Womens Health Core Curriculum

WO EN'S HEALTH
A CORE CURRICULUM
\.
*
Contents
Foreword v 4 Lower abdominal pain 49

Preface xi Edited by Vivienne O'Connor
A note to the student xii
Pelvic pain Ian Jones 50
Contributors xiii Endometriosis Vivienne O'Connor 51
Pelvic inflammatory disease
Abbreviations xvii
Vivienne O'Connor 52
Photographs and illustration credits xix
5 Contraception 55
Introduction Beverley Vollenhoven and Gareth Weston
Anne Ellison and Robert Burrows Edited by Beverley Vollenhoven
Reversible contraceptive methods 56

The menstrual cycle and
Emergency contraception 60
vaginal bleeding 5 Irreversible contraception 60
Edited by Beverley Vollenhoven
6 Health education before and
Premenstrual syndrome during pregnancy 63
Cindy Farquhar and Neil Johnson 7
Lucy Bowyer and Ratnasari Padang
Dysmenorrhoea
Edited by Lucy Bowyer
Abnormal bleeding
Counselling before pregnancy 64
Women with genetic concerns 67
Delayed puberty
Fall Langdana and Rosemary Reid 18 7 Antenatal care 73
Polycystic ovary syndrome Wayne Gillett 23
Hyperandrogenism Wayne Gillett 25 Edited by Sandra Carr
Premature ovarian failure
Michel Sangalli and Lynda Croft 28 Lifestyle issues in pregnancy Penelope Black
and William AW Walters 74
2 Vaginal discharge 33 Antenatal care - first trimester
Stephen O'Callaghan 77
Leo R Leader
Ectopic pregnancy Ujliana Milkovic-Pefkovic
and Thomas Taif 79
Miscarriage Lijliana Milkovlc-Petkovic and
3 Sexually transmitted infections 39
Thomas Tait 82
Edited by Vivienne O'Connor Antenatal care - second trimester
Warwick Giles 84
Genital herpes Mark Erian 40 Antenatal care - third trimester
Female genital warts (condylomata Andrew Bisits 86
acuminata) Mark Erian 41
Syphilis Ian Jones 42 8 The fetus 93
Gonorrhoea Ian Jones 44
Martha Finn
Chlamydia Vivienne O'Connor 44
HIV / AIDS Vivienne O'Connor 45
Fetal growth 94
Sexually transmitted Infections and
Assessment of fetal wellbeing 99
pregnancy Vivienne O'Connor 46
vii
Women 's health : A core curriculum
Co nte nts
9 Medical disorders in pregnancy 105 14 Specific obstetric emergencies 163 22 The menopause and beyond 235
Edited by Martha Rnn Nadia Badawl, Michele Batey, Jonathon Morris, Edited by Martha Rnn
Michael Nicholl
Hyperemesis g ravidarum Regina Wulf 107 Edited by Lucy Bowyer The menopause Alas/air MacLennan 236
Anaemia Petra Porter 109 Management at the menopause
Isoimmunisation Louise Komman and Antepartum haemorrhage 164 Alastair MacLennan 237
Helen Savala 111 Primary postpartum haem orrhage 167 Postmenopausal bleeding Paul Duggan 243
Abnorm al g lucose tolera nce Helen Lomml 113 Umbilical cord p ro la pse 169
Hypertension Mark Brown 116 Ma lpresentatlons 170 23 Principles of operative
Th romboembolic disease Petra Porter 119 Shoulder dystOCia 172 gynaecology 249
10 Infections in pregnancy 125 15 The newborn 177 Phil Wolters and Clement Chan
Michael Humphrey and Ajay Rane Paul Croven and Nadia Badewi
Edited by Vivienne O'Connor Edited by Lucy Bowyer 24 Principles of oncology 253
Rubella 126 16 Routine management of the Edited by Martha Finn
Hepatitis B 126 puerperium 187 Screening for cancer of the cervix
Urinary tract inlection 127
Edited by Sondra CalT Jennifer Cook
Varicella zoster virus 128 254
Parvovirus B19 129 Cervical carcinoma Jennifer Cook 259
Normal puerperium Sandra Corr 188 Screening tor b reast cancer Phillip Corson
Cytomegalovirus 129 261
Care after caesarean delivery Endom etrial cancer Bruce Ward
Toxoplasmosis 130 264
Michoel Humphrey 192 Gestaftonal trophoblastic disease
Group B Streptococcus 130
Puerperal sepsis Sandra Carr 193
Cho rloam nionitis 130 Marc JNC Kelrse 267
Secondary postpartu m haemorrha ge Cancer 01 the ovary Marc JNC Kelrse 270
Jon Dickinson 195
11 Preterm birth 133 Gen ital tract trauma ChrlS/ine White 197 25 Women and society 277
Edited b y Martha Finn 17 The psychological experience
Regina Wulf of pregnancy 203 Teenage pregnancy Karen Harris 278
Pre term labour 134 Jonathan Rampono Violence a gainst women and girls Dawn Miller.
136 Edited by Sandra Corr Angela Taft a nd Kelsey Hegarty 280
Preterm prelabou r rupture 01 m embranes
Loss and grlet In women's lives
12 Maternal, perinata l m ortality 139 The Psychological experience 204 Cella Devenish and Jeremy Tuohy 282
Psychologic al and psychiatric disorders 206
Gerord Garllan and Clement Chan
Postnatal mental health 207
Edited by Lucy Bowyer Index 287
18 Infertility 211
Maternal mortality 140
142 Michael G Chapman and Una Conway
Perinatal mortality
13 Labour and delivery 145
19 Unplanned pregnancy and
Edited by Beverley Vollenhoven ond Mortha Rnn
termination 217
Normal labour Andrea Barkehall-Thomas Paul Duggan and JeHrey Robinson
(Edited by Beverley Vollenhoven) 146 Edited by Martha Rnn
Prolonged and dystuncftonal labour
Andrea Barkeha ll-Thomas 20 Genital prolapse 223
(Edited by Beverley Vollenhoven) 15 1 Paul Duggen
Active managem ent of labour Roslyn MecKenzie Edited by Mertha Finn
(Edited by Martha Finn) 152
OperaMve vaginal delivery 21 Incontinence 229
Andrea Barkehall-Thamas Paul Duggan
(Ediled by Beverley Vollenhoven) 154 Edited by Martha Finna
Prolonged pregnancy Nader Gad
(Edited by Marthe Finn) 156
Mf:
*
Women's health : A core curriculum
Beverley Vollenhoven MBBS (Hons), PhD,

FRANZCOG, CREI
Abbreviations
Senior Lecrurer and Clinical Supervisor,
Department of Obstetrics and Gynaecology,
Monash Universiry, Melbourne, Vic.
William AW Walters MBBS, PhD, FRCOG,
FRACOG, FACSHJ; FRSM
Emeritus Professor, Acting Head, Discipline of 17-0HP 17-hydroxyprogesterone E oestrogen
Reproductive Medicine, John Hunter Hospital, ACE angiotensin-converting enzyme ECF extracellular fluid
Newcastle, NSW ACIS adenocarcinoma-in-siru ECG elecrrocardiograph
ACR albumin creatine ratio ECV external cephalic version
Bruce Ward MBBS, PhD, FRCOG, FRANZCOG, EDD estimated date of delivery
ACTH adrenocorticotropic hormone
CGO EE ethinyl oestradiol
Gynaecological Oncologist, Mater Medical AFI amniotic fluid index
AFP alpha-fetoprotein ELA endometrial laser ablation
Centre, Brisbane, Qld. ELISA enzyme-linked immunosorbent assay
AIDS acquired immune deficiency syndrome
Phi! Watters MBBS, MRCOG, FRACOG, FRCOG, ALT alanin e transaminase
FRANZCOG AMC Australian Medical Council FBC full blood count
Honorary Senior Lecrurer, School of Medicine, FBE full blood examination
AP antero-posterior
Universiry of Tasmania, Hobart, Tas. FDIU fetal death in utero
APH anteparrum haemorrhage
FMH feromaternal haemorrhage
Gareth Weston MBBS, MPH, PhD APTT activated partial thromboplastin time
FNAB fine-needle aspiration biopsy
Department of Obstetrics and Gynaecology, AST aspartate transaminase
FSH follicle-stimulating hormoneF
Monash Universiry, Melbourne, Vic.
BMD bone mineral densiry GBS group B Streptococcus
Christine White RN, RM, BHlthSc (Nurs), Jl.fN BPS biophysical profile score
Clinical Midwife Consultant, King Edward GDM gestational diabetes melli rus
BV bacterial vaginosis GFR glomerular filtration rate
M emorial Hospital for Women, Perth, Wi\.
GHb glycosylated haemoglobin
Regina Wulf Medical State Examination (Germany), CF cystic fibrosis GnRH gonadotrophin-releasing hormone
Registrar in Obstetrics and Gynaecology, Royal CIN cervical intraepithelial neoplasia
Darwin Hospital, Darwin, NT. CMY cytomegalovirus . HAIRAN hyperandrogenism, insulin resistance,
COCP combined oral contraceptive piLI acanthosis nigricans
CRH corticotrophin-releasing hormone Hb haemoglobin
CRL crown rump length HbAlc haemoglobin Al c
CSF cerebrospinal fluid HBcoreAg hepatitis B core antigen
CTG cardiotocography HBeAg hepatitis B e antigen
CVS chorionic villus sampling HBIG hepatiris B immunoglobulin
HBsAg hepatitis B surface antigen
HBsAg+ve hepatitis B surface antigen positive
D&C dilatation and curettage
HCG human chorionic gonadotrophin
DCIS ductal carcinoma in-siru HDN haeqlOlytic disease of the newborn
D&E dilatation and evacuation HELLP haemolysis, elevated liver enzymes and
DHEA dehydroepiandrosterone low platelets
DHEAS dehydroepiandrosterone sulfate HG hyperemesis gravidarum
DIC disseminated intravascular HIV hwnan immunodeficiency virus
coagulopathy HMB heavy mensrrual bleeding
DMPA depot medroxyprogesterone acetate HNPCC hereditary nonpolyposis colon cancer
DNA deoxyribonucleic acid HPV human papillomavirus
DUB d:'sfunctional uterine bleeding HSIL high-grade squamous intraepithelial
DVf deep vein (venous) thrombosis lesion
MG'
*
Women's health: A core curriculum
HSV herpes simplex virus

hormone therapy
PCOS
PCR
polycystic ovary syndrome
polymerase chain reaction
Photograph and illustration credits
HT pulmonary embolism
PE
lAT immune antiglobulin test PG prostaglandin
intracytoplasmic sperm injection PGF 2 (l prostaglandin F2 (l
ICSI
immunoglobulin G PID pelvic inflammatory disease
IgG
immunoglobulin M PKU phenylketonuria
IgM
International Liaison Committee on PMS premenstrual syndrome
!LCOR
Resuscitation POD pouch of Douglas For all figures not listed below, see the source Peter Farkas/Clinical Photography Unit,
intermenstrual bleeding POEC progestOgen-only emergency
J..t'AB aclmowledged in the caption and detailed in Royal Darwin Hospital
intrauterine device contraception the reference list of each chapter. p 59, Fig 5.1; p 101, Fig 8.6; p 102, Fig
IUD
intrauterine insemination POP progestogen-only pill 8.7; p 226, Fig 20.4; P 257, Fig 24.5;
IUI
inttauterine growth restriction PPH postpartum haemorrhage Australian Institute of Health and Welfare
IUGR P 262, Fig 24.10; p. 263, Figs 24.11,
intrauterine pregnancy PPROM preterrn prelabour rupture of
IUP p 143, Fig 12.1; P 244, Fig 22.7 24.12; P 269, Fig 24.15; P 271, Fig 24.16
in vitro fertilisation membranes
IVF prelabour rupture of membranes Australian Prescriber Eric Hu/Royal Darwin Hospital
IVH intraventricular haemorrhage PROM
PSN presacral neureCtomy p 240, Fig 22.3
p 256, Figs 24.2, 24.3, 24.4; P 257, Figs
LAVH laparoscopic assisted vaginal PT prothrombin time Professor Suzanne Abraham 24.6,24.7; p 2S9, Fig 24.8; P 265, Fig
hystereCtomy PV per vaginam (for D Uewellyn-Jones) 24.13; P 267, Fig 24.14
LCR ligase chain reaction p 19, Figl.l0; p 21, Fig 1.12; P 94, Fig
lureinising hormone-releasing hormone RBC red blood cell Alastair MacLennan/Departrnent of Nuclear
LHRH 8.1; p 148, Fig 13.2; p 150, Fig 13.3; P
RCT randomised controlled trial Medicine and Bone Densitometry, Royal
LLETZ large loop excision of the 180, Fig 15.2; p 182, Fig 15 .3; P 260 Fig
transformation zone Rl"'lA ribonucleic acid Adelaide Hospital
24.9 '
last menstrual period RPR rapid plasma reagin p 238, Fig 22.1
LMP
LNG-IUS levonorgcstrel intrauterine system Paul Duggan
SFH symphysis-fundal height p 225, Fig 20.2; P 226, Fig 20.3
LS!L low-grade squamous intraepithelial sex-hermone-binding globulin
SHBG
lesion SIDS sudden infant death syndrome
LUNA laparoscopic uterine nerve ablation selective serotonin reuptake inhibitor
SSRl
STI sexually transmitted infection
M CH mean corpuscular haemoglobin
MCHC mean corpuscular haemoglobin TCRE transcervical resection of the
concentration endometrium
MCV mean corpuscular volume TENS transcutaneous electrical nerve
MEA microwave endometrial ablation stimulation
MIS minimally invasive surgery TIT thyroid function test
MR1 magnetic resonance imaging TL tubal ligation
MSAFP maternal serum alpha-fetoprotein TOP termination of pregnancy
TPHA T. pallidum haemagglutination assay
NSAID nonsteroidal anti-inflammatory drug
TSH thyroid-stimulating hormone
NTD neural tube defect
TVS transvaginal ultrasound scan
NTS nuchal translucency scan
TVT tension-free vaginal tape
OA occipito-anterior urinary tract infection
UTI
OCP oral contraceptive pill
OD optical density VBAC vaginal birth after caesarean section
OP occipito-posterior VDRL venereal disease reference laboratory
VZV varicella zoster virus
P progestogen
PAPP-A pregnancy associated plasma protein A WHO World Health Organization
PBAC piCtorial blood-loss assessment charr
postcoital bleeding ZIG zoster immune globulin
PCB
iif
*1
The menstrual cycle and
vaginal bleeding /
Edited by Beverley Vollenhoven V
Premenstrual syndrome, dysmenorrhoea, abnormal bleeding Cindy Farquhar and Neil Johnson
Delayed puberty Fall Langdana and Rosemary Reid
Polycystic ovary syndrome, hyperandrogenlsm Wayne Gillett
Premature ovarian failure Michel Sangeli and Lynda Croft
Learning objectives
Knowledge recall the physiological changes in the

endometrium during the menstrual
At the end of this chapter, the student cycle
will be able to:
• describe the Investigations for
menorrhagia In a teenager and a
Premenstrual syndrome
woman of perimenopausa l y ears
define premenstrual syndrome ond
Indicate Its prevalence outline the principles of management of
menorrhagia
list the common symptoms of
premenstrual syndrome Delayed puberty
outline a management plan for a describe the pubertal process and the
woman with premenstrual syndrome development of secondary sexual
characteristics
Dysmenorrhoea
• list the common causes of delayed
differentiate between primary and puberty
secondary dysmenorrhoea
outline an investigation and
list the causes of secondary management plan for delayed puberty
dysmenorrhoea
Polycystic ovary syndrome
d(scuss the social and economic effects
of dysmenorrhoea • define polycystic ovary syndrome
construct a plan for Investigation and describe the clinical manifestations of
management of dysmenorrhoea polycystic ovary syndrome
Abnormal vaginal bleeding summarise the long-term complications
of polycystic ovary syndrome
define the terms menorrhagia,
dysfunctional uterine bleeding , describe the prinCiples of management
intermenstrual bleeding and postcoital of a woman with polycystic ovary
bleeding syndrome
(Continued over)
•
1 The menstrual cycle and vagi nal bleeding
Women 's health: a core curriculum
(leaming objectives continued)

write a prescription for a nonsteroidal anti-
inflammatory drug or oral contraceptive
pill and explain to the patient how she
* Premenstrual syndrome Symptoms and signs
Women with PMS will often feel 'overwhelmed'
Hyperandrogenlsm should take the medication Common clinical presentation or 'out of control' and have one or more of a range
appreciate the wide variation in hair For one week out of every four, before her of psychological and physical symptoms. The
take a comprehensive history from a
distribution and density in different ethnic woman with menorrhagia menstrual period, a busy professional woman symptoms are not an exacerbation of another psy-
groupS with a young family feels 'out of control', snap- chiatric disorder. Thus PMS is, in part, a diagnosis
counsel a woman concerning treatment of exclusion.
describe the normal cycle of hair growth ping at her children, weeping and foiling to
options for menorrhagia
cope at work. She would like you to prescribe Typical psychological symptoms include:
• list the normal sites of androgen • elicit a relevant personal and family '0 pill to sort out my hormones'.
production history from a peripubertal girl • affective lability - tearfulness, irritability or
anger
discuss the causes of excess androgen take a comprehensive history from a girl
production and its effects presenting with primary amenorrhoea • anxiety or tension
Epidemiology • depression
discuss the social consequences af • assess the development of secondary • loss of interest, difficulty concentrating, lack of
hyperandrogenism sexual characteristics in a girl Premensnual syndrome (PMS) is defined as the energy, sleep disturbance, appetite disturbance.
counsel a woman on the benefits of weight cyclical occurrence JUSt before menses of a range
outline an Investigation plan that
distinguishes benign from malignant loss and the long-term consequences of ,. of symptoms that are severe enough to impact on Physical symptoms accompanying PMS may
causes of hyperandrogenism polycystic ovary syndrome lifestyle, relationships or work, and that resolve include:
with the onset of menses. A symptom-free week
• explain the cosmetic and drug treatment examine a woman for signs of • breast tenderness
hyperandrogenism and virilism after menses is an essential diagnostic feature.
options for hyperandrogenlsm While 95% of women of reproductive age experi- • fluid retention and weight gain
Premature ovarian failure counsel a woman with premature ovarian ence some physiological symptoms premensnu- • headaches
failure on the use of hormone therapy and • aching joints.
define premature ovarian failure ally, approximately 50/0 of women are severely
assisted reprod uction .
incapacitated by these symptoms. The typical age
list the causes of premature ovarian failure at presentation is 30-40 years. PMS presents in all Evidence
outline how to investigate and confirm the Attitu des ethnic groups, although the reported symptom A substantial placebo response in PMS should not
diagnosis of premature ovarian failure clusters may vary with ethnicity. discredit the psychosocial aspects of the
At the end of this chapter, the student doctor-patient encounter. Indeed, the response to
discuss the short- and long-term effects of
should reflect upon : Pathoph ysiology an interested, understanding, empathetic and edu-
premature ovarian failure
• the effects of premenstrual syndrome on
cational approach from the doctor is very impor-
discuss a management plan for a woman Both medical and social models of the pathophys- tant. However, because this placebo response is a
with premature ovarian failure. family and social dynamics iology and approach to the management of PMS possibility, studies of possible treatments must be
• the broader social and economic impacts have been proposed. The most plausible hormon- double-blind randomised controlled trials (RCTs)
of abnormal vaginal bleeding al explanation is high levels - or, probably more to assess treatment effects rigorously - lower lev-
Skills accurately, rapidly declining levels - of proges- els of evidence are notoriously unreliable.
• the implications of delayed puberty for
At the end of this chapter, the student interactions at school and In the family terone (or the progesterone/oestrogen ratio) in the Attention to lifestyle, relationships and work
should learn how to: luteal phase of the cycle. Other medical patho- interactions may shift the focus of what was
• obesity as a public health issue
physiological theories include contributing factors assumed to be PMS. Changes that allow women to
• counsel a woman on the evidence-based the social consequences of such as increased renin-angiotensin-aldosterone exert greater control over their lives are most
treatments and other strategies for hyperandrogenism and obesity activity, changing prostaglandin levels, vitamin
management of premenstrual syndrome
likely to produce a lasting benefit. Relaxation
psychosocial and health implications of deficiency, excess prolactin secretion and endoge-
premature 'ageing' for a woman and her techniques are often helpful. Exercise may allevi-
exp lain the nature of primary nous endorphin depletion.
family.
ate symptoms for some women. Homeopathy and
dysmenorrhoea The psychosocial models acknowledge that the
herbal remedies have been used, but robust evi-
symptoms may be exacerbated by:
dence of their efficacy is lacking.
• a negative anticipation of mensnuation There is evidence from RCTs to support
• pressures of caring for famil y and pursuing a the effectiveness of selective serotonin reuptake
career inhibitors (SSRls). The response to gonadotrophin-
• an underlying predisposing personality releasing hormone (GnRH) agonists - so-called
• stereotypic expectation among men and medical oophorectomy - usually gives a useful pre-
women of premensnual symptoms. diction of the response to surgical oophorectomy.
•
l). · ~\l\J, s""",~r1,:-
1c-1''''-(c.0\.Of'j V~ c..A·
~ . ~c.. viS Oo(/o...M Kt.L .
(fl.VN4 1 The menstrual cycle and vagin o l bleed ing
Women's health: a core curriculum
! rl
However this approach remains conrroversial,

