision of transformation zone (LLETZ) carry significant risks of haemorrhage (up to 25%) and pregnancy loss. • Staging is performed as in non-pregnant woman: • CXR • MRI of the abdomen and pelvis. • Occasionally examination under anaesthetic (EUA) may be needed. E Cervical cancer: diagnosis, p. 86.
Prognosis • No evidence that when early-stage disease is diagnosed in pregnancy the prognosis is worse than for non-pregnant women.
Management of cervical cancer in pregnancy • Should be managed by an experienced MDT. • Treatment will depend on: • gestational age at diagnosis • stage • size of the lesion • wishes for future fertility. Invasive (stages IA2, IB, and IIA) • No evidence that pregnancy accelerates the disease. • Disease-specific survival is independent of the trimester during which the diagnosis is made. • Careful counselling is required including the option of TOP (2wks following chemotherapy is best to allow time for the neutrophil count to recover prior to delivery • CD is required for obstetric indications only.
Non-Hodgkin’s lymphoma • Less common in pregnancy as it is more likely to occur in older individuals; however, AIDS-related non-Hodgkin’s lymphoma is an i problem particularly in low-income countries. • Treatment principles are similar to that of Hodgkin’s lymphoma.
Benign and malignant tumours in pregnancy
Leukaemia • Incidence is between :75,000 and :00,000, but is i. • Acute leukaemias are the most common: • acute myeloid leukaemia accounts for 2/3 of cases.
Presentation • Acute leukaemia usually presents in the 2nd and 3rd trimesters. • Common symptoms including: • fatigue • fever and night sweats • breathlessness • weight loss • i bruising or bleeding • lymphadenopathy • frequent infections.
Diagnosis • Blood film and bone marrow biopsy.
Management of acute lymphocytic leukaemia in pregnancy H It is both possible and appropriate to treat acute lymphocytic leukaemia in pregnancy. • In the st trimester, discussion about TOP should be undertaken given the importance of adequate treatment and the high chance of maternal and fetal morbidity if not. • Very steroid responsive: • high-dose steroids for –2wks may prolong the pregnancy to a more favourable gestation for delivery. • There are a variety of chemotherapeutic agents used as part of induction, consolidation, and maintenance regimens. • Intrathecal therapy is often used (as is methotrexate, but H contraindicated in pregnancy).
Acute promyelocytic leukaemia • Type of acute myeloid leukaemia associated with DIC and bleeding complications. • Treatment with all-trans retinoic acid (ATRA) should be started as soon as possible. H ATRA not advised in the st trimester due to teratogenicity so TOP versus continuation must be discussed. H If continuing with the pregnancy, an anthracycline should be used and ATRA initiated in the 2nd trimester.
Management of acute myeloid leukaemia in pregnancy Tyrosine kinase inhibitors for those who are BCR-ABL (‘Philadelphia chromosome’) +ve, are advised against in pregnancy.
st trimester • TOP should be discussed to facilitate the early commencement of optimal treatment. 2nd and 3rd trimesters • Decision for treatment and delivery needs to be individualized. • Delivery of a pancytopenic mother is undesirable therefore where possible induction treatment should be commenced with an elective delivery after the mother has recovered. • A standard induction regimen can be used (daunorubicin and cytarabine ‘3 +0’ schedule). Other therapies • High-dose steroids: • no dose adjustment required • monitoring for hyperglycaemia should be commenced. • Antifungals: • amphotericin B is considered the safest antifungal in pregnancy and is recommended if treatment is required. • Prophylaxis for Pneumocystis jirovecii: • co-trimoxazole (trimethoprim and sulfamethoxazole) can be used in pregnancy (after the st trimester). • Antivirals: • aciclovir can be used in pregnancy if indicated. • Blood products: • should be CMV −ve and irradiated. • DVT prophylaxis: • should be prescribed to all pregnant women with an active malignancy. Delivery considerations • Timing depends on gestation and chemotherapy plans. • Delay of >2wks following chemotherapy is best to allow time for the neutrophil count to recover prior to delivery. • CD is required for obstetric indications only. • Anaesthetic input is important as regional analgesia and anaesthesia may be contraindicated in the presence of significant neutropenia, thrombocytopenia, or coagulopathy. • Active management of the 3rd stage is advised due to the i risk of bleeding. • Paediatric team should be informed and present at delivery.
Further reading British Society for Haematology (205). Management of AML in pregnancy. M https://b-s-h.org.uk/guidelines/guidelines/management-of-aml-in-pregnancy/
Benign and malignant tumours in pregnancy
Malignant melanoma • Melanoma is one of the commonest cancers diagnosed in pregnancy. • Australian studies report an incidence of 45:00,000 pregnancies.
Presentation • Changes in skin pigmentation during pregnancy may make diagnosis more challenging. • 2/3 of melanomas occur in pre-existing naevi.
Diagnosis H Any suspicious lesions should be biopsied. • Excisional biopsy allows histological analysis and may be curative. • CXR, MRI, and CT may be used to assess for distant metastases, found most commonly in the lung and brain.
Management of melanoma in pregnancy • No evidence that the development of melanoma in pregnancy is associated with a worse long-term prognosis. • Surgery can be performed in pregnancy. • Sentinel node assessment using radioisotopes does not cause significant uterine radiation and can be performed in pregnancy if required. • Transplacental passage of melanoma can occur, resulting in a risk of metastatic melanoma in the fetus: • placenta should be sent for histology • paediatricians should be notified for neonatal assessment.
Metastatic disease • Pregnancy is associated with i lymphangiogenesis which is thought to contribute to i risk of lymphatic melanoma metastases. • Placental metastasis is rare and is only observed with widespread metastatic disease. • Associated with a 22% risk of neonatal metastatic melanoma which has a very poor prognosis. • It may also result in intrauterine death.
Prognosis • Despite an i incidence of nodal disease there is no evidence that pregnancy adversely affects survival of women with melanoma.
Ovarian cancer • Despite ovarian cancer being the 2nd most frequent gynaecological cancer in pregnancy, only 2–0:00,000 adnexal masses seen in pregnancy are malignant. • Histological distribution is similar to the non-pregnant population: • germ cell (6–40%) • borderline (2–35%) • epithelial (28–30%) • sex cord stromal (9–6%).
Diagnosis • Based on removal of the mass, inspection of the abdominal cavity and biopsy of any suspicious lesions. E Benign ovarian tumours: imaging, p. 784, and E Benign adnexal masses, p. 480.
Management of ovarian cancer in pregnancy Borderline tumours • Management similar to non-pregnant women. • Aim for vaginal birth with surgical management in the postpartum period. Non-epithelial tumours • Often large and symptomatic. • Surgery involves unilateral salpingo-oophorectomy with full peritoneal staging. Epithelial tumours • Management depends on stage at presentation. • MDT involvement is essential. • Treatment for stage I disease is similar to non-pregnant women: • adnexectomy with full peritoneal staging. • Those with high-risk stage I disease should be offered adjuvant chemotherapy. • Those with advanced disease should be offered neoadjuvant chemotherapy and interval debulking surgery: • debulking surgery should take place as soon as possible • include the option of TOP • if TOP is declined, neoadjuvant chemotherapy should be given in the 2nd and 3rd trimesters, completing cytoreductive surgery after delivery. E Ovarian cancer: treatment, p. 828.
Further reading RCOG (20). Management of suspected ovarian masses in premenopausal women. Green-top guideline no. 62. M www.rcog.org.uk/globalassets/documents/guidelines/gtg_62.pdf
Benign and malignant tumours in pregnancy
Colorectal cancer • Occurs in ~:3,000 pregnancies.
Presentation • Most cases are diagnosed during the 2nd and 3rd trimesters. • Common presenting symptoms are bleeding (more frequent with rectal cancer) and abdominal pain. • 25% of cases present as an emergency with constipation, acute bowel obstruction, and perforation.
Diagnosis • Delay in diagnosis is common. • Symptoms can overlap those of pregnancy: • change in bowel habit • anaemia • abdominal distension • rectal bleeding (being attributed to haemorrhoids). • ~50% of women will have metastatic disease at diagnosis. • Colonoscopy can be performed safely during pregnancy and should not be withheld.
Management of colorectal cancer in pregnancy • Treatment is influenced by: • tumour location and stage • gestational age • context of the presentation, i.e. a surgical emergency. • If early stage and gestation, resection may be possible. • Neoadjuvant chemotherapy is advised for patients diagnosed with advanced disease at non-viable gestations. • Evidence regarding mode of birth is conflicting: • tumours may cause obstruction during labour and delivery by CS is often advocated.
Prognosis • Often present at a more advanced stage in pregnancy compared with non-pregnant women. • Patients diagnosed in the 2nd trimester have the worst survival: • may be due to delays in investigations and initiation of treatment in an attempt to prolong the pregnancy. • Outcomes have not improved over time.
Thyroid cancer • Prevalence: 4.4:00,000 births. • Papillary thyroid cancer is the most common histological subtype (75–80%). • The prevalence of thyroid nodules during pregnancy is between 3% and 2%.
Presentation • A hard, painless thyroid nodule is suspicious of malignancy.
Diagnosis • USS may reveal characteristic features of malignancy including: • irregular or indistinct borders • microcalcifications. H USS is not diagnostic. • Tissue diagnosis using fine-needle aspiration can be safely performed safely in all trimesters. • MRI is used for staging. • TFTs are usually normal in women with thyroid cancer.
Management of thyroid cancer in pregnancy • Surgery is the treatment of choice for differentiated carcinoma. • Radio-iodine should not be used as it destroys the fetal thyroid. • Small papillary carcinomas, with no spread to the cervical LNs, may be monitored with USS and surgery delayed until after delivery if there is no change in size or evidence of metastasis. • Surgery is the ° treatment modality for advanced disease and/or rapidly growing tumours. • 2nd trimester is the optimal time for performing surgery. • Limited data on the optimal management of medullary and anaplastic carcinomas, surgery is the preferred management. • Risk of maternal hypothyroidism and hypoparathyroidism after thyroidectomy should be anticipated. • Chemotherapy may be appropriate for distant metastasis.
Prognosis • Pregnancy does not appear to have any adverse effect on survival.
Substance misuse and psychiatric disorders Substance misuse in pregnancy 500 Morbidity and mortality 501 General principles of management 502 Alcohol misuse and dependency 504 Drugs of abuse: opiates 506 Drugs of abuse: cocaine 508 Drugs of abuse: stimulants 509 Drugs of abuse: benzodiazepines 510 Drugs of abuse: cannabis 511 Drugs of abuse: other 512 Perinatal psychiatric disorders 513 Depression 514 Anxiety disorders 516 Eating disorders 518 Other psychiatric disorders 519 Personality disorders and learning disabilities 520 Suicide and self-harm 521 Postnatal psychosis 522 Psychiatric medications: principles 524 Psychiatric medications: antidepressants 525 Psychiatric medications: other 526
Substance misuse and psychiatric disorders
Substance misuse in pregnancy The prevalence of substance abuse in the perinatal population is uncertain, arguably more so than in other populations. Reasons for under-identification may include reluctance to disclose amid fears of loss of custody. • Polydrug use is common and must always be considered. • i Risk of severe adverse outcomes for maternal and infant health. • Associated with: • social adversity including poverty, abuse, and loss of custody • tobacco smoking • psychiatric and medical comorbidities.
Implications for antenatal care • Substance misuse services are often separate from maternity services, predisposing to fragmented antenatal care. • Women often find it difficult to engage with optimal antenatal care, which further i the risks of adverse outcomes. • Screening for drug and alcohol misuse should be a routine part of antenatal care.
Definitions relating to substance abuse • Substance misuse disorders are categorized in the International Classification of Diseases, 11th Revision (ICD-11) under ‘Disorders due to substance use’. • Substances identified: alcohol, cannabis and synthetic cannabinoids, opioids, sedatives, cocaine, stimulants (amphetamines, cathinones), caffeine, hallucinogens, nicotine, volatile inhalants, MDMA, dissociative agents (ketamine, phencyclidine). The ICD-11 categorizes the pattern and consequences of misuse: • Intoxication: acute psychoactive of substance use. • Harmful use: pattern of use that damages health. • Dependence: disorder of regulation of use; physiological, behavioural, and cognitive features including physiological tolerance and withdrawal, craving, prioritization of use over other daily activities despite harm (usually for >12mths). • Withdrawal: characteristic acute psychological and physical features following cessation or administration of an antagonist. • Delirium: disturbed attention and acute confusion due to acute intoxication or withdrawal. • Psychosis: delusions and hallucinations due to intoxication or withdrawal from the substance. • Substance-induced mental disorders: such as mood or anxiety disorders or dementia.
Morbidity and mortality
Morbidity and mortality Adverse effects of substance misuse • Risks compounded by association with social deprivation, nutritional deficiency, and poor hygiene. • Worsens outcomes of comorbid health problems. • Association with other mental disorders which are a known risk factor for maternal mortality. • IV drug use is associated with: • transmission of blood-borne viruses (prevalence of hepatitis C 50– 80% and hepatitis B 30–50% in UK drug users) • VTE • SC abscess • bacterial endocarditis • sepsis • difficult venous access in emergencies. • Withdrawal effects may cause direct harm to the fetus and neonate.
Obstetric complications • Preterm labour. • Placental abruption. • Haemorrhage. • FGR and low birth weight. • Miscarriage, stillbirth, neonatal death.
Fetal and neonatal complications • Congenital abnormalities. • Neonatal adaptation syndrome: • irritability • hypertonia and hyperreflexia • agitation • feeding problems • poor sleep • seizures.
Social impact • Risks of abuse to and neglect of children must always be considered. • Formal child protection proceedings are usually required.
Death • In the UK in 2014–2016, 43 women died due to substance misuse; with a mortality rate of around 1.7 per 100,000. • This accounted for >1/3 of mental health-related deaths.
Substance misuse and psychiatric disorders
General principles of management Maternal management Pregnancy presents a unique opportunity for services to engage with substance misusers. The goal of management must be clear. Achieving lifestyle stability and ‘clean’ drug use may be more desirable and realistic for some (especially opiate users), while complete abstinence should be the goal for others (especially alcohol and stimulant users). Screening • All women should be screened at their booking assessment. Use of specific biomarkers is not routine in the UK; identification ultimately relies on: • self-reporting • index of suspicion in the clinician. • A detailed history of use of illicit drugs, tobacco, and alcohol should be taken, including: • frequency • route of administration • how use is funded. Antenatal management • Multi-agency care is required to address complex medical, psychological, and social problems which includes: • maternity services • 1° care • substance misuse services • mental health services • social care and 3rd-sector support services (housing, domestic abuse, child protection). • A lead clinician or care coordinator should be identified. • Flexible appointments should be offered to facilitate engagement with antenatal care. • Contraceptive advice should be offered. • Patient education to i awareness of the associated risks to health. Labour • Delivery in an obstetric-led unit is recommended. • Prior anaesthetic review due to potential difficulties with IV access.
Fetal and neonatal management • Detailed anomaly USS: • consider fetal echo where appropriate. • Serial USS due to i risk of FGR. • Neonatal review even if the baby is not admitted to the special care baby unit.
General principles of management
Substance misuse and psychiatric disorders
Alcohol misuse and dependency • Up to 20% of pregnant women may drink more than the recommended limit, and up to 3% are dependent on or misusing alcohol. • Alcohol is teratogenic. • Complete abstinence is the 1° goal of management. • Acute alcohol withdrawal risks serious morbidity and mortality including delirium tremens, seizures, and miscarriage. • Gradual detoxification using long-acting benzodiazepines such as diazepam or chlordiazepoxide should be offered. • Detoxification should be under medical supervision in pregnancy due to i risks of complications including seizures.
Screening in pregnancy • This should be a core component of routine antenatal care. • T-ACE, AUDIT (or the abbreviated AUDIT-C), and TWEAK have been validated and recommended for use in pregnancy.
Maternal effects of alcohol misuse • Miscarriage. • Preterm labour. • More likely to need induction of labour or CD. • Associated with poor engagement with antenatal care.
Infant effects • Low birthweight. • Neonatal intensive care admission. • Fetal alcohol syndrome. • Stillbirth (related to placental dysfunction with heavy intake).
Treatment • • • •
Psychosocial interventions and detoxification to achieve abstinence. Motivational interviewing can d consumption in pregnancy. Evidence of benefit of engaging with regular antenatal appointments. Drugs for maintenance treatment, including. acamprosate and disulfiram, not recommended in pregnancy due to lack of safety data.
Alcohol misuse and dependency
Fetal alcohol syndrome • Spectrum disorder arising in a dose-dependent fashion. • It is not known how much alcohol causes fetal alcohol syndrome, only complete abstinence guarantees no risk. • Usually only severe cases are identified. • Classic triad of symptom clusters: • FGR • CNS problems: developmental delay, and behavioural, learning problems, soft neurological signs such as motor skill problems • craniofacial abnormalities: micro-ophthalmia, short palpebral fissure, short nasal bridge, microcephaly, thin upper lip and small philtrum, oral cleft, maxillary hypoplasia.