being co~sidered by many to be excessively inva-
* Dysmenorrhoea " Se.vo~ 'I
,-------------------------------------------------~
Ureter ------li--t-l+l-=f---fl
sive when cure cannot be guaranteed. Refs have Common clinical presentation
Umbilicus ---......,~
failed to provide supporting evidence for the effec-
During a consultation with a 34-year-old
tiveness of evening primrose oil, which proVIdes woman who Is concerned that she has not Small bowel ---IIL...--h4----\-+
linoleic and gamolenic acids, precursors of been able to conceive 12 month. after stop-
prostaglandin E or progestogens. . ping the oral contraceptive pili, a coincidental Caecum
-\-l,<:~~_l..-..\\..-- Pelvic peritoneum
Other rrearrnents that are commonly used m finding Is that she has always hod debilitating
Appendlx----1\----\----/-.f.-,l>,) ~.>Y~~~-.w.....:>.--\--4I>__- Fallopian tube
practice, but for which there is either conflicting menstrual period pain. She has always been
evidence or an absence of eVIdence from Refs, told by her mother and the family GP that 'this laparotomy
~?-~~~~\!ti-SigmOld colon
include the combined oral contraceptive pill is the normal thing all women go through'. scar Ovary
::;:;; _ (COCP), continuous progestogens, pyridoxine Inguinal ring Surface of uterus
(vitamin B6), nonsteroidal antl-mflammatory Myometrium (adenomyosis)
drugs (NSAIDs), calcium or magnesium. . Round
Uterosacral ligament
When certain physical symptoms are a prOID!- Epidemiology ligament
Rectovaglnal septum
nent part of a woman's PMS, specific treatments Dysmenorrhoea is painful mensrrual cramps of Bladder
Cervix
may be indicated: uterine origin. It is very common, affectmg up to Uterovesical Vagina
spironolactone for fluid retention 50% of all women. It is termed secondary dys- told
___ ~\..-7~.z.:...--7'L..--perineum
bromocriptine or everung pruruose oil for menorrhoea when identifiable pathology such as Groin
breasr tenderness. endomerriosis, adenomyosis, pelvic congestion or
pelvic adhesions indicating pre~ious inflammanon Vulva and
Bartholin's
Natural history is present; miillerian abnormalities, cervical steno- gland
sis and gynaecologlc malignancy are all rare causes
Women usually find strategies to cope with PMS, of secondary dysmenorrhoea. In all women with
with assistance from an understanding doctor, As pain and vaginal bleeding, pregnancy should be FIGURE 1.1 The distribution of endometriosis ( Based on Smith 2002, p 105)
the pathophysiology relates to cyclical hormonal considered and excluded.
change, the condition resolves afrer menopause. Primary dysmenorrhoea refers to mensrrual
cramps in the absence of .organic pathology. women. Most of the PGF 1a is released during the condition affecting up to 1 in 6 of all women (most
Impact/outcomes Primary dysmenorrhoea typically begIns 6-12 first 48 hours of mensrruation, coinciding with the of whom have mild disease). It results from one or
PMS affects family and social dynamics. It has months afrer menarche (the onset of menses), once greatest severity of symptoms. more of four possible mechanisms:
been deemed., in eXtreme cases, to be responsible the cycles become ovulatory (anovulato.ry cycles The following conditions are the most com-
for criminal acts; indeed., PMS has been used as a tend to be associated with non-painful menses). mon causes of secondary dysmenorrhoea: • rerrograde menstruation
successful legal defence against murder charges. Secondary dysmenorrhoea usually commences • coelomic metaplasia
years afrer menarche, in women more advanced • endometriosis • inrraperitoneal immune system deficiencies
into their reproductive years. Pain from secondary • adenomyosis • embolic transport of endometrial cells via the
Health maintenance • pelvic congestion bloodsrream or lymphatics.
dysmenorrhoea also rypically occurs 24 hours .or
lifestye adaptations - including the more before menstruarion and lasts for Its enme • pelvic pain related to previous pelvic inflam-
adoption of a healthy diet, exercise matory disease and adhesions. Adenomyosis is the occurrence of ecropic
duration. endomerrial implants within the myomerrium.
and relaxation techniques - may
help to manage PMS. Endometriosi5 is the occurrence of ectopic Pelvic congestion is associated with chronic
Pathophysiology endomerrial tissue ourside the uterus. The mOSt dilatation of the pelvic veins, particularly in the
Prostaglandin F2a (PGFrol is the agent responsible common sites are the ovaries (where the tissue may luteal phase, primarily under the influence of
for primary dysmenorrhoea. It IS produced i l l the form 'chocolate cysts'), the pouch of Douglas, the oesrrogen. Such veins are prone to stasis of blood.,
secretory endomerrium and mduces contracnons uterosacral ligaments and the broad ligamenrs, leading to engorgement - or congestion - of the
of the myometrium. Progesterone IS reqU1[ed f~r although other sites may be affected (Fig 1.1). Deep pelvic organs.
the endometrial production of PGF 2a; this nodular lesions may affect the rectovaginal seprum. Chronic pelvic pain is a cornmon sequel of pre-
explains the absence of dysmenorrhoea in anOVU- In severe endomerriosis, adhesions and scarring vious acute pelvic inflammatory disease (PID). This
latory cycles. The amount of PGF 2a produced by mvolvmg all pelvic organs may result in a 'frozen has ofren been referred to as 'chronic PID', but
women with primary dysmenorrhoea IS far grea((;:r pelvis'. Rarely, endometriosis can occur at sites dis- should more appropriarely be called 'recurrent
than that produced by non-dysmenorrhoelc tant from the pelvis. ;:: ndometriosis is a cornmon pelvic pain following acute PID', since rrue chronic
•
1 The m enstrua l cycle an d vag inal bl eeding
Women 's health : a core c ur riculum
simple opiates and can be used in combination

PID (chronic pelvic inflammation where causative Investigations with non-NSAID analgesics
microbiological organisms may be continually iso- Transvaginal pelvic ultrasound examination may • the COCP - useful for primary dysmenor-
lated from the genital tract) is rare. This rype of diagnose or exclude ovarian cystS (including rhoea in up to 900/0 of all cases, since anovula-
pelvic pain often has the hallmark of pelvic adhe- endometriomas), or suggest a tubo-ovarian mass. tory cycles tend not to be associated with
sions ' other common causes of the latter are Pelvic magnetic resonance imaging (MRl) may give painful menses; helpful in some cases of sec- ~~""1
endo:netriosis and previous pelvic surgery. additional information; for example, it may help ondary dysmenorrhoea. /o.vJ.I/O~'"
with the diagnosis of adenomyosis. Laparoscopy RCT evidence supports the effectiveness of S'lf
Symptoms and signs under general anaesthesia is the gold-standard progestogens, COCp, gestrinone, danaz61 and .!Z)
The crampy central lower abdominal pain of pri- diagnostic test for causes of dysmenorrhoea or GnRH agonists for pelvic pain related to ~c ~ I
mary dysmenorrhoea, which can radiate to the pelvic pain (Fig 1.2). endometriosis, although in direct comparisons none v.. r1!A~1
lower back and upper thighs, may precede the Although parterns of pain and associated of these medical treatments is clearly superior to the ~~
onset of menses by several hours, tends to be most symptoms may scrongly suggest either primary or others. Usually these would be malled, ill this order, ...,,::. \ CJ..
severe in the first 24 hours and only occasionally secondary dysmenorrhoea, the most reliable diag- for a therapeutic response on cost and acceptability (i r'f \Jw '-I.I
lasts for longer than 48 hours. There may be asso- nosis is made by laparoscopy. Laparoscopic inspec- grounds, although danazol is now rarely used ~'i-
ciated symptoms, including vomiting, diarrhoea, tion of the pelvis enables endometriosis and pelvic owmg to androgenising side effects. c,.-
headache, fatigue and, rarely, syncope. congestion to be diagnosed and excludes patholo-
Secondary dysmenorrhoea rypically has its onset gy in· women with primary dysmenorrhoea. ~)
Laparoscopy does not need to be performed for all
Surgical treatment Sllw t(,Y
more than 24 hours prior to the onset of menses,
lasts for the entire duration of menstruation and young '.'.'omen with dysmenorrhoea, but the RCT evidence supports the effectiveness of laparo- l ~ SIf;
may be felt more on the left or right side. Associated option of its use in diagnosis should be discussed. FIG URE 1 .3 The laparosc oplc Image seen on scopic surgery for endometriosis in relieving pain. e-f~ifJV
symptoms may suggest a diagnosis of endometriosis Laparoscopy has the further advantage that the TV mon itor (Based on McKay Hart & Laparoscopic excision of deep and nodular ~r{
_ deep dyspareunia (pain with sex-ual mtercourse), surgical treatment for endometriosis or pelvic Norman 2000, p 84) endometriotic lesions is rational, although most 0---.J-)
non-menstrUal pain, dyschezia (defaecatory pain) or adhesions may be carried out simultaneously Wlth procedures include a combination of excision of
other bowel symptoms (constipation or diarrhoea, the diagnostic procedure, provided the woman has the deeper lesions and either ele=osurgical or
• high-frequency transcutaneous electrical nerve
often accompanied by menstrual exacerbations). A had appropriate prior explanation and given con- laser ablation of superficial endometriosis.
stimulation (TEN S)
history of infertility would also increase the index sent to such surgery, if required. In recent years, it RCT evidence does not support the use of:
• a multidisciplinary approach with a team of
of suspicion for endometriosis. has become standard practice to attach a camera to health professionals (including gynaecologists, • laparoscopic adhesiolysis (unless pelvic adhe-
Tenderness on pelvic examination, especially if the laparoscope eyepiece, allowing projection of pain specialistS, psychologists and counsellors), sions are severe)
associated with a fixed retroverted uterus or ten- the image to a television monitor (Fig 1.3). This which significantly improves many important • neuroablative surgical procedures, including
der nodules in the uterosacral ligaments or recto- facilitates precise laparoscopic surgery by provid- outcome measures for women with chronic laparoscopic uterine nerve ablation (LUNA)
vaginal seprum, suggests endometriosis. ing the surgeon and assistants with a magnified pelvic pain and presacral neurectomy (PSN) for women
view of the pelvic pathology. • counselling supported by an ultrasound scan to with either primary dysmenorrhoea or
Laparoscopy carries a low surgical risk in slim exclude pelvic cysts - effective in accelerating endometriosis, although some RCTs have sug-
women with no previous abdominal surgery, resolution of symptoms in acute exacerbations gested LUNA may be effective for women with
although the recognised major hazards are bowe~ of chronic pelvic pain. severe primary dysmenorrhoea.
bladder, ureteric or vascular injury. Such injuries
occur in fewer than 1 in 1000 low-risk women, but RCT evidence does not support the use of vita- Many women ultimately request a hysterecto-
this risk increases in the context of prior surgery, obe- min E, acupuncture, low-frequency TENS or my for very severe dysmenorrhoea and pelvic pain
spmal manipulation. ill general, whether or not they have endometrio-
sity or if complex endometriosis surgety is required.
sis. Hysterectomy is the only effective treatment
Conservative or alternative for some conditions, such as adenomyosis. While
Medical treatment a tOtal hysterectomy often improves symptOms of
treatment options pelvic pain (and cettainly prevents further men-
First-line treatment of primary or secondary dys-
There is RCT evidence to support the use of the menorrhoea includes: strUal periods!), pelvic pain relief cannot be guar-
following treatments, although many do not have anteed following hysterectomy, and some women
an established place in clinical practice: • analgesics, including paracetamol or opiate With chronic pelvic pain syndromes do not
analgesics improve following hysterectomy. The best ap-
• vitamin Bv vitamin B6, magnesium, fish oil
(omega-3 fatty acids) and a Japanese herbal • NSAIDs - owing to anti-prostaglandin mech- proach to hysterectomy is usually a laparoscopic
FI GURE 1.2 How ih e laparosco pe Is used (Based arusms, NSAID are usually more effective than aSSisted vagmal hysterectomy (LAVH), which
on McKay Hart & Norman 2000. P 84) combination
w,
Women's health : a core curriculum
1 The menstrual c y cl e and vag inal bleeding
combines the speedier recovery from vaginal sur- Ovulation

gery with the abiliry to remove all pelvic
endometriosis and adhesions. Whether to remove 50 0 - __ oProgesterone 40 1400
the ovaries at such an operation is an issue that
must be carefully discussed with women in A 50-year-old woman consulls you otter experi- o--a Oestradiol
advance. Nowadays, healthy ovaries are usually encing several years at symptoms that she hod 40 • ___ . FSH
conserved in women of reproductive age to retain attributed to menopause. These began with
Irregular periods and Intermenstrual bleeding. _lH
the benefits of ovarian steroid hormone produc- E ""i5 1000
tion, although this might increase the likelihood of
recurrent pelvic pain and the need for future sur-
but now she has postCOital bleeding. which Is
affecHng her sex IIIe.
::l
--
J:
'"
30
......... .....-...
_
E
,s
e'"
gical oophorectomy.
u.. ,,-~ ~ 20 c
A 28-year-old woman InSists you reter her lor a 'C
c 20
hysterectomy. as she is led up with very heavy a
• '~"
Natural history regular menstrual bleeding. :s CJl 500
e
0.
For some women, dysmenorrhoea improves after 10
childbirth. Pelvic pain from all causes tends ro
regress after menopause. Epidemiology
b
o
Menorrhagia is defined as abnormally heavy men- Menstrual
Impact/outcomes Proliferative
strual bleeding (HMB). The traditional definition is
Dysmenorrhoea affects not only personal health, a blood loss greater than 80 mL per period. The val- ~1 +'-----------I-~---------------4
but has a big economic impact through lost work- idated method for measuring menstrual loss, the Receptive 10
ing hours, Clear explanation of the cause and alkaline haematin technique, is available only as a implantalion
benign narure of primary dysmenorrhoea, and research too!' Other validated techniques, such as
reassurance that it docs not affect fertility, are the pictorial blood-loss assessment chart (pBAC),
important. Conversely, the infertiliry somerimes have been used to obtain an objective measurement
associated with endometriosis can make a painful of menstrual loss. Individual perceptions and cul-
condition more difficult to endure. Some women rural perceptions may playa role in what is accept-
with dysmenorrhoea may develop a chronic pain ed as 'normal'. Thus, in practical terms, a woman's
syndrome that is notoriously difficult to treat. own definition of her HMB is what is normally
used in clinical practice. As it is women who expe-
rience the impact upon qualiry of life and who
undergo investigation and treatment, sensible clini-
cians will encourage women to have a role in decid- a
Health maintenance ing on the management plan, after a full discussion Day at cycle
It Is important tor a woman to of available options. The prevalence of HMB
understand the physiological nature increases with advancing age in the reproductive
at primary dysmenorrhoea , years. It accounts for 2-4% of all GP consultations, FIGURE 1.4 The me nstrual cycle showln (0) h
but over 15% of GP referrals to specialists. HMB is (Based on Rymer et 01 199 7, P 2:'. Fig 36? ormona l chonges ond (b) endometrial changes
the commonest cause of iron-deficiency anaemia in
developed countries. Management of HMB has a
substantial cost implication for any health service. periods. If it occurs while the "oman is takin
Dysfunctional uterine bleeding (DUB) encom- the COC~ it is call~d breakthrough bleeding. g in the endometrium are largely determined by the
va PO~rCOltaI bleedmg (PCB) is bleeding or bloody flucruatIng concentrations of ovarian hormones.
passes both ovulatory DUB presenting as regular
HMB (menorrhagia) and anovulatory DUB pre- gIn dIscharge after sexual intercourse. Up to ov ulanon, the endometrium increases in
senting as irregular vaginal bleeding. It implies that thickness and endometrial glands proliferate (pro-
anatomical causes have been excluded and that a Anatomy and pathophysiology liferatIve phase). After ovu lation, under the influ-
subtle benign hormonal dysfunction is the under- ence of progesterone from the corpus luteum
lying cause.
Thhe phrsiology of normal cyclical biological
~h:ges resultIng from the interaction of the hypo-
the endometrium undergoes secretory changes u:
Intermenstrual bleeding (I1vlB) is vaginal bleed- preparation for reception of the implant-
d lIUC-plruItary-ovanan hormonal axis is
ing that occurs between expected menstrual Ing embryo. If a pregnancy does not occur, the
emonstrated in Figure 1.4. Physiological events
decreaSIng levels of progesterone from the
ME
1 The menstrua l cycle a nd vaginal bleeding
Women 's health: a c o re cu rric ulum
as squamous metaplasia. An exaggerated appearance Ovulatory DUB may result from an excess of tain the typical bleeding pattern. Menstrual bleed-
degenerating corpus luteum becom~ insufficient plasminogen activator, resulting in the breakdown ing problems may interfere with a woman 's so-
to maintain the endometnal mtegnty, allowmg of columnar epithelium on ci;e ectoceIVlX ~ knowr;
as a cervical ectopy or ectropIon (the term erosIOn of fibrin plugs (fibrinolysis) at the open spiral cial life, sex life and relationship. Paradoxically,
spasm of the spiral arterioles in the basal layer of arterioles of the endometrium (these fibrin plugs women with 1MB or PCB sometimes delay con-
the endometrium, and synchrorused sheddmg of is no longer used for this normal appearance).
normally minimise the heaviness of menstrual sulting a doctor because of a fear of cancer. This is
the more superficial endometrial layer occurs at The following conditions may be the cause of
bleeding). It may also result from an imbalance of particularly unfortunate, since cancers presenting
menstruation. Typically, the menstrual period lasts menorrhagia: prostaglandin (PG) levels - PGFza brings about with abnormal bleeding (typically endometrial or
5 days and the length of the cycle is 28 days, • fibroids arteriolar vasoconstriction and PGE z vasodilata- cervical cancer) have a high chance of curative
although these times vary m different women and • endometrial or endocervical polyps tion in these vessels, and poor constrictive activ- treatment if recognised early. Menorrhagia can
from cycle to cycle in the same woman. . • endometrial hyperplasia ity may lead to heavier blood loss. Anovulatory lead to fatigue from anaemia and, if severe, short-
Wilen the cervix is exanuned usmg a vagmal DUB usually results in irregular bleeding, as the ness of breath.
• adenomyosis
speculum, the squamocolumnar junction can usually normal cyclical stimulation of the endometrium Important examination signs include pallor and
• hypothyroidism
be seen, where the pink squamous epIthelium on the by steroid hormones does not occur. Three com- a pelvi-abdominal mass that may be present with a
ectocervix adjoins the more red-coloured columnar • coagulopathy
• presence of an intrauterine contraceptive mon patterns are recognised: fib roid uterus. Vaginal speculum examination may
epithelium emerging from the endocemcal canal. reveal a vulval, vaginal or cervical lesion, including
This exposed area of columnar epithelium on the device (IUD) • in adolescents soon after menarche, owing to
• endometrial or endocervical carcinoma cervical ectopy, polyp or malignancy. Bimanual
ectocervix is known as the trarJ.sformatlon zone, low oestrogen concentrations
DUB, if pregnancy and the above causes have pelvic examination is the best way to clinically
since the columnar cells are replaced, over many • in women with polycystic ovary syndrome diagnose a fibroid uterus (irregularly enlarged) and
years, by squamous cells in a normal process known been excluded. (PCOS), owing to unopposed oestrogen stimu- this may be confirmed by a pelvic ultrasound scan.
lation
• in women in the few years before menopause, Investigati ons
owing to a sharp rise and then fall of oestrogen
concentrations. Pregnancy should always be excluded. Women
with irregular bleeding must be investigated to
An older term for anovulatory PCOS-type exclude genital tract pathology. This usually
DUB was metropathia haemorrhagica. Women involves a hystt:roscopy and endometrial biopsy.
with PCOS-type DUB will often have infrequent Women who present with menorrhagia should
periods, rhen long periods with heavy bleeding. be investigated as follows:
They often develop 'Swiss-cheese endometrium'
(cystic hyperplasia). • A full blood count is performed for all women.
Intermenstrual bleeding might be purely DUB • Coagulopathy and thyroid functi on tests are
(and this is the case for most younger women with performed only if other clinical features suggest
1MB), but it is a warning symptom for endome- these diagnoses. However, teenagers with pro-
trial pathology. Postcoital bleeding may have a found HMB should have a coagulopathy
benign aetiology from a cervical ectopy, but PCB is screen because of the higher incidence of von
a warning symptom for cervical carcinoma, and the Willebrand's disease and idiopathic thrombo-
cervix must be inspected carefully to exclude this. cytopenia. ""
'9j.,A transva~al pelvic ultrasound scarfShould be
Symptoms and signs pertorme or women who are at hIgher risk of
endometrial pathology (hyperplasia and carci-
A woman presents not necessarily with heavy peri- noma): women >45 years of age and those
ods, but often with a change to her 0"''Tl typical with weight > 90 kg, nulliparity, a history of
cycle. It is important to ascertain the age of men- irUertility, a family histoty of endometrial or
arche, the typical bleeding pattern in teenage colon cancer.
years, the typical bleeding pattern if COCP has • A transvaginal sonohysterogram (ultrasound
been used, the commencement of menstrual cycle with saline fluid infusion into the uterine cavi-
abnormalities, their progression and any relation- ty) may provide the contrast needed to distin-
ship to body weight. Women with heavy periods guish endometrial polyps from submucous
often describe clots or flooding (causing social fibroids.
FIGURE 1 5 Multiple fibromyomas. ranging In size from 2 mm to 9 cm In dlamet~r. s~en embarrassment) and the need to use towels in • CT and MRI scans are expensive and there is
during abdominal hysterectomy (Reproduced w ith perm ission from Ma ckay. Belsc er. addition to tampons. A menstrual calendar may be no evidence of superiority over transvaginal
Pepperell & Wood 1992. P 385. Fig 27.1) helpful, especially if bleeding is irregular, to ascer- ultrasound.
ME
Women 's health: a core curricu lum
1 Th e m enstrual c y cl e an d vaginal blee ding
progestogens, such as me d roxypro gesterone .d I Irregular DUB

acetate or norethisterone, were the most WI ~y An OCP or cyclical oral progestogens are usually
prescribed medication for HMB well lIltO e effective.
1990s but when used only in the luteal phase they H a woman presents with continual intractable
are th~ least effective! Long-course oral progesto- heavy vaginal bleeding, which is believed to be DUB,
~~--"-"QQl~-- Subserous
gen treatment (used for 3 out of every. 4 weeks) this can usually be controlled by bed rest, oral
is effective, but long-term use is limited by a tranexamic acid and high-dose oral progestogen
high incidence of side effects, The. OCP reduces treatment (such as norethisterone 15 mg three times
Submucous
HMB even if fibroids are a conmbutlIlg cause. daily, reducing after 48 hours to 10 mg three times
FIGURE 1.6 The Pipelle endometrial sompling device Ethamsylate is ineffecnve and no longer used. The daily). In this event, it is wise to control the cycle by Intramural
(Based on McKay Hart & Norman 2000, p 112)
Side effects of rlanazol, gestrlnone and GnRH I giving long-course oral progestogen treatment
analogs prohibit thelf use for HMB. The levo- -1! ofI I. (3 weeks out of 4) for at least 3 months. Rarely,
norgeStrel mtrautenne system (LNG-IUlb~ tht ~~intravenous high-dose oeStrogen or traneXarrllC acid
• Endometrial biopsy is indicated if the endome-
If
trial thickness is 12 rrun or greater, or if ultra-
sound is not available in the above higher-nsk
most
re~easeseffecnve notlSurgIcal
progestogen hormoneopoon
to att for blrthet
loamyMB. ""I_VV'[~might be usefuL Emergency D&C is occasionally
u£fi .
scenarios, Pipelle sampling, which can be per- endometrium.
""'" Bleeding may be expecte d to be Iess - ·.a m".",,", if medical treatment proves ins oent.
formed in the clinic during a pelVIC examma- than half as heavy as It was before mseroon (Wlth
around 1 in 5 women becorrung amenorrhoeiC),. at Surgical FIG URE 1.9 The d istrib ution and types of
tion for most women, is a less lIlvaslve method flbrolds (Based on Wllcocks & Phillips 1997,
of endometrial biopsy (Fig 1.6), The Plpelle IS the cost of an irlSertion procedure (the deVICe
P 227, Fig 14,1)
needs to be replaced every 5 years) and Irregular Endometrial ablation techniques are designed to
inserted into the uterine caviry until resIStance
at the fundus is encountered; the plunger .IS bleeding for the fust 2-3 months after msernon, partially or full)' destroy the endometrium. Two
The choice of medical treatment IS often influ- generations of techniques are available. First- gical expertise, and evidence suggests that they
then withdrawn to produce a ~acuum and os- prodUCe results comparable to those of first-gener-
sue is sucked into the Pipelle as It IS rotated and enced by a woman's other requirements. A woman generation techniques are performed under
needing contraception would choose the OCP or hysteroscopic guidance and include transcervlcal ation techniques. They may often be performed
slowly withdrawn, It is less common for a with local anaesthetic or intravenous sedation in
dilatation and curetrage (D&C) to be necessary, LNG-IUS ' a woman wishing to conceive or to resection of the endometrium (TCRE) (Fig 1.8),
have no:Wormonal treatment would choose rollerball ablation and endometrial laser ablation an outpatient setting, and include thermal balloon
especially as there is no evidence of any thera- ablation and microwave endometrial ablation
tranexamic acid or an NSAlD; the LN G-IUS or an (ELA). Second-generation techniques have been
peutic advantage from a D&C. . . (MEA)_ Generally, ablation is successful for four
• Hysteroscopy, a fine telescopic exanunaoon of SAID would be most appropnate for a woman developed for selected cases that require less sur-
with dysmenorrhoea. Combinations of tranexarruc out of every five women with regular HJ\1B, one
the endometrium, is the gold-standard diagnos- of whom is likely to become amenorrhoeic; ooe in
acid and NSAIDs may be used if response to eIther
tic technique for endometrial pathology diagno- five ablations are not successful, while the tech-
one alone is insufficient.
. (F'Ig 1.7) . This can often be performed
SIS . ( ,on an nique is unsuitable for women with irregular DUB.
outpatient basis with local anaesthesia a para- Blodder Hysterectomy involves major surgery, although
cervical block') if a suffiCiently narrow- it should be possible to carry Out at least 70% of
calibre hysteroscope and minimal distensIOn hysterectomies by the vaginal route (rather than
medium (carbon dioxide or salme) are used. abdominal hysterectomy) for DUB.
Tre atm ent Fibro id s

For some women, explanation of the concept of The distribution of uterine fibroids and their
DUB ('no disease') as a cause for HMB IS suffiCient nomenclature is shown in Figure 1.9. Submucous
and no other treatment is reqUired. Anaerrua fibroids that distort the endometrium are rypically
should be treated by iron replacement. associated with Hj\lB. Heavy bleeding may also
occur where the uterus is substantially enlarged by
Medical intramural fibroids, which increase the surface
An antifibrinolytic agent, such as tranexamic acid area of the endometrium, Hysterectomy (via the
1 g tablets taken four times dally dunng menstru- abdominal route) has traditionally been the treat-
ation, is the most effective oral medical tr~atment Uterus
ment of choice for women with HMB related to
for HMB. NSAlDs, such as mefenamIC aCid fibroids. There is now increasing evidence con-
500 mg tablets taken three times daily durmg FIGUR E 1. 7 The hysteroscope (Based on FIGURE 1.8 How a TCRE Is performed (Based cerning other treatments.
;v1cKay Hort & ~lorman 2000, p 112) On ymon ds & Symonds 1998, p 232, Fig 22.9) There is insufficient evidence to support med-
menstruation, are also helpful. Cychcal oral
ical treatment options (other than OCP) . Evidence
Ht.{~ ~~fI.-'" L..,. ~V\N>.~
SwYtl -u:-t ME
- M.'I0vA~ ,Jc~
L 1<A~ loW v\(c,t...l
k~ho",)
- "'-'tS~", V'V'o7 ll'r

- ~I.cri~\r. [ "lj.4 c,-.. ,
1 The m enstrua l cycle and vag inal b lee ding
Women's health: a c or9 c urr iculum
does not support the surgical removal of fibroids Impact / outcomes

to treat infertility or to prevent a fibrOId from Menorrhagia may affect social activity, relation-
turning into a malignant leiomyosarcoma (very ships and employment. Inadequate treatment.of
rare, fewer than 1 in 1000 cases). Myomectomy menorrhagia may lead to chromc anaerma, ill- 5G)
(removal of fibroid) rather than. hysterectomy health and psychological upset. The cost of men- >-
should be considered for women Wlth HMB who strual hygiene productS may be qwte conSiderable E
.B Height
wish to retain fertility and for whom there are no for women with intractable HMB.
II
'"
C
other treatment options. Submucous fibroids Fertility issues may have an impact on the man- G)
impinging on the uterine cavity may be resected agement of anovulatory DUB .. Ovulanon mduc- E
~
with a transcervical myomectomy techmque SlIDI- tion treatments (such as clormphene citrate for 0
anovulatory PCOS) will often improve cycle con- .s
lar to TCRE. :E
In women who need to undergo hysterectomy trol as ovulation is established. C>
a;
for fibroids, preoperative medical treatment to Fear of a cancer diagnosis is prominent among :J:
shrink fibroids (for example with GnRH analogs) women with menstrual bleeding disorders. In
may allow a less invasive operation: for example, some cases this can delay presentation for medical
a vaginal rather than an abdominal hysterectomy: advice and compromise the prognosis. Abnormal 8 9 10 11 12 13 14 15 16 17 18
Fibroid embolisation (by an intervennonal radi- menstrual bleeding should be invesngated thor- ,- Age (years)
ologist) is a new technique that might avoid a hys- oughly, especially in women who. have u:regular
terectomy in some circumstances, although rare bleeding, 1MB, PCB or other risk factors for
hazards associated with embolisation (such as the endometrial cancer.
FIGURE 1. 10 The sequence of pubertal events (Based on Llewellyn -Jones 1999, p 9, Fig 2.1)
need for emergency hysterectomy soon after- Health maintenanc e
wards, premature ovarian. failur~ or severe li£e-
threatening sepsis) mean thiS reqUIres further eval- Early presentatio n with symptoms o f
uation before it can be widely recommended. abnormal menstrual bleeding allows physically, s~xually and psychologically. The onset development of the breast, known as thelarche, is
early detection of endometrial generally varies between 9 and 14 years. the first sign of oestrogenisation and usually occurs
cancer and a good prognosIs. The physical e"cnts of puberty tend to follow around 10-11 years of age (Fig 1.11). The growth
Natural history Cervical screening programs have
been shown to prevent deaths from an ordered sequence in time (Fig 1.10) . Although of sexual hair is controlled by adrenal androgens
Most cases of DUB run a benign course, although the most obvious changes are within the reproduc- and is termed adrenarche.
abnormal menstrual bleeding may herald malig- cervical cancer.
tive system, the first sign is generally a pubertal Depositio]] of subcutaneous fat occurs and gives
nancy and this should be excluded. The peak inci- growth spurt. Girls tend to go through puberty both the more rounded female contour and the
dence for endometrial carcinoma occurs at age 61
and only 25% of cases occur before menopause.
The majority of younger women who develop
endometrial cancer have experienced prolonged
* Dela yed puberty earlier than boys and are therefore often taller and
heavier than boys of the same age; at later stages,
females grow less than males because of earlier
epiphyseal closure. The growth spurt is followed
greater prominence of the labia majora and the
mons pubis. The infantile uterus enlarges and its
body increases in relative size compared to the
cervix. The uterine lining changes from cuboidal to
unopposed oestrogen stimulation of the endo- Common clinical presentations
by the early development of secondary sexual colW1U1ar and becomes secretory. The vagma length-
metrium, as can occur in anovulatory PCOS, A child is taken to see her GP because she has characteristics. Menarche, the first menstruation,
where the endometrium is not exposed to the pro- ens, thickens and begins to sectete mucus_ The pelvis
become self-conscious In the school changing occurs between 11 and 14 years. Finally, secondary
tective effectS of progesterone. The peak incidence acquires the female configuration. All these changes
rooms about the fact that she has not devel- sexual development is completed and is accompa-
for cervical carcinoma is currently under 50 years oped breasts or pubic hair like her classmates.
occur under the influence of oestrogen.
nied by a further growth spurt. Menstruation usually first occurs at around
and continues to fall. Those countries with well-
A mother takes her daughter to see the GP 13 years of age (11-14 years) arid this links to
organised cervical cytology screening programs Seconda ry sexual characteristics
because all her daughter'S peers seem to have approximately Tanner stage 4-5 of breast develop-
have reduced their incidence of cervical cancer, commenced their menses, but her daughte f
with appropriate use of colposcopy and conserva- Secondary se 'ual characteristics comprise five ment. In 95% of girls it has occurred by age 13.
has not. ch~ges: the development of breasts, pubic and Bleeding can be erratic and sometimes heavy
tive excisional surgery for cervical intraeplthelial
neoplasia (CIN), the premalignant condition . of axillary hair, the growth spurt and the onset of because many initial 'menstruations' represent the
the cervix. Very rarely, abnormal vagillal bleeding menstruation (menarche). shedding of the uterine cavity endometrium when
may be due to fallopian rube cancer or to a hor- Normal puberty The first physical sign of puberty is generally oestrogen-stimulated growth outgrows blood sup-
mone-producing cancer of the ovary (granulosa breast development, followed by growth of sexual ply, rather than the culmination of an ovulatory
Puberty is the time at v.'hich, under the influence hair in the pubic area and then the axillae. The hormonal cycle.
cell tumour), which influences endometrial
of sex hormones, a ch ild becomes an adult
growth and shedding.
Women's health: a co re c urric u lum
All the physical changes of pubeny occur as a

History and examination
(0 result of endocrine maturation. Stimulated by
C0 C0 luteinising hormone-releasing hormone (LHRH) Past general health, height and weight records are
from the hypothalamus, the pituitary gland important, along with relevant behaviour such as
Stage 1 extreme exercise or abnf)rmal eating habits.
secretes follide-stimulating hormone (FSH). This
release of FSH is pulsatile and begins initially at Physiologic delayed pubert;. tends to be familial
I night but, as the pulse frequency and amplitude and hence the height and pubertal milestones of
older siblings and parents are important.
increase, it is also secreted by day. In turn, the FSH
On physical examination, in addition to Tanner
l' stimulates the ovaries to increase the release of
17~ oestradiol, which stimulates breast growth.
The ovaries also secrete androgen, primarily dehy-
staging of any secondary sexual characteristics
present, a search for signs of hypothyroidism,
gonadal dysgenesis and chronic illness should be
Stoge 2 droepiandrosterone (DH£A), which instigates the made. The commonest form of gonadal dysgenesis
(0 development of sexual hair growth. The matura- is associated with Turner's syndrome (45XO) (Fig
tion of the hypothalamus is also associated with an 1.12). Other signs of this syndrome include short
increased secretion of growth hormone and hence stature, web neck, lymphoedema, coarctation of
the growth spun. aorta and scoliosis.
Neurological examination is important. Signs
Dela yed puberty of intracranial disease, restricted visual fields or
Since there is a wide variation in normal develop-
Stage 3
ment, it is difficult to define the patient with
abnormally delayed sexual maturation, Delayed
pubeny may be defined as the absence of second-
ary sexual characteristics by the age of 14 years.
Common causes of delayed p ubeny can be classi-
fied as foUows:
Hypergonadotrophic hy pogonadism
Stoge 4
Ovarian fail ure with abnormal or normal karyotype
Hypogonadotroph lc hypogonadism
Reversible: ~q ~ - We..
• Physiologic/constitutional delay
• Weight loss/anorexia
Stage 5
• Primary hypothyroidism
• Prolactinomas and other pituitary adenomas
• Congenital adrenal hyperplasia
Irreversible:
• GnRH deficiency
. St 2 breast b ud stage: e levation of breast and • Craniopharyngioma
Stage /, preadolescent: elevation of papilla °fn:~ e a~Z~la; region . Stage 3, further enlargement of
papilla os a small mound, with enlargement a r 'ectlon of areo la and papilla to
breast and areola without separation of their chonbtours 'tsstatggee4sP:~ture stage: projection at papilla Eugonadism
d ' ry mound above the level of t e reas. a ,
~o~~ ~e~~~i~~ f~om recession of the areola to the general contour of the breast.
• M ullerian agenesis
FIGURE 1,11 St ages of breast de velopment (Base d on Hac k e r & M oore 1998 , P 570, Fig 49.4 : • Androgen insensitiviry syndrome FIGURE 1.1 2 A p atient w i th Turner's syndrome
adapted (rom Marsha ll & Tanner 1969)
• Imperfo rate hymen (From Lle w e lly n-Jones 1999, p 316, Fig 42.2)
-OJ
Women's health : a core cu rrlcu ' c"n
1 The m e nst ru al c yc le ond vagina l b lee d ing
absent sense of smell are key findings. Anatomical

defects of the miillerian ducts must be sought,
especially when a disparity between normal puber-
Specific conditions associated
with eugonadism . * PolYcystic ovary
syndrome
the European definition of pcas, about 80% of
women with ultrasound evidence of polycystic
ty and absent menses is encountered. An imperforate hymen can lead to obstruction of ovaries have peas . The more stringent US cri-
the flow of me nstrual blood (cryptomenorrhoea), teria, which do not utilise ovarian morphology,
whereby girls with a functioning uterus present Common clinical presenlaflons
Investigations show a 4.5-11.2% prevalence of pcas. Women
with cyclical lower abdominal pain. In the A 35-year-old wom~n cannot predict when her with pcas have an increased incidence of diabetes
These include X-rays for bone age, brain imaging, advanced stages, a palpable abdominal swelling next period will be. Her cycles of 6- J 2 weeks mellitus, dyslipidaemia and possibly hypertension.
gonadotrophin and prolactin concentrations, will be present and separation of the labia will are aSSOCiated with increasingly heavy and All of these place the woman with pcas at a
adrenal and gonadal steroid measurements, and reveal the classic blue-coloured membrane. prolonged bleeding. higher risk of cardiovascular disease.
assessment of thyroid function. Patients with ele- Treatment is by incision and excision of the mem-
vated gonadotrophins require a karyotype, pelvic brane, leading to the release of large amounts of
A 36-year-old woman and her partner seek
help because of her inability to conceive. She
Pathogenesis - ~ .e..wl..:,~
ultrasound and, very occasionally, a diagnostic tarty chocolate-coloured fluid. c~ ~ -71' V\l~
has irregular cycles and can sometimes go The pathogenesis of polycystic ovaries and pcas
laparoscopy. Vaginal agenesis in the absence of a uterus can without a period for up to 3 months. On exami-
be managed by nonsurgical and surgical methods. is unknown. Insulin resistance is thought to be a
nation, she Is overweight with a 8MI of 38. She
The nonsurgical method involves reaching rhe gIrl key metabolic consequence of a complex genetic
Treatment of delayed puberty has mild faCial hirsutism and ocne.
to apply a vaginal dilator to the central dimple in trait disorder. The resulting hyperinsulinaemia
In physiologic delay, reassurance that the antici- the area of the introitus so that a functional vagina A 28-year-Old Woman with painful periods has causes an overproduction of ovarian androgens
pated development will occur is the only manage- a pelvic ultrasound showing large-volume and a decrease in serum sex-honnone-binding
can be produced. Surgical methods include creat-
ment needed. Removal or correction of the polycystic ovaries. globulin (SHBG), leading to elevated serum-free
ing a pouch or using a split skin graft to create a
primary aetiology when possible is imporrant, as neovagina. When the girl is sexually acnve, ha~mg testosterone. The high androgen concentrations
in the treatment of hypothyroidism. In hypo- intercourse will increase the length of the vagma. interfere with follicular growth and ovulation,
gonadism, hormone therapy will initiate and sus- Indeed, fonnation of a neovagina is only under- Definition and diagnosis thereby causing menstrual disturbances and infer-
tain maturation and function of secondary se,,:ual taken when the girl is approaching sexual activity. tility. Insulin may have direct hypothalamic effeCts,
characteristics and promote achievement of height Girls with comp lete androgen insensitiviry syn- The polycystic ovary syndrome (PCaS) is the such as stimulating appetite and gonadotrophin
potential. Long-term treatment is important to drome have a nortnal 46 XY karyotype but are commonest endocrine disturbance affecting secretion. Women with pca s are pron e to eating
prevent osteoporosis. phenotypically female. T he testes are normal and women. It may be characterised by the ultrasound disorders, perhaps because of a link with leptin,
Treatment can be initiated with very small may be found anywhere along the line of testicu- appearance of polycystic ovaries and the associa- which affects the hypothalamic pulsatility of
doses of ethinyl oestradiol 1 !-,g daily for approxi- lar 'descent from the abdomen to the labia. The tion of one or more of the follOwing clinical symp- gonadotrophin-releasing honnone, with impor-
mately 6 months, increasing to 2, 5, 10 and 20 fLg risk of malignancy in these gonads is around 5% toms or biochemical fe atures: oligomenorrhoea,
amenorrhoea, clinical or biochemical hyperandro-
cant effeCts on reproduction. -1- ~'L c.>Js, J-..t
at 6-monthly intervals. Low-dose ethinyl oestrad- and hence thev should be removed after the com-
iol is not widely available, and arrangements may pletion of pub·eny. This diagnosis can be devastat- genism, obesity, or elevated serum LH concentra-
tion. The accepted ultrasound criteria for defining
Clinical manife stations -- t ri.,>U \)t-\ .
need to be made with specialist uni ts. The lowing, and extensive counselling of the mdivldual
polycystic ovaries are at least 10 follicles (usualJy The clinical signs and symptoms of pcas include
dose 171' oestradiol patch can be used as an alter- and family is often required.
8-10 mm in diameter) arranged peripherally menstrual cycle disturbances ranging from amenor-
native. around a dense core of ovarian stroma or scattered rhoea to irregular menstruation (typically those of
Traditionally, the cacp has been the drug of Health maintenance '
throughout an increased amount of stroma. In unopposed oestrogen effeCts), obesity, infertility and
choice for long-term treatment. With the advent of Reassurance Is the basis af manage- North America, the syndrome is described by the Signs of androgen excess (hirsutism, alopecia, acne).
a large variety of hortDone therapy (HT) prepara- ment at physialagically delayed Biochemical abnormalities include elevated serum
combination of hyperandrogenism and chronic
tions, a greater choice is available. puberty.
anovulation, where other secondary causes (e.g. concentrations of LH, testosterone, androstene-
Regimes with HT are superior because the type adult-onset congenital adrenal hyperplasia) have dione, dehydroepiandrosterone sulfate (DHEAS)
of oestrogen it contains and the dose are not asso- been excluded. In the N orth American context, and insulin. There is considerable heterogeneity of
ciated with an increased incidence of hypertension there IS no. need to identify the presence of poly- the symptoms and signs amongst women with
or unfavourable changes in lipid profiles. The cysnc OVarIes by ultrasonography. ather causes of pcas, and for an individual these may change over
overall oestrogen intake over a long period of time hyperandrogenaemia are discussed in the next sec- orne. Polycystic ovaries can exi>t without clinical
is also increased, as there is no hormone-free non of this chapter. signs of the syndrome, which may find expression
week, and this is beneficial in women with over time. Weight gain and loss are associated with
Turner's syndrome who have no endogenous Epidemiology increasing and decreasing symptoms respectively.
oestrogen production. Girls on long-term oestro-
Using the ultrasound criteria outlined above sev- PsychOSOCial stressors also affect how the individual
gen supplementation should have their bone mineral studies have sh own that approxim'ately woman copes and manages her condition. The
eral density checked at regular intervals . hyperandrogenic effeCts of hirsutism and acne can
20-25% of women have polycystic ovaries. Using
be distressing, especially in the younger woman.
WI
t \ \A...t ~II\. ~ .s "'-.l.v....J.,oJ;.t Lt.u.c.c,- "'y~1( uV'CArc> ~ vIA .
Women's health: a c ore c urr icu lum
T L~ J 1 The menstru al cycle and va gi n a l b leeding
Symptom Frequency (range)