Management of pregnancy in women abusing alcohol • Attempt to d harm by: • counselling about risks • encourage antenatal attendance by providing supportive, non- judgemental environment • facilitating contact with specialist substance misuse services including Alcoholics Anonymous (AA) • screening for abuse • facilitating access to social services and support agencies. • Detailed anomaly USS. • Serial USS to assess growth and fetal health. • Multidisciplinary management with involvement of maternity, paediatric, social services, and specialist alcohol services. • May need child protection proceedings.
Substance misuse and psychiatric disorders
Drugs of abuse: opiates Opiate drugs • All are potentially drugs of misuse. • Include prescribed (primarily for analgesia) and illicit drugs. • Natural opiates derived from the opium poppy include codeine and morphine (and its prescribed derivative, oxycodone). • Synthetic opioids include methadone, fentanyl, and tramadol. • Act on endogenous opioid receptors.
Routes of administration • Route depends on the drug and the person’s pattern of misuse. • Can be smoked, taken orally or intranasally, or be injected.
Effects of opiates • Acute intoxication: euphoria, analgesia, sedation, respiratory depression, nausea and vomiting, hypotension, pupillary constriction. • Dependency: following regular use over a period of wks. • Withdrawal: range from mild (rhinorrhoea, lacrimation, sweating, yawning, myalgia, arthralgia) to severe (diarrhoea, dysphoria, insomnia, agitation, piloerection, and shivering). • Drugs with a shorter half-life are more prone to misuse and produce a withdrawal syndrome more quickly. • Heroin withdrawal symptoms arise 4–12h post-dose, peak at 48–72h, and subside after 7–10 days. • Withdrawal can be distressing but is not life-threatening.
Effects on pregnancy • i Risk of APH and preterm labour. • Withdrawal risks miscarriage and premature labour. • Higher analgesic doses intrapartum and postpartum may be needed. • Monitoring of opiate toxicity required with i doses.
Effects on infants Not thought to be teratogenic. • Opiate misuse often associated with multiple other risk factors. • i Risk of FGR, stillbirth, and neonatal death. • Neonatal withdrawal usually occurs within 48h of birth. • Withdrawal includes irritability, exaggerated startle response, jitteriness and tremors, poor feeding, and hypotonicity. • Severe withdrawal can be fatal in neonates. • May require admission to intensive care for IV methadone to prevent acute withdrawal.
Drugs of abuse: opiates
Maintenance treatment • Methadone (opioid receptor agonist) or buprenorphine (opioid receptor partial agonist) available. • Both have longer half-life than heroin, with more stable plasma levels, allowing once-daily dosing without acute withdrawal. • Outcomes better for mothers and infants if enrolled in substitute prescribing programme compared to women not in treatment. • Maternal mortality and morbidity are d. • d Use of illicit or IV opiates. • d Exposure to impurities with illicit opiates. • Avoidance of lifestyles associated with illicit drug use. • i Contact with healthcare services.
Management of pregnancy in women abusing opiates • Attempt to d harm by: • counselling about risks • offering substitute prescribing to reduce use of illicit opiates • encourage antenatal attendance by providing supportive, non- judgemental environment • facilitating contact with specialist substance misuse services including Narcotics Anonymous (NA) • screening for abuse • facilitating access to social services and support agencies. • Screening for blood-borne viruses. • Low threshold for antibiotics with symptoms of sepsis (may be atypical pathogens). • High index of suspicion for VTE symptoms (may be unusual sites). • Detailed anomaly USS. • Serial USS to assess growth and fetal health. • Multidisciplinary management with involvement of maternity, paediatric, anaesthetics (difficult IV access), social services, and specialist addiction services. • Will probably need child protection proceedings. • Advice about breast-feeding will need to factor in other drug use, infection with blood-borne viruses, and lifestyle factors. • Advice about postnatal contraception.
Substance misuse and psychiatric disorders
Drugs of abuse: cocaine Routes of administration • Intranasal is the major route. • IV use (including ‘speed-balling’ with heroin) has high mortality. • Crack, the free alkaloid base of cocaine, can be smoked or injected.
Effects of cocaine • Stimulant effects through monoamine (serotonin, noradrenaline, and dopamine) reuptake inhibition in the CNS. • Sympathomimetic effects include tachycardia, i BP, vasoconstriction, and sweating. • Psychoactive effects include euphoria and anorexia. • Harmful effects arise due to overstimulation of CNS and sympathetic nervous system include stroke, myocardial infarction, arrythmias, psychosis, anxiety, agitation, and anorexia. • Crack is more addictive with a more intense high, and is associated with more chaotic lifestyles and social adversity than cocaine.
Effects of cocaine on pregnancy • Harm arises from placental vasoconstriction and teratogenicity. • Vasoconstriction leads to pre-eclampsia and placental abruption. • Maternal mortality is i due to cerebrovascular complications (intracranial bleed and emboli), and cardiac arrhythmias. • Downregulation of myometrial β-adrenoreceptors may cause miscarriage, uterine irritability, and preterm labour.
Effects on infants • Teratogenicity: especially microcephaly and cardiac defects. • FGR due to placental dysfunction. • Neonatal effects: • neonatal adaptation syndrome or a limited withdrawal syndrome may occur • hypotension and cardiac arrhythmias • sudden infant death • neurodevelopmental delay.
Management of pregnancy in women abusing cocaine • Attempt to d harm by: • counselling about risks • encourage antenatal attendance • facilitating contact with specialist substance misuse services • facilitating access to social services and support agencies. • Detailed anomaly USS, serial USS with cardiac USS at 23–24wks. • May need child protection case conference. • No substitute prescribing is available for cocaine.
Drugs of abuse: stimulants
Drugs of abuse: stimulants General principles • Drugs include: • amphetamines (including methamphetamine, ‘crystal meth’) • MDMA (‘ecstasy’). • Stimulant drugs are sympathomimetic. • Psychoactive effects derived from activation of CNS dopaminergic, serotonergic, and noradrenergic pathways. • Amphetamines may also be used an appetite suppressant.
Routes of administration Can be smoked (crystal meth), taken orally, intranasally, or IV.
Effects in pregnancy • Limited evidence base for effects in pregnancy. • Misuse associated with other maternal and infant risk factors. • Unclear relationship with congenital abnormalities. • Neonates may show hyperactivity and poor feeding. • May i risk of miscarriage, preterm labour, and FGR.
Substance misuse and psychiatric disorders
Drugs of abuse: benzodiazepines General principles • Benzodiazepines are effective in a range of neurological and psychiatric conditions such as anxiety, agitation, insomnia, and epilepsy. • Dependency can arise within wks of regular use. • Act on γ-aminobutyric acid (GABA)-A receptors and enhance response to GABA, the predominant inhibitory neurotransmitter in the CNS.
Routes of administration • Illicit or recreational use is predominantly oral. • Medical use can be oral, IM, IV, or SC.
Effects • Sedation is the most prominent acute effect. • Drug half-life dictates its use. • Lorazepam and midazolam (half-lives 24h) can be used as an anxiolytic and for alcohol detoxification. • Tolerance can quickly develop. • Withdrawal syndrome, as with alcohol, is driven by CNS excitation. • Withdrawal symptoms include agitation and insomnia, with seizures and delirium tremens in severe cases.
Effects in pregnancy • Limited research means it is not known how much exposure is required to i the risk of congenital abnormalities. • Oral cleft from 1st-trimester use found in early studies. • More recent evidence indicates antenatal benzodiazepine use unlikely to be associated with congenital malformations. • May be specific associations, e.g. lorazepam and bowel atresia. • Neonatal withdrawal may arise from late-pregnancy exposure. • ‘Floppy baby syndrome’, with feeding and breathing difficulties, may arise from intrapartum use. • Long-term effects of benzodiazepines on the infant are not known.
Management in pregnancy • Sudden cessation not advised for regular users, just as with alcohol. • Short half-life drugs should be switched to diazepam for more stable plasma levels, enabling a more gradual withdrawal.
Drugs of abuse: cannabis
Drugs of abuse: cannabis General principles • The most commonly used illicit drug across the world. • Usually smoked but can be ingested in food or drinks.
Maternal and infant effects • Direct effects are difficult to study as the majority of users smoke cannabis with tobacco (often without filters). • Long-term use, especially in adolescence and early adulthood, is associated with an i risk of developing psychotic disorders including schizophrenia, in those predisposed. • Possible association with low birth weight and preterm labour.
Management • There is no replacement therapy. • Nicotine replacement therapy may constitute a key intervention. • Harm reduction advice centres on reducing use with tobacco.
Tobacco • Rates of cigarette smoking are declining but it remains a major cause of maternal and infant morbidity. • Smoking is associated with a range of adverse outcomes: • miscarriage • placental abruption • low birth weight • neonatal death • sudden infant death syndrome (‘cot death’). • Women should be advised to stop or at least d smoking: • specialist smoking cessation advisers should be available • nicotine replacement therapy can be used in pregnancy.
Substance misuse and psychiatric disorders
Drugs of abuse: other Hallucinogens • Common hallucinogens include: • psilocybin (active substance in ‘magic mushrooms’) • mescaline (from the peyote cactus) • lysergic acid diethylamide (LSD) • ketamine. • Very little data available on their effects in pregnancy. • Misuse associated with other maternal and infant risk factors.
Volatile substances (‘glue sniffing’) • Inhalation of solvents and adhesives, including: • toluene • acetone • petrol • cleaning fluids • aerosols. • Often associated multiple other risk factors. • Can cause sudden death from respiratory depression and arrhythmia. • Animal studies indicate teratogenic effects in pregnancy.
Perinatal psychiatric disorders
Perinatal psychiatric disorders Overview • Perinatal disorders may be new-onset or pre-existing conditions persisting or recurring in the perinatal period. • Perinatal illness rates are similar to non-perinatal female populations. • Key distinguishing features of perinatal disorders are greater management complexity and the impact of illness.
Effects on broader health • i Rates of obstetric illnesses and adverse outcomes are associated with psychiatric morbidity, including persistent hyperemesis, pre-eclampsia, GDM, FGR, preterm labour, and placental abruption. • Relationships between different conditions are highly individual; the evidence does not support causal relationships. • Risk of adverse outcomes is further compounded by association with risk factors such as smoking, substance misuse, and poverty. • Women with multimorbidity have complex health and social needs, requiring integrated care from multiple specialists and services.
Effects on the family • Risk of adverse child outcomes (physiological, psychological) i with maternal mental illness but most do not suffer harm. • Maternal mental illness can affect children via biological (e.g. genetics, antenatal nutrition, hypothalamic–pituitary–adrenal axis dysfunction), psychological (e.g. attachment and parenting styles), and social (e.g. family support, socioeconomic resources) mechanisms. • Parent–infant psychosocial interventions may be required, although the evidence base for these interventions is limited.
Importance of screening • Universal availability of maternity and universal health services in developed nations enables systematic population-based screening. • There are a range of validated and practicable screening tools available to detect common mood and anxiety disorders. • Routine screening should also include a basic history of personal and family mental illness and substance misuse.
Planning pregnancy • Preconception planning can help identify relapse triggers and early warning signs. • Rationalizing psychotropic medication can reduce fetal risks.
Further reading NICE (2014, updated 2020). Antenatal and postnatal mental health: clinical management and service guidance. Clinical guideline [CG192]. M www.nice.org.uk/CG192
Substance misuse and psychiatric disorders
Depression • Prevalence in perinatal population is 10–15% (3% severe). • Most common complication of pregnancy and the postpartum. • Clinical features must persist for at least 2wks for a diagnosis: • core symptoms: low mood, anhedonia, and low energy • somatic symptoms: impaired sleep, concentration, appetite • cognitive symptoms: hopelessness, helplessness, poor self-esteem, guilt, suicidality • psychotic symptoms: in severe cases. • Depression is categorized by severity (mild, moderate, severe), which is determined by: • the number of symptoms • degree of functional impairment • associated risks (especially suicide). • Functional impairment may distinguish depression from sadness. • Associated adverse pregnancy outcomes include: • low birth weight • preterm delivery. • Associated adverse infant outcomes include developmental behavioural and emotional disorders. • Depression is, for the majority of patients, a recurrent illness. • Early identification of women with antenatal depression may help d the prevalence and impact of postnatal episodes. • The evidence that postnatal depression represents a separate clinical entity to non-perinatal or antenatal depressive disorder is equivocal. • It is probably as common antenatally as it is postnatally. • There does seem to be a pattern of postnatal recurrences in multiparous women with previous postnatal episodes.
Postpartum ‘baby blues’ • >50% of women experience brief emotional instability and mood disturbance starting around 3 days after delivery and resolving spontaneously within 10 days. • It may initially be difficult to distinguish baby blues from depression, but the time course and severity of the conditions differ markedly. • Severe baby blues is associated with progression to clinical depression. • Clinical treatment is not usually indicated for baby blues.
Screening for depression • A history of depression is the most significant risk factor for perinatal depression. • Asking about psychiatric history is routine for all women at their booking assessment. • NICE recommends the use of the Whooley depression screening tool, which can be administered quickly and can be used at any clinical encounter: • during the past month, have you often been bothered by feeling down, depressed, or hopeless? • during the past month, have you often been bothered by having little interest or pleasure in doing things? H Answering yes to either question results in a positive screen. • Other screening questionnaires like the Edinburgh Postnatal Depression Scale (EPDS) are also helpful in identifying postnatal depression, and are routinely used by health visitors in many services.
Substance misuse and psychiatric disorders
Anxiety disorders • ‘Anxiety’ is not a diagnosis but an umbrella term that includes disorders, symptoms, and normal emotions. • Range of disorders that share common symptoms. • Anxiety symptoms are: • cognitive: intense fear, worry, ruminating • somatic: palpitations, shortness of breath, sweating, shaking, agitation; driven by autonomic arousal. • Prevalence rates are between 1% and 10%, depending on the locality and disorder. • Highly comorbid with mood disorders. • Associated with adolescent mental disorders. • Generalized anxiety disorder (GAD): • most common anxiety disorder • persistent symptoms for at least 6mths. • Panic disorder: • symptoms more intense than GAD, with recurrent, brief, acute episodes (there may be no anxiety in between). • Phobias: • symptoms arise in the presence or anticipation of a feared stimulus, l functionally impairing avoidance behaviours • tokophobia, fear of childbirth, may be so significant it may constitute an indication for elective CD • needle phobia can impact antenatal and intrapartum care, and in severe cases mental capacity legislation may be invoked to administer essential parenteral treatment. • Obsessive–compulsive disorder: • repetitive, distressing, irrational thoughts, or acts centring on a fear of something bad happening • often exacerbated in pregnancy. • Health anxiety disorders (somatoform or somatic symptom disorders): • associated with excessive healthcare-seeking behaviour • iatrogenic harm may occur through excessive investigations or treatments. • Post-traumatic stress disorder: • can arise from any traumatic experience, including birth trauma • may affect future family planning and engagement with antenatal and intrapartum care • symptoms include reliving experiences (flashbacks, nightmares), hyperarousal (agitation, irritability, poor concentration, insomnia), and avoidance of reminders of the event.
Screening for anxiety disorder • NICE recommends routine screening for GAD. • As with depression screening, this can be administered quickly at any clinical encounter: • During the past 2wks: • have you been bothered by feeling nervous, anxious or on edge? • have you been bothered by not being able to stop or control worrying? • Answers score 0–3, depending on persistence of symptoms. • Scoring ≥3 is usually an acceptable cut-off for diagnostic assessment.
Substance misuse and psychiatric disorders
Eating disorders Eating disorders are often comorbid with other mental disorders: • Depression. • Obsessive–compulsive disorder. • Substance misuse. • Personality disorder.
Anorexia nervosa • Characterized by: • body image disturbance • food avoidance • severe low weight.
Bulimia nervosa • Characterized by: • recurrent episodes of binge eating • compensatory behaviours such as self-induced vomiting and purging through use of diuretics and laxatives.
Binge eating disorder • Similar to bulimia nervosa but without the compensatory behaviours (patients are usually overweight).
Risks in pregnancy • Adverse neonatal outcomes as a result of: • d food intake • low maternal weight • recurrent vomiting and purging. • Eating disorders are associated with: • FGR • low birth weight • prematurity • congenital anomalies. • Pregnancy may constitute a protective factor against eating disorder behaviours, but the inevitable body changes in the perinatal period may be exacerbate eating disorder cognitions, which may lead to compensatory behaviours postnatally. • Close antenatal monitoring is required: • monitoring weight and food intake may need careful negotiation with the woman • specialist eating disorder services may need to be involved in more severe cases.
Other psychiatric disorders
Other psychiatric disorders Bipolar affective disorder • Relapsing–remitting illness characterized by recurrent episodes of depression and mania (bipolar I) or hypomania (bipolar II). • Affects ~1% of women of childbearing age. • Mania: severe mood elation or irritability with somatic (d sleep, psychomotor agitation, i energy) and cognitive (i self-esteem, grandiosity) symptoms and psychosis. • Mania lasts >1wk, hypomania is milder and shorter lasting. • Mania and hypomania can lead to reckless and dangerous behaviour. • Between episodes patients can remain well for substantial periods. • Childbirth is a significant risk factor for relapse. • At least 25% may relapse postnatally. • All pregnant women with bipolar affective disorder should have their treatment plan reviewed by a psychiatrist as early as possible.