will induce endometrial atrophy and is effective
for long-term control of excessive and irregular
long-term consequences
The metabolic abnormalities that give rise to
* Hyperandrogenism
Ollgomenorrhoea 29-52% bleeding patterns. /" ........ ..\~ fli~ "",.,.Af'C".Le~h~l,.~ L - PC OS also put the .woman at risk of the longer- Common clinical presentallons
Spironolactone is an antiandrogen that acts by term ChrOillC condiuons of diabetes and cardiovas- During a routine consultation and examination
Amenorrhoea 19-51%
blocking androgen receptors. A 40-800/0 reduction cular disease. P~olonged anovulation, panicularly for contraception, the doctor notices that the
Hirsutism 64-69% III assoClatlon With obeSlty, appears to be a signifi-
in sexual hair can be achieved with spironolactone, woman has marked laclal and abdom inal hir-
35-41% but it may also take 6 months to take effect. Trus cant nsk factor for endometrial cancer in pre- sutism.
Obesity
menopausal women. Further studies are required
drug is best prescribed in low doses (25-50 mg
however, to determine the incidence of thes~
27-35% A 32-year-<lld woman has always been moder-
Acne
3-6% daily), increasing every 6 months if there is no ately overweight. She Is concerned about her
Alopecia condiuons, and clinical studies are required to
reduction of hirsutism, to a maximum of 200 mg evaluate the net benefit of the various screening weight gain In the last year and that she has
Acanthosis nig ricans <1-3%
daily. With the use of this drug, renal function tests been getting fewer periods.
20-74%
strategtes for each.
Infertility should be performed every 6 months to exclude The American college guidelines (Azziz 2003) A 25-year-<lld singer being treated with danazol
Elevated serum LH 40-51% electrolyte abnormalities. recommend that all women with PCOS be for endometriosis has noticed an Increase l.n
29-50% Clomiphene citrate is used to induce ovulation screened for both glucose intolerance and dyslipi- facial hair, and is concerned that she cannot
Elevated testosterone
in women with anovulatory cycles who suffer t-t,o ~ daenuas. In the absence of other clear clinical reach the high notes.
TABLE 1.1 Clinical sign s and symptoms, and from infenility. Clomiphene resistance is common, ~ gutdelines, the practising clinician ought to have a A 46-year-<lld nulliparous woman has noticed a
bio chemical changes associa te d with PCOS especially in the group who have elevated LH con- IA.e rugh degree of suspicion for long-term effects, and marked Increase In hair growth, acne, amenor-
centrations. Gonadotrophins, and then in vitro v-4... should promote good healthcare strategies of rhoea and a rapid weight gain.
Similarly, obesity is associated with low self-esteem fertilisation (NF) , are other options if clomiphene 2) ''1 weIght control, exerCise, stopping smoking and
and psychological difficulties. fails. vv-t... psychOSOCial stress relief.
Table 1.1 summarises the expected frequency Various pamal destructive operations of the
of the various clinical signs and symptoms and bio- ovary have been shown to temporarily improve Definition and causes
chemical parameters. ovulation and pregnancy rates. Laparoscopic ovar- Hyperandrogenism describes the clinical signs of
For the differential diagnosis of a woman pre- ian drilling, in which small burns are generated Women suffering from peas should be
androgen excess: rursutlsm, acne and alopecia.
~ given every encouragement and sup-
senting with hyperandrogenism or ovulatory dys- within the ovarian cortex, may be used to correct .I . l port to maintain a healthy lifestyle Table 1.2 descnbes the differential diagnosis and
function, see Hyperandrogenism. anovulation in about 50% of women. With this 'V v'\.~'( we lght loss programs, exercise, no typIcal features that will help rule them in. The
procedure ovulatory cycles will return, albeit 12.. I smoking) to avoid the long-term con- most co=on pathological cause of hyperandro-
Treat ment briefly, The validity of the drilling operation stems sequences of peas . gerusm IS peos, which affects 5-1 0% of women
m the reproductive age group (see discussion of
The management of PCOS is symp tom-oriented. from the older operation of wedge resection,
General measures include weight loss, wruch has which was shown to lead to a resumption of nor-
been shown to improve ovulation and the ability mal menses in some women. A reduction
to conceive. Both hirsutism and improvements in of intraovarian androgens occurs with destruc- Diagnosis Approx . frequency Clinical features Iypical of diagnosis
the menstrual cycle may occur with weight reduction/excision of ovarian stroma and follicles. The Polycystic ovary syndrome 80-85% Ultrasound features of PCOS and exclusion of other
tion. Hirsutism may be managed by mechanical brief respite in intraovarian androgens leads to a causes
means, such as bleach.ing, plucking, waxing, shav- resumption of normal fo lliculogenesis. The surgi- HAIRAN 3-4% Severe Insulin resistance, acanthosis nigrlcans
ing, depilatory creams and electrolysis. cal option should be used with caution, however,
IdiopathiC hirsutism 5-10% Normal androgens , normal ovulation
Oral contraceptives will establish normal men- since adhesion formation is an adverse outcome.
srruation and often improve hirsutism and acne. There appears to be no advantage in using ovarian 21-OH-deficient nonclassic 1-2% An elevated 17a-hydroxyprogesterone, followed by
adrenal hyperplasia further Increase with ACTH stimulation test .
The antiandrogen cyproterone acetate -is available diathermy rather than gonadotroph.ins for ovula-
in some contraceptive brands and will funher help tion induction in women who do not respond to Ovarian/adrenal tumours Rare History Is key : sudden and severe signs, weight gain
the reduction of unwanted hair, but it may take as clomiphene. Other e.g. Cushing's: <5% History and examination are key to all of these also
long as 6 months to see an effect. There is increasing evidence that metformin acromegaly: hypothyroidism; abnormal thyroid function , elevated prolactin '
Other options for treatment of the disordered (an insulin-sensitising agent) will improve the reg- hyperprolactlnaemla: drug-
Induced, chronic skin
menstrual cycle include any therapy that regulates ulation of the menstrUal cycle and hence ovula- conditions
and/or reduces the impact of the anovulatory tion, and may increase the performance of other
cycle. Unopposed oestrogen effects will increase treatments such as NF. However, further srudies TABLE 1.2 Differential diagnosis of hirsutism
the risk of endometrial hyperplasia. The LNG-IUS are required to identify which patients will benefit
L..i) cR contains the progestogen levonorgestrel, wruch from this treatment .
. . - - - '"
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-
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1 The m e nstrual cyc le and va g in a l b leed in g
women's health: a core curric ulum
tually becomes a diffuse pattern of hair loss. PhYSical examination and acts by androgen receptor blockade. In severe
pcos, above). The diagnosis of PCOS, however,
However, alopecia may be due to other. causes Examination should include body mass index and
cases, cyproterone acetate may be prescribed in a
does not rule out other causes, since there may be larger dose (50-100 mg per day) and combined with
such as weight loss, thyroid dysfunCtIon or general signs of cardiovascular health. The degree
dual pathology. . oestrogen (30 mg ethinyl oestradiol) to control the
anaemia. Certain drugs, like danazol, may also of hirsutism is assessed by the well-known
The HAIRAN syndrome conSISts of hyperan- mensrrual cycle,
cause hair loss. Ferrirnan-Gallwey score (Ferriman & Gallwey
drogenism, insulin resistance, and acanthosIs 1961). Vtrilising fearures should be actively sought. Spironolactone also acts as an androgen recep-
nigricans. Acanthosis?igricans IS a velvety, tor blocker. It is an aldosterone antagonist, a mild
hyperpigmented change In the crease areasof the Virilisation diuretic and an antihypertensive agent (see PCOS).
Investigations
skin, It is a disorder charactensed byseveremsulm Virilisation is characterised by clitoromegaly, Side effects include dizziness, diuresis, nausea,
resistance and enlarged hyperthecotIc ovaries. deepening of the voice, androgenic muscle devel- Pelvic ultrasound to assess for PCOS is the most use- fatigue and headaches. Six months' treatment with
21_hydroxylase-deficient nonclasslc adrenal opment, breast atrophy, severe hirsutism and male ful investigation. Serum FSH, LH and prolactin will spironolactone is associated with significant subjec-
hyperplasia is a homozygous r~cesslve disorder pattern baldness, and is assOCIated. WIth severe aid the diagnosis of PCOS or the uncommon hyper- tive improvements in hirsutism, but its value for
that leads to excessive accumulano n of the precur- hyperandrogenism. Androgen-secrenng rumours prolactinaemia, which causes hyperandrogenism. arne in clinical practice is difficult to assess from
sor of the enzyme, namely 17u-hydroxyproges- Measurement of circulating androgen concentra- currently available research. It is best combined
should be suspected if androgeruc symptOms are
terone and an increase in adrenal androgen tions (e.g. tOtal testosterone) has limited diagnostic with the COCP.
sudden or severe. utility, except in the minimally hirsute or nonhirsute
producion. Excluding all other causes leads to the The effects of either cyproterone or spironolac-
diagnosis of idiopathic hirsunsm. woman ..,vith a mensrrual cycle disorder. Androgen tone may take 6 months to achieve. These drugs
Ovulatory dysfunction
levels do not necessarily reflect androgen produc- will not reverse the terrninalisation of veHus hairs
This is expressed as an abnormality of mensrruation rate. Androgen-secreting rumours are suspected already transformed, but will stop new terminal
Signs and symptoms tion that varies between amenorrhoea and Irregu- by histoty and physical examination. An elevated hairs from growing. A:; patients age, they may
1ar bleeding. The high androgen concentrations 17a-hydroxyprogesterone (17u-OHP) suggests an experience a reduction in hair growth, associated
Hirsutism interfere with follicular bi ology. TyplCally, the adrenal cause (21-0H-deficiem nonclassic adrenal with a loss of hair follicles and a decrease in andro-
Hirsutism is an excessive hair growth in androgen- abnormal bleeding is associated with unopposed hyperplasia), The 17u-OHP should be an early- gens. Insulin-sensitising agents (e.g. metformin)
sensitive areas of the skin in women. It marufests oestrogen activity. morning specimen taken in the first 2 weeks of the will improve ovulatoty function, but their role in
as an excessive or inappropriate development and mensrrual cycle. If abnormal, stimulation with hirsutism is not clear.
growth of the pilosebaceous unit. A ,summary of Obesity adrenocorticotropic hormone (ACTH) is performed Glucocorticoids are commonly used for sup-
the anaroIDY and physiology of harr growth IS to investigate for nonclassic adult-onset congenital pressing adrenal androgen production in patients
Obesity also contributes to a worsening o.f the adrenal hyperplasia (CAH). Suppression tests (e.g.
found in Gray's textbook of anatomy (WIlliams with late-onset CAH.
effects of hyperandrogenism, espeaally those of dexamethasone) will help distinguish ovarian causes
et al 1995). Androgens cause transformation of
ovulatory and menStrUal dysfunctIOn. The meta- from adrenal abnormalities like Cushing's Long-term consequences
the vellus (fine and soft) hair inro termmal. haIr.
bolic risks including irnparred glucose tolerance, disease/syndrome or adrenal cancer. Cushing's and
The variability in sensitivity of the pilos.cba- The metabolic sequelae for hyperandrogenism result
ceo us unit affects the extent to w hich an mdivId- hypertenst'on and dyslipidaemias, are more com- acromegaly should be investigated if there is clinical from the associated hyperinsulinaemia and insulin
ual is affected by androgen excess. The hair cycle mon in the obese. suspicion. resistance, and the dyslipidaemias. These patients
varies in different parts of the body: It ranges from are potentially at long-term risk of diabetes and car-
3 ro 6 months on the face to 5 or more years on Psychological effects Treatme nt
diovascular disease but the precise extent and natu-
the scalp, Familial and ethnic differences will also The symptoms of hyperandrogenismcan be severe General measures are as described under pcas (see ral histoty of these risks are not known. In the
cause a wide variation. and distressing for women, espeCially younger above). These include measures to control associ- absence of other clear clinical guidelines, the practis-
Rapid development of hirsutism should alert women. Similarly, the association WIth obeSity will ated ovulatoty dysfunction, infertiliry and obesity. ing clinician ought to have a high degree of aware-
the clinician to the possibility of an adrenal or have further negative effects, with social reJecoon Psychological and social disability will require close ness of long-term effects, and should promote good
ovarian neoplasm. and isolation being common. emotional support, and counselling should always healthcare strategies of weight control, exercise,
be at the forefront of a management plan. The sur- stopping smoking and psychosocial stress relief.
Acne gical measures used for PCOS \\~U not help hir- . .Screening for diabetes mellitus, by a fasting blood '
Assessment and investigation sutism or acne. sugar test, should be an annual event.
Acne is commorrly present in female adolescents,
Specific phannacological m~a:;ures can be used
and persistence into the 20s is a feature of History to reduce the effects of excess androgen. The COCP Health maintenance
hyperandrogenism. A:; with hirsutism, there IS no
This should include information about the age of decreases ovarian androgen production but is not
correlation berween the degree of acne and fre e useful for women who already express fearures of
Women suffering from hyperandro-
testOsterone concentrations. onset and its relationship to thelarche and men- genism, whether problematic or not,
arche. The rates of development of all the fearures more than mild hyperandrogenism. Use of contra- should be advised on lifestyle
of androgen excess, mensrruaJ history, weIght ceptive brands containing the antiandrogen cypro- changes that may modify long-term
AndrogeniC alopecia terone acetate will be required to reduce unwanted
changes, family histoty, diet and lifesryle should all health consequences.
This may be the sole sign of hyperandrogenism. hair, Cyproterone acetate is a strong progestogen
Typically it occurs initially at the vertex but even- be sought.
Wi
1 The menstrual cycle an d vaginal bleeding
Women's health: a core curricu lum
* Premature ovarian
fa ilure
slight rise in pulse. Genital and urinary tract symp-
toms include a rise in vaginal pH, dryness and
increased risk of urinary infection. Psychological
function. It is thought that the ovary is damaged by
annbodies ill the same way that the thyroid gland is
damaged in autoimmune thyroid disease. Premature
ovarian failure is also associated with Addison's dis-
It is important to emphasise that premature
ovarian failure can be transient and that in most
cases one can never be certain that no follicles
remain in the ovary. The chance of a return to fer-
changes are also common, such as mood swings,
anxiety, insomnia, loss of libido and depresslOn. ease, type 1 diabetes, hypoparathyroidism and per- tility and subsequent natural pregnancy is around
Common clinical presentation nicious anaemia. 5-15% for women with a normal karyotype.
32-year-old nulliparous woman has Just There is some evidence that viral infections can There is no evidence that any treatment can
A Pathophysiology cause premature ovarian failure, the most common enhance this rate, and egg donation with IVF or
returned from overseas and has not had her
period for a year. She Is also having problems Premature ovarian failure is due to a reduction in being mumps. adoption remain options.
with intercourse and complains of vaginal dry- the number, or to the absence, of oocytes within
ness and lack of libido. the ovaries. Women with raised FSH, amenor- Iatrogenic causes Long-term consequences
rhoea and ovarian follicles in the ovaries have a
Iatrogenic causes include any pelvic surgery, par- Women with premarure ovarian failure experience
rare condition called resistant ovary syndrome,
ticularly ovarian cystectomy or hysterectomy symptoms of oestrogen deficiency, have an increased
which is believed to be due to either the absence of
where there may be damage to the ovary or the age-related mortality rate and are at increased risk of
Physiology gonadotrophin receptors on the follicles.or a
ovarian blood supply. Pelvic radiotherapy and sys- osteoporosis. Long-term hormone therapy that does
Menopause occurs with permanent cessation . of posrreceptor signalling defect. In the maJonty of not prevent conception is indicated until the age of
women, the cause of premarure ovarian failure is temic chemotherapy can also cause premarure
menstruation following the loss of ovanan acnvny. natural menopause is reached. Women should also
On average, menopause occurs at 50 years of age unknown. Identif}'ing a cause can help WIth the .~ ovarian failure. The effea depends on the dose
given and the age at the starr of therapy. Before be informed of the need for adequate calcium intake
(range 48-55 years). When it occurs before 40 years psychological trauma of an early menopause and and physical activiry. Long-term follow-up is neces-
of age (affecting 1% of women), it IS defined as pre- its consequences. commencing these therapies, the option of ovarian
cryopreservation can be offered in the hope that sary to check for the development of associated
mature ovarian failure. In 10-30% of such cases, It The causes largely fall into twO main groups: autoimmune endocrine disease.
genetic and autoimmune. techn ology to produce marure eggs from ovarian
occurs in the context of primary amenorrhoea.
In the embryo, germ cells develop from the tissue may be developed in the furure.
gonadal ridge and migrate to the primitive ovary. Genetic causes Health maintenance
They multiply to form approximately 7 million
Assessment and investigations Smoking Is assocJated with the onset
Two intact X chromosomes are needed for normal
oocytes. H owever, fewer than 500 eggs are re- ovarian function. The most common genetic cause A full history and examination are required as of menopause at on earller age .
quired duriog the reproducti e life span. Before of premarure ovarian failure is Turner'ssyndrome, other causes of secondary amenorrhoea need ro be Adequate physical activity and
birth, rwo-thirds of the eggs are destroyed, and considered, including PCOS, pregnancy, hyper- calcium intake min imise bone loss In
where there is one X chromosome rrussmg, 45 XO. women. Up-la-date Information about
berween birth arid 40 years of age they are gradu- Generally women with Turner's syndrome are of prolacnnaenua, stress, anxiery and weight disor- the risks and benefits of hormone
ally reduced from 1 million to 10,000 in each short stature and present with primary amenor- ders, cervical stenosis and Asherman syndrome. replacement Is Important.
ovary. Beyond 40 years of age, the destructive rhoea. The very early development of the ovary The diagnosis of premature ovarian failure is
process is accelerated. After menopause, there are appears to be normal but there is an accelerated confinned by measuring FSH and oestradiol con-
no remaining ovarian follicles. Currently, It. IS loss of germ cells prior to birth. Turner's syndrome centrations. The FSH concenrration needs ro
thought that acceleration of the oocytedesrruCtlon mosaics (45XJ46XX) or deletions in either arm of be measured on two separate occasions. Concen- References and further reading
process is the cause of premature ovarian failure. the X chromosome can also cause premature ovar- trations greater than 20 IUIL are rarely associated
During the normal menstrual cycle, FSH surnu- ian failure. There is evidence that a specific parr of with a successful pregnancy, and a level greater ACOG Practice Bulletin 2002 Clinical maoagement
lates the ovary to enable the follicle to marure. With the X chromosome is required for normal ovarian than 40 IUIL is diagnostic of ovarian failure. guidelines for obstetrician·gynecologists. Obstetrics and
advancing age, and particularly after the age of 40, Gynecology 100(6):1389-1402.
function. Oestrogen concentrations are low. Investigations
the number of primordial follicles, which secrete Premarure ovarian failure can occur where no should also include karyotyping, particularly with Adams J, Polson DW, Franks 5 1986 Prevalence of
inhibin decreases and more FSH is required to identifiable genetic defect can be found, and yet premarure ovarian failure and primary amenor- polycystic ovaries in women with anovulation and
marure'the follicle. As the FSH level requirements several members of the family are affected. It rhoea. Thyroid function tests and a general auro- idiopathic hirsutism. British M~dical Journal (Clinical
increase, anovulatory cycles become more frequent seems that familial premarure ovarian failure has anobody screen are performed, together with a R<search edo) 293:355-359.
and the menstrual cycle lengrh increases. This usu- several modes of inheritance. Other inherited dis- beta-human chorionic gonadotrophin (~-HCG) Azziz R 2003 The evaluation and management of hirsutism.
ally happens 2-8 years before menopause. orders associated with premarure ovarian failure level to exclude pregnancy. Ulrrasound is useful to Obstetrics and Gynecology 101:995-1007.
In the posrrnenopausal state, when no follicles include galactosaemia, fragile X syndrome and look at ovarian volume and evidence of remaining
remain in the ovary, oestradiol levels decrease and blepharophimosis. follicles. Balen A, Michelmore K 2002 What is polycystic ovary
FSH levels increase. With the decrease in oestrad- Once the diagnosis of premature ovarian fail- syndrome? H wn.m Reproduction 17(9):2219-2227.
iol, clinical features develop. Vasomotor symptoms Autoimmune causes ure 1S made, referral ro a specialist is indicated and Carpentet SEK, Rock JA 2000 Paediatric and adolescent
occur in up to 50-800/0 of ·: :omen. Hot flushes last the prognosis, implications for fertility, and long- gynecology, 2nd ecln. Lippincott Williams & WUkins
Premature ovarian failure due to an autoimmune
berween 1 and 4 minutes and are associated with a term oestrogen deficiency need to be discussed. Baltimore, pp 181-204. '
cause is usually associated with abnormal thyroid
rise in temperarure, peripheral vasodilatation and a
Wi
Women's health: a co re c urriculum 1 The m enstrual c ycle and vaginal bleeding
Clark M ..I, Thornley B, Tomlinson L et al 1998 Weight loss Marshall WA, Tanner jM 1969 Variations in pattern of
in obese infertile women results in improYC!rnem in pubertal changes in girls. Archives of Disease in
Questions 5. Which of the following scenarios would
reproductive outcome for all forms of fertility Childhood 44:291.
treatment. Human Reproduaion 13:1502-1505. be cause for concern in a 14-year-old
Mackay EV, Beischer NA, Pepperell Rj, Wood C 1993 1. Which is the most reliable method for girl?
Conway SG 2000 Premarure ovarian failure. British Illustrated textbook of gynaecology. WB Saunders! diagnosing endometriosis?
Medical Bulletin 56(3):643-649. BaiII~re Tindall, Sydney. a. Height of 150 cm
a. Pelvic MRI
Edmonds DK 1993 Primary amenorrhoea. Progress in McKay Hart D, Norman J 2000 Gynaecology ,Uusrrated, b. Hysteroscopy b. Breasts which are smaller than those
Obstetrics and Gynaecology 10:281-295 .
Farquhar C, Anoll B, Ekeroma A et al 2001

5th edn. Churchill Livingstone, Edinburgh.
Rymer ], Fish ANj, Chapman M 1997 Gynaecology, 2nd

c. Laparoscopy / of her peers
(3 Absence of any signs of pubertal
d. Transvaginal pelvic ultrasound development
An evidence-based guideline for the management of edo. Churchill livingstone, Edinburgh.
urerine fibroids. Australian and New Zealand Journal e. A thorough history of the nature of d . Widespread pubertal hair extending
of Obstetrics and Gynaecology 41 :125-140 . Smith RP 2002 Netter's obstetrics, gynaecology and pelvic pain symptoms onto the medial surface of the
women's bealth. Icon Learning Syscems, Teterboro. thighs and caUs in g embarrassment
Farquhar CM, Williamson K, Gudex G et al 2002 . 2. Which of the followin g is supported by
A randomized controlled trial of laparoscoplc ovanan when swimming
Speroff I., Glass RH, Kase NG 2001 Abnormal puberty and the strongest evidence of effectiveness
diathermy versus gonadotroph.in therapy for women growth problems. In: Speroff L, Glass RH, Kase NG for treatment of premenstrual e . Absence of menses, but with hair
with clomiphene-resistant polycystic ovary syndrome. syndrome?
(eds) Clinical gynecologic endocrinology and infertility, .0' and breast secondary sexual
Fertility and Sterility 78 :404-411.
Farquhar CM, Lee 0, Toomath R et al 2003 Spironolactone

versus placebo or in combination with steroids for
6th edn. Lippincott Williams & Wilkins, Baltimore,
pp 361-399 .
Speroff L, Glass RH, Kase NG, Seifer DB (eds) 2001

a. Selective serotonin reuptake
inhibitors
b . Evening primrose oil
I 6.
characteristics well developed
A 16-year-old girl comes to see you

hirsutism andlor acne. In: Cochrane Database of with her mother because she has not
Syste matic Reviews ([he Cochrane Library) . Online. Clinical gynecologic endocrinology and infertiliry, 6th c. Pyridoxine (vitamin 96 ) yet had a period. On examination, she
Available: hnp:!/www.update-software.com!cochrane. edo. Lippincott Williams & WLlkins, Baltimore,
d. Progestogens Is short in stature and there is no
pp 431-448.
~ condary sexual development.What
Fcrriman D, Gallwey JD 1961 Clinical assessment of body
Symonds ElVl, Symonds 1M 1998 Essential obstetrics and
e. Spironolactone Is the most likely diagnosis i
hair growth in women. Journal of Clinical
Endocrinology and Metabolism 21 :1440-1445. gynaecology, 3rd edo. Churchill L vingstone, a . Prolactlnama
Edinburgh.
3. Which of the following Is the most
Garden SA 1998 Problems with menstruation. In: Garden effecflve nonsurgical option for b . Congenital adrenal hyperplaSia
SA (ed) Paediatric and adolescent gynaecology. Arnold, Wilcocks j , Phillips K 1997 Obstetrics and gynaecology. ovulatory dysfunctional uterine
London, pp 127-154. bleed in g? c. Imperforate hymen
Churchill Livingstone, New York.
a. NSAIOs @ rurner 's syndrome ..,.
Hacker NF, Moore]G 1998 Essentials of obstetrics and Wtld RA 2002 Long-term health consequences of PCOS.
gynaecology, 3rd edn. Saunders, Philadelphia. Human Reproduaion Update 8:213-241. b. Tranexamic acid e . Mosaic 46XY I 45XO
Jacobs HS, Conway GS 1999 Le ptin, polycystic ovaries and c. Short-course pragestogens
WLlli.ms PI., Bannister LH, Berty MM er 01 (eds) 1995 7. A 30-year-old woman presents with a
polycystic ovary syndrome. Human Reptoducnon Gray's anatomy: the anatomical basis of medicine and ~ Levonorgestrel intrauterine system 6-month history of amenorrhoea and a
Update 5:166-171. surgery, 38th edo. Churchill Livingstone, London,
e. Transcervical resection of the vague history of hot flushes. Which of
Kalantaridou SN, Nelson LM 2000 Premarure ovarian pp 400-405 . endometrium the following statements is incorrect?
failure is not premature menopause. Annals of the New
Working Party for Guidelines for the Management of a . ~-HCG Is useful to exclude
York Academy of Sciences 900:393-402. 4. Which of the following is a
Heavy Menstrual Bleeding 1999 An evidence-based pregnancy
characteristic feature of Turner's
Llewellyn-Jones D 1999 Fundamentals of obstetrics and guideline for the management of heavy menstrual syndrome?
bleeding. New Zealand Medical ]oumal112:1 74-1 77. b . FSH is useful to diagnose ovarian
gynaecology, 7th edn. Mosby, London. failure
a . Karyotype of 46XX
b . Tall stature c. If the FSH Is >40 lUll, c lomiphene
can be given to induce OVUlation
c. Hyperprolactinaemia
d . If the FSH is >40 lUlL, a karyotype is
d . Web neck indicated
e. Ventricular septal defect
e. A family history Is relevant /"
w_
.. Women's health: a core curriculum
8. A 3D-year-old woman presents with a

6-month history of amenorrhoea and a
previous year. Her serum testosterone Is
elevated, as is a measurefl1ent of 17a-
Vaginal discharge
hydroxyprogesterone . What Is the usual
I. vague history of hot flushes. Which of
next management option? Leo R Leader
the following statements Is incorrect?
I a. Ovarian resistance syndrome is a
a. Prescribe a COCP containing
possible diagnosis.
cyproterone acetate. Edited by Lucy Bowyer
b . Perform an adrenal stimulation test.
b. A prolaclinoma should be excluded.
c. Reassure her that the diagnosis of
c. Thyroid disease should be excluded PCOS does not necessarily need
if ovarian failure is diagnosed.
treatment. /
d . Long-term oestrogen/progesterone d. Prescribe an aldosterone
substitution is contraindicated in anatagonist.
case of ovarian failure.
e. Use depilatory agents to control
e. Pregnancy is the most common hirsutism .
cause of amenorrhoea In this age
group. 11 . Which of the following is the single
. Learning objectives
most useful investigation in a woman
9. The ultrasound diagnosis of polycystic presenting with hirsutism and
ovaries is based upon which of the oligomenorrhoea?
following parameters? Knowledge Skills
a. Serum-free testosterone
a. An ovarian volume greater than At th e end of thi s chapter, the student At th e en d of this c hapte r, the studen t
12 cc b. Total testosterone wIll be able to : sh o uld learn how to:
b. Any ovarian abnormality that c. SHBG
contains more than one follicle discuss the role of oestrogen in the distinguish between a normal and a
d . Ovarian Ultrasound d evelopment and maintenance of pathological vaginal discharge
larger than 15 mm in diameter /'
e.DHEAS vaginal epithelium throughout a
c. Ten follicles (usually 8- 10 mm in woman's life develop a professional and articulate
diameter) arranged peripherally approach to an embarrassing problem.
12. Cyproterone acetate is effecli e in • list th e causes of vaginal discharge
around a dense core of ovarian reducing hirsutism because it Is which th roughout a w oman 's life
stroma of the following?
d. Multiple ovarian follicles in an Iden tify common infections of the lower
a. A strong progestogen and acts b y genital tract Attitu des
enlarged ovary androgen receptor blockude
construct an appropriate diagnostic At the e nd o f th is c ha p te r, the student
e. Follicles larger than 20 mm in b. An oestrogen and suppreises and management plan for each
diameter that persist longer than ovarian function sho ul d reflect upo n:
diagnosis considered
3 months
c. An Insulln-sensitising agent ..".-r • outline the management of recurrent the Importance of a woman 's
10. A 25-year-old woman menstruating d. An aldosterone anatagonist candidal infection. understanding of normal physiology.
every 3-4 months has noticed
increasing acne and hirsutism over the e. A depilatory agent
Wi
Women 's health: a c Ole urric ulum
2 Vaginal discharge
Common clinical presentations Management of leukorrhoea Candida' vaginitis (thrush) antibi otics, which destroy the normal vaginal
A 21-year-old woman taking the oral Take a history and make specific enquiries about: Candidal (or monilial) vaginitis is caused by flora.
contraceptive pili (OCP) presents with the timing of discharge - midcycle or premen- Candida albicans, a yeast-like fungus that appears First-line treatment is often topical: imidazole
excessive vaginal discharge. strual exacerbation; oral contraception - espe- [JUcroscoPlcalJy as long filaments (mycelia) or as drugs are very effective: for example, clotrima-
cially oestrogen concentration; use of douches, spores. zole. in cream or pessaries for 3 to 6 days. Vaginal
A 70-year-old woman consults for a vaginal
discharge and soreness.
additions to bath water or deodorising sprays; It can be found in the vaginas of 15-30% of applicaoons may be supplemented with local cream
recent medications - especially vaginal applica- asymptomatic women and is usually treated only for vulvitis. Many patients prefer to use oral treat-
tions, spermicides, antibiotics; and recent preg- when It IS symptomatic. Itching is the predominant ments, such as ketoconazole or fluoconazole, as such
nancy (Leader et al 1996). . symptom. The discharge is classically thick, white treatments are not messy like vaginal applications,
Normal vaginal discharge On examination, assess the amount of diS- and cheesy, and tends to stick to the walls of the but oral treatment should not be used during preg-
charge and check whether there is any redness of vagina, leaving a reddened area when removed. nancy.
In women of reproductive age the vagina is moist, the vulval, vaginal or perianal skin. Exclude pel vIC The vagina may be extremely sore, making exam- Recurrent infection occurs as local intravaginal
due to secretions from vaginal transudate and cer- or vaginal infection : if there is any doubt, take a ination painful. spores gernunate or WIth reinfection from a sexu-
vical mucus, and, to a lesser extent, to uterine, fal- high vaginal swab and an endocervical swab for The organism thrives in the presence of carbo- al parmer. Spores are not affected by either local
lopian tube and Bartholin's gland secretions. The culture and sensitivity. The diagnostic feature of hydrate, and is therefore more common during or oral treatment. Relapse is more likely to occur
volume of secretion that is accepted as normal by leukorrhoea is that there are no pus cells visible on pregnancy or the second half of the menstrual
individual women varies greatly, Excessive normal at the time of the menses, probably as a result of
microscopy in a wet saline preparation. cycle, in diabetes and following broad-spectrum changes in the pH in the vagina. Precipitating
secretion (leukorrhoea) usually produces staining Explain the physiology of the normal cycle.
of underclothes and vaginal odour due to the heat causes, such as antibiotic use, diabetes or even
Strong reassurance that the discharge is not due to Hrv, should be sought.
denaturation of the proteins in the secretions. an infection or any abnormality may be all that is
Secretions are clear to white and range in consis- Treatment of recurrent thrush is usually oral
required. Eliminate any aggravating cause such as therapy for 5 days, which can be repeated in sub-
tency from thick mucUS before menstrUation to a a high-dose oestrogenic pill, nylon underwear or
thin, watery, more profuse secrenon at ovulanon, sequent menstrual cycles. This pulse therapy will
inappropriate vaginal applications (Reed. & E~ler kill any spores thar start to germinate as conditions
Leukorrhoea is associated with: 1993). Give general advice regarding hYgIene, lim- become more favourable premenstrUally. The part-
• increased production of the ovarian steroids iting local heat to the genital area, avoiding ner should be treated either with local imidazole
(oestroge ns in particular), which occurs at the deodorising sprays, and wearing conan under- cream applied twice daily for 7-10 days or oral
time of ovulation; with the use of oestrogemc clothes that absorb some of the secretions. ketaconazole.
hormonal preparations (e.g. oral contraceptives Ablative therapy (cryocautery, diathermy, laser) to
or hormone therapy); in pregnancy the cervix is used in a minority of persisrent cases Gardnerella vag initis
• cervical ectropion (also incorrectly called a cer- to reduce the number of endocervical glands,
vical erosion), caused by hyperrrophy of the However, if the original precipitating factor is still This can be found in the vaginas of 10-30% of
endocervical columnar glands and their exten- present (e.g. oral contraception), relief will be asymptomatic women and is caused by a small,
sion from the cervical canal onto the ectocervix short-lived. non-monle, gram-variable coccobacillus (Gar-
dnerella vaginalis).
• increased vaginal transudate, which occurs with
sexual excitement and vaginal irritation (such as Pathological discharges The typical clinical presentation includes a vari-
chemical irritation from vaginal douches, per- able amount of thin discharge that has a fishy or
These usually present with other symptoms, such unpleasant odour, ofren more pronounced after
fumed producrs, vaginal applications or even use as vaginal/vulval pruritus, dyspareunia or pelvic intercourse and caustng local irritation but not
of spermicides) pain. J\ilany of the infective causes of vagInal
• increased uterine secretions: before menstrua- pruritus. Microscopic examination of a wet prepa-
discharge produce a classical vaginal reacoon; ranon mounted on a slide will show large numbers
tion, secretory changes in the endocervical and however, more frequently there is a nonspecific
endometrial glands may produce a premenstrual of coccobacilli fl oating between and attached to
discharge and a nonspecific vaginal reaction. vaginal epithelial cells in a stippled manner ('clu e
increase in vaginal discharge; following men- It is important to realise that organisms that cells').
struation, the last days of menstrual flow may be may cause a pathological discharge can be present
prolonged; irritation from an intrauterine con- Treatment is with tinidazole or metronidazole.
in the vaginas of many women, without producing
Alcohol sho uld be avoided, as these drugs are
traceptive device (IUD) any symptoms (Sobel 2000) . In studies of well FIGURE 2.1 Speculum examination of lateral metabolised in the liver and can cause nausea and
• granuloma (arising in the suture line at the vagi- women who have been attending family planning va Inal wall affected by candldol vaginitis vomiting.
nal vault following a hysterectomy), which can clinics, 15-30% of women have been found to shOWing w hite ' cottage cheese' -like
give rise to a profuse di charge that is besr treat- have Monilia or GardnereLla vaginalis, 10-15% app earance of adherent discharge (From Ten per cent of men will be asymptomatic
Trichomonas and 10-20% Chlamydia trachomatis. P kin et al 2003, p '03 , Fig 2) carriers of this bacterium and so should be treated
ed by cautery, either chemically or by diathenny. initially or if there is recurrence,
-E
7
2 Vagina l disc harge
Trichomonal vaginitis Childhood vaginitis

This is caused by a flagellate unicellular organism. This is uncommon and may be associated with a Questions
It is harboured, usually asymptomatically, in wide range of organisms, which are usually of low 2. Candida infection :
2-10% of males and can be transmitted sexually. It virulence. Select the correct answer to complete the a . is also known as Gardnerella
can also be found in the vaginas of 10--15% of Whenever a child presents with a vaginal dis- statement.
vaginitis
asymptomatic women. The discharge is classically charge, always suspect a foreign body. However,
1. White vaginal discharge :
frothy and yellow-green in colour, variable in Neisseria gonorrhoeae and Trichomonas vaginalis b. is also known as moniliasis /
amount and has a typical fishy odour. It is often do occur in children, and the possibility of abuse a . is called diarrhoea
c. is caused by a bacterium
associated with dysuria and prurirus. The vaginal should be considered. b. is always abnormal
walls and cervix may have an inflamed appear- d . is less common in women with
ance, with punctate 'strawberry' spots. The diag- c. is commonly caused by syphilis diabetes
Health maintenance
nosis can be made microscopically. Tinidazole or d . must always be examined with a
Most vaginal discharges are physio- va ginal swab for culture e. can be treated with antibiotics.
metronidazole are again used for eradication; the
logical. Wearing undergarments
male parmer should also be treated. made of natural fibres and avo iding e. may occur with Candida infection .
the use of perfumed products In the
Sexually transmitted infections
See Chapter 3 for chlamydia, gonorrhoea and
genital area will help to min im ise
vaginal Irritation and leukorrhoea. /
other sexually transmitted infections.
Atrophic vag initis References

Lack of oestrogen in posnnenopausal women Leader LR, Bennen M], Wong F 1996 Handbook of
results in a very thin vaginal epitheJium, which is obstetrics and gynaecology. Chapman Hall, London.
easily injured or infected. The responsible organ-
isms are usually nonspecific (producing a mixed Pitkin J, Beattie All, Magowan BA 2003 Obstetrics and
growth on culture) and of low virulence. gynaecology - an illustrated text. Chutchill
The discharge is thin, purulent and often Livingstone, Edinburgh.
blood-stained, and the vagina may appear red and Reed BD, Eyler A 1993 Vaginal infections: diagnosis and
ha':e many tiny bleeding points. Vaginal, vulval management. American Family Physician
and perineal soreness are frequently present and 47: 1805- 1818.
may make an adequate examination of the patient
Sobel JD 2000 Bacterial vagiuosis. Annual Review of
difficult.
Medicine 51:349-356.
Treatment of atrophic vaginitis consists of
oestrogen, locally in the vagina using either tablets
(oestradiol 25 f.45) or creams (oestriol). Oral
oestrogens can be used and, if the uterus is still in
situ, progestogen must be used to reduce the risk
of endometrial hyperplasia.
ME
*3
Sexually transmitted
I
infections
I
I Edited b y Vivienne O 'Connor
Genital herpes, female genital warts (condylomata acuminata) Mark Erion

Syphilis, gonorrhoea Ian Jones
Chlamydia, HIV I AIDS, sexually transmitted infections and pregnancy Vivienne O'Connor
Learning objectives
Knowledge • list the treatment options for removal of

genital warts
At the end of this chapter, the student Syphilis
wi ll be able to:
describe the symptoms, signs and time
Sexually transmitted Infectlans (ST/S) - frames of the primary, secondary and
general principles tertiary stages of syphilis
describe high-risk behaviour for the evaluate the diagnostic and screen
development of STis tests for syphilis
• discuss the educational initiatives to outline a management plan for the

Inform people about STis treatment of syphilis
summarise the public health impli - Gonorrhoea