Schizophrenia and schizoaffective disorders • Relapsing–remitting or chronic psychotic illness. • Not clear how relapse rates are affected in the perinatal period. • In schizoaffective disorders, psychoses coexist with mood disorders. • Schizophrenia is associated with d fecundity and fertility. • Clinical features during child-bearing age are usually dominated by ‘positive psychotic symptoms’: • abnormal beliefs (delusions) • abnormal perceptions (hallucinations). • Important to elicit the place of the baby in the symptoms. • Perinatal psychoses are associated with difficulties in meeting the baby’s needs—child protection proceedings are usually necessary. • Maintenance treatment with antipsychotics is usually required. • All women with schizophrenia in the perinatal period should be under psychiatric care. • Multimorbidity and risk factors for adverse outcomes are common in people with schizophrenia, e.g. smoking, obesity, diabetes. • The lifetime risk of schizophrenia for a child with one affected parent is in the order of 10%.
Substance misuse and psychiatric disorders
Personality disorders and learning disabilities Personality disorders • There are several different personality disorders and it remains a contentious diagnosis. • Diagnosis is determined by the dominant personality traits. • Features must be evident in formative years, persist, and lead to pervasive intra-and interpersonal and social difficulties. • Often comorbid with mood, anxiety, and substance misuse disorders. • Associated with social adversity, especially past or current abuse. Emotionally unstable personality disorder • Most common personality disorder in clinical settings (borderline personality disorder is a subtype). • Twice as common in women as men. • Population prevalence estimated at ~5%. • Emotionally unstable personality disorder features include: • emotional volatility • unstable relationships • low self-esteem • recurrent threats or acts of self-harm. • Anxious-avoidant, dependent, and obsessive personality disorders are also common. • Psychotropic drugs are often prescribed to treat symptoms but the evidence for this is weak; there are no licensed drug treatments. • Psychological treatments available, with mentalization-based therapy and dialectical behavioural therapy having robust RCT evidence, but access often very limited.
Learning disabilities and autism spectrum disorders • These are separate diagnostic categories but they often coexist in people with one or other of these conditions, especially severe autism spectrum disorder. • Patients may have specific communication and behavioural needs. • Commonalities in management of both conditions. • Specialist input may be required to facilitate antenatal care. • Ability to maintain independent living skills, parenting capacity, and mental capacity to consent to interventions (and even sexual intercourse) may need to be assessed (usually by specialist teams). H Women with these conditions may be vulnerable to exploitation; safeguarding for the mother and baby must always be prioritized.
Further reading WHO (2022). International Classification of Diseases, 11th Revision. M https://www.who.int/classifications/classifi cation-of-diseases
Suicide and self-harm
Suicide and self-harm Suicide in the perinatal period Evidence of this comes from mainly from the UK Confidential Enquiry into Maternal Deaths reports. • Latest data show a mortality rate of 4.57 per 100,000 from mental health-related causes (mainly suicide and substance misuse). • Suicide is the 3rd highest cause of early postnatal and the highest cause of late postnatal death (2018), with 2.9 per 100,000 births. • Majority of suicides occur postnatally, mostly by hanging or overdoses, while pregnancy appears to be protective. • Most common psychiatric associations are depressive and substance misuse disorders. • Unlike mental disorders in general, suicide seems to be more common in socially privileged women. • Suicide is also associated with: • psychosocial adversities (chaotic lives, abuse, emotional instability, pregnancy, or custody loss) • inadequate antenatal care. • Infanticide is extremely rare but such thoughts should be explored in women presenting with severe mood or psychotic illness.
Self-harm in the perinatal period • Motivation varies between individuals and incidents. • Self-harm is commonly deployed as a maladaptive coping strategy for distress and a means of regulating unstable and extreme emotions. • How the patient came to the attention of medical services following self-harm is often highly informative of intent and further risk. • Incidents are often impulsive. • Self-harm is often a recurrent behaviour. • Overdosing and cutting are the most common methods. • More violent methods such as hanging or jumping from a height may be associated with greater suicidal intent. • A history of self-harm is common in people who complete suicide.
Substance misuse and psychiatric disorders
Postnatal psychosis H This is a descriptive rather than diagnostic term.
Presentation • Early postnatal period represents the highest risk period for the onset of severe illness across a woman’s life span. • The highest risk of onset is on day 1 after delivery. • Episodes usually have prominent mood symptoms; they are usually affective rather than schizophreniform psychoses. • Content of psychosis will often involve the baby or motherhood. • Risk to the baby usually arises through neglect or accidental harm; desire or intention to harm the baby is extremely rare. • Aim to manage the mother with her baby, under close supervision. • Rapid symptom evolution over hours, while most psychotic illnesses evolve over wks–mths. • NICE guidelines regard suspected postnatal psychosis as an emergency and recommend that women be assessed within 4h. • Confusion is often present—delirium is a key differential diagnosis and investigations for organic aetiology should be considered. • Early warning signs may be non-specific, e.g. severe sleep deprivation, agitation, and severe anxiety. • The UK Confidential Enquiry into Maternal Deaths highlights ‘red flag signs’: acute mental state change, pervasive sense of estrangement from baby and family, and thoughts or acts of violent self-harm.
Epidemiology • Incidence 1–2 per 1000 births. • Can arise in women without any identifiable risk factors. • Around 1/2 to 2/3 of women whose index episode was postnatal will have non-perinatal recurrences. • The only consistent obstetric association is primiparity. • Counsel about future pregnancies essential: >50% recurrence rate.
Risk factors • Bipolar affective disorder. • Previous episode of puerperal psychosis. • 1st-degree relative with either of the above factors.
Treatment and recovery Treatment plans must comprise biological, psychological, and social interventions; the timing of each intervention may vary, however. • Antipsychotic medication will be required. • The short-term prognosis is good, and most patients recover within a few months. • Setting for acute treatment depends on the risks presented to the mother and her baby, and the availability of family support. • Treatment should aim to keep mother and baby together; either at home or in a specialist mother and baby psychiatric hospital.
High-risk patients H A woman with bipolar affective disorder and a personal or family history of puerperal psychosis requires advance planning to mitigate the risk of postnatal psychosis. Management options include: • Prophylactic mood stabilizer (limited evidence for prevention). • Promoting sleep in early postpartum: consider hypnotics, infant feeding strategies, available family support. • Postnatal pain management. • Monitoring of mental state in the community. • Access to urgent assessment if early warning signs present.
Substance misuse and psychiatric disorders
Psychiatric medications: principles Psychotropic medications are increasingly commonly prescribed across the adult population. An estimated 10% of women of child-bearing age in the US are prescribed psychotropics, mostly antidepressants. Prescriptions are lower in Europe but on the increase. • All women on regular psychotropics should have their medication reviewed as pregnancy will affect the risk:benefit analysis. • Prescription must be with consent of the women making a fully informed choice. • Conduct individualized risk:benefit analyses; risks of medication weighed against the risks of undertreated mental disorder (in turn dependent on individual psychiatric history). • Sudden medication cessation without expert oversight is not advised. • All prescriptions are off-label; no drug is licensed in pregnancy or breast-feeding. • For mild non-psychotic disorders, non-pharmacological approaches such as cognitive behavioural therapy should be 1st-line; antidepressant efficacy is not superior to that of placebo. • Within drug classes there is little difference in absolute risks; drug choice should be guided by what has previously worked for the patient as well as the evidence base. • Switching medication solely due to purported risk profile risks undertreating mother while exposing the baby to another drug. • Risks from breastmilk exposure for most drugs likely much lower than antenatal exposure because placental drug levels are on average 5–10× higher than breastmilk. • More caution is required in prescribing medication for breast-feeding mothers of preterm babies. • Drug choice, especially postnatally, should factor in sedative effects and practicalities of caring for a newborn baby.
Evidence base for psychiatric medications in pregnancy • Evidence for safety profiles based on observational studies only. • Causation therefore cannot be determined, and confounding by indication is difficult to control. • Majority of research is antenatal. • Research in breast-feeding limited to small, uncontrolled studies and case reports often confounded by antenatal drug exposure. • There are few long-term studies. • Major long-term adverse outcomes are not known to be associated with most psychotropics; absence of evidence, however, does not imply evidence of absence. • Risk profiles must be put into context of baseline population risks of miscarriage (10–20%) and congenital malformations (2–3%). • Absolute risks are generally low, while relative risks are more variable—this must be carefully communicated to patients.
Psychiatric medications: antidepressants
Psychiatric medications: antidepressants 1st-line drugs for depressive and anxiety disorders, with consistent evidence of effectiveness in moderate and severe conditions.
Pregnancy • Overall, the absolute risk i of harm to babies seems small and the clinical significance unclear. • Selective serotonin reuptake inhibitors (SSRIs) have been most studied. • Unlikely to be teratogenic: • SSRIs (paroxetine, fluoxetine) may affect cardiovascular development. • Small absolute risk i of persistent pulmonary hypertension of the newborn associated with SSRIs: • from ~2/1000 to ~3/1000 • paroxetine most strongly associated and sertraline least. • Associated with neonatal abstinence syndrome: • evidence base for this is limited • seems to be benign and self-limiting for most babies. • Equivocal evidence of association with autism spectrum disorder: • the effect of confounding by indication cannot be ruled out.
Breast-feeding • Levels of drug in breastmilk can vary. • Most antidepressants are 50yrs, when persistent.
Box 14.1 How to do a speculum examination • Cusco’s bivalve speculum is more frequently used, but Sim’s speculum normally used in examination of pelvic organ prolapse. • Use a warm and well-lubricated speculum. • Part labia minora adequately with the left hand. • Insert speculum upwards and backwards (direction of vagina). • Advance into vagina fully (until it cannot advance any further). • Directly visualize as you open blades exposing cervix: only open enough to see cervix fully. • If cervix not seen: close blades, withdraw slightly, change direction (usually more anterior), and open again. • Speculum removal: ensure the blades are open while sliding over cervix, avoiding trapping it—watch what you are doing! • Blades should be closed at introitus, not trapping any vagina. Common problems to avoid • Obvious non-familiarity with the speculum: patients spot this a mile off and will automatically tense up. • Inadequate labial parting leads to inversion and pain (start badly and all patient confidence quickly disappears). • The speculum is only partially inserted ‘so as not to cause pain’: the cervix will usually not be seen, l repeated insertion. • Failure to find cervix 1st time: likely to be more anterior and closer to the introitus—pull back and move anterior as above. • Not watching for adequate opening of blades and continuing unnecessary wide opening. • Not having control of closure and pulling out a still-open speculum.
Gynaecological anatomy and development
Gynaecological examination General examination • Height and weight. • BMI (=weight (kg)/[height (m)]2): • H i risks with i BMI • General, e.g. signs of anaemia, thyroid disease.
Abdominal examination • Inspection: skin quality, abdominal distension, surgical scars (umbilical or Pfannenstiel), any visible masses or distension. • Palpation: • superficial palpation for guarding, tenderness, rigidity • deep palpation for any masses; if present determine if arising from the pelvis (‘can I get below the mass?’) • pelvic masses are compared to the equivalent sized pregnant uterus (e.g. 20/40 sized, firm, mobile fibroid uterus). • Percussion: dull if the mass is solid, tympanic if distended bowel, shifting dullness and fluid thrill in cases of ascites. • Auscultation: usually used postoperatively to detect bowel sounds.
Good practice for intimate examinations • Full explanation of procedure and reasons for it should precede examination. • Verbal consent should be obtained. • A trained chaperone is mandatory. H Do not use partners, friends, or children as chaperones. • The patient must be able to undress and dress in privacy and cover herself at all other times. • Any students or extra personnel present should be introduced and consent obtained for their presence before procedure. Further General Medical Council (GMC) guidance on intimate examinations can be found at: M http://www.gmc-uk.org
Pelvic examination • All equipment must be ready (speculum, KY jelly, swabs, cytobrush, pipelle, etc.) before the patient is exposed. • Position the woman: • dorsal (most common in gynaecological outpatient setting) • lithotomy (used for vaginal surgery, the feet suspended from poles) • Sim’s (examination of pelvic prolapse, type of the left lateral). • Inspection: describe any swelling, inflammation, skin changes, lesions, or ulceration seen anywhere on the vulva. • Do the same for the vagina and cervix once the speculum is passed. • Speculum examination: E Box 14.1 p. 533, for description of technique. Describe findings in vagina and on cervix. 2 Don’t forget to take any swabs required such as HVS for vaginal pathogens and flora or endocervical for Chlamydia and/or Gonorrhoea. • Bimanual (VE): see Box 14.2 for description of technique.
Box 14.2 How to do a bimanual vaginal examination • The lubricated index and middle fingers of the right hand are introduced into the vagina. The fingers of the left hand are on the abdomen above the symphysis pubis, and the uterus and adnexae are palpated between the two hands (‘bimanual palpation’). • Cervix: • consistency (soft and smooth or irregular and hard) • tenderness • external os (?open during miscarriage). • Uterus: • axis (anteverted, axial, or retroverted) • size (equivalent to gestational wks of a gravid uterus) • consistency (soft in a gravid uterus, firm, or hard with fibroids) • mobility (may be fixed in endometriosis/adhesions). • Adnexae: • normal ovaries are usually not palpable • any masses (cystic/solid) and describe approximate size. • Direct digital pressure into the fornices assesses tenderness. • Cervical excitation: is a specific sign elicited by moving the cervix laterally thereby stretching the fallopian tube on the side that you are moving the cervix towards (i.e. by moving the cervix to the right and the uterine fundus will tip to the left, stretching the right fallopian tube.) 2 Uterine masses usually move with cervix, ovarian masses do not. 2 Obese patients are usually difficult to palpate—consider ultrasound.
Gynaecological anatomy and development
Anatomy: female reproductive organs E Female pelvis, p. 10, for anatomy of the bony pelvis.
Vagina • Fibromuscular tube, 7–10cm long. • The cervix enters through the anterior wall. • In the resting state, the anterior and posterior walls are opposed.
Uterus • • • •
~8 × 5 × 3cm in size (non-pregnant). Composed mainly of smooth muscle. Divided into the corpus and cervix uteri. Cylindrical and joins the uterine cavity at the internal os and the vagina at the external os. • Anteverted in 80% of women (the remainder are retroverted or rarely axial).
Uterine (fallopian) tubes • 10cm long; lie in the upper part of the broad ligament. • Divided anatomically into: • isthmus (medial)—opens into the uterus at the ostia • infundibulum (lateral) with fimbrial end closely applied to the ovary • ampulla—in between (where fertilization takes place).
Ovaries • ~3 × 2cm during reproductive years. • Attached to the posterior surface of the broad ligament by the mesovarium. • Situated in the ovarian fossa at the division of the common iliac artery (the ureter runs immediately underneath). • See Fig. 14.1.
Supports of the uterus, vagina, and pelvic floor • Middle: • transverse cervical ligaments (cardinal ligaments) • pubocervical ligament • uterosacral ligaments. • Lower: • levator ani muscles and coccygeus • urogenital diaphragm • the superficial and deep perineal muscles with the perineal body. 2 Defects and weaknesses of these supporting structures due to fascial tearing and denervation during parturition and surgery can cause organ prolapse and problems with urinary incontinence.
Anatomy: female reproductive organs Mesovarium (ovarian ligament)
Corpus Ovary albicans Corpus luteum
Vagina Fig. 14.1 Basic coronal view of the female pelvis. Adapted from Pocock G, Richards C. (2004). Human Physiology: The Basics of Medicine, 2nd edn. Oxford: OUP. By permission of Oxford University Press.
Gynaecological anatomy and development
Anatomy: blood supply and relationship to other structures Blood supply Uterus • The uterine artery: • branches from the internal iliac • runs behind the peritoneum to enter the lateral border of the uterus, through two layers of the broad ligament • anastomoses with the ovarian and vaginal arteries. • The venous drainage is to the internal iliac vein. Ovaries • The ovarian arteries: • branches of the abdominal aorta from below the renal arteries. • The right ovary drains directly into the inferior vena cava. • The left ovary drains into the left renal vein. Vagina • Supplied by: • vaginal artery. • inferior vesical artery. • clitoral branch of the pudendal artery.
Urinary tract Ureters • Retroperitoneal throughout. • Enter the pelvis in the base of the ovarian fossa. • Run above the levator ani in the base of the broad ligament. • Insert into the bladder posterolaterally. H The ureters are very close to the uterine artery near the lateral fornix and can be injured at hysterectomy. Bladder • Lies anterior to the uterus. • Three layers: serous (peritoneal), muscular (detrusor smooth muscle), and mucosa (transitional epithelium). • Supplied by superior and inferior vesical arteries (internal iliac artery).
Rectum • Lies posterior to the uterus (separated from it by loops of small bowel lying in the pouch of Douglas). See Fig. 14.2. • A thin rectovaginal septum separates the vagina and rectum. • Supplied by superior, middle, and inferior rectal arteries (from the inferior mesenteric, internal iliac, and pudendal arteries respectively).
BLOOD SUPPLY AND RELATIONSHIP TO OTHER STRUCTURES
Lymphatic drainage of the pelvic organs • Vulva and lower vagina l inguinofemoral l external iliac nodes. • Cervix l cardinal ligaments l hypogastric, obturator, internal iliac l common iliac, and para-aortic nodes. • Endometrium l broad ligament l iliac and para-aortic nodes. • Ovaries l infundibulopelvic ligament l para-aortic nodes. H Knowledge of lymphatic drainage is important when considering metastatic spread from genital tract cancer.