cations of notifiable diseases and Indicate the prevalence of gonorrhoea
contact tracing Infection
Genital herpes • describe the symptoms of gonorrhoea
indicate the prevalence of genital infection
herpes list the long-term consequences of
describe the clinical findings and untreated gonorrhoea infection
laboratory diagnostic tests • outline a plan for the diagnosis and
management of gonorrhoea
• outline a management plan for primary
and recurrent infection Chlamydia
Genital warts describe the worldwide distribution of
ChlamydIa infection
indicate the prevalence of HPV Infection
and Its significance with respect to outline the short- and long-term
development of genital warts and consequences of pelvic infection with
genital neoplasia Chlamydia
• describe the clinical appearance and • describe the laboratory investigations In
distribution of genital warts the diagnosis of ChlamydIa infection
(Continued over)
3 Sexually Ironsmltted Infectio ns
Women's health: a c ore curriculum
• take a history and perform an acutely painful and precipitate dysuria and reten- valaciclovir 500 mg can be given 12-hourly for
(Learning objectives continued) examination for an STI with sensitivity tion of urine. Herpetic lesions can cause anorectal 5-10 days. Side effects of the above medica-
and respect in a non-judgmental spasm, discharge from the vagina and/or urethral tions include headache and nausea. Symp-
• design a plan for the diagnosis an.d manner discharge and local lymphadenopathy. Systemic tomatic management with analgesia and topical
management of Chlamydia Infection manifestations include fever, myalgia and, rarely, lignocaine 2% jelly is offered to those with
• explain the diagnosis t.o a woman with
HiV/AIOS a sexually transmitted Infection and autonomic neuropathy and even meningitis. pain. Treatment of secondary infections with
describe the epidemiology at HIV counsel her antibiotics and antifungals ma y be required. In
Infection explain to the patient the importance of Natural history severe cases, admission to hospital and the
adequate treatment for an infection insertion of an indwelling urinary catheter may
summarise the pathophysiology of HIV The primary episode may be atypical and asymp-
and follow-uP of contacts tomatic; occasionally, it is associated with very be required.
infection Recurrent herpes infections are managed with
provide pre-test counselling for a woman severe, painful manifestations that last for 4 weeks
list the Investigations performed to
about to undergo an HIV screen. suppressive regimens of acyclovir 200 mg 8-hourly
diagnose HIV infection and monitor host or more. Prolonged severe infection should raise
or 400 mg 12-hourly, valaciclovir 500 mg dally or
response the suspicion of immunosuppression, e.g. HIV
farnciclovir 250 mg bd for 3-4 months. This treat-
Attitudes infection.
• identify particular health issues of ment should then be discontinued intermittently
relevance to HIV-positive women
Recurrence may be precipitated by sexual con-
to assess the need for further courses. Episodic
At the end of this chapter. the studen t tact, fever, stress and general illness. The recurrent
therapy should be initiated by the patient at the
Srts and pregnancy should reflect upon: lesions may involve the genitals, anus and perianal
first sign of prodromal symptoms or very early
• describe the consequences of area, buttocks, legs and perineum. Neuralgic pain
• the need for community education on lesions .
antenatal infection with hepatitis B. .. in the lower back, perineum and inner or back of
Chlamydia. gonorrhoea. herpes. syphilis responsible sexual behaviour thighs represents nerve root irritation. Grouped
and HIV. • the requirement of informed consent for localised lesions along sacral dermatomes may
testing for STis. in particular HIV Health maintenance
occur unilaterally. Rarely, meningoencephalitis
Skills confidentiality may occur. There is an increased risk of HIV ttans- Community education about at-risk
mission and acquisition of opportunistic infections behaviour and STis Is Important and
At the end of this c hapte r. the student the effect of a diagnosis of pelvic in immunocompromised individuals. particularly relevant to individuals
infection upon personal relationships. under 25 years of age.
sh ould learn how to: body image and self-esteem.
Diagnosis
counsel regarding safe sexual
behaviour Laboratory diagnosis is essential to confirm the
infection and provide characterisation of the
strain. A polyme rase chain reaction (peR) test per-
formed from swabs or scraping of the lesion is
* Female genital warts
( CO ndylomata
* Genita l herpes
mild. However, they can pass on the infection to
sexual partners and newborns.
nearly 100% sensitive and can determine the virus
type. In some laboratories, culture of the virus may
be available. The lesion is swabbed and the swab is
kept in a viral transport medium, preferably cool,
acuminata)
Common clinical presentations
Common clinical presentations Pathophysiology during transportation to the laboratory. The virus A woman describes new lumps around her
A woman attends the emergency department Genital herpes is an infection with herpes simplex culture is more than 90% sensitive, with sensitivi- genitalia and anus.
because she has such severe genital pain that vims type 1 or type 2. About .10% of gemw ty decreasing if the swab was taken later than
she is unable to urinate. A woman has noticed that her partner has a
lesions are caused by HSV-2 acqUIred from symp- 36 hours afrer the active episode. However, this
penile wart. .
Having recently had casual sexual intercourse, tomatic or asymptomatic sexual partners, and method is expensive, labour-intensive and slow.
a 20.year-old woman no~ces some blistering from genital, oral and sexual contact- False-negative tests for HSV are not uncommon if
around her labia. taken more than 48 hours after the onset of an
Signs and symptoms attack or afrer medication has been applied. Epidemiology
Classically, there is blistering and ulceration of the Anogenital warts are caused by the human papil-
directly infected region(s), which i l l ,,":omen are
Management lomavims (HPV). Over 50% of sexually active
Epidemiology
usually on the labia majora, labia nunora and Drug treatment varies according to whether the adults have been infected with HPY, but most of
Seroprevalence studies show that 220/0 of adults around the clitoris and urethra. The leSIOns are infection is primary or recurrenL For a primary these in fection s are subclinical, benign and
have herpes simplex type 2 vlms (HSV-2). Most frequently multifocal, bilateral and at different infection, acyclovir 200 mg is given five times daily unrecognised. Clinical manifestation of H.PV in
women with HSV-2 infection are not aware that or 400 mg 8-hourly for 5-10 days. Alternatively, the form of genital warts is common.
stages of development and resolution. They can be
they have genital herpes, as their symptoms are
WI
'.
3 Sexuall y transmitted Intectlons
women's health: a c ore c urri c ul um
woman's and treating doctor's preferences, and of antibiotics. A resurgence occurred in the 1980s Early congenital syphilis
Pathophysiology the presence of concomitant pathology, e.g. cervi- and 19905, coinciding with the increased inci- Early lesions include rhinitis, rash, hepato-
More than 70 subtypes have been identified. cal intraepithelial neoplasia (CrN) or other STIs. dence of HIV infection. splenomegaly, meningitis, bone involvement and
Visible genital wartS are usually caused by HPV Treatment options for small areas include local anaemia, changes that are similar to those in sec-
types 6 or 11 and are usually benign. Types 16, 18, application of medications such as podophyllm, Pathophysiology ondary syphilis. This condition is infectious.
31, 33, 35 are mostly subclinical and can be seen podophyllotoxin, trichloroacetic acid, 5 -fluoro-
uracil, interferon and imiquimod, which have all Syphilis is caused by the spirochaete Treponerna
by colposcopy and not macroscopically. They are Late congenital syphilis
been tried with different degrees of success. pallidum, one of a group of related spirochaetes
associated with cervical dysplasia and with vulval,
penile and anal squamous intraepithelial neo- Cautery may be performed under local or gen- that includes T. pallidum subsp. pertenue (yaws) Similar to late acquired syphilis, this presents with
plasia. HPV is usually a sexually transnutted eral anaesthesia: local discomfort and scarring are and T. carateum (pinta). The infection may be teeth changes, deafness, gummas and neurosyphilis.
infection. Rarely, permatal infecDon can affect the recognised complications of this, and anal pain acquired or congenital.
and discomfort may be disabling. Laser treatmen t The usual mode of transmission is through sex- Diagnosis and management
newborn or infant.
is suitable fo r larger, multiple wartS, and treatment ual intercourse, but the infection can spread
around the urethral mearus and anus. Cryotherapy through blood contamination from using shared If primary syphilis is suspected, the chancre should
Natural history be sampled and the sample subjected to dark back-
causes cytolysis at the dermal-epidermal junction. needles, needles tick injuries or by direct contact
The incubation period is variable and may be pro- The freeze-thaw-freeze technique is employed with open lesions. It can also spread to the ferus ground examination, looking for the spirochaetes.
longed. Without treatment, the warts may stay the until a halo of a few millimetres appears around through transplacental transmission. Secondary syphilis is diagnosed serologically, but
same, enlarge or regress spontaneously, especially sprrochaetes may also be found in mucous mem-
each lesion. Necrosis and blistering are known
in young women. Immunosuppression and preg- branes. Tertiary syphilis should be investigated
complications. Excision under a local or general Signs and sym ptoms
nancy are often associated with persiStent, larger with serological testing and, where possible, CSF
anaesthetic is suitable for pedunculated and read-
and more numerous warts. Extragenital lesions examination if neurosyphilis is suspecred.
ily accessible warts. The recurrence rate varies Primary syphilis
may occur in the oronasal cavity and larynx. with the method and individual characteristics TeSts specific for syphilis - e.g. T. pallidum
from 0 to 400/0. A primary chancre develops at the site of inocula- haemagglutination assay (TPHA) - remain reac-
Signs and symptoms tion after an incubation period of approximately tive even after treannent. They are useful only for
WartS may appear as single or multiple fleshy Prevention 21 days. The adjacent lymph nodes are enlarged the diagnosis of the fIrst infecrion. Negati ve TPHA
lesions. On non-hairbearing skin, they are of a soft Male sheaths (condoms) reduce the infection rate and nonsuppurating. serology in the presence of syphilis may occur in
consiStency, but on skin with hair they are firm and of new sexual partners, but are not completely very early infection and in the immune-deficient
keratinised. They have a broad base and may be effective in preventing transmission, as the area of Secondary syphilis patiem with HIV infection. Reagin tests such as
pedunculated or pigmented. Occasionally, they may the venereal disease reference laboratory (VDRL)
skin and mucous membranes infected with HPV After 2-3 months, fever, headache, malaise and test and rapid plasma reagin (RPR) test are non-
cause pain or pruntuS, or be Enable WIth bleeding.
may be quite extensive and include scrotal skin, general aches and pains may precede or accom- specific for syphilis, and biological false-positives
Large wartS may make intercourse difficult ~r
painfu4 and may affect urination or defecanon if perineum or inner rh ighs. pany the signs of secondary syphilis. The most occur. However, these teSts show a significam fall
common symptom is a generalised, symmetrical in titre or become nonreactive in response to treat-
*
they obsrruct the urethra or anal canal respectively.
maculopapular rash on the face, palms and soles. ment and are useful in follow-up management.
I I Diagnosis Sy p hilis Other signs include condylomata lata; patchy . Screening for syphilis generally involves a com-
alopecia; oral, pharyngeal or genital ulcers; or bmanon of TPHA and RPR. Syphilis serology in
Direct examination of anogenital wartS is crucial widespread lymphadenopathy, If untreated these the asymptomatic patient, however, can be inter-
for clinical diagnosis. Confirmation by histOlogical clinical signs resolve spomaneously, leading to preted only with the aid of a comprehensive histo-
examination may be required, especially if the latent syphilis.
antenatal screening. ry of past infection and treatment for syphilis.
lesions are atypical, ulcerated, attached to under-
Treatment is with parenteral penicillin (unless
lying srructures, or exhibit frequent recurrences The female partner of a man diagnosed with Latent syphilis there is penicillin sensitivity). Alternative options
(to exclude malignancy). . syphilis presents for advice.
The presence of perianal or anal canal wartS is This is indicated by positive syphilis serology in mdude erythromycm and doxycycline.
A young woman has noticed a painless ulcer
not in itself evidence of anal receptive intercourse. the absence of symptoms or signs of the disease.
In her vulval area.
However, proctoscopy should be offered to those
who have perianal wartS or those who have been Tertiary syphilis Health maintenance
engaging in anal sex. After approximately 3 years or more, te rti~ ry Contact tracing is essenlial for all STis
Epidemiology and some Infections are required by
syphilIS may present with gummas in any o r~an law to be notified.
Management Or with cardiovascular or central nervous sys~e~
Syphilis was epidemic in late fifteenth-century
Europe. Reported syphilis peaked around the disease.
Management depends on the type, number and
Second World War and decreased with the advent
distribution of wartS, available resources, the
ME
3 Sexua lly transm itted infections
Women's health : a c o re curr icul um
floxacin can be used in cases of penicillinase- Diagnosis had three phases: men having sex with men, intta-
* Gonorrhoea resistant Neisseria gonorrhoeae. Follow-up IS
recommended 1 week afrer eompletmg a treat-
Samples should be taken from the endocervix, ure-
thra and urine. Chlamydial tests include culture,
venous drug users and heterosexual transmission.
Pathophysiology
ment regimen to ensure cultures are negatJve. immunofluorescence and detection of antigen or
nucleic acid. First-catch urine tests by polymerase The humatl immunodeficiency virus is a retrovirus
A 25-year-old woman presents with Infertility Outcome chain reaction (peR) or ligase chain reaction which can be found in the blood, vaginal fluids or
and tubal blockage. (LCR) are alternatives to swab tests. N on-culture semen of infected people. The virus can be trans-
In 60-80% of cases, pelvic infection in women
An asymptomatic woman presents with her under the age of 25 years is caused by gonorrhoea tests may give false-positive results and should be mitted to others during sex, by sharing needles and
partner. He Is complaining of urethritis. or Chlamydia. This can lead to infertility, chrOille interpreted with caution. syringes, through a contaminated blood tratlsfu-
A woman presents with a mucopurulent pelvic abscess and pelvic pain. . sion and by vertical transmission in childbirth or
Without treatment, gonorrhoea m men causes Management during breastfeeding.
vaginal discharge.
prostatitis, vesiculitis and epididymitis. In the new- 1. Check for other STIs as Chlamydia may occur
born, ophthalmia neonatorum (conJunCtlVltIS concurrendy with gonorrhoea. Signs and symptoms
within 21 days of birth) is a notifiable disease. 2. For local infections, give azithromycin 1 g orally
Epidemiology The initial illness usually occurs within 2 weeks of
as a single dose (category B1 in pregnancy), or
infection and has symptoms similar to those of
Gonorrhoea is the second most commonly re- doxycycline 100 mg twice a day for 10 days
*
ported notifiable STI in Australia. The prevalence (category D in pregnancy), or erythromycin glandular fever: headaches, fever, swollen glands
is influenced by the spread from asymptomanc 800 mg twice a day for 10 days (cate- and body rash. After a dormant phase, the sympto-
people and others with at-risk behaVIOur.
C hlamydia gory A in pregnancy). matic carrier state occurs once the immune system
3. Where there is PID, azithromycin and metron- is affected. There are a wide range of clinical mani-
Pathophysiology Common clinical presentation idazole are recommended, followed by doxy- festations including fatigue, fever, weight loss,
cycline. diarrhoea and glandular swelling. Autoimmune
Gonorrhoea is caused by the gram-negative diplo- A 19-year-old woman presents for colposcoPY
deficiency syndrome (AIDS) has severe effects on
coccus N eisseria gonorrhoeae. It is contagrous and because of an abnormal cervical smear test.
Outcome s the immune system, causing the body to be over-
spread mainlv by coitus. . Chlamydia Infection was also found as part of
It affects 'mucosal and glandular strUCtures m In women, upper genital, peritoneal, joint and whelmed by infections and cancers. The most com-
a routine screen. mon of these are pneumonia, Kaposi's sarcoma
the genital tract, reCtum, oropharynx and conJunc- ocular manifestations can occur, and Chlamydia
tivae. The incubation penod IS usually 2-7 days infections are associated with tubal blockage and in- (rare .in women) and lymphoma.
but can be longer. fertility. In men, Chlamydia may cause epididymitis.
Epidemiology Diagnosis and ma nagement
Signs and symptoms In industrialised western society, virtually all Health maintenance Antibodies to HIV appear approximately 3 months
In more than 60% of women, the condition is Chlamydia trcu:.hom atis infections are sexually Scree ning for other STis is important. afrer infection and remain throughout life.
asymptomatic: hence contact .tracmg 15 lIDpOrtant. transmitted. Chlam ydia is the most common STI as several may co-exist . After the primary infection, the viral load stabi-
The most common symptom IS cervlcms and a dis- in Australia. In many deveiopmg. countnes? a- :r lises at a 'set point'. The disease is monitOred with
coloured vaginal discharge. .. . choma is endemic and child-to-child trans.truSSlon HIV/viral load and CD4/CD8 lymphocyte counts.
Other presentations include vulvms, dysuna,
dyspareunia, pharyngitis, pam on defecatlon, rec-
tal bleeding and heavy, pamful pen ods. In men,
classical symptoms include urethral discomfort,
is common.
Pathophysiology
* HIV/AIDS
Rising viral load and falling lymphocyte count
indicate the need for antiretroviral therapy.
Chlamydia trachomatis is an obligate intracellular Treatment

dysuria and a yellow urethral discharge, while parasite. If symptoms occur, these usually appear
25% of males are asymptomanc. woman whose partner Is an Antiretroviral therapy is consrandy changing. It is
1-3 weeks afrer exposure. ~.I I...I,nv,.... ,'''. drug user has a postlve test to HIV common to use a combination treatment with
Diagnosis and management attar presenting for routine STI screening. three drugs. Specialist assisrance should be sought
Signs and symptoms
Diagnosis is confirmed by demonstrating the organ- to investigate and plan management.
In 70-90% of wo men, the infection is asymptO-
ism in culture. Appropriate swabs are taken from matic. Whete there are symptoms, they are likely
the endocervix, urethra, anus, throat or abscess. Epidemiology Specific considerations
to be mucopurulent discharge and/or cervlCltl~
A presumptive diagnosis can be made by finding postcoital bleeding and lower abdommal pam. Women represent 6% of adult cases of human 1. Fifty per cent of HIV-positive women have a
gram-negative intracellular diplococa m smears. 10-150/0 of cases, there may be pelVIC mflamm a- immunodeficiency virus (HIV) in Australia. In the high risk of HPV and therefore are at an
Most gonorrhoea infections are sensmve to developed world, the epidemiology of HIV has increased risk for cen·i. cal cancer.
penicillin. Spectinomycin, ceftnaxone or orclpro- to ty disease (PID).
WE
3 Sexually transmitted intec llon>
Women's health : a core cur riculum
d her partner and other children and imiquimod should not be used during preg- would be valuable in monitoring any increase in
During vaginal intercourse, women a,re at high- ch ec ke d , an . d . d 'f nancy. The baby can acquire the genital wart virus cases in other countries with a lower prevalence.
h ld be screened for infeenon an vaccmate I
2. er risk than men of acquiring HI\ mfeenon ~o~ualready infected. The main risk for the neonate from the vagina during childbirth; rarely, this can Screening should be offered to pregnant women
after appropriate counselling is given about the
and several other STIs, probably mcluding cause neonatal laryngeal warts. Genital warts are
is at delivety. The combination of liTIIDunoglobulm
HSV-2 infection, gonorrhoea and Chlamydia. and immediate postparrum vaccmatlon prevents not considered to be an indication for performing limitations of the testing and the implications of
3. Reproductive issues: pregnancy outcome ma~ a caesarean section. the results. HIV transmission to the fetus can be
the majority of perinatal transmiSSIOns. markedly reduced by the use of antiviral medica-
be affected by an HIV diagnosIS, whether It IS
made before or during pregnancy. Chlamydia Syphilis tions during the pregnancy and a caesarean section
delivery; in developed countries, breastfeeding the
Mother-to-fetus infection can occ~ at the time of All pregnant women should be screened for infant should also be avoided.
Counselling and testing for HIV birth by direct transmission. The mfant may de- syphilis because it is easily treated, whereas
It is essential that the patient give informed con- velop conjunctivitis or pneumonltls: the nsks are untreated syphilis in pregnancy causes potentially
Health maintenance
sent before any testing and after explanaoo n about thought to be up to 250/0 and 15% respeenvely. If severe disease in both the mother and the fetus. As
a general rule, tetracyclines should not be used in
the possible results. Explam a mother tests positive for Chlamydra dunng preg-
th e implications of th'
Antenatal screening may consider-
that there is a 3-mon WID . d ow' fr om exposure to nancy the risk to the neonate IS reduced by a pregnancy. If the nonspecific screening test is p.osi- ably reduce the risk of vertical trans-
antibody development, and therefore a repeat test cours~ of antibiotics. Erythromycin is the first drug tive, exposure to syphilis should be confirmed mission of Infection to the fetus and
neonate.
will be necessary before a negaave test can be con- of choice. Azithromycin or alilOluCillin are mdicat- with a positive T. pallidum haemagglutination
firmed. Confidentiality issues are. Important. ed if erythromycin is not tolerated. assay (TPHA). There is a high incidence of syphilis
A positive result may have. imphcanons for life alilong Aboriginal women, and a number .of babies
insurance and immigranon, In addinon to ralsmg Bacterial vaginosis (BV) with congenital syphilis have been born in recent Further reading
serious social and psychologlcallssues. Although not a sexually transrrutted infecti.on, BV years. These women should be rescreened in the
Bowde n FJ, Tabrizi SN, Garland SM et al 2002 Infectious
-. . -.
Wherever possible, partners should be
is a common cause of vaginal discharge. It IS char-
acterised by an imbalance in the normal vagtnal
flora, with a decrease in LactobaCIllus spp and an
third trimester to exclude recent infection. If there
has been no antenatal screening, mother and baby
should be screened at the time of birth and fol-
dise ..... 6: Sexually transmitred lniections: new
di agnostic ap proaches and treatments. Medical Journal
of Australia 176 (11):551-557.
involved in the counselling process. increase in Gardnerella spp, Mycoplasma spp and lowed up in the posmatal period. Maternally
anaerobic bacteria. Epidemiol.ogl cal srudles sug- acquired antibodies will be detectable in non- Brown ZA, Selke SA, Zeh j et al199 7 Acquisition of herpes
gest an increased risk of rruscarnage, preterm infected infants for some months afrer delivery. si mplex virus during pregnancy. New England journal
* delivery and low-birth-welght mfa~ts amo ng of Medicine 337:507-515.

Advice from the pathologist, paediatrician, obste-
women with BY. However, the mecharusms are not trician or sexual health service can be obtained if
Sexually transmitted completely underst.ood and inter:enti.on studies there is doubt about interpreting neonatal syphilis
Crum Cp, BerkowitZ R5 2002 H uman papilloma viruses:
Applications, caveats and prevention . Journal of
infections and have not been sh.own to be effecnve m reduang serology. Penicillin is the drug of choice for treat- Reproductive Medici ne 47 (7):519-528; discussion
preterm delivery. There is insuffiClent eVidence to ment of the pregnant woman. 528-529.
pregnancy recommend routine screenmg 10 average-nsk
Sexual health: at hrtp :liwww.health.qld .go.l.au1scxhealth
pregnant women. Gonorrhoea
Sisk EA, Robertson ES 2002 Clinical implications of hwnan
Common clinical presentations 'Herpes A baby passing through a birth canal infecred with papilloma virus infection . Frontiers in Bioscience
A pregnant woman seeks advice afte' recently gonorrhoea may develop conjunctivitis or a pha- 7:77-84.
Vertical transmission and perinatal infection w ith
tyngeal infection. Gonorrhoea should also be sus-
having casual unprotected Intercourse. HSV are most likely to occur \\~th vagmal dehvery Stanberry LR, Rosenthal SL 2002 Genital herpes simplex
pected with a 'sticky eye' in the neonate.
A pregnant woman's antenatal screen test is at the timE of primary or active maternallnfecnon. virus infection in the adol escent: special consideration
The risk of neonatal infection is about 41%. 10 Ophthalmia neonatorum (conjunctivitis within
positive for syphilis. for management. Paediatric Drugs 4 (5):291-297.
babies born to women who acqUIre infeenon 21 days of birth) is a notifiable disease.
At 39 weeks' gestation, a woman notices for the first time near the onset.of labour, and Whitely Rj, Kimberlin S\V, Roizman B 1998 Herpes
painful vulval blisters. Chlamydia simplex viruses. Clinical Infectious Diseases
bo ut 30/0 in women with
aCaesarean
established Infecnon.
26:541-553.
section may be m . d'leate d'm pr.oven
Conjunctivitis can occur in 30-50% of neonates and
active primary HSV maternal infection. About pneumonia in 10-20% of neonates born through an Zur Hausen H 20Q2 Papilloma viruses and cancer: from
Consideration should be given to the effect of the 15% of neonatal infeCtlon results from posmatal infected birth canal to a mother with Chlamydia. basic studies to clinical application. Nature R~t'Ws.
Cancer 2 (5):342-350.
infection on the mother, the ferus and the neonate. traIlSmission from oral lesions.
HIV
Genital warts
Hepatitis B Universal screening may be cost-effective in some
These can increase in pregnancy: Excision can some- countries, aIld testing .of pooled antenatal sera
The woman who is hepatitis B surface antigen pos- times cause scarring. Podophyllin, podophyllotoXlD
itive (HBsAg+ve) should have her liver enzymes
ME
c . It may be caused by a Chlamydia

Lower abdominal pain
Questions infection,
d. It should be treated with saline eye
Edited by Vivienne O'Connor
1. Which of the following statements Is
incorrect? drops.
a. An Increase In vaginal discharge e. The mother should be tested for
indicates the presence of an STI. vaginal infections. Pelvic pain Ian Jones
b. An increase in vaginal discharge Endometriosis Vivienne O'Connor
may be related to the use of 3 . Which statement is incorrect? Pelvic Inflammatory disease Vivienne O'Connor
hormone therapy.
( f0P.. n ulcer of the vulva can be caused
c . An increase in vaginal discharge / V by use of steroid cream.
could suggest cervical cancer.
b. An ulcer of the vulva is painless if
d . A positive culture for Gardnerella
caused by syphilis.
vaglnalls does not Indicate a
sexually transmiHed Infection. c. An ulcer of the vulva could be a
e. There may be an Increase in vaginal vulval malignancy. Learning objectives
discharge during pregnancy. d. An ulcer of the vulva is painful if
caused by the herpes virus. ....,. Knowledge Skills
2. Which of the following statements is
not true of '~ic ky eye' In the neonate? e . Delivery by caesarean section
A~ the end of this chapter, the student At the end of this chapter, the student
a. It can be caused by a herpes should be considered for primary will be able to: should learn how to:
infection . herpetic infection of the lower
genital tract close to term. Pelvic pain • explain the concept of endometriosis in
It Is always due to gonorrhoea.
a clear and understandable way
list the differential diagnoses of acute
pelvic pain and of chronic pelVic pa in address the psychological component
of chronic pelvic pain .
outline the investigation and
management of a patient with acute
pelvic pain
• outline the Investigation and Attitudes
management of a patient with chronic
pelvic pain At the end of this chapter, the student
• discuss the psychosocial context of should reflecl upon:
chronic pelvic pain
• the association between chronic pain,
Endometriosis low self-esteem, sexual abuse and
outline the causation theories of domestic violence.
endometriosis
describe the natural history of
endometriosis
outline a plan of investigation and
management of endometriosis
Pelvic Inflammatory disease
recognise the relationship between
pelvic Inflammatory disease and STis
• describe the consequences of
untreated pelvic inflammatory disease
• outline an Investigation and
management plan for acute and
chronic pelvic inflammatory disease.
4 Lo w",r abdomi nal pain
Women's health: a co re curricu lu m
* Pel vic pain

• complication of an ovarian cyst: rupture,
haemorrhage into a cyst, torsion
• ovulation pain
Signs and symptoms
A detailed assessment of the pain is required,
including:
Natural history
In the acute situation, a diagnosis is usually made
based on the history, examination and investiga-
Common clinical presentation tions, and most often the problem is treated and
• retrograde menstruation • character, site, intensity, duration, periodicity,
Lower abdominal pain (LAP) is a common • primary dysmenorrhoea resolved. In the chronic situation, management
gynaecological and obstetric problem , radiation, onset also depends on the underlying cause and is more
• trauma to the upper genital tract following • aggravaring and relieving features
Associated symptoms may Include nausea, likely to be long-term.
vomiting, vaginal discharge, vaginal bleeding, instrumentation. • effeCts of micturition, defecation, vomiting,
painful menstruation, dyspareunia : abdominal The non-gynaecological causes of acute LAP coughing on the LAP
bloating, and urinary and bowel symptoms, • associated features of nausea, vomiting, sweat- Health maintenance
include: ing, urge to pass urine or faeces Recognition of past sexual abuse or
1 • effect of any pain relief administered previ- domestic violence and appropriate'
• cystitis
• ureteric colic
MIJC ously for this pain counselling may reduce the risk of
Pathophysiology • relationship to last menstrual period (LMP),
development of chronic pelvic pain ,
• acute appendicitis
LAP may originate from the genital tract organs, the menses, micturition, defaecation, move-
the bowel or the urinary bladder. It may also be • diverticulitis
*
ment, coitus, previous pregnancy or surgical
referred pain from the musculoskeletal system or • bowel obstruction
procedures
~'
other intra-abdominal structures higher up m the • mesenteric thrombosis.
• p,ast obstetric and gynaecological history Endometriosis
abdomen, or the pain may be psychosomanc. The , • past medical, surgical and psychiatric history
pain may be physiological, resulnng fr?m ovula- Chronic LAP Common clinical presentation
social history, including marital, sexual and
tion (mittelschmerz), premenstrual pelvIc vascular Chronic LAP is often more difficult to diagnose occupational history A 25-year-old woman complains of very painful,
congestion, retrograde menstruaClon or prllllary than acute pain. Gynaecological causes include: • history of physical or mental abuse, including periods and abdominal pain in the week
dysmenorrhoea. An underlymg depressIOn? anXI- domestic violence before menstruation,
ety state, sexual problem, or domesnc vIOlence • chronic pelvic inflammatory disease (PID) • orthopaedic and postural problems
should always be kept m mmd as a prtmary or sec- • endometriosis/adenomyosis • history of previous trauma
ondary component of the pain. . ' • ovarian masses, both benign and malignant • medication and medication allergies,
A working knowledge of the mnervanon of the
• complications of uterine fibroids Epidemiology
pelvic viscera assists in evaluating the cause of Physical exa mination
lower abdominal pain. The embryoruc ongm of a pelvic vascular congestion syndrome. The prevalence of endometriosis is unknown,
particular organ determines its nerve supply. Less common gynaecological causes of chronic What is the general appearance of the patient? Is since the pathological findings and symptoms are
Sensory impulses travel via both the somanc and LAP include: ofren not aligned: a woman with extensive disease
she shocked, distressed, tense, anxious, moving
may be asymptomatic and vice versa. The point at
the autonomic nervous systems. , about or lying still with her pain?
Diagnostic laparoscopy is a valuable tool U1 the • un ruptured ectopic pregnancy which a possible physiological problem becomes
Examine the vital signs and then perform a pathological may be different for each woman.
investigation of chromc L<\p' HO,wever, the poor • lo,,\'-grade PID general examination, including abdominal and
correlation of the laparoscoplC findings Wlth the • polycystic o\'ary disease musculoskeletal examinations. If appropriate, Pathophysiology
degree of pain, the high proportion of normal varicose veins in the broad ligament perform a pelvic e::amination: observe signs of
findings, and the finding of [runor adheSIOns and
• prolapsed ovaries intO the pouch of Douglas trauma, discharge, bleeding, foreign bodies, tissue The precise cause of endometriosis has not been
minimal endometriosis connnue to cause confu-
• genital prolapse, coming through the cervix, polyps, malignancy determined. The main theories include retrograde
sion for the clinician.
(unlikely to cause acute pain), and take appropri- menstruation, coelomic metaplasia, an altered
Non-gynaecological causes include: autoimmune response to menstrual blood in the
ate specimens for pathology (see below). Perform
Differential diagnosis a bimanual pelvic examination, checking for cervi-
peritoneal caviry, or a combination of these.
• appendiceal abscess Oestrogen is important in maintaining the pres-
Acute LAP • intra-abdominal adhesions cal excitation on moving the cervi..x. Then check ence and prol iferation of the tissue - endometri-
• di, cniculitis uterine size, consistency, tenderness, mobility, osis is not seen before adolescence and settles after
The gynaecological causes of acute LAP include:
• irritable bowel syndrome shape and consistency. Palpate each of the fornices menopause,
• threatened, incomplete and septic abortion • Crohn's disease, inflammatory bowel disease and the adnexa for masses, tenderness and fixity, Endometriotic tissue containing glands and
ectopic pregnancy _ AD malignancy of the small or large bowel , Based on the history and examination, make a epithelium are found in sites outside the endome-
acute salpingitis E:.p.;\" \'t;t'{ bladder dysfunction, urinary tract calculi list of differential diagnoses and give feedback to ttial cavity of the uterus. The precise definition of
tubal or ovarian abscess 0 - , the patient on these. Appropriate investigations endometriosis has varied over time and this has
osteoarthritis, lumbar disc protruslOn, other
• endometritis I- On \ musculoskeletal disorder. will assist you in refining your diagnosis. led to difficult;, in interpreting research results.
• pelvic peritonitis
81
4 Lo wer a bdominal pa in
Women 's health: a core c urriculum
ness~ tenderness in the adnexa and on moving the Further reading

The histological confirmation of endomeuiotic tis- Health maintenance
cervIX. There may be vaginal discharge, abnormal Abbott J, Hawe J, Shaltoot N et al 2002 Pelvic pain scores
sue is suggested as the gold standard. Recently it Use of the oral contraceptive pill bleedUlg or dyspareunia. However there is not in women without pelvic pathology. Journal of the
has been suggested that the degree of pain is more minimises the risk of developing good evidence to relate these non~pecific symp- American Associarion of Gynecologic LJparoscopisrs
likely to be associated with the depth of invasion endometriosis. toms to PID. 9(4):414-417.
into the tissues.
Natural history Campbell J, Jones AS, Dieoemann J et al 2002 Intimate
*
bulL The most frequent sites affected include the
parmer violence and physical health consequences.
, r"'-'''' I c pouc~, pelvic side-walls and adnexa. Archives of Internal Medicine 162(10):1157-1163.
I' f'H."~ The-large bowel and bladder may also be involved, Pelvic inflammatory Early diagnosis and treatment can resolve the
problem. Where the disease has been present for
and endometrioric tissue has been found at distant Endometriosis Association of Victoria websitt: at
sites, including the lung (causing haemoptysis),
disease longer or there IS recurrent disease, the risk of http://ww\v.en dometriosis.org.au.
tubal damage Ulcreases.
and within abdominal scars. Common clinical presentation wngstreth GF, Drossman DA 2002 New developments tn
Impact and outcomes the diagnosis and treatment of irritable bowel
Signs and symptoms A 22-year-old woman is admitted to the syndrome. Current Gastroenterology Reports
emergency deportment with severe lower Tubal and pelvic organ damage can result in 4(5) :427-434.
The most frequent symptom is pelvic pain. This abdominal pain and greenish vaginal anatomical distortion and the development of
may presently acutely with an accident to an discharge. adheSIOns. The sequelae are an increased risk of Ross J 2001 Pelvic inflammatory disease: extracts from
endometriotic cyst on the ovary, but most com- 'clinical evidence' . British Medical Journal
ectopic pregnancy, infertility and chronic pelvic 322:658-659.
monly pr€sents as a chronic problem. Endo- pam. PID has high morbidity: about 20% of
metriosis may also present with dysmenorrhoea and affected women become infertile, 20% develop Ross J 2002 An update on pelvic inJlammatory disease.
dyspareunia. Epidemiology chroruc pelvic pain, and 10% of those who con- Sexually Transmitted Infections 78( 1):18-19.
Abdominal and pelvic e.,xarnllation reveal ren-
The exact incidence of PID is unknown because it ceive have an ectopic pregnancy.
derness in the pouch of Douglas, uterus and Simms I, Warbunon F, Westrom L 2003 Diagnosis of pelvic
cannot be diagnosed reliably from clinical symp- mflammatory disease: rime for a rethink. Sexually
adnexa. Rarely, this may be associated wirh the pal-
toms and signs. Direct visualisation of the fallopian Health maintenance Transmitted Infections 79(6);491-494.
pation of endometrioric nodules. Endometriosis tubes by laparoscopy is the best single diagnostic
may also be diagnosed during investigation for sub-test, but it is invasive and not used routinely in clin- Education about responsible sexual VaUe RF, Sciarra JJ 2003 Endometriosis: !Teaonent
activity and prevention of STls should strategies. Annals of the New York Academy of
fertility. ical practice. PID is most common in young women reduce the risk of acute pelvic
under 25 years of age following a sexually trans- Sciences 99 7:229-23 9.
inflammatory disease and Its
Naturo l history mitted infection. It may also present afrer vaginal sequelae.
This is variable and individual. Women may have douching or surgical inrervention, such as afrer a
endometriosis in mild or severe fonus that may be termination of pregnancy or insertion of an
asymptomatic or cause severe problems. The latter intrauterine contraceptive device (IUD).
may resolve with time, remain static or progress.
. (S Us:' hw.. t athoPhYSIOl09y Qu estions 2. Which of the following statements are
Im pact/outcomes \'/., U M ost cases seem to resulr from infection ascending true of ectopic pregnancies?
from the cervLx. Initial epithelial damage caused 1. Which statement Is incorrect?
This depends on the effect on the woman's quali- by bacteria (especially Chiarnydia trachomatis and a . Ninety-five per cent occur in the
ty of life and her needs. Management is directed Neisseria gonorrhoeae) allows the opporrunistic a. Chronic abdominal pain can be fallopian tube.
towards these needs - resolution of pain, entry of other organisms. In mild cases, these are caused by endometriosis. 0 PID is the most important tactor in
I decrease in menstrUal bleeding and the desire to the predominant pathogens; in severe or recurrent b. Chronic abdominal pain, by the aetiology.
I . ~l1ecome pregnant. Management options include disease, rhe aetiology is often polymicrobial, with definition, has been present for at c . Bleeding is usually the first symptom.
~(. Jurgery (most often by the laparoscope) to remove the primary pathogens being mixed _vith other least 6 weeks.
_ } the lesions and restore the anatomy to as near a conun.ensals and anaerobic genital flora. d. The diagnosis is ruled out by a
c. Chronic abdominal pain may be the negative pregnancy test. ~IJ\) '
normal state as possible. A complere pelvic clear- result of childhood sexual abuse.
ance (removal of the urerus, tubes and ovaries, and e . Va ginal Candida infection increases
other endometrioric deposits) is the last resort and Signs and symptoms d. Chronic abdominal pain can be due the risk of ectopic pregnancy.
to PID resulting from a previously
is not guaranteed to resolve all rhe problems in the The symproms and signs of PID may be minimal, undiagnosed chlamydial infection.
long term. Medical options (where pain is rhe pri- so a high index of suspicion is necessary, particu-
mary concern) are directed rowards the use of lady for chlamydial disease. In the acute situation, e. Twenty per cent of women with PID
analgesics, hormone stabilisation and oestrogen marked abdominal pain may be associated wirh a have difficulty conceivi ng .
( re~~~~;::1 : up prr ession.
r- fever, abdominal guarding and rebound render-
Iy ""\"~ 'V I \~ ,U'f-.fAc.~
..1
I~""IIEI .rvo l
~
~~o~
~~~I..A--'l .n~p
vv
f(C)~~lt~ ,,'-.(. - r; vv4 '1 f'l\ .
\eL1\-
_
\ \vJ.. '_ 4--CoC1:'0 \ l ~ '" wv'<'\NJ
0~ \\1'.
b v'-*
volu'
t Y\...Q
,.l.U .l( .
tl U. Cl- V'w'f
\",,\VV\c.oU'~'()
8"'''''Clo ~'f ",-, "\ (l.t:)""]- Cvv """'~ ~,\ I(. \:,ovV-. ~""~ ~"" )
Contraception
Beverley Vollenhoven and Gareth Weston
Edited by Beverley Vollenhoven
Learning objectives
Knowledge Skills
At the end of this chapter, the student At the end of this chapter, the studen t
will be able to: should learn how to:
Reversible contraception explain to a woman the efficacy,

benefits, risks and side effects of various
explain the methods of reporting forms of contraception
contraceptive efficacy
describe how e ach method of
describe the various methods of contraception works
reversible contracepti on In terms of
efficacy, benefits, risks and side effects counsel a woman about emergency
contraception
discuss the suitability of these methods
for women at different ages, women counsel a woman and her partner
with medical problems, women with about permanent contraception ,
multiple sexual partners and for
II breastfeeding mothers
Emergency contraception
Attitudes
evaluate the available types of
emergency contraception AI the end of this chapter, the student
• discuss the suitability of these methods
should reflect upon:
for women of different parity and sexual
behaviour the need to tailor contraception to the
individual
Irreversible contraception
the need for contraception in minors
• evaluate the types of irreversible and the mentally/physically
contraception challenged,
• list the likely reasons for requesting
reversal of sterilisation,
..if
5 Con traception
Women's health: a core cu rri culum
o There may be a slightly increased risk of breast

Facfs
A wide range of contraceptive options is available 1. Highly eNectlve contraception In motlvoted cancer, but only of localised disease, and this may • COCP does NOT cause weight gain.
women (annual failure rate 0.1%) be due to acceleration of the onset of existing
for couples. Different methods . may be used. by • Prolonged COCP use does NOT cause infertility.
couples at different stages of the1l" lives. Providing 2. Reduced risk of: cancers. Some studies show no increased risk. • 'Pill holidays' are NOT required to reduce risk of
• Iron-deficiency anaemia • EndometriosiS endometrial/uterine carcinoma.
information, education and advice for couples on
• Dysmenorrhoea • Fibroids Pill administration
all aspectS of contraception is an important role • Endometrial cancer Contraindicotions
• Menorrhagia • History of thromboembolism
for the health professional. • Functional/simple • Ovarian cancer The woman should be advised that she must take
There are twO methods of reporting contracep- • Bacterial 51ls • Suspected breast cancer
ovarian cysts seven active pills before the COCP will be effective • Smokers :>35 years old
tive efficacy: • Premenstrual syndrome (efficacy is immediate if she starts active pills on • Markedly impaired liver function tests/jaundice
1. The Pearl inde-x gives the number of failures day 1 of her cycle). This contraceptive method • Cerebrovascular/cardiovosculor disease
BOX 5,1 Benefits of the COCP may fail to be effective if a pill is missed by > 12 • Acuie/chronic/cholestallc liver disease
per 100 woman-years of exposure (usually
based on 1 year of exposure). hours (particularly if this increases the pill-free Relative contraindications
2. The life table analysis calculates a failure rate interval), if the woman has vomiting and/or diar- • Migraines
The following types of preparations are available: rhoea, or if there is a drug interaction. Drugs that • Uncontrolled hypertension
for each month of use, with comparison of con- • Epilepsy (need 50 ~g EE/day)
rraceptive methods by cumulative failure rates o low-dose (<50 ,t.g EE) or high-dose (;;<50 ft.g EE) may interfere with the COCP include antibiotics, • Sickle cell disease
for any specific length of exposure. monophasic (same daily dose of E and P) anti epileptic medications, antituberculous drugs • Active gallbladder disease
o biphasic (two-step P dose) and antifungals.
If there is risk of failure, an additional contra-
*Reversible contraceptive triphasic (two-step E dose, three-step P dose).
The mechanisms of action of COCPs are:
ceptive method should be used until seven active
pills have been taken after the risk ceased.
BOX 5.2 Facts abo u t lhe COCP and its
contralndications
methods o suppression of follicular selection and ovula- - or within 3 hours - every day); with obesi-
tion at h'·pothalamus/pituitary (E and P) Health maintenance
ty, there is an even greater risk of failure (2 pills
Common clinical presentation o endometrial atrophy, thickening of cervical Women on the combined oral a day should be taken) .
mucus, and reduced tubal motility (P). contraceptive pill should ovoid o Other potential problems include follicular
A 25-year-<lld woman requests 0 reversible
smoking to minimise the risk of venous CYStS (20%, usually asymptomatic) and an
method of contraception ond would like to The benefitS of COCPs are given in Box 5.1. thromboembolism.
know her options. increased risk of ectopic pregnancy (relative,
due to effect on tubal motility).
Side effects/risks
o There is an increased risk of venous throm- Progestogen-only p ill (POP) / Inje ctable progestogens
Combined oral co ntraceptive pill boembolism. The incidence is 3-4 in 10,000 minipill
women using the COCp, compared with 1 in Depo-Provera (depot medroxyprogesterone acetate,
(COCP) This is an oral pill with no oestrogen and a small DMPA) is a highly effective contraceptive, admin-
10000 women who don't use it. In pregnancy
This is a daily oral pill containing oesrrogen (E) - th~ risk of venous thromboembolism increases dose of progestogen (e.g. 30 ~g levonorgestrel, istered as a 3-monthly injection. It works in the
ethinyl oesrradiol (EE) - and a progestOgen (P). 30 times. There may be a greater risk with a 350 ft.g norethisterone). It actS by changing the same way as the COCP and is commonly used for
ProgestOgens used in COCPs include: COCP using a third-generation progestogen, nature of the cervical mucus and the endomet- women who have difficulty complying with an
o If the woman is over 35 years old and IS a rium, which prevents implantatio n; 40 % of OCp, or for women for whom oestrogen is con-
first generation: norethisterone and its deriva- smoker, there is also an increased risk of car- women on the POP continue to ovulate. traindicated:
tives diovascular disease (lower with third-genera- It is mainly indicated for women who are breasr- The main problems with this drug are the
o second generation: norgestrel group - levo- feeding because, unlike the COCp, it has no effect short- and long-term side effectS, as follows:
tion Pl·
norgesrrel, the most androgenic of the available o There is a dose-dependent increase in cere- on breast milk. It should also be used by women for
brovascular disease if EE ",50 mg/day. o irregular vaginal bleeding. Of the women using
progestOgens . whom oestrogen is contraindicated (e.g. past histo-
third generation: desogestrel, norgesnrnate and If the woman has wei !-controlled hypertension, this drug, 20% have prolonged regular or irreg-
o o ty of deep vein thrombosis - DVT).
gestOdene. These have beneficial effectS on the COCP is not contraindicated. ular bleeding episodes, 40% amenorrhoea and
lipids and reduced effects on carbohydrate For the woman with well-controlled diabetes 40% scant regular periods. This is the most
o
Si de 'effectsj p ro b Iems
mellirus, the COCP is not contraindicated, but common reason for ceasing the drug. This
metabolism
o fourth generation: cyproterone acetate, dros- some preparations may cause reduced glucose o There may be irregular vaginal bleeding (this irregularity can be treared by giving low· dose E.
tolerance. causes 20% of users to cease). o weight gain (6 kg after 4 years of use) due to
perinone. These are amiandrogens and benefit
The COCP may accelerate gallbladder disease. o The POP has an increased risk of pregnancy increased appetite
women with mild hirsutism and acne.
o The COCP may increase the risk of cervical compared with the COCP (shorter half-life of o delayed return to fertility - up to 1 year after
Drosperinone is also a mild diuretic, and min- cessation (20% of users)
cancer. 19 hours, and must be taken at the same time
imises bloating and breast tenderness.
81
ttl'
Women's health: a core c urriculu m
5 Contraception
• possible osteoporosis with long-term use (sup- that is more common in users of inert IUDs
plemental E may be required if use is long-term (less likely with Cu IUDs) : if it occurs, remove
or from a young age). the IUD and treat with penicillin G 500 mg qid
for a month.
• There is a 30% miscarriage risk if pregnancy
Health maintenance occurs. Remove IUD immediately.
Hormonal contraception has definite • The absolute risk of ectopic pregnancy is not
health benefits, especially reducing increased by IUDs, only the relative risk.
the Incidence of heavy painful
menses, endometriosis, and endo- Contraindications
metrial and ovarian cancer.
An IUD should not be used in the foUowing con-
ditions:
• risk of endocarditis
Implantable progestogens • surgery (contraindicated)
Implanon (desogestrel) is a single-rod implant and • copper allergy and Wilson's disease (if intend-
is effective for 3 vears. The indications are the ing to use copper IUD)
s~e as for DlItrPA. It is highly effective, with • immunosuppression (relative)
irregular bleeding as a major side effect. Fertiliry • pregnancy.
rerurns immediately upon removal and there is no
adverse effect on bone density. Post-insertion
Check strings in siru with a speculum examination
Intrauterine device (IUD) after the next period. The woman should check
the stri ngs after each period.
There are three types of intrauterine devices:
inert IUDs; e.g. Lippes loop (plastic), stainless Barrier methods
steel IUDs (mainly in China/SE Asia)
copper IUDs (CuT380A is effective for 10 These include both male and female condoms and
years and multiload Cu375 for 5 years) the diaphragm. Condoms have the added benefits
hormone-releasing IUDs (Mirena, with levo- of protecting from STls and pelvic inflammatory
disease (PID) and reducing the incidence of cervi-
norgestrel coating, lasts for 5 years) . Mirena
cal cancer.
IUDs are also an effe ctive treatment for menor-
rhagia (9 7% reduction of menstrual blood loss Diaphragms need to be properl y fitted over the
cervix to be effective. Insert up to 6 hours before
at 1 year).
intercourse, and remove at least 6 hours after-
wards. There is an increased risk of vaginal irrita-
Mechanism of action
tion and urinary tract infections. Spermicides
The sterile inflammatory response interferes with inactivate sperm in the vagina, work for up to
sperm motiliry and therefore prevents fertilisation. 8 hours and can protect against STIs (including
The IUD also prevents implantation. H1V), but can cause allergic reactions. Condoms
(male and female) protect from STls as well as
Side effects/problems providing a contraceptive effect, but can reduce
• Menorrhagia/dysmenorrhoea may occur (15%) sensit:iviry in intercourse.
with copper and inert IUDs. FIGURE 5 . 1 Common methods of contraception:
• There is a slightly incre ased but not long-term Natural family planning
: - mo~oPhasic oCP; B - triph asic OCP; C - POP (minipill); D - postcoi tal contraception '
risk of intrauterine infection after insertion Narural methods of contraception involve avoid- in - ma e condom; F - female condom; G - diaphragm; H - IUD s; I - Implanon rod and'
(IUDs are not protective like OCP'progesto- ing intercourse during the fertile parr of the men- sertlon trocar. (Pho to co urtesy Peter Fa rk os/Ro yal Darwin Hos pital)
gens or barrier methods). The)' are contraindi- strual cycle (i.e. peri ovulation) .
cated in women who are at ris!·: of bacterial The rhythm/calendar method entails absti-
endocarditis. Actinomycosis is an infection nence from intercourse for 1 week before and
5 Co ntraceptio n
Women 's health: a core curriculum
ovulation (i.e. subtract 14 days from the Transcervical sterilisation Kaunitz AM 1992 Oral contraceptives and gynaecological
1 week after ovulation (i.e. on days 8-21 of a cancer: .an update for the 1990s. American Journal of
expected date of the next menses and add 5). This technique aims to destroy the proximal Obstetncs and Gynecology 167:1171.
28-day cycle). It is only practical if the woman has The failure rate is 2-30/0. section of the fallOPian tube by inserting a spring Kovacs G 1994 Steroidal contraception 1995. Royal
regular cycles. The cervical mucuS method 4. Mifepristone (RU486) - not yet available in
hysteroscop lcaUy. It can be performed with IV Austrahan College of Obstetricians and Gynaecologists
involves abstaining from intercourse when cervical AuStralia: 10 mg is administered as a single sedanon/paracervical block. Other methods Contmumg Education, resource unit 114.
mucus is increased in volume, thin and clear (peri- dose. It can be used within 5 days, and is as llldude heat, chemicals, and plugs used to block Schwing! PJ, Guess HA 2000 Safety and effectiveness of
ovulatory change). The symptothermal method effective as POEC, but the onset of menstrUa- the tube hysteroscopically. vasectomy. Fertility and Sterility 73:923.
entails daily measurement of basal body tempera-
ture to detect the 0.3°C temperature rise that tion is delayed. Shearman RP 1995 Contraception and sterilization. In:
marks ovulation, together with observation of Further reading Whitfield CR (ed) Dewhurst's textbook of obstetrics &
mucus changes.
* Irreversible American Fertility Society Guideline for Practice 1994
Contraceptive choices.
gynaecology for postgraduates. Blackwell Science
Oxford, pp 568-579.
SperoH L, Darnel' P 1992 A clinical guide for
'
Health maintenance contraception Cheng L et .1 1999 Interventions for emergency contracepnon. Lippincott Williams & Wilkins
contracepoon. In: The Cochrane Database of Baltimore. '
Barrier contraceptive methods protect Systematic Reviews (The Cochrane Library 3). Online.
against sexually transmitted infection. Common clinical presentation Ava,lable : hrrp:llwww.update-sorware.comlcochr<lue Yusuf F, Siedlecky S 1999 Contraceptive use in AustralW.:
Consider investigation for STI in a eVidence fro m the 1995 National Health Survey
woman who requests emergency A couple with three children have decided that Glasier AF 2003 Ferrility control. In: Shaw RW Sourrer WP. Australian and New Zealand Journal of Obstetri'cs and
their family is complete, They would like advice Stanton SL (eds) Gynaecology, 3rd edn. Churchill ' Gynaecology 39:58.
contraception,
about methods of sterilisation. LlYIngstone, Edinburgh.
* E m erg~ncy
contracepti on
vasectomy
This is safe, cheap and has lower morbidity than Q uestions 4, Which of the following are forms of
female sterilisation. The failure rate is 1 in 2000 emergency contraception?
1. Which of the following is an absolute
if twO consecutive semen analyses 2-4 weeks a, EE 100 >lg with levonorgestrel 500 >lg
Common clinical presentation contraindication to the COCP?
apart and at least 8 weeks post-procedure show given 12 h apart ('\\.\..~(>-t.)
azoospermia. Early complications include haema- a. Simple migraine
• A 26-year-old woman hod unprotected b . 1,5 mg levonorgestrel .
intercourse 24 hours ago. She asks your advice
toma, infection, sperm granulo mas, epidi- b. Well-controlled hypertenSion
about the use of emergency contraception dymo o rchitis and congestive epididymitis c, Previous pulmonary embolus c . IUD '
(1-6% of men). There is no epidemiological evi- d, Past history of ChOleCystectom y /
and her opNons. d , MifeprlstonEj
dence of increased autoimmune disease, athero-
sclerosis, prostate cancer, impotence or testicu- e. Menorrhagia
e. All of the above
lar cancer after vasectomy. Rever al of vasectomy 2. Which is the most common side eHect
Methods has a 50% success rate if done within 10 years. of all P-only contraceptives? 5. Which of the following women may
There are four emergency contraception methods. a. Weight gain request reversal of a tubal ligation at a
later date?
1. Yuzpe method: 100 p.g EE and 0.5 mg levo- Tubal ligation (TL) b. Irregular bleeding