Sacrum Fallopian tube Ovary Uterus Bladder
Cervical canal Rectum
Symphysis pubis Urethra Clitoris
Labium majus Labium minus
Fig. 14.2 Basic sagittal view of female pelvis demonstrating relationship to other pelvic organs. Adapted from Pocock G, Richards C. (2004). Human Physiology: The Basics of Medicine, 2nd edn. Oxford: OUP. By permission of Oxford University Press.
Gynaecological anatomy and development
Anatomy: external genitalia Perineum • The area inferior to the pelvic diaphragm can be divided into: • anterior urogenital triangle (pierced by the vagina and the urethra) • posterior anal triangle. • The superficial and deep perineal fascias are continuous with the labia majora and are attached: • anteriorly to the pubic symphysis • laterally to the body of the pubis. • The superficial perineal muscles are: • superficial transverse perineus • ischiocavernosus • bulbocavernosus.
Vulva The external genital organs are known collectively as the vulva and are composed of the mons pubis, labia majora and minora, and clitoris. • Labia majora: lateral boundary of the vulva from the mons pubis to the perineum. • Labia minora: • anteriorly join to cover the clitoris • posteriorly form the fourchette. • Clitoris: • composed of erectile tissue covered by a prepuce • supplied by a branch of the internal pudendal artery. • The vestibule: • lies between the labia minora and the hymen • the urethra lies anterior in the vestibule • posteriorly and laterally lie the vestibular or Bartholin’s glands. See Fig. 14.3.
Anatomy: external genitalia Mons pubis
Urethral orifice Vestibule Position of Bartholin’s gland
Labium minus Labium majus Vaginal orifice
Perineum Anus Fig. 14.3 External female genitalia. Reproduced from Collier J, Longmore M, Brinsden M. (2006). Oxford Handbook of Clinical Specialties, 7th edn. Oxford: OUP. By permission of Oxford University Press.
Gynaecological anatomy and development
Female genital mutilation: overview Female genital mutilation (FGM) is defined by the WHO and the United Nations (UN) agencies as ‘the partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons’ (see Table 14.1 for classification and Box 14.3 for complications). Table 14.1 Classification of FGM (WHO 2007) Type I
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy)
Partial or total removal of the clitoris and labia minora, with or without excision of the labia majora (excision)
Narrowing of the vaginal oriﬁce with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (inﬁbulation)
Unclassiﬁed: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterization
Box 14.3 Complications of FGM Immediate complications • Death. • Severe pain and shock.* • Haemorrhage.* • Infection including septicaemia. • Adjacent organ damage and genital swelling.* • Acute urinary retention.* Long-term complications affecting pelvic organs • Failure of wound healing. • Recurrent UTI and urinary calculus formation.* • Urethral obstruction and difficulty in passing urine. • Pelvic infections, BV, and abscess formation.* • Menstrual difficulties and associated infertility. • Dyspareunia and sexual dysfunction.* • Fistulae, mainly urinary and obstetric. Long-term impact on reproductive health • AIDS, HIV, and other blood-borne diseases. • Problems with pregnancy and childbirth.* • Psychological or psychiatric problems. * Common complications.
Female genital mutilation: management
Female genital mutilation: management The management of girls and women affected by FGM is really determined by the complication that they present with, principally: • Problems with sexual intercourse, menstrual flow, and/or micturition: de-infibulation under GA. • Problems during and/or following delivery: obstructed 2nd stage of labour and/or major tears or urethral injury—de-infibulation under local anaesthetic/regional block and/or appropriate repair. • Individual problems: such as infection, adjacent organ damage, and fistulae can be managed on an individual basis.
De-infibulation • Obstructing skin/scar divided in the middle. • Anterior/upward episiotomy in labour. • Incision extended until external urethral meatus visible. • Edges of incised surfaces freshened and sutured. • The urethra needs to be protected to avoid injury. • Extensive reconstruction may be needed in severe cases. • De-infibulation should be carried out by practitioners experienced in dealing with this problem. (E Female genital mutilation, p. 339.)
FGM overview • Deeply rooted cultural tradition in 30 countries, mainly in western, eastern, and north-eastern Africa, and in some countries in Middle East and Asia. • Highly complex social, religious, and political problem. • At least 200 million girls and women alive today have been subject to FGM, and >3 million estimated to be at risk for FGM annually. • Mostly carried out on young girls between infancy and adolescence, and occasionally on adult women. • May be carried out by a wide range of ‘practitioners’ mostly untrained with a variety of ‘instruments’. • Complications (E Box 14.3, p. 542) are common. • Management is related to the individual complications/presenting symptoms: usually de-infibulation. • Prevention of FGM is an ongoing major international human rights issue. H It is an illegal practice in the UK and most parts of the world including areas where it is commonly practised. H It is now mandatory to report new FGM in the UK as a criminal offence.
Gynaecological anatomy and development
Malformations of the genital tract: overview These congenital malformations range from asymptomatic minor defects to complete absence of the vagina and uterus. The prevalence is estimated to be as high as 3%.
Aetiology They arise from failure of the paramesonephric (Müllerian) ducts to form, fuse in the midline, or fuse with the urogenital sinus: • Complete failure to form: Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome. • Partial failure to form: unicornuate uterus. • Failure of the ducts to fuse together properly: • longitudinal vaginal septa • bicornuate uterus • uterus didelphys (complete double system). • Failure to fuse with the urogenital sinus: transverse vaginal septa. • Remnants of the mesonephric (Wolffian) ducts may be present as lateral vaginal wall or broad ligament cysts: usually trivial incidental findings and rarely of clinical significance. H Always look for renal and urinary tract anomalies (up to 40% coexistence).
Clinical features Presentation often depends on whether it causes obstruction of menstrual flow. • MRKH syndrome (vaginal agenesis): painless 1° amenorrhoea, normal 2° sexual characteristics, blind ending or absent vagina (dimple only). • Imperforate hymen: cyclical pain, 1° amenorrhoea, bluish bulging membrane visible at introitus. • Transverse vaginal septum: cyclical pain, 1° amenorrhoea, possible abdominal mass ± urinary retention due to haematocolpos, endometriosis due to retrograde menstruation, not all obstructed, may present with dyspareunia. • Longitudinal vaginal septa and rudimentary uterine horns: dyspareunia alone if no obstruction, but if one hemi-uterus or hemi-vagina is obstructed then i cyclical pain in the presence of normal menses ± abdominal mass from haematocolpos, and endometriosis. • Uterine anomalies (bicornuate uterus, arcuate uterus, uterine septa): often asymptomatic, incidental finding at CD, may present with 1° infertility, recurrent miscarriage, preterm labour, or abnormal lie in pregnancy ( a causal relationship with these conditions is controversial).
Malformations of the genital tract: overview
Embryology of the female genital tract in a nutshell • Genetic sex is determined at fertilization. • Fetal sex becomes apparent in the normal fetus by the 12th wk of development. • By the 6th wk of development the following structures start to appear either side of the midline: • genital ridges (induced by primordial germ cells from the yolk sac) • mesonephric (Wolffian) ducts (lateral to the genital ridge) • paramesonephric (Müllerian) ducts (lateral to the mesonephric ducts). • In the female fetus the mesonephric ducts regress. • The paramesonephric ducts go on to develop into: • the fallopian tubes (upper and middle parts) • the uterus, cervix, and upper 4/5 of the vagina (this results from the lower part of the ducts fusing together in the midline). • The lower 1/5 of the vagina develops from the sinovaginal bulbs of the urogenital sinus, which fuses with the paramesonephric ducts. • The muscles of the vagina and uterus develop from the surrounding mesoderm. 2 Development of male genitalia is instigated by a single transcription factor encoded on the Y chromosome (SRY gene). This leads to the differentiation of the gonad to a testis, and production of testosterone and anti-Müllerian hormone (AMH) with subsequent masculinization. In the absence of the SRY gene, fetus will develop female phenotype. 2 The mesonephric ducts also sprout the ureteric buds (which go on to form the kidneys and ureters) and caudally develop into trigone of the bladder. Hence, there is a close association between genital tract and urinary tract abnormalities.
Gynaecological anatomy and development
Malformations of the genital tract: management Investigations • A thorough history and examination are required. • Abdominal and transvaginal (TV) USS are invaluable (but TV may not be appropriate if not sexually active). • MRI is the gold standard, especially if complex surgery is planned. • EUA ± vaginoscopy, cystoscopy, and hysteroscopy may be required. • Karyotyping to exclude 46XY female (androgen insensitivity syndrome) if uterus and upper vagina are absent. H Renal tract USS ± IV urography should always be undertaken because of high incidence of related renal tract abnormalities.
Aims for the management of genital tract malformations • Minor anomalies usually need nothing more than reassurance, particularly if an incidental finding, as most are of no clinical significance. • Management should be a multidisciplinary approach including psychological help for the patient and her parents, as well as arranging correction of anomaly. • The aim of any treatment should be well defined.
Treatment • Imperforate hymen: easily corrected by a cruciate incision in the obstructive membrane. • Vaginal septa: should be removed surgically: • resection of longitudinal septa usually straightforward • transverse septa can be more complex, especially if high and thick, requiring surgical vaginoplasty. • Obstructive uterine anomalies should also be surgically corrected or removed: • usually performed laparoscopically • technically difficult so should only be performed in centres with expertise in this area. • MRKH syndrome: vaginal dilation is 1st-line treatment for creating a functional vagina. If this fails, surgical vaginoplasty can be performed by several techniques. Timing should be related to when sexual activity is anticipated. • Patients should be given information regarding their condition; support groups are often very helpful.
Malformations of the genital tract: management
Aims for the treatment of genital tract malformations • Creation of a vagina suitable for penetrative sexual intercourse. • Relief of menstrual obstruction and associated pain. • Prevention of long-term sequelae of endometriosis due to obstruction and retrograde menstruation. • Restoration or optimization of fertility wherever possible.
Gynaecological anatomy and development
Disorders of sex development Sex determination occurs in embryo, with female phenotype being the default setting. Male genitalia require testosterone to develop; the sex determining region gene (SRY) on the Y chromosome is responsible for development of testis, which in turn secretes AMH, causing regression of paramesonephric ducts. If any part of this process fails, resulting offspring may be genetically male, but phenotypically female. In 25% of disorders of sex development (DSDs) there are other congenital malformations or disorders. A full family history including consanguinity may be appropriate.
Causes of DSDs, classified according to karyotype 46XX karyotype • Virilizing forms of congenital adrenal hyperplasia (CAH). • Ovo-testicular DSD (previously termed true hermaphroditism). • Maternal virilizing condition or ingested drugs. • Placental aromatase deficiency. 46XY karyotype • Androgen insensitivity syndrome (AIS). • Defects of testosterone biosynthesis (e.g. 5α-reductase deficiency, 17β-hydroxysteroid dehydrogenase deficiency). • Swyer’s syndrome (pure gonadal dysgenesis). • Partial gonadal dysgenesis 2° to single gene mutations. • Leydig cell hypoplasia. Abnormal karyotype • Turner’s syndrome (45XO): aneuploidy or mosaicism. • XO/XY mixed gonadal dysgenesis.
Later presentations of DSDs • DSD is not synonymous with ambiguous genitalia; many conditions will present much later. • Androgen insensitivity, Swyer’s syndrome, and Turner’s syndrome often present with 1° amenorrhoea. • Although often associated with a degree of genital ambiguity, 5α- reductase deficiency and 17β-hydroxysteroid dehydrogenase deficiency may present with virilization at puberty.
Disorders of sex development
Family support See Box 14.4.
Box 14.4 Coping with a child with ambiguous genitalia The child with ambiguous genitalia at birth • Keeping parents informed and psychologically supported at a very difficult time is of prime importance. • Referral to a dedicated MDT is essential. • Pressure to decide on sex of rearing should not be allowed to interfere with giving time to allow parents to come to terms with their child’s condition or reach the correct diagnosis. • Parents must be full partners in allocation of sex of rearing. • Access to relevant support groups is invaluable. The intersex adult • Intersex advocates have recently begun to consider ‘normalizing’ practices such as genital surgeries at birth as undesirable, removing the patient’s own bodily autonomy and self-determination, unless the surgery is absolutely medically necessary for the comfort of the child. • A corollary of repeated surgical interventions during childhood is also associated with missing schooling, which can have negative effects on the patient’s education and social development. • Several different intersex organizations have parental guidance that may be helpful. Support groups • Androgen Insensitivity Syndrome Support Group (AISSG): M www.aissg.org • Living with CAH—CAH support group: M www.livingwithcah.com • DSD Families—information and support for families: M https://dsdfamilies.org • InterACT—advocates for intersex youth: M https://interactadvocates.org/ • OII-UK–Intersex in the UK. Handbook for parents: M https://oiiuk.org/746/handbook-for-parents/
Gynaecological anatomy and development
Ambiguous genitalia at birth Genitalia are said to be ambiguous when their appearance is neither that expected for a girl nor for a boy. Incidence is ~1:4000 births. The extent ranges from mild clitoral enlargement to micropenis with hypospadias. Never guess the sex of a baby. It may take wks to determine and requires MDT involvement led by a single clinician, usually a paediatric endocrinologist. A full family history, drug history, and whether the mother has experienced any virilization during pregnancy should be ascertained.
Examination • Presence of gonads in labioscrotal folds. • Fusion of labioscrotal folds. • Size of phallus and site of urinary meatus. 2 Findings can be scored using the External Masculinization Score, with investigation warranted by a specialist if the score is 1500mU/L or low LH/FSH. H Urinary or serum hCG—never forget pregnancy as a cause of amenorrhoea, even 1°. 2 Puberty can be induced with low-dose oestrogen (oral or patches) and growth hormone. This is a specialist area for a paediatric endocrinologist.
Delayed puberty and primary amenorrhoea
Management of delayed puberty • Referral to an appropriate specialist is critical. • Input may be required from endocrinologists, psychologists, and neurosurgeons. • Treatment will depend on diagnosis.
Gynaecological anatomy and development
Vaginal discharge: in childhood Vaginal discharge is the commonest gynaecological symptom in young girls and is often associated with itching or soreness. The history is usually from the carer, but the child should be engaged in the conversation and asked questions about her complaint, which should include: • Duration, frequency, and quantity of the discharge. • Colour and odour. • Blood staining. • Whether the child wipes ‘front to back’. • Use of bubble baths, soaps, washing powders. • Previously tried creams or ointments. Examination should be done carefully with the carer present. Frog- leg position or knee–chest position can be used and often seated in the mother’s lap can be most reassuring for the child. A cotton-tipped swab may be used to collect a sample of discharge, for microbiological assessment, from the posterior vulva. 2 If the discharge is bloodstained, particularly purulent or profuse, then EUA and vaginoscopy (with removal of any foreign body) are appropriate.
Differential diagnosis • Vulvovaginitis. • Foreign body (commonly small bits of toilet paper). • Trauma (including sexual abuse). • Rare tumours. • Skin disease.
Vulvovaginitis • Most common cause of vaginal discharge and soreness. • Often occurs when girl starts to be responsible for going to toilet. • Normally no specific organisms are isolated. • Treatment based on simple measures: • wiping front to back • avoidance of perfumed soaps, bubble bath, and biological washing powder for underwear • loose cotton underwear (avoid tights, leggings, and pants at night) • a simple emollient such as nappy cream may be helpful. H Antifungal, antibiotic, or steroid creams are unhelpful and may cause further irritation. • If these measures are unhelpful, a short course of oestrogen cream may be beneficial. • The symptoms always improve at puberty.
Vaginal discharge: in childhood
Sexual abuse H Always needs to be considered, but it is an area fraught with difficulty. Seek senior advice if you have any concerns. 2 Many chronically sexually abused girls show no signs on examination. • Inspection of the hymen can be misleading for inexperienced doctor as irregularities, notches, and hymenal tags can all be normal findings. • If STI is detected in a young girl it is normally an indicator of abuse, but not always. • If abuse is suspected, the child should be referred to a lead doctor responsible for child protection. • The child should be examined by most experienced doctor available; if possible, refer to a local dedicated centre. If abuse is suspected H It is your duty to disclose confidential information if there is an issue of child protection. H If swabs are to be useful medico-legally, set protocols for a chain of evidence need to be followed. Seek senior advice urgently.
Gynaecological anatomy and development
Vaginal discharge: in adolescence Vaginal discharge in adolescents may be: • Physiological leucorrhoea requiring explanation and reassurance only. • A foreign body, such as a retained tampon. • Due to any of the infections that affect adult women (E Sexually transmitted infections, p. 628).
The adolescent consultation The adolescent consultation differs from that of an adult patient as obtaining a history may be more complicated. • Usually the girl will be accompanied by a parent and unwilling to disclose information in front of them. • It is important to give her an opportunity to talk to you away from her parent; this may be easily achieved by asking the parent to sit outside for the examination. • Your manner should be frank and non-judgemental. • She may need advice regarding contraception, as well as treatment for her presenting symptom. 2 The girl may be very anxious about the examination and may be much more forthcoming with information once this is completed. 2 Always explain what you are going to do, as this helps to allay anxiety.
Sexually transmitted infections in adolescents • The rates of STIs in teenagers are i rapidly. • Teenagers are likely to have unprotected intercourse and are biologically more susceptible to infections than adults. H The risk of PID in a sexually active 15yr-old may be up to 10× that of a sexually active 25yr-old. H Always remember that a teenager having consensual sex may also be the victim of abuse.
Further reading The BASHH has specific guidelines for the treatment of infections and has a pro forma for consultations with the under 16s. M http://www.bashh.org
Vaginal discharge: in adolescence
Gynaecological anatomy and development
Dermatological conditions in children and adolescents Many dermatological conditions affect children and may well present on the vulva. Children will generally present with itching and soreness, with skin changes being noticed by a carer. Adolescents may be slow to present due to embarrassment and uncertainty of what are normal changes associated with puberty.
Labial adhesions • The labia minora stick together due to the hypo-oestrogenic state. • Usually asymptomatic: • noticed at nappy changing or bathing by the carer • occasionally may be associated with soreness (if an element of vulvovaginitis is present) or dysuria. • Usually resolves spontaneously at puberty with no long-term problems. • Treatment is not usually required. A short course of daily topical oestrogen cream can be useful if there is associated dysuria or pain. It may also be reassuring for the carer to see the adhesions disappear; however, they must understand that the adhesions are likely to reappear when treatment is stopped. • Surgery is not indicated, unless the adhesions persist after puberty. • USS to check for Müllerian structures can be offered for reassurance if the adhesions are severe.
Lichen sclerosus • Chronic inflammatory condition. • Occurs in ~1:900 prepubertal girls. • Usually presents with severe itching associated with dysuria and surface bleeding, but can be asymptomatic. • Shiny, white crinkly plaques are classically distributed in a ‘butterfly’ pattern around the anogenital area. The vagina is spared. • Diagnosis is usually by inspection alone in children. E Vulval dermatoses: lichen sclerosus, p. 790. H Rubbing and scratching by the child leads to telangiectasia, purpura, fissures, and bleeding, with possible 2° bacterial infection. This can wrongly lead to suspicions of sexual abuse. • Can be associated with other autoimmune diseases (careful examination is required for other signs of illness). • Treatment is symptomatic relief with use of topical corticosteroids. • Symptoms generally improve at puberty, although the condition will still be present. • Long-term follow-up is required (association with squamous cell carcinoma in adulthood).
Dermatological conditions in children and adolescents
Other common dermatoses found in young people Molluscum contagiosum • Caused by Molluscum contagiosum virus, a member of the poxviruses. • Common in nursery and primary school children. • Lesions are typically 1–5mm, shiny pale pink, domed papules with a central depression, found on the trunk and limbs, but anogenital spread is common. • Destruction of the papules is painful and can lead to scarring so is not recommended. • Resolves spontaneously in 6–18mths (but may take up to 3yrs). Irritant dermatitis • Trigger factor is dependent on age group: • urine and faeces in infants. • bubble bath, soap, and sand in toddlers and young girls • shampoo and shower gels in adolescents. • Check no 2° infection with Candida. • Advise avoidance of triggers and use of a simple barrier cream. Threadworms (pinworms) • Common in schoolchildren with poor hand hygiene. • Worms migrate from the anus and cause anogenital itching. • Skin is excoriated and sore and can have 2° infection. • Treat with systemic antiparasitic (such as mebendazole) and a local barrier cream. • Emphasize the need for improved hand washing to prevent reinfection. Eczema and psoriasis • May present on the vulva as part of a generalized condition. • Vulval ulceration: differential diagnosis: • aphthous ulcers • Behçet’s disease • Lipschütz ulcer • herpes simplex (in a young child, consider the possibility of abuse). Warts • In sexually active teenagers, human papillomavirus (HPV)-6 and -11 are most common. • In children, common cutaneous warts (HPV2) are found. • Most will resolve untreated within 5yrs (destructive treatments may be poorly tolerated in children, but may be useful). H Sexual abuse should be considered in children with anogenital warts, but vertical transmission can present up to 3yrs of age and transmission can occur from existing warts on the child’s fingers.
Gynaecological anatomy and development
Gynaecological disorders: in adolescence Following menarche there is a continuing change in pituitary–ovarian activity. Regular ovulatory cycles usually establish within 2–3yrs. If irregular cycles or menorrhagia persist after this time, then there may be an underlying disorder. H Vaginal examination should only be performed on sexually active and consenting adolescences, and only if it will add to the assessment.
Menstrual disorders E Chapter 15. Amenorrhoea E Menstrual disorders: amenorrhoea, p. 578. • 1°: • with no 2° sexual characteristics should be investigated by 14yrs • with 2° sexual characteristics by 16yrs. • 2°: • diagnosed after no periods for at least 6mths • eating disorders are common in this age group and, if missed, anorexia nervosa can have life-threatening complications. H Don’t forget pregnancy—talk to the girl privately. Oligomenorrhoea Normal puberty is associated with an i in insulin resistance. • If associated hirsutism or excessive weight gain, consider polycystic ovary syndrome (PCOS). • Weight loss should be strongly advised if overweight. • Long-term risks of insulin resistance and endometrial hyperplasia are harder to get across to adolescents. • Management can be with the COCP and advice regarding weight d. • Norethisterone can be taken (21 days with 1wk break). It is important to explain this is not licensed as a contraceptive. Menorrhagia • Try to get them to quantify loss in terms of pad soakage. • The COCP is very useful in this age group. • Tranexamic acid and mefenamic acid are also effective. • Acquired or congenital bleeding disorders can be present in 15%. Do not assume that heavy, painful periods, irregular menses, or pelvic pain are a physiological part of adolescence.
Gynaecological disorders: in adolescence
Ovarian cysts in childhood and adolescence Consider all types occurring in adults but with varying frequency (E Benign ovarian tumours: diagnosis, p. 782). • Simple unilateral, unilocular cysts are the most commonly found cysts in children and adolescents (most resolve spontaneously). • Complex/solid ovarian tumours are most likely to be germ cell in origin, most commonly benign cystic teratomas. H 10% of ovarian tumours in children are malignant. • Epithelial tumours account for 80% of adolescents: • associated with an early menarche and menorrhagia • has a significant effect on schooling, sleep, exercise, and family life • treat with NSAIDs and the COCP • pain unresponsive to NSAIDs/COCP should be investigated with transabdominal pelvic ultrasound ± diagnostic laparoscopy • consider Mirena® intrauterine system (IUS) (may need insertion under GA). • Endometriosis often presents atypically in adolescents and symptoms may be non-cyclical. Up to 38% of adolescents with chronic pelvic pain have endometriosis. • Rare Müllerian anomalies (e.g. obstructed rudimentary horn) may present with cyclical pelvic pain of i severity and predispose to endometriosis: if suspected, get an MRI. H Chronic pelvic pain is commonly reported in individuals who have suffered sexual abuse. Be aware of any signs of ongoing abuse.
Gynaecological anatomy and development
Gynaecological cancers: in childhood The most common is an ovarian germ cell tumour with the 2nd being a vaginal embryonal rhabdomyosarcoma (sarcoma botryoides).
Ovarian cancer in children • Incidence 1.7/million in girls 80% are germ cell tumours (most are dysgerminomas). • Others include epithelial tumours (especially in the teens) and sex-cord stromal tumours (usually 85% for all stages.
Non-ovarian cancers in children • Most common is vaginal embryonal rhabdomyosarcoma, but this is still extremely rare, with incidence of ~0.5/million girls. • Most present before the age of 5yrs with vaginal bleeding, discharge, and classically a polypoid mass in the vagina. • EUA, biopsy, cystoscopy, and rectal examination are required for diagnosis. • Multiagent chemotherapy is the mainstay of treatment. • 5yr survival is ~82% overall. • Clear cell adenocarcinomas of the cervix and vagina are now incredibly rare, as diethylstilbestrol (DES) (a synthetic oestrogen) has not been used in pregnancy since the 1970s. H Extremely rare. All should be managed in a tertiary referral centre with links to the UK Children’s Cancer Study Group (UKCCSG).
Gynaecological cancers: in childhood
Gynaecological anatomy and development
Fertility implications of childhood cancer • Childhood cancer has a cumulative risk of ~1:650 by age 15yrs. • Most common are leukaemias. • Advances in the treatment means the overall survival has reached 80%, l i numbers of young adults affected by the reproductive consequences. • Lowest live birth rates are with alkylating agent chemotherapy, and radiotherapy to CNS and/or abdomen and pelvis.
Late effects of cancer therapy Ovary • Premature ovarian failure can be caused by radiotherapy or chemotherapy, in particular alkylating agents. • A prepubertal ovary is more resistant to damage (i reserve of primordial follicles). • Can present as delayed puberty, 2° amenorrhoea, or premature menopause depending on: • age at time of treatment • dose of radiotherapy • chemotherapeutic agents used (some have no effect on ovarian function). • Can present as precocious puberty, i risk if treatment at 45yrs on ‘the menopausal change’—it needs further investigation to exclude genital tract cancer.
Bleeding and pain: what is normal? • Bleeding can be for 1–7 days with an average of 3–5 days. • Reported amount of blood loss is highly variable. • Periods described as ‘heavy’ should always be viewed as such. • Pain is ‘normal’ (vasospasm and ischaemia), but is highly variable. 2 Pain interfering with normal functioning needs to be addressed. H Bleeding between periods (IMB), after intercourse (PCB), or totally erratic/ constant bleeding is ALWAYS abnormal.
What is a normal menstrual cycle?
Normal menstruation and its disorders
Menstrual disorders: amenorrhoea • 1° amenorrhoea is lack of menstruation by age 16 in the presence of 2° sexual characteristics or by age 14 in their absence. • 2° amenorrhoea is the absence of menstruation for 6 months.
Diagnosis History Emphasis on: • Sexual activity, risk of pregnancy, and type of contraceptive used. • Galactorrhoea or androgenic symptoms (acne, hirsutism). • Menopausal symptoms (night sweats, hot flushes). • Previous genital tract surgery (including LLETZ). • Issues with eating, stress, or excessive exercise. • Drug use (especially dopamine antagonists). Examination • BMI 30kg/m2, hirsutism, 2° sexual characteristics (Tanner staging). • Stigmata of endocrinopathies (including thyroid) or Turner’s syndrome. • Evidence of virilization (deep voice, clitoromegaly). • Abdominal: for masses due to tumours or genital tract obstruction. • Pelvic: imperforate hymen, blind-ending vaginal septum, absence of cervix and uterus.
Management Must be guided by the diagnosis and fertility wishes. Options include: • Treat any underlying causes including attaining normal BMI. • Cabergoline or surgery for hyperprolactinaemia. • Cyclical withdrawal bleeds (COCP for PCOS). • HRT for POF. • Relief of genital tract obstruction: cervical dilation, hysteroscopic resection, incision of hymen. • Specific treatment for endocrinopathies and tumours. 2 Major congenital abnormalities, AIS, etc. should be managed by MDTs in specialist centres.
Common causes of amenorrhoea Physiological causes H Pregnancy must always be excluded. • Lactation. • Menopause. Iatrogenic causes • Progestogenic contraceptives: Depo-Provera®, Mirena® IUS, Nexplanon®, POP. • Therapeutic progestogens, continuous COCP use, GnRH analogues, rarely danazol.
Menstrual disorders: amenorrhoea
Investigations for amenorrhoea H Pregnancy test. • FSH/LH: • i in premature ovarian failure (POF) • d hypothalamic causes (not useful in PCOS). • Testosterone and sex hormone-binding globulin (SHBG) are most useful for PCOS. • Prolactin should always be tested. • TFTs. • Pelvic USS: • can define anatomical structures, congenital abnormalities, Asherman’s syndrome, haematometra, and PCOS morphology • can indicate ovarian activity or endometrial atrophy in POF. • Karyotype if uterus is absent or suspicion of Turner’s syndrome. • Specific tests for endocrinopathies where clinical suspicion.
Pathological causes of amenorrhoea • Hypothalamic: • functional—stress, anorexia, excessive exercise, pseudocyesis • non-functional—space-occupying lesion, surgery, radiotherapy, Kallman’s syndrome (1° GnRH deficiency). • Anterior pituitary: • micro-or macroadenoma (prolactinoma) or other space- occupying lesion • surgery • Sheehan’s syndrome (postpartum pituitary failure). • Ovarian: • PCOS • POF • resistant ovary syndrome • ovarian dysgenesis, especially due to Turner’s syndrome (45XO). • Genital tract outflow obstruction: • imperforate hymen • transverse vaginal septum • cervical stenosis • Asherman’s syndrome (iatrogenic intrauterine adhesions). • Agenesis of uterus and Müllerian duct structures: • sporadic or associated with AIS (E Malformations of the genital tract: overview, p. 544). • Endocrinopathies: • hyperprolactinaemia • Cushing’s syndrome • severe hypo/h yperthyroidism • CAH. • Oestrogen-or androgen-secreting tumours: • usually ovarian or adrenal, e.g. granulosa-thecal cell tumours and gynandroblastoma.
Normal menstruation and its disorders
Menstrual disorders: oligomenorrhoea When cycles are >32 days they usually represent anovulation or intermittent ovulation. Transient oligomenorrhoea is common (‘stress’ or emotionally related causes are often cited) and usually self-limiting.
Causes of oligomenorrhoea 2 Similar to many of the causes of 2° amenorrhoea: • PCOS is the commonest cause (E Polycystic ovarian syndrome: overview, p. 652). • Borderline low BMI. • Obesity without PCOS. • Ovarian resistance l anovulation, e.g. incipient POF, is rare, but important. • Milder degrees of hyperprolactinaemia need to be excluded as well as mild thyroid disease.
Management of oligomenorrhoea What does the patient want? Regular periods or fertility? • Provide reassurance. • Treat any underlying causes as for amenorrhoea. • It is not uncommon for no cause to be found, but serious pathology must be excluded. • Attain normal BMI (weight loss or gain as appropriate). • Provide regular cycles: • COCP or cyclical progestogens • for PCOS a minimum of 3–4 periods/yr is recommended to d the risk of endometrial hyperplasia due to unopposed oestrogen. • Full fertility screening should be performed if ovulation induction is required.
Menstrual disorders: oligomenorrhoea
Normal menstruation and its disorders
Menstrual disorders: dysmenorrhea H Dysmenorrhoea: the pain has no obvious organic cause. 2 Dysmenorrhoea: the pain is due to an underlying condition. Pain is highly subjective and varies greatly between women. However, if a woman describes her periods as unacceptably painful, then they are!
Diagnosis History • Timing and severity of pain (including degree of functional loss): • commonly premenstrual pain i in the 1st 1–2 days of bleeding, then eases. • Pelvic pain and deep dyspareunia (may signify pelvic pathology). • Previous history of PID or STIs. • Previous abdominal or genital tract surgery (may cause adhesions). Examination • Abdominal exam to exclude pelvic masses. • Pelvic exam: • cervical excitation • adnexal tenderness • mobility, and masses.
Investigations • STI screen (including Chlamydia swab). • USS: • endometriomata • adenomyosis • fibroids • PID sequelae, e.g. tubo-ovarian abscess • congenital abnormalities. • Laparoscopy is usually reserved for women with USS abnormalities, medical treatment failures, or those with concomitant subfertility.
Trial of hormonal therapy When no disease is identified then ovulation suppression by tricycling COCP, or GnRH analogues for up to 6–12mths will limit the number of ‘periods’ and therefore pain. This is an empirical trial of hormonal therapy. 2 Pain clinic, psychological support, and self-help groups may be of benefit to some women who wish to maintain their fertility, especially when they have other pelvic pain symptoms.
Menstrual disorders: dysmenorrhea
1° dysmenorrhoea Pain in the menstrual cycle is a feature of ovulatory cycles and is due to uterine vasospasm and ischaemia, nervous sensitization due to PGs and other inflammatory mediators, and uterine contractions. A maternal or sibling history of dysmenorrhoea is very common and the problem usually starts soon after menarche. Theories accounting for 1° dysmenorrhoea include: • Abnormal PG ratios or sensitivity. • Neuropathic dysregulation. • Venous pelvic congestion. • Psychological causes.
2° dysmenorrhoea Underlying causes include: • Endometriosis. • Adenomyosis. • PID. • Pelvic adhesions. • Fibroids (though not always causal). • Cervical stenosis (iatrogenic post-LLETZ or instrumentation). • Asherman’s syndrome. • Congenital abnormalities causing genital tract obstruction, e.g. non- communicating cornua.
Management of dysmenorrhoea • Appropriate reassurance and analgesia may be all that is required. • Symptom control: • mefenamic acid 500mg tds with each period is effective • COCP to abolish ovulation, tricycling will minimize periods • Mirena® IUS and other progestogens • paracetamol, hot-water bottles, etc., may be helpful for some • TENS, vitamin B1, and magnesium may be of benefit to some women. • Treat any underlying causes: • endometriosis—COCP, progestogens, GnRH analogues • antibiotics for PID • relief of obstruction (usually surgical). • Therapeutic laparoscopy—for above indications: gold standard for diagnosis +management of endometriosis/adhesions/ complicated PID. • Hysterectomy is now rare for this indication alone. • Laparoscopic uterine nerve ablation (LUNA) is not currently recommended.
Normal menstruation and its disorders
Dysfunctional uterine bleeding: scope of the problem Dysfunctional uterine bleeding (DUB) is a diagnosis of exclusion and is defined as any abnormal uterine bleeding in the absence of pregnancy, genital tract pathology, or systemic disease. • Heavy menstrual bleeding (HMB, previously referred to as menorrhagia) is the commonest symptom and DUB will ultimately be the cause in 50–60% of women with this symptom. • DUB is responsible for 15–20% of gynaecological referrals to hospital and an even higher proportion of GP gynae consultations. 2 Objective measures of blood loss >80mL are clinically meaningless and should not be used outside research. 2 If women report their periods are unacceptably heavy, then they are!
Aetiology The exact causes of DUB are unknown. Proposed mechanisms at the endometrial level include: • Abnormal PG ratios (+other inflammatory mediators) favouring vasodilatation and platelet non-aggregation. • Excessive fibrinolysis. • Defects in expression/function of matrix metalloproteinases (MMPs), vascular growth factors, and endothelins. • Aberrant steroid receptor function. • Defects in the endomyometrial junctional zone. The medical treatments tend to reflect the underlying pathologies (E Dysfunctional uterine bleeding: diagnosis and investigations, p. 586).
Dysfunctional uterine bleeding: scope of the problem
DUB at a glance • HMB is the commonest gynaecological symptom you will see, and most of these women will have DUB. • DUB is an umbrella term and only diagnosed after exclusion of pathology. • Women with a history of HMB without other related symptoms (IMB, pelvic pain/pressure symptoms) can have pharmacological treatment without physical examination (unless Mirena® IUS is chosen). • TV USS or hysteroscopy is the 1st-line investigation depending on the woman’s symptoms. • In the presence of erratic bleeding or risk factors for endometrial pathology (IMB, infrequent bleeding who are obese/PCOS, taking tamoxifen or if treatment for HMB has failed) offer an outpatient hysteroscopy +endometrial biopsy. • The majority of women will respond to medical therapy, especially tranexamic ± mefenamic acid. • The Mirena® IUS is an excellent treatment that significantly d the number of women requiring surgery. • Surgery should only be used in women who have completed their family and have had failed adequate medical therapy. • Endometrial ablation: microwave endometrial ablation (MEA), balloon ablation, or NovaSure® are easy to perform and should be offered before hysterectomy. • Hysterectomy (laparoscopic preferred to vaginal/open) has higher morbidity and cost, but is a guaranteed cure, and long-term satisfaction rates are high.
Differential diagnosis for DUB • Submucous fibroids. • Adenomyosis. • Endometrial polyps, hyperplasia, or cancer. • Very rarely, hypothyroidism or coagulation defects.
Normal menstruation and its disorders
Dysfunctional uterine bleeding: diagnosis and investigations Diagnosis Symptoms • Heavy and/or prolonged vaginal bleeding (with clots and flooding): irregular, heavy periods usually occur at the extremes of reproductive life (post-menarche and perimenopausal). • May be associated with dysmenorrhoea. • Symptoms of anaemia and disruption of life due to bleeding. • A smear history and contraceptive use are vital information. H Totally erratic bleeding, IMB, or PCB should prompt a search for cervical or endometrial pathology. Clinical signs • Anaemia. • Abdominopelvic examination is usually normal: • if the uterus is significantly enlarged, fibroids are likely.
Investigations 2 Pregnancy should always be considered and excluded. H Refer women using ‘suspected cancer pathway referral’ (seen within 2wks) for endometrial cancer if has PMB. • FBC (Hb +MCV). • Ferritin, TFTs, and clotting screens are not routine investigations: • only consider if clinically indicated. • Cervical smears not done opportunistically if smear history normal. • STI screen including Chlamydia. • Start pharmacological treatment for HMB without further investigations if the history ± examination suggests the woman is low risk for fibroids, uterine cavity abnormalities, histological abnormality, or adenomyosis. • If risk factors for endometrial disease (e.g. IMB, infrequent bleeding in women who are obese, have PCOS, or are taking tamoxifen), or if no clinical response: • TV USS: looking for fibroids, polyps, and endometrial thickness (2 risk of endometrial pathology with a normal TV USS is small, but it may be less accurate during menstruation) • hysteroscopy and biopsy (outpatient) may be appropriate as above or if there is no response to initial medical treatment • endometrial biopsy should only be taken in context of hysteroscopy, a ‘blind’ sample is not recommended • hysteroscopy is recommended with DUB in a woman if USS reveals focal pathology, e.g. polyp, or is unable to assess the whole endometrium, biopsy is inadequate, or bleeding is persistent or repeated.
DIAGNOSIS AND INVESTIGATIONS
Normal menstruation and its disorders
Dysfunctional uterine bleeding: medical management Regular DUB Includes fibroids 10cm. • Typical endometrial ablation results in normal size cavities: • 80–90% of women are significantly improved • 30% will become amenorrhoeic • 20% will need a 2nd procedure by 5yrs. • The above-listed newer procedures are generally very safe and straightforward; however, there is a small risk of bleeding, infection, uterine perforation, and failed procedure. • They are generally carried out under GA, but may occasionally be done under cervical block.
Hysteroscopic removal of fibroids/polyps • Transcervical resection of submucosal fibroid/polyp using electrical energy.
Uterine artery embolization • Non-surgical way of shrinking fibroids. • Performed by radiologist.
Myomectomy • Removal of intramural or subserosal fibroids. • Performed laparoscopically or open. • Can maintain fertility.
Ulipristal acetate • 5mg (up to four courses). • Shrinks fibroid size. • Risk of serious liver injury during use. • Only indicated if patient is not eligible for surgery (risks of surgery outweigh risks of liver damage).
Dysfunctional uterine bleeding: surgical management
Hysterectomy • Hysterectomy is the only guaranteed cure for DUB, but RCTs have shown higher morbidity, longer recovery, and financial costs compared to endometrial ablation. • Complications include: • haemorrhage • infection • bladder, ureteric, or bowel injury (98% of these are undertaken under clause C—risk of injury to the physical or mental health of the woman (Box 6.). At least /3 of British women will have had a TOP by the time they reach 45yrs of age.
Box 6. UK law Legislation varies throughout the world, with terminations remaining illegal in some countries. The Abortion Act 967 states that TOP is legal in the UK if two doctors decide in good faith that in relation to a particular pregnancy one or more of the following grounds are met: • A: continuance of the pregnancy would involve risk to life of pregnant woman greater than if pregnancy were terminated. • B: termination is necessary to prevent grave permanent injury to physical or mental health of pregnant woman. • C: pregnancy has not exceeded 24th wk and continuance of the pregnancy would involve risk, greater than if pregnancy were terminated, of injury to physical or mental health of pregnant woman. • D: pregnancy has not exceeded 24th wk and continuance of pregnancy would involve risk, greater than if pregnancy were terminated, of injury to physical or mental health of any existing child(ren) of family of pregnant woman. • E: there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped. 2 Clauses A, B, and E have no time limit. 2 Clauses C and D have a legal limit of 24wks.
Do doctors have an obligation to participate in TOPs? According to the GMC: • Doctors must ensure their personal beliefs do not prejudice patient care. • Doctors have the right to decline to participate in TOPs on grounds of conscientious objection. If so, they must always refer the patient to another doctor who will help. What about patients 20wks. • Routine histopathological examination of tissue obtained at TOP is not recommended. • Provide written patient information, which should include: • symptoms that may be experienced following TOP • symptoms requiring further medical attention • contact numbers. • Follow-up within 2wks of TOP. • Refer for further counselling if required. • Discuss and prescribe/provide ongoing contraception.
Termination of pregnancy: management
Box 6.2 Complications of TOP • Significant bleeding needing transfusion (–4:000). • Genital tract infection (5–0%). • Uterine perforation (surgical TOP: –4:000). • Uterine rupture (mid-trimester medical TOP: 2wks, heavy PVB or pain • If PVB persists >2wks attend for TVS
• Bleeding and pain cease • Closed cervix
• Empty uterus • Endometrial thickness 2wks • Serum hCG to exclude EP • Review if PVB persists >2wks and consider endometritis or retained products of conception
• Bleeding ± pain • Possible open cervix
• Heterogeneous tissues ± gestation sac • Any endometrial thickness
• Expectant preferable but can be medical/ surgical • Anti-D if >2wks, heavy PVB, pain or medical/surgical management
Missed miscarriage/ early fetal demise
• Bleeding ± pain ± loss of pregnancy symptoms • Closed cervix
• Fetal pole >7*mm with no fetal heart • Mean gestation sac diameter >25*mm with no fetal pole or yolk sac
• Seek 2nd opinion on viability or if not available rescan in 7 days • Expectant/medical/ surgical • Anti-D if >2wks or medical/surgical management
• Bleeding ± pain • Open cervix
• Intrauterine gestation sac ± fetal pole ± fetal heart activity
• Expectant/medical/ surgical • Anti-D if >2wks or heavy PVB or pain or medical/surgical management
Pregnancy of uncertain viability
• ± Bleeding ± pain • Closed cervix
• Intrauterine gestation sac 5 × 06/mL. • Progressive motility >32%. • Total motility >40%. Azoospermia: no sperm in ejaculate. Oligozoospermia: d number of sperm in ejaculate.
Investigations • • • • •
FSH:LH i in testicular failure. Testosterone: d in testicular failure. Karyotype: exclude 47XXY. CF screen: congenital bilateral absence of the vas deferens (CBAVD). Y-microdeletions (AZF-a and -b complete arrest in spermatogenesis, AZF-c variable phenotype from oligo-azoospermia).
Management • Treat any underlying medical conditions. • Address lifestyle issues (d alcohol 2yrs. Success is dependent on many factors including: • Duration of subfertility: d success with i duration. • Maternal age: • pregnancy rates are highest between 25 and 35yrs with a steep decline thereafter • elevated basal FSH and/or low AMH/antral follicle count levels may indicate a poor response to ovarian stimulation. • Previous pregnancy: i chance of successful IVF outcome. • Previous failed IVF cycles: d chances of success. • Presence of hydrosalpinx: unilateral and bilateral up to 20% and 40% d in success rate respectively. • Smoking and BMI >30kg/m2: d success rates.
Intracytoplasmic sperm injection • • • •
A single sperm is injected into the ooplasm of the oocyte in ICSI. Used for men with abnormal semen parameters. Can be tried when failed fertilization has occurred in IVF cycles. Higher fertilization rates if the selected sperm exhibit progressive motility, but otherwise there are no strict selection criteria. • i Success of IVF with severe male factor subfertility. • Sperm may be retrieved from ejaculate or surgically from epididymis or testes. H There are concerns regarding transmission of genetic mutations when using ICSI. Sperm containing DNA damage induced from i oxidative stress are capable of fertilizing oocytes. H There is also an i incidence of Y- chromosome microdeletions in subfertile men (AZF-c mutation has variable phenotype) and this may be further propagated by transmission to the offspring born by ICSI.
ASSISTED CONCEPTION: IN VITRO FERTILIZATION
IVF: how it’s done In preparation, the HFEA consents and ‘Welfare of the Child’ issues must be considered. • Down-regulation of the HPO axis using GnRH analogues from day 2 (luteal phase) of the previous cycle: alternatively, in antagonist cycles (‘short protocol’) GnRH antagonists are co-administered with gonadotropins from day 2 of the cycle during ovarian stimulation. • Ovarian stimulation achieved with recombinant FSH or human menopausal gonadotropins: response is monitored by ultrasound follicle tracking. • Follicular maturation by administration of hCG, or GnRH analogue in an antagonist cycle, when mature-sized follicles are seen on USS. • TV oocyte retrieval by needle-guided aspiration (36h after hCG). • Sperm sample collected (or thawed if frozen), prepared, and cultured with oocytes overnight (standard IVF) or oocytes injected with a single sperm and cultured (ICSI). • Fertilization checks of embryos the following day. • Embryo transfer by a fine catheter through cervix on day 2–3 (cleavage stage) or day 5 (blastocyst stage): • a maximum of two embryos are transferred in women 0M/mL. • NICE recommends up to six cycles of IUI. There is no consensus on the role of simultaneous ovarian stimulation, but this should be considered in endometriosis and unexplained infertility when outcome is less favourable. 2 If >3 mature follicles develop, the treatment cycle should be cancelled as there is a high rate of multiple pregnancies (>25%).
Donor insemination • • • •
Indicated in men with azoospermia and failed surgical sperm recovery. Single women with no male partner. Same-sex couples. Insemination is usually intrauterine: with/without ovarian stimulation and 24–36h after hCG administration. Success rates vary from 4% (aged 40–44yrs) to 2% (45yrs) • those with repeated IVF failure.
Assisted conception: other techniques
Special concerns regarding donation of gametes There are strict criteria for gamete donation, which is regulated by the HFEA. • Ideally, donors should have no severe medical, psychiatric, or genetic disorders. • Donors must be counselled. • Donors must undergo a full infection screen. • Donors may be known or anonymous to the recipient. • Egg donors should ideally be 5 units of alcohol. • These women were more often sexually assaulted by a stranger or someone they met within 24h prior to the assault.
Sexual abuse in children Concern for children is heightened by: • Repeated A&E attendances. • Poor parent–child interactions or behaviour. • Child known to social services. • Any injuries to child 1yr) • syphilis and HIV (if congenital infection excluded) • chlamydia (if >3yrs). • Any victim who has children or any young person 5yrs after. Disadvantages • i risks (although absolute risk is very low): • VTE • stroke • cardiovascular disease. • Small i risk of breast cancer: returns to the background risk 0yrs after stopping. • Very small association with i risk of cervical cancer if taken for >5yrs.
The COCP and VTE The absolute risk of VTE is: • Background risk: 5:00,000 women/yr. • 2nd-generation COCP: 0–5:00,000 women/yr. • 3rd-generation COCP: 25:00,000 women/yr. • Pregnancy: 60:00,000 women/yr.
Combined oral contraceptive pill: regimens Assessment of suitability of COCP for an individual woman • Assessment of medical eligibility should include: • medical conditions • lifestyle factors • family medical history • drug history • a recent accurate BP and BMI.
‘Pill-teach’ • Contraception is immediate if the woman starts the COCP between days and 5 of her cycle taken daily at the same time. • If st pill is after day 5, other contraception is needed for 7 days. • One pill daily for 2 days followed by 7 pill-free days: • some formulations have seven ‘dummy pills’, rather than the pill-free interval. • If vomiting or diarrhoea, use extra contraception from the onset of illness and continue it for the next 7 days.
Special circumstances • Postpartum (not breast-feeding): • start day 2 after delivery. • Post-termination: • within 7 days of termination. • Switching from other oral hormonal contraception: • start immediately if using other contraception reliably. • Switching from implant or injectable progestogens: • start at any time up to removal of implant or when injection due.
Drug interactions • No additional contraception is needed if taking antibiotics unless associated with diarrhoea/vomiting. • COCP should not be prescribed to lamotrigine users as it d serum drug concentration and therefore can i seizure frequency. • Patients taking enzyme-inducing medication should be offered alternative contraceptive method due to d efficacy: • if she decides to continue the COCP, the ethinylestradiol should be i to 50 micrograms, or the pill-free interval d to 4 days.
Combined oral contraceptive pill: regimens
Missed pill rules • Missed pills may lead to failed contraception. • The risk of pregnancy is greatest at the beginning and the end of the pack. If pill is missed • Take the missed pill as soon as possible. • Continue the rest of the pack as usual. • No additional contraception is required. If ≥2 pills are missed • Take the most recent missed pill as soon as possible. • Continue the rest of the pack as normal. • Additional contraceptive cover is required until seven consecutive pills have been taken. • If the missed pills are in day –7: • emergency contraception should be considered. • If the missed pills are in day 8–4: • emergency contraception not needed. • If the missed pills are in day 5–2: • omit the pill-free interval. • Qlaira® has different missed pill rules (see manufacturer’s advice).
Other combined hormonal contraceptives Vaginal ring • Ethinylestradiol with etonogestrel. • Remains in situ for 2 days, then removed for 7 days to induce a withdrawal bleed. Transdermal patch • Ethinylestradiol with norelgestromin. • Replaced weekly for 2 days, then 7 patch-free days to induce a withdrawal bleed. 2 Efficacy and side effect profile as for COCP.
Progestogen-only pill • POPs currently marketed contain either LNG, norethisterone, or desogestrel. • If used reliably, at the same time every day, POPs are >99% effective. • Failure rate 0.3–4.0% per 00 woman-yrs: • d with age. • Cerazette®, a POP (75 micrograms desogestrel), reliably blocks ovulation, i efficacy.
Mode of action • Thickened cervical mucus (4h after dose). • Thin endometrium preventing implantation. • Inhibition of ovulation (60% old POP, 97% desogestrel).
Indications Useful in conditions where COCP is contraindicated: • During lactation—has no effect on quality or quantity of milk. • History or current VTE. • BMI >35kg/m2. • Maternal medical conditions including AF, cardiomyopathy with impaired cardiac function, hypertension, complicated valvular heart disease, SLE, and migraine with aura.
Side effects • Menstrual disturbance: • common reason cited for cessation of POPs • prolonged bleeding and breakthrough bleeding or spotting. • Headaches, mood changes, and weight changes have been reported with the use of POPs but not been supported by definitive evidence.
Drug interactions • Broad-spectrum antibiotics do not affect the efficacy of POP. • Rifampicin and other enzyme-inducing drugs i the metabolism of POP and have the potential to d its efficacy.
Contraindications to the POP • Pregnancy. • Undiagnosed genital tract bleeding. • Current breast cancer. • Severe arterial disease. • Active hepatic disease.
How to take the POP • Take the pill daily, at the same hour. • If started on day of the cycle, no extra contraception is required. • If started after day 5, extra contraception should be used for 48h. • After miscarriage or TOP: • start on the day of the miscarriage or TOP. • After delivery: • start on day 2 (whether breast-feeding or not). • From COCP to POP: • if the st POP is taken the day after the last active COCP, no other contraception is needed.
Missed POP rules • If >3h late or 27h since last dose: • take missed pill as soon as possible • take subsequent pill at the usual time • use extra contraception for the next 48h. • If woman vomits within 2h of ingestion: • take another pill now • use extra contraception for the next 48h. ® 2 For Cerazette , the same rules apply if missed pill is >2h late.
Long-acting reversible contraceptives Injectable progestogen Depo-Provera® (MDPA) (given 2-weekly): • Useful for women who are unable or unwilling to take a pill. • Contains 50mg of medroxyprogesterone. • When used as recommended failure rate is 30kg/m2, smoking cessation, and treatment of chronic cough and constipation. • Pelvic floor muscle training: for at least 3mths should be considered as the st-line treatment: • physiotherapists usually individualize the programme, but 3 sets of 8–2 slow maximal contractions sustained for 6–8s each per day is a common regimen • the exercises need to be continued long term. • Biofeedback: refers to the use of a device to convert the effect of pelvic floor contraction into a visual or auditory signal to allow women objective assessment of improvement. • Electrical stimulation: can assist in production of muscle contractions in women who are unable to produce muscle contraction. • Vaginal cones: have been developed as a way of applying graded resistance against which the pelvic floor muscles contract.
Pharmacological management of SUI Duloxetine is the only drug licensed for the treatment of moderate to severe SUI: • It is an SNRI that enhances urethral striated sphincter activity via a centrally mediated pathway. • However, it is associated with significant side effects. It is not recommended for st-line use by NICE. • Nausea is the most frequently reported side effect (up to 25%). • Other side effects include dyspepsia, dry mouth, insomnia or drowsiness, and dizziness.
Indications for conservative treatment of SUI • Mild or easily manageable symptoms. • Family incomplete. • Symptoms manifest during pregnancy. • Surgery contraindicated by coexisting medical conditions. • Surgery declined by patient.
Stress urinary incontinence: conservative management
Stress urinary incontinence: surgical management Surgery may be considered when conservative measures have failed and the woman’s quality of life is compromised. Before attempting surgical repair, it is important to be clear about the underlying cause of the incontinence: USI may be successfully treated surgically, but detrusor overactivity may be made worse, and the effects are largely irreversible.
Periurethral injections • Injectable periurethral bulking agents have lower immediate success rate (20–40%) and effects wear off over time. • The procedure has low morbidity and can be performed under local anaesthetic in outpatient settings. • Injectables or bulking agents may be appropriate for: • frail, older, or unfit women • young women who have yet to complete their family • patients at higher risk of voiding dysfunction. • The most commonly used periurethral bulking agents are: • glutaraldehyde cross-linked bovine collagen • water-based gels (Bulkamid®).
Burch colposuspension • Largely replaced by tension-free vaginal tape (TVT), but having a resurgence in popularity. • The retropubic space is entered through a low transverse suprapubic incision and two or three sutures placed between the paravaginal fascia and ipsilateral iliopectineal ligament (Cooper’s ligament) at the level of the bladder neck. • Complications may include haemorrhage; injuries to the bladder or ureter; voiding difficulties; de novo detrusor overactivity; enterocele or rectocele formation. • Overall, meta-analysis of published data suggests that the efficacy of the Burch colposuspension as a ° procedure is 90% and as a repeat procedure is 83% (Table 22.).
Laparoscopic colposuspension • Efficacy and complications similar to those of the open procedure. • The surgery is technically more demanding and requires considerable laparoscopic expertise.
Autologous fascial sling • A strip of rectus fascia is harvested and inserted in a similar fashion to performing a TVT. • Success rates are quoted as up to 93%. • Surgical morbidity is higher (wound complications, hernia) and rates of voiding dysfunction are i. • In the current climate of controversy surrounding mesh surgery, some patients are requesting this as an alternative to TVT.
Stress urinary incontinence: surgical management
Fig. 22.5 Insertion of TVT. The tape is placed in a U-shape under the urethra and the tension adjusted to prevent leakage as the woman coughs. Illustration reproduced by courtesy of ETHICON Women’s Health and Urology.
Tension-free vaginal tape (TVT) 2 Prior to the mesh controversy, this was the most commonly performed surgical procedure for USI in the UK. • See Fig. 22.5. • A polypropylene tape is placed under the mid-urethra via a small vaginal incision, using local, regional, or general anaesthesia. • Cystourethroscopy is carried out to ensure no damage to the bladder or urethra. • The procedure is minimally invasive and most women return to normal activity within 2wks. • Complications: • moderately high risk of bladder injuries 5–0%, but these do not seem to have long-term sequelae, if treated appropriately • bleeding in retropubic space, infection, and voiding difficulties • tape erosion into the vagina and urethra has also been reported. • The objective cure rate is 82–98% (mean 94%).
Transobturator tape (TOT) • The polypropylene tape is passed via a transobturator foramen, through the transobturator and adductor muscles. • The main difference from TVT is that the retropubic space is not entered and the risk of bladder perforation is low. It may be preferred if there has been extensive abdominal/pelvic surgery. • Potential disadvantages of transobturator slings are a higher risk of nerve trauma, with chronic groin pain described in up to 20% of patients.
The UK ‘mesh controversy’ • At the time of publication, all vaginally inserted mesh procedures are suspended by NHS England due to concerns about complications. • NICE guidance published in 209 recommends offering patients a choice of incontinence procedure after detailed discussion about risks and benefits.
Further reading NICE (209). Urinary incontinence and pelvic organ prolapse in women: management. NICE guideline [NG23]. M www.nice.org.uk/guidance/ng23
Stress urinary incontinence: surgical management
Overactive bladder syndrome: overview Definition • OAB is a chronic condition, defined as urgency, with or without urge incontinence, usually with frequency or nocturia. • It is used to imply probable underlying detrusor overactivity, but this is a diagnosis only made on urodynamic testing (Fig. 22.6).
Aetiology • Idiopathic in most cases. • Neurogenic detrusor overactivity is found in the presence of conditions such as multiple sclerosis, spina bifida, and upper motor neuron lesions. • 2° to pelvic or incontinence surgery. • OAB due to outflow obstruction is uncommon in women.
Clinical features of OAB • Symptoms of OAB include urinary frequency, urgency, urge incontinence, and nocturia. • Provocative factors often trigger it, such as cold weather, opening the front door, or hearing running water. • Bladder contractions (detrusor overactivity) may also be provoked by i intra-abdominal pressure (coughing or sneezing), which must be distinguished from SUI. • Quality of life can be significantly impaired by the unpredictability and large volume of leakage.
Investigations Urine culture To exclude infection, as symptoms overlap those of UTI. Frequency/volume chart • Typical features are i diurnal frequency associated with urgency and episodes of urge incontinence. • Voids are frequently small in volume. • Nocturia is a common feature of OAB. Urodynamics • Involuntary detrusor contractions during the filling phase of the micturition cycle, which may be spontaneous or provoked. • Video-urodynamic testing is better in women with neurological diseases, to exclude vesicoureteric reflux or renal damage 2° to a persistent significant rise in intravesical pressure.
Diagnosis • Urodynamic assessment is helpful for the diagnosis of OAB in women with multiple and complex symptoms. • Other factors, such as metabolic abnormalities (diabetes or hypercalcaemia), physical causes (prolapse or faecal impaction), or urinary pathology (UTI or interstitial cystitis), need to be excluded before the diagnosis of OAB is made.
Overactive bladder syndrome: overview
Key points • OAB is a common condition affecting ~ in 6 women. • Incidence of OAB i with age. • OAB is the 2nd most common cause of urinary incontinence. • OAB is the most common cause of incontinence in older women. • Urodynamic assessment is required to make a diagnosis of detrusor overactivity. • Quality of life is often severely affected by OAB symptoms.
Fig. 22.6 Urodynamic trace showing detrusor overactivity. The upper trace of intravesical pressure (Pves) vs time shows a sharp i of pressure within the bladder. The middle trace of pressure within the abdomen (Pabd) shows no similar i. The lower trace, obtained by subtracting intra-abdominal pressure from intravesical pressure (Pdet =Pves –Pabd), shows significant detrusor overactivity.
Overactive bladder syndrome: management I Conservative management Behavioural therapy • Advice to consume –.5L of liquids per day. • Avoid caffeine-based drinks (tea, coffee, cola) and alcohol. • Various drugs, such as diuretics and antipsychotics, alter bladder function and should be reviewed. Bladder retraining • The principles of bladder retraining are based on the ability to suppress urinary urge and extend the intervals between voids. • Reported cure rates using bladder retraining alone are 44–90%. • It may be offered in conjunction with pelvic floor muscle training. Hypnotherapy and acupuncture • These can be successful in some cases. • The relapse rate is very high.
Pharmacological interventions Anticholinergic (antimuscarinic) drugs • The mainstay of pharmacotherapy; they block the parasympathetic nerves, thereby relaxing the detrusor muscle. • Advise about the side effects before starting treatment (some may be better tolerated than others) (Table 22.). • Dosage needs to be titrated against efficacy and adverse effects. • Adverse effects of anticholinergics may include: • dry mouth (up to 30%) • constipation, nausea, dyspepsia, and flatulence • blurred vision, dizziness, and insomnia • palpitation and arrhythmias. • Some data are emerging, suggesting a link between long-term anticholinergic medication use (anticholinergic burden) and an i incidence of dementia. Women on long-term treatment should have their medication reviewed annually, or every 6mths if >75yrs. β3-adrenoceptor agonists • These activate β3-adrenoceptors, causing the bladder to relax, thus aiding filling and storage of urine. • Mirabegron (25–50mg od) is recommended for use where anticholinergics are not tolerated, ineffective, or contraindicated. Oestrogens • Intravaginal oestrogens may be tried in women with vaginal atrophy. • Treatment with vaginal oestrogen often helps with symptoms of urgency, urge incontinence, frequency, and nocturia. • Systemic HRT is not recommended for treatment of urinary symptoms.
Overactive bladder syndrome: management I
Contraindications to anticholinergics • Acute (narrow-angle) glaucoma. • Myasthenia gravis. • Urinary retention or outflow obstruction. • Severe ulcerative colitis. • Gastrointestinal obstruction. • Use with caution in dementia or cognitive impairment. Table 22. Anticholinergic drugs and their doses Drug
2.5–5mg, 2–4 times/ day
Selective, M, M3
• Use d dose in elderly and avoid if frail (risk of falls and confusion) • Transdermal patch available (may have d side effects)
• Less likely to cross
Overactive bladder syndrome: management II Use of botulinum toxin A • Botulinum toxin A blocks neuromuscular transmission, causing temporary paralysis. • Increasingly used as an intervention for refractory OAB, with an efficacy of up to 90%. • It is injected cystoscopically into the detrusor, usually under local anaesthetic. • It can cause urinary retention in 5–0% of cases, in which case intermittent self-catheterization may be required. • Repeat injections are required every 6–2mths. • The long-term effects of repeat injections are unknown and are the subject of ongoing research.
Neuromodulation and sacral nerve stimulation • Provides continuous stimulation of the S3 nerve root via an implanted electrical pulse generator and is thought to improve the ability to suppress detrusor contractions. • It is being i used in the treatment of refractory detrusor overactivity. • Overall, neuromodulation has up to 50% clinical success rate.
Surgical management of OAB • Surgery is reserved for those with debilitating symptoms and who have failed to benefit from medical, behavioural, and/or neuromodulation therapy. • Procedures such as detrusor myomectomy and augmentation cystoplasty have limited efficacy and complication rates are high, hence they are rarely indicated. • Permanent urinary diversion is occasionally indicated in women with intractable incontinence.
Overactive bladder syndrome: management II
Anatomy of the pelvic floor The pelvic floor consists of muscular and fascial structures that provide support to the pelvic viscera and the external openings of the vagina, urethra, and rectum (Fig. 22.7). The uterus and vagina are suspended from the pelvic side walls by endopelvic fascial attachments that support the vagina at three levels.
Levels of vaginal support Level The cervix and upper /3 of the vagina are supported by the cardinal (transverse cervical) and uterosacral ligaments. These are attached to the cervix and suspend the uterus from the pelvic sidewall and sacrum. Level 2 The mid portion of the vagina is attached by endofascial condensation (endopelvic fascia) laterally to the pelvic side walls. Level 3 The lower /3 of the vagina is supported by the levator ani muscles and the perineal body. The levator ani, together with its associated fascia, is termed the pelvic diaphragm. 2 The axis of the vagina is also important. It normally lies horizontally on the levator muscles. This protects it during coughing and other activities that i intra-abdominal pressure (Fig. 22.7). 2 Damage occurring at the different levels of vaginal support causes different types of prolapse. It is therefore important to have an understanding of this anatomy.
Aetiology of prolapse • Pregnancy and vaginal delivery: prolapse is uncommon in nulliparous women. Vaginal delivery may cause mechanical injuries and denervation of the pelvic floor. The risk is i with large babies, prolonged 2nd stage, and instrumental delivery (forceps). • Congenital factors: abnormal collagen metabolism, e.g. Ehlers–Danlos syndrome can predispose to prolapse. • Menopause: the incidence of prolapse i with age. This may be due to the deterioration of collagenous connective tissue that occurs following oestrogen withdrawal. • Chronic predisposing factors: prolapse is aggravated by any chronic i in intra-abdominal pressure, resulting from factors such as obesity, chronic cough, constipation, heavy lifting, or pelvic mass. • Iatrogenic factors: pelvic surgery may also influence the occurrence of prolapse: • hysterectomy is associated with subsequent vaginal vault prolapse (particularly when the original indication was prolapse) • continence procedures, although elevating the bladder neck, may lead to defects in other pelvic compartments (Burch colposuspension may predispose to rectocele and enterocele formation).
Anatomy of the pelvic floor (a) Round ligament
Cardinal ligament Pelvic brim Levator ani Ischiopubic ramus Perinea muscle
Uterosacral ligament Levator ani
Perineal body Fig. 22.7 (a) Coronal view of the pelvis, showing cardinal ligaments and levator ani. (b) Lateral view of the pelvis, showing the uterosacral ligaments and levator ani. Reproduced with permission from Impey L. (999). Obstetrics and Gynaecology. Oxford: Wiley-Blackwell Publishing.
Prolapse: classification Definition Prolapse is defined as protrusion of the uterus and/or vagina beyond normal anatomical confines. The bladder, urethra, rectum, and bowel are also often involved.
Incidence The incidence of prolapse is difficult to define, as many women do not seek help and clinical examination does not necessarily correlate with symptoms. It is probably extremely common and is present in varying degrees in older parous women.
Classification of prolapse Types of uterovaginal prolapse are classified anatomically, according to the site of the defect and the pelvic viscera that are involved (Fig. 22.8). • Cystocele is prolapse of the anterior vaginal wall, involving the bladder. Often there is an associated prolapse of the urethra, in which case the term cysto-urethrocele is used. • Uterine (apical) prolapse is the term used to describe prolapse of the uterus, cervix, and upper vagina. If the uterus has been removed, the vault or top of the vagina, where the uterus used to be, can itself prolapse. • Enterocele is prolapse of the upper posterior wall of the vagina. The resulting pouch usually contains loops of small bowel. • Rectocele is prolapse of the lower posterior wall of the vagina, involving the anterior wall of the rectum.
Grading of prolapse There are many grading systems. None is perfect, and some are complex and impractical. In 996, the International Continence Society (ICS) Committee for Standardization published its Pelvic Organ Prolapse Quantification (POP- Q) scoring system which compares a number of points in the vagina to the level of the hymen. Another frequently used system is the Baden–Walker classification.
Grading of prolapse (Baden–Walker classification) • st degree: the lowest part of the prolapse descends halfway down the vaginal axis to the introitus. • 2nd degree: the lowest part of the prolapse extends to the level of the introitus and through the introitus on straining. • 3rd degree: the lowest part of the prolapse extends through the introitus and lies outside the vagina. 2 Procidentia describes a 3rd-degree uterine prolapse.
Prolapse: classification (a)
Area of prolapse
Fig. 22.8 Types of prolapse. (a) Normal pelvis, (b) uterine prolapse, (c) cystocele, (d) rectocele, (e) enterocele. Reproduced with permission from Impey L. (999) Obstetrics and Gynaecology. Oxford: Wiley-Blackwell Publishing.
Prolapse: clinical assessment Symptoms Symptoms may be absent, but the most commonly reported are: General • Dragging sensation, discomfort, and heaviness within the pelvis. • Feeling of ‘a lump coming down’. • Dyspareunia or difficulty in inserting tampons. • Discomfort and backache. Cysto-urethrocele • Urinary urgency and frequency. • Incomplete bladder emptying. • Urinary retention or d flow where the urethra is kinked by descent of the anterior vaginal wall. Rectocele • Constipation. • Difficulty with defecation (may digitally reduce it to defecate). 2 Symptoms tend to become worse with prolonged standing and towards the end of the day. In case of grade 3 or 4 prolapse, there may be mucosal ulceration and lichenification, resulting in vaginal bleeding and discharge.
Examination • Exclude pelvic masses with a bimanual examination. • Vaginal examination is best carried out with the woman in the left lateral position, using a Sims speculum. • The walls should be checked in turn for descent and atrophy. • If absolutely necessary, an Vulsellum forceps may be applied to the cervix so that traction will demonstrate the severity of uterine prolapse (this can cause marked discomfort, perform very gently). • Sometimes, prolapse may only be demonstrated with the woman standing or straining. • An assessment of pelvic floor muscle strength should be carried out (Box 22.).
Quality of life assessment • Symptoms can affect quality of life, causing social, psychological, occupational, or sexual limitations to a woman’s lifestyle. • Self-completion questionnaires allow a comprehensive assessment of prolapse symptoms and their impact, such as the Vaginal Symptoms module of the International Consultation on Incontinence Questionnaire (ICIQ-VS) (M www.iciq.net).
Investigations • USS to exclude pelvic or abdominal masses (if suspected clinically). • Urodynamics are required if urinary incontinence is present. • ECG, CXR, FBC, and U&E (if appropriate pre-surgery).
Prolapse: clinical assessment
Box 22. Modified Oxford system for grading pelvic floor muscle strength A system of grading using vaginal palpation of the pelvic floor muscles: • 0: no contraction. • : flicker. • 2: weak. • 3: moderate. • 4: good (with lift). • 5: strong.
Prevention of pelvic organ prolapse • Ensure excessively long labour is prevented. • Careful consideration of pelvic anatomy when performing instrumental deliveries. • Encouraging persistence with postnatal pelvic floor exercises. • Weight d. • Treatment of chronic constipation. • Treatment of chronic cough (including smoking cessation).
Prolapse: conservative management Physiotherapy Physiotherapy has a role in the management grade and 2 prolapse: • Pelvic floor muscle exercises: are most effective when taught under the direct supervision of a physiotherapist; these will improve the tone in young parous women, but are unlikely to benefit women with more significant uterovaginal prolapse. • Biofeedback and vaginal cones (E Stress urinary incontinence: conservative management, p. 752).
Intravaginal devices (pessaries) Vaginal pessaries (Fig. 22.9) offer a further conservative line of therapy for women who decline surgery, who are unfit for surgery, or for whom surgery is contraindicated. They should be changed 6-monthly and topical oestrogen may be given to d the risk of vaginal erosion. • Ring pessary: is most commonly used and is available in a number of different sizes (52–29mm); the ring is placed between the posterior aspect of the symphysis pubis and the posterior fornix of the vagina. Patients may be taught to self-insert and remove the device to facilitate sexual activity. • Shelf pessary: can be used when a correctly sized ring pessary will not sit in the vagina and/or where the perineum is deficient (it may be difficult to insert and remove and its use precludes penetrative intercourse). • Hodge pessary: can be used to correct uterine retroversion. It is of classical interest, but in practice is virtually never used now. • Cube and doughnut pessaries: are, very rarely, used for significant prolapse, when others are not retained.
Factors influencing management of prolapse • Severity of symptoms. • Grade of prolapse (asymptomatic grade prolapse does not require treatment). • Age, parity, and wish for further pregnancies. • Patient’s sexual activity. • Presence of aggravating features such as smoking and obesity. • Urinary symptoms. • Other gynaecological problems such as menorrhagia. • Comorbidity and previous surgeries.
Prolapse: conservative management
Fig. 22.9 Types of pessary for uterine prolapse include rings, cubes, shelf, and doughnuts. Reproduced by courtesy of Milex Products Inc., Chicago © 2002.
Prolapse: surgical management, anterior and posterior compartments Surgery offers definitive treatment of prolapse. Choice of procedure depends on patient and type of prolapse that exists.
Anterior compartment defect Anterior colporrhaphy (anterior repair) • Appropriate for the repair of a cysto-urethrocele. • A longitudinal incision is made on the anterior vaginal wall and the vaginal skin separated by dissection from the pubocervical fascia. • Buttressing sutures are placed on the fascia. • The surplus vaginal skin is excised and the skin is closed. • The repair is traditionally performed under regional or general anaesthesia; however, it can also be performed under local anaesthesia, allowing early mobilization and discharge home. • While morbidity is low, the long-term success rate of conventional anterior colporrhaphy is disappointing; recurrence rates of up to 30% have been reported. This may in part be due to failure to identify a coexisting apical defect. Paravaginal repair • Abdominal approach to correct an anterior defect. • The retropubic space is opened through a Pfannenstiel incision and the bladder is swept medially, exposing the pelvic sidewall. • The lateral sulcus of the vagina is elevated and reattached to the pelvic sidewall using interrupted sutures. • A cure rate of 70–90% has been reported (may also be done laparoscopically). • It isn’t a commonly performed procedure, it is very invasive if performed via laparotomy, and the author’s personal experience suggests higher recurrence rates than published data suggest.
Posterior compartment defect Posterior colpoperineorrhaphy (posterior repair) • Appropriate for correction of a rectocele and deficient perineum. • It involves the repair of a rectovaginal fascial defect and removal of excess vaginal skin. 2 Care must be taken when removing redundant vaginal skin, as vaginal narrowing can result in dyspareunia. 2 Perineoplasty is performed by placing deeper sutures into the perineal muscles, building up the perineal body to provide additional support.
PROLAPSE: SURGICAL MANAGMENT I
Prolapse: surgical management, uterovaginal and vaginal vault Uterovaginal (apical) prolapse Vaginal hysterectomy • May be combined with the procedures previously described (E Prolapse: surgical management, anterior and posterior compartments, p. 772), in cases of significant uterine descent or menstrual problems (Table 22.2). Manchester repair (or Fothergill repair) • Now rarely performed. • Cervical amputation is followed by approximation and shortening of the cardinal ligaments anterior to the cervical stump. • This is combined with an anterior and posterior colporrhaphy. Hysteropexy/sacrohysteropexy • Can be performed if patient wishes to preserve uterus as an open or laparoscopic procedure (Fig. 22.0). • Uterus and cervix are attached to sacrum using bifurcated non- absorbable mesh. • Theoretical advantage of hysteropexy is stronger apical support when compared with vaginal hysterectomy.
Vaginal vault prolapse Sacrospinous ligament fixation • Involves suturing the vaginal vault to the sacrospinous ligaments, using a vaginal approach. • Low immediate postoperative morbidity; success rate 70–85%. H As vaginal axis is changed by this procedure, there is risk of postoperative dyspareunia. Sacrocolpopexy • The vault is attached to the sacrum using a non-absorbable mesh, and if can be performed either as an open procedure or laparoscopically. • It has a higher success rate, of ~90%, and a better anatomical result than sacrospinous fixation. H Mesh erosion into the vagina, or rarely into the bladder or bowel, is a possible late complication.
PROLAPSE: SURGICAL MANAGEMENT II
Table 22.2 Operations available for uterovaginal prolapse Defect
Abdominal route (open or laparoscopic)
• Anterior colporrhaphy • Transvaginal mesh repair (currently suspended)
• Paravaginal repair • Sacrocolpopexy with placement of mesh over anterior vaginal wall
• Vaginal hysterectomy • Sacrospinous fixation
• Hysteropexy (laparoscopic or open) • Sacrocolpopexy
• Posterior repair • Transvaginal mesh repair (currently suspended) • Perineal body reconstruction
• Sacrocolpopexy to correct recto/enterocele
Fig. 22.0 Bifurcated mesh in position for sacrohysteropexy. Reproduced from Springer-Verlag London Ltd., Female Pelvic Reconstructive Surgery, 2002, p 87, Figure 3.0 Stanton and Zimmern. With kind permission of Springer Science and Business Media.
Recurrent urogenital prolapse • ~/3 of all prolapse surgery is for recurrent defects. • Vaginal epithelium may be scarred and atrophic: • making surgical correction technically more difficult • i the risk of damage to the bladder and bowel. 2 Use of synthetic meshes was common for repair of recurrent prolapse, as they may offer more support where endopelvic fascia has proved to be deficient. Due to concerns regarding complications all vaginally inserted meshes are currently suspended by NHS England.
Use of ‘mesh’ in urogynaecological surgery • This has been the source of much attention from patients and the media. • Concerns have been raised due to potential adverse effects, including pain, mesh erosion, and sexual dysfunction. • NICE recommends that surgeons performing mesh insertion have had specialist training and carry out a sufficient case load to maintain their skills: • all surgeons should maintain audit data and contribute to national audit databases (such as the British Society for Urogynaecology) • all surgeons should work within the context of the MDT. • Patients must be provided with information about risks of surgery and should be made aware of alternative procedures. • NHS England ‘paused’ all vaginal mesh surgeries (as of July 208) pending further review (still paused at time of going to press). • Abdominally inserted mesh can still be offered but is subject to high vigilance.
Further reading NICE (209). Urinary incontinence and pelvic organ prolapse in women: management. NICE guideline [NG23]. M www.nice.org.uk/guidance/ng23
Benign and malignant gynaecological conditions Benign neoplasms of the lower genital tract 778 Benign neoplasms of the uterus 780 Benign ovarian tumours: diagnosis 782 Benign ovarian tumours: imaging 784 Benign ovarian tumours: histology 786 Benign ovarian tumours: management 788 Vulval dermatoses: lichen sclerosus 790 Other vulval dermatoses 792 Idiopathic vulval itch and pain 794 Cancer screening in gynaecology: overview 796 Ovarian cancer screening 798 Endometrial cancer screening 800 Cervical cancer: pathology 802 Cervical cancer: prevention 803 Cervical screening 804 Cervical cancer: cytology, colposcopy, and histology 806 Management of cervical intraepithelial neoplasia 808 Management of cervical glandular intraepithelial neoplasia 80 Gynaecological cancer: a multidisciplinary approach 82 Cervical cancer: aetiology and presentation 84 Cervical cancer: diagnosis 86 Cervical cancer: treatment 88 Sentinel lymph node biopsy 820 Ovarian cancer: aetiology 822 Management of BRCA mutation 824 Ovarian cancer: presentation and investigation 826 Ovarian cancer: treatment 828 Ovarian cancer: chemotherapy and follow-up 830 Rare ovarian tumours: germ cell 832 Rare ovarian tumours: other 834 Borderline ovarian and low-grade serous ovarian tumours 835 Low-grade ovarian carcinoma 836 Endometrial hyperplasia 837 Atypical endometrial hyperplasia 838
Endometrial cancer: aetiology and histology 840 Endometrial cancer: presentation and investigation 842 Endometrial cancer: surgical treatment 844 Endometrial cancer: non-surgical treatment 846 Rare uterine malignancies 848 Vulval intraepithelial neoplasia: overview 850 Vulval intraepithelial neoplasia: management 85 Vulval cancer: aetiology and investigation 852 Vulval cancer: treatment 854 Rare vulval malignancies 856 Vaginal cancer 858 Rare vaginal cancers 860 Gestational trophoblastic disease: hydatidiform mole 862 Hydatidiform mole: management 864 Gestational trophoblastic disease: choriocarcinoma 866 Principles of chemotherapy 868 Classes of chemotherapy agents 870 Side effects of chemotherapy: haematological and gastrointestinal 87 Side effects of chemotherapy: other 872 Chemotherapy for gynaecological cancer 874 Radiotherapy: principles 876 Radiotherapy: gynaecological cancers 878 Radiotherapy: side effects 879 Hormone replacement therapy after gynaecological cancer treatment 880 Principles of palliative care 882 Pain and its management 884 Other symptoms in advanced gynaecological cancer 886
Benign & malignant gynaecological conditions
Benign neoplasms of the lower genital tract Benign neoplasms are very common in the genital tract; most are innocent and easy to recognize.
Vulva (See Fig. 4.3, p. 54.) • Bartholin’s cyst: arises from blocked Bartholin’s duct. Bartholin’s gland normally 50% of the fibroid mass extends outside the uterine contours. • Cervical: relatively uncommon and can cause surgical difficulty due to the proximity to the bladder and the ureters. • Pedunculated: mobile and prone to torsion. • Parasitic: have become detached from the uterus and attached to other structures. • IV leiomyomatosis: very rare, spread through the pelvic veins and vena cava to involve the heart.
Diagnosis Clinical examination (hard, irregular uterine mass) may be sufficient. TV or abdominal USS can differentiate the types and dimensions of the fibroids. Rarely, MRI may be needed when the scan is inconclusive. H Leiomyosarcomas are very rare—consider if fibroid painful/rapidly growing/bleeding—imaging cannot reliably diagnose or exclude.
Endometrial polyps (adenoma) These are focal overgrowth of the endometrium and are malignant in 40yrs, but may occur at any age. Treatment is usually resection during hysteroscopy and the polyp should be sent for histological assessment to exclude malignancy.
Benign neoplasms of the uterus
Treatment options for uterine fibroids • No treatment: if minimal symptoms. • Mirena® IUS: st line if heavy bleeding and fibroids 45yrs—guaranteed cure of fibroids. • Uterine artery embolization: uterine artery is catheterized generally using the unilateral approach; embolic agent with a diameter of 300–750µm used, e.g. polyvinyl alcohol powder or gelatin sponge (minimally invasive procedure with avoidance of a GA). • MR-guided focused ultrasound therapy: non-invasive procedure using high doses of focused ultrasound waves to destroy fibroids.
Benign neoplasms of the fallopian tube Hydrosalpinx, pyosalpinx, and tubo- ovarian masses following PID or endometriotic adhesions may present as a benign mass in the pelvis. The diagnosis is essentially by ultrasound and laparoscopy. Most tumours of the fallopian tubes are malignant. Although they were thought to be rare, data from series of breast cancer gene (BRCA) +ve women undergoing prophylactic bilateral salpingo-oophorectomy (BSO) suggest that many of what were thought to be ovarian cancers arise from serous tubal intraepithelial carcinoma (STIC lesions) in the fimbriae of fallopian tubes.
Further reading NICE (208, updated 202). Heavy menstrual bleeding: assessment and management. NICE guideline [NG88]. M www.nice.org.uk/guidance/ng88/ RCOG (203). Uterine artery embolisation in the management of fibroids. M www.rcog.org.uk/guidance/browse-all-guidance/other-guidelines-and-reports/uterine-artery- embolisation-in-the-management-of-fibroids/ RCOG (204). The distal fallopian tube as the origin of non-uterine pelvic high-grade serous carcinomas. M www.rcog.org.uk/globalassets/documents/guidelines/scientific-impact-papers/sip44hgscs.pdf RCOG (209). Morcellation for myomectomy or hysterectomy. M www.rcog.org.uk/globalassets/documents/guidelines/consent-advice/consent-advice-no-3- morcellation-myomectormy-hysterectomy.pdf
Benign & malignant gynaecological conditions
Benign ovarian tumours: diagnosis Ovarian cysts are frequently physiological, due to follicular cyst (≤3cm) and corpus luteal cyst (≤5cm) formation during the menstrual cycle. In a woman who is having periods, a cyst of cm) are frequently seen in postmenopausal women (up to 4%) on TVS.
Presentation • Asymptomatic. • Chronic pain: • dull ache • pressure on organs (urinary frequency or bowel disturbance) • dyspareunia (endometrioma) • cyclical pain (endometrioma). • Acute pain (cyst accident): • bleeding (into the cyst or intra-abdominal) • torsion • rupture. • Abnormal uterine bleeding. • Hormonal effects.
History and investigation History Menstrual history (LMP, cycle length, menorrhagia); pain (site, nature, radiation—typically down leg/s, duration, precipitating factors); bowel/ bladder function; abdominal distension; medical and family history. Acute presentation of cyst accident often associated with nausea, vomiting, and loss of appetite (rule out appendicitis). Examination • Systemic: pulse, BP, anaemia, temperature. • Abdominal: mass arising from pelvis, tenderness, signs of peritonism, upper abdominal masses or ascites suggest cyst less likely to be benign. • Pelvic: PV discharge/bleeding, cervical excitation, adnexal mass or tenderness (mobile or fixed, smooth or nodular, size). Haematological tests • FBC. • Tumour markers: • CA25 (consider CA9-9 and CEA if suspicious USS) • add AFP, hCG, LDH in a woman 7cm due to difficulty visualizing entire cyst at time of ultrasound, if not considering surgical management.
Box 23. Modified RMI RMI =U × M × CA25 • U =ultrasound score (0, , or 3). • M =menopausal status ( =premenopausal, 3 =postmenopausal). • CA25 =serum cancer antigen 25 level (U/L). Ultrasound scoring system • Features looked for on USS: • multilocular cyst • evidence of solid areas • evidence of metastases • ascites • bilateral lesions. • Final U score: • 0 if no features • if feature • 3 if 2 or more features. Reproduced from Tingulstad S, Hagen B, Skjeldestad FE, et al. (996). ‘Evaluation of a risk of malignancy index based on serum CA25, ultrasound findings and menopausal status in the pre- operative diagnosis of pelvic masses’ BJOG 03(8): 826–3 with permission from Wiley.
Table 23. RMI score and ovarian cancer risk Risk
Risk of cancer