norgestrel are given 12 h apart with an anti- Tubal ligation is highly effective (1 in 200 lifetime c. Mood disturbance a . A woman in a stable relationship
emetic. The failure rate is 2-3% if given within failure rate) and involves blocking the fallopian d.Headaches b. A womon who had the procedure at
72 h. Nausea is a common side effect related
tubes by diathermy, clips, rings or transection (all e.Acne 40 years of age . - /
to E. can be pedormed laparoscopically as day proce-
2. Progestogen-only emergency contraception dures) . An increased risk of ectopic pregnancy is 3. Which of the following contraceptive
c A woman who had her last child ~
(POEC): twO doses of 0.75 mg lcvonorgestrel 5 years ago
are given 12 h apart. As there is no E, there is
less nausea/vomiting. This method is more suc-
cessful than Yuzpe (1.1% failure if given within
associated with TL using diathermy. Successful
reversal rates vary with the method of 11. used
(80% with clips); a request for reversal is more
methods does not give protection
against bacterial STls?
~I UDs
d. A woman who underwent the
procedure at the time of a
/
Likely if the woman is dO years old, single or in an b, COCP caesarean section
72 h) and better tolerated. It can also be given
unstable relationship, if TL is performed im-
as a single 1.5 mg dose with the same efficacy. mediately postpartum or at caesarean section, c. Depo-Provera e . A woman who had her last child
3. Copper IUD insertion prevents implantation if d. Condoms 3 years ago
inserted within 5 days of the most likely day of or after the death of a child.
w.,
.,
*6
Health education before and
during pregnancy
Lucy Bowyer and Ratnasari Padang
Edited b y Lucy Bowyer
Learning objectives
Kno wle dge Sk ills
At the end of this chapter, the student At the end of this chapter, the student
will be able to: should learn how to :
Counselling before pregnancy: general outline to a woman the requirements of

a normal, balanced d iet and how It
discuss the prevention of anaemia, should be modified in pregnancy
rubella infection and neural tube
defects in pregnancy counsel a woman about the prevention
of neural tube defects with folic acid
Identify women w ith lifesty le issues that supplementation
have an impact on pregnancy
counsel a woman about the risks of
identity preexisting medical conditions smoking in pregnancy and encourage
that have an impact on pregnancy or her to quit
may be affected by pregnancy explain to a patient the difference
• list appropriate pre-pregnancy between a screening and a diagnostic
investigations test
Women with genetic concerns • explain to a woman the principles of

screening for Down syndrome
indicate the prevalence, mode of
• counsel a woman who has a positive
inheritance and populations at risk for antenatal screen test for Down syndrome
Down syndrome , thalassaemia and
cystic fibrosis interpret a family pedigree with
conventional symbols.
• identify the underlying genetic or
biochemical abnormality leading to
each of these disorders
A ttitudes
• describe briefly the clinical
manifestations of each disorder At the end of this chapter, the stUdent
critically appraise the screening and should reflect upon:
diagnostic tests for Down syndrome
different cultural and personal belief
outtine the screening and diagnostic systems Influencing patient preferences
tests for thalassaemia and cystic fibrosis . in the uptake of prenatal screening .
w,
6 Health educ a ti on befo re a nd du ring
. pregna ncy
women's health: 0 core c u rriculum
* Counselling before
pregnancy
may also be conducted for infectious diseases that
can have an impact upon the progress of preg-
nancy, such as HIY, hepatitis B and C, and syphilis.
should
.th be. planned
Wl al
. and managed m· conJuncnon
. .
an mfecnous diseases consultant to reduce
vClth load and maximise the CD4 count (see
apter 10).
Diet Smoking, alcohol and
A well-balanced diet is particularly important in recreational drugs
A healthy 30-year-old woman is planning to pregnancy. There is some evidence that multivita-
conceive and requests advice about diet and min and mineral supplements may reduce fetal Smoking is harmful to the reproductive system
alcohol In pregnancy. abnormalities in pregnancy. In particular, the rou- and to the ferus. It can reduce fertility and there-
A 28-year-old woman with type 1 Insulln- tine supplementation of folic acid is recom- fore It may be harder to conceive. Smoking during
dependent diabetes mellitus Is considering mended, as discussed below. Soft cheese should pregnancy leads to an lilcreased risk of miscar-
pregnancy but has heard that diabetes poses be avoided in pregnancy due to the risk of Listeria ?age, pcieterm delivery, small-for-gestational-age
a higher risk of fetal abnormalities. infection from unpasteurised dairy products. ~s an an mcreased rate of antepartum haemor-
FIGURE 6.1 The felus affected by lumbo-sacral
Calcium requirements are higher in pregnancy, so m yelo-menlng ocele r ge and abrupnon. Posmatal smoking increases
• A concerned mother of one child who was
pregnant women should be advised to maintain a the risk of sudden infant death syndrome (SIDS).
very small at birth wishes to have another
regular intake of calcium-rich foods, such as dairy All smokers should be advised of the risks that
child. She smokes 20 cigarettes a day. second most common fetal abnormality after car-
productS, fish and tofu/soy productS. Coffee, tea> smoking carnes for their pregnancy - in particu-
• Having previously had a baby with spina and caffeine-containing drinks should be kept to a diac anomalies. The neural tube develo sand lar, the rISks of miscarriage and abruption - and
biflda, a 33-year-old mother would like to minimum throughout pregnancy because a h.igh begms to close during the fifth week of gesrfnon at should be encouraged to stop smoking with .
minimise the risk of recurrence. intake of caffeine has been linked with reduced a rune when some women mav not be aware t1~ey programs and support information. qwt
fertility and increased risk of miscarriage. are pregnant. Therefore It IS advised that folic acid f It IS possible that even moderate consumption
be taken before mtended conception. Women who o alcohol reduces fertility Uensen et al 1998).
fa~e never had an affected pregnancy should take a 1herefore, If there IS a delay in conceiving alcohol
General advice Iron-deficiency anaemia o c aCId dose of 500 /-lglday and women with re- s ould be avoided. Fetal alcohol syn~ome is
Although it used to be most unusual for the aver- Iron-deficiency anaemia is more common among vlously affected offspring should take 5 mg/dar: clearly assOCiated with excess alcohol intake but it
age healthy woman to ask for medical advice women with heavy mensrrualloss, vegetarians and IS unclear at what level alcohol causes feral dam-
before planning a pregnancy, nowadays many vegans. Pregnancy and lactation demand at least Vi ral screening age. It IS probably adVisable to limit alcohol intake
women will consult their general practitioner for a 1000 rug of iron per day. In addition to the physio-
Infection with both rubella (German measles) and to one or [WO uruts per week during pregnancy
check-up before trying to conceive. This is a great logical anaemia of pregnancy (caused ' by the
~arlcella (chickenpox) can cause fetal abnormali-
Cenam recreational drugs, particularly ~he
opporrunity to make sure that the woman is in haemodilution of a relatively greater increase in
~mphetarrunes and cocaine, are very harmful to
general good health and to give advice that \~~U plasma volume compared with red cell mass), a es m the first and second trimester of pregnancy.
~though most girls are vaccinated during child-
fi e developmg ferus. Organogenesis occurs in the
optimise healthy conception. Once the woman is woman who is iron-deficient at the start of preg-
pregnant, the time available for investigations and nancy is likely to feel tired and symptomatic ood or adolescence agaiIlSt rubella, they may not 6 rst 12 weeks of embryonic development crable
.1) and It IS dunng this time that the ferus is most
the consideration of options is limited. ~av ~ ~en exposed to varicella. A positive child-
through the pregnancy (Hercberg 2001) . iron
deficiency is generally easily treated by iron [to story of chickenpox is usually memorable. vulnerable to teratogens. However, after the first
3 months .of pregnancy, certain drugs, infections
History replacement (e.g. with a ferrous sulphate supple- . not, Immunoglobulin G (IgG) titres for both
VLrUses should be checked. Low-level · . and radianon can still be harmful to the develop-
There are certain factors that cannot be altered: ment) throughout pregnancy; the addition of vita- rub II . di unmuruty to
. e a may m cate the need for repeat vacu·na- ment
v' d of the U· ferus. Most area health servICes
. pro-
age, genetic background, race, social class, and min C helps the absorption of iron. Women who non I e counse mg to advise doctors or mothers
bl' and. a \' accme
. f or · .
chickenpox is now avail-
previous medical and obstetric history. Pre- are iron-deficient should be retested after replace- a e. Smce both viral diseases can have a profound about the potential effects of teratogenic agents.
conception counselling should always start with a ment therapy has begun to ensure that absorption
thorough medical histOry, including family and is adequate.
ar
eFe~ pon fetal development (not to mention the
High-risk pregnancies
c ml~l manlfestanons of adult chickenpox), it is
social background, and diseases. The histOry will seosl e to vaccmate vulnerable women before
direct the focus of further counselling. Folic acid and the prevention of Diabetes
pregnancy.
neural tube defects Women who are HN-positive carry a risk of uP Women with .type 1 (insulin-dependent) diabetes
Investigations to.30 01o (dependent upon the population) of trans :ve a higher mCldence of fetal abnormalities than
Folic acid supplements may halve the risk of neu-
Pre-pregnancy investigations should include a full mltnng the vu:
'Ii . al inf"
ecnon vertically to their ferus - e general population. Those who receive pre-
ral rube defects (NTDs) in the ferus, such as spina
blood count (FBC) as well as rubella and varicella bifida (Fig 6.1) and anencephaly (MRC Vitamin [datment With antiviral agents can significant!; cdonbcepnon counselling have a lower incidence of
immunoglobulin titres. The FBC may reveal iron- Srudy Research Group 1991). The incidence of re uce the
worn . nskd to around 2% . If an ruLITU ..
v-posmve la encore lated co mp 1·Icanons
. at all stages of
deficiency anaemia and other conditions such as NTDs is 1-2 per 1000 live births, making it the an mten s to get pregnant, the pregnancy pregnancy.
thalassaemia and sickle-cell anaemia. Screening
Wi
6 He a lth education b e fore and d u ring pregnancy
Women's heallh : a c ore curriculum
to conceive are advised co take 5 mg of folic acid Antenatal care not diagnostic for the abnormality (Newberger
Complete 2000). It 15 tmportant to provide both pre- and
Organ Differentiation daily. Around the world, many different models exist for
(weeks) formation (weeks) post-test counselling. A positive screemng test
the care of pre~ant women during pregnancy and generally mdicates that a diagnostic test should be
Spinal cord 3-4 20 other chroniC diseases and previous delivery.. It 15 Important that women be given dIscussed.
3 28 pregnancy problems appropnate adVICe at the beginning of pregnancy Diagnostic tests accurately identify fetuses with
Brain about a SUItable model of care for their individual
3 20-24 Pregnancy outcomes for women with renal, thy- abnormalities .. A .diagnostic test has a high speci-
Eyes needs. Women with high-risk medical or obstetric fiCity and senSIOVlty, but the invasive nature of the
4-5
roid and heart disease, hypertension and asthma backgrounds should be triaged to hospital care
Olfactory are significantly improved if they receive pre- test poses a ruk to the pregnancy. Thus diagnostic
apparatus WIth a consultant obstetrician and may need to be tests are not commonly offered as first-line tests to
3-4 24-28 conception counselling. seen m consultation with other specialists_ The
Auditory Outcomes for women with problems in previous the general population, but rather to those with
apparatus maJonty of women will have a low-risk pregnancy nsk factors such as advanced maternal age or bigh-
pregnancies, such as miscarriage, preterrn labour or and may choose lIlldwifery care, obstetric medical
5 24-28 nsk screenmg results. Prenatal diagnostic tests
Respiratory stillbirth, are discussed in Chapters 7, 11 and 13 . care,. or care shared by a general practitioner and
system mclude chonoruc villus sampling (CVS), anmio-
6 a lIlldWlfe or obstetrician_ Those who develop centeSIS, cordocentesis and ultrasound_
Heart Social issues problems during pregnancy, whether maternal or
3 24 fetal, should be. offered the appropriate care.
Gastrointestinal Women who are well supported in pregnancy by Down syndrome (trisomy 21)
system Many countries, mcluding Australia, offer success-
12 their partners, families or friends have a lower risk - Down syndrome is the most commonly recognised
Liver 3-4 ful homeblrth models to low-risk women .
of posmatal depression and anxiety. Because many chromosomal cause of mental disability, with a
Renal system
Genital system
Face
4-5
3-4
5
12
women in wealthy countries are unlikely co have
more than twO babies, they rely on information
from friends, family and professionals to cope
with a unique and unfamiliar experience. Isolated
* Women with
genetic conce rns
prevalence of 9.2 cases per 10,000 live births_
There IS a strong association between the inci-
dence of D O,""ll syndrome and advancing maternal
8 age (Table 6.2)_
Limbs 4-5 women, single mothers, teenage mothers and
TABLE 6.1 Differe n tiation of fG t al tissue (weeks those with a history of mental illness may require
from conception) (From Hanrettv 2000. p 16) additional professional support to deal with the A 40-year-old woman is pregnant and Maternal age at Incidence of Down
demands of pregnancy, particularly if they are concerned about the risk of having a child delivery (years) syndrome
The first trimester is the critical period of obliged to work in later pregnancy. Social support with Down syndrome.
organogenesis during pregnancy, but good diabet- ,is also vital through labour: studies have shown that 20 I in 1500
A consanguineous Lebanese couple book an
ic control is essential both pre-concepnon and women who are well supported by a parmer, fami- antenatal appointment. 25 I in 1350
throughout pregnancy to reduce the risk o f fetal ly member, friend or doula (labour support person)
A father-to-be has a brother with cystic "brosis 30 1 in 909
anomalY fetal macrosomia, growth restriction and have a lower incidence of caesarean section and
preter~' labour. Blood glucose levels of women perceive less pain in labour_
and wishes to know the risk of his child being 35 1 in 384
with diabetes should be controlled more strictly affectGd.
36 1 In 307
during pregnancy than at any other time in order
37 1 In 242
to reduce the incidence of fetal abnormahoes: fin-
38 1 In 189
gerprick blood sugar levels should ideally be kept Prenatal screening versus
between 4 and 8 mmoVL. These patients should be 39 1 in 146
diagnostic testing
managed in conjunction with a diabetes physician
40 1 In 112
and should have overall control monitored with Prenatal diagnosis is. the science of identifying
41 1 in 85
haemoglobin Ale (HbA1J levels_ structural and funcoonal abnormalities in the
developmg fetus. It offers an opportunity to influ- 42 1 in 65
Epilepsy ence the mCldence and severity of various genetic 43 1 in 49
Women ,vith epilepsy, particularly those caking diseases wlthm the community. For some women
44 1 in 37
anriconvulsants, have three times the risk of fetal and theu partners, prenatal diagnosis is nor
structural anomalies (Fig 6.2) compared to normal acceptable for personal or religious reasons, while 45 1 In 28
women. These women should be assessed before FIGUIlE 6.2 A unilateral cleft lip: such cronio-
for others It will be an integral part of the preg-
nancy. TABLE 6.2 InCidence o f Down sy ndrome by
conception to review and possibly change their facial defects are ossocloted with antlconvul- maternal age (Adapted from Cuc kle et 01
anticon,: ulsants to the least reratogenic regimen. sants. as '.'iell as neural tube and cardiac . Prenatal. screening rests identify a fetus ar 1987)
Because many anticonvulsants are folate antago- defects ,From Pitkin et 01 2003. P 6. Fig 2) Increased nsk of having an abnormality, bur are
nistS, women taking such medication and planning
Wi
6 He alth ed ucation b efore a nd during pregnancy
Women's health: a core cu rri culum
Counselli ng thalassaemia minor generally have clinically

Down syndrome is caused by the presence of insignificant microcytic anaemia.
Consultation with a genetic counsellor is advisable
an extra, partial or whole chromosome 21. The
before any prenatal diagnostic test. If diagnostic Carrie r sc reeni ng and
majority of cases (950/0) are conce1ved by non-
tesong reveals a fetal abnormaliry, the parents prenatal d ia g nos is
dysjunction of maternal chromosomes dunng
should be given assistance to address any concerns
meiosis, the minority by unbalanced translocaoon In the mother, thalassaemia is diagnosed by mean
and help them make a decision whether to termi-
or mosaicism. nate or continue the pregnancy. corpuscular haemoglobin concentration (MCHC)
Down syndrome is usually identified soon after and haemoglobin electrophoresis. Prenatal diagnosis
birth by a characteristic pattern of dysmorphic fea- mvolves DNA analys1s of fetal cells from either first-
tures, including a flat fac1al profile, hypotorua, Tha iassaemia trimester CVS or second-trimester amniocentesis.
slanted palpebral fissures and loose skin on the
back of the neck. It is associated Wlth a w1de spec- Thalassaemias are autosomal recessive inherited
trum of phenotypic marUfestations. Affected mdi- disorders characterised by a reduction in the syn- Cystic fibrosis (CF)
viduals have mild to severe mental retardaoon, thesis of globin chains (0 or ~; Table 6.3) . This
results in reduced haemoglobin synthesis and a CF is the most common potentially fatal cause of
with IQ scores ranging from 25 to 75. In the severe chronic lung disease in Caucasian young
absence of severe congenital heart dlsease, life hypochromic microcytic anaemia. Of the total
FIGURE 6.4 Image o f a mniocentesis needle Australian population, 1% are estimated to be car- adults. With an incidence of 1 in 2500 live births
expectancy of Down syndrome individuals 1S in Australia, the carrier frequency is 1 in 25 and
good, with over 50% living longer than 50 years, In situ riers of the thalassaemia trait. Alpha(o)-thalas-
saemia is most common among patients from transmission is autosomal recessive. The most
but morbidity is high. common gene mutation is 6F508, which is respon-
protein A, PAPP-A). Increased nuchal translucency China and Southeast Asia. Adults normally have
SIble for 75-88% of cystic fibrosis cases in north-
Prenatal scree ning te sts thickness low PAPP-A and high ~HCG serum level four copies of a globin genes. Absence of all four
ern-hemisphere populations.
are all ~ssociated with the fetus having an ct globin genes is lethal and results in hydrops
Abnormalities in the epithelial cell membrane
Although the risk of having a child with Down increased risk of DO\>.1l syndrome. The combina- fetalls. Beta(~)-thalassaem ia is the result of
syndrome increases considerably afrer the age of reduced or absent ~ globin chain synthesis. It is result in altered chloride transport and water flux
tion of NfS and serum markers detects over 80%
35 most babies with Down syndrome are born to most co mmon in patients from the Inruan subcon- across the cell. Viscous mucous secretions predis-
of Down syndrome cases (compared :mth 70% pose to glandular obstruction and tissue damage.
w;meo under 35 years of age, since more women detection rate if NTS is used alone), WIth a false - tinent and Mediterranean countries (Italian, Greek
under 35 have babies. Screening is performed dur- and Lebanese). Paoents With CF suffer from chronic lung disease,
positive rate of 5%. gastrojmcstinal and nunitional abnormalities and
ing the firSt and second trimesters. . The second trimester maternal serum (MSS) Children who inherit beta-thalassaemia major
The first trimester screerung IS performed are normal at birth, but at 6 months of age, when infertility. The median lifespan increased from
screening for Down syndrome is performed
berween the 11th and 14th weeks of gestation, Hb synthesis switches from Hb F to Hb A, they 1 year in 1950 to 31.1 years in 1996. The chief
berween 15 and 20 weeks' gestation, and measures
using a nuchal translucency scan (NTS; Fig 6.3\ develop severe transfusion-dependent anaemia. determinant of morbidi~ ' and mortality is the rate
serum alpha-fetoprotein (AFP), unconjugated oest-
of progression of lung diSease.
with or without biochemical screenmg of maternal rio~ 0 and ~ HCG. Down syndrome is associated Numerous clinical problems ensue, including
serum (~HCG and pregnancy associated plasma with high ()HCG and low levels of AFP and uncon- growth failure and bony deformities. The clinical Prena ta l diagnosi s
jugated oestrioL The test can detect 70% ~f affected course is modified by transfusion therapy, but
pregnancies with a false-posmve rate of 5 Vo. transfusional iron overload (haemosiderosis) often Population carrier screening is usually applied to
results. Death usually occurs berween 20 and 30 high-nsk populations by performing common
years from cardiac failure. Patients with beta- mutation DNA analysis. Newborns are screened as
Pren a t a l d iagnos is part of the Guthrie test, when the baby is 3 days
Definitive prenatal diagnosis of Down syndrome ~ globin Hb A Hb A, Hb F old. Those with a positive result are then referred
requires culture of fetallplacental cells and karyo- genes (%) (%) (% ) for diagnostic genetic testing. Prenatal diagnosis is
typing of fetal chromosomes. Karyotypmg IS rou- Normal 97-99 1-3 performed by D A analysis of fetal cells, usually
tinely offered to all women who are 35 years or obtamed by CV5 at 10-12 weeks' gestation. For
Thala ssaemia major ~o~o o 4-10 90-96
conclusive genetic testing, definitive knowledge of
older, and to those with risk factors such as a ~.~. 0- to 4- 10 90-96
known translocation. the type of both parental mutations is required.
Thala ssaemia minor ~~. 80-95 4-8 1-5
Amniocentesis (Fig 6.4) is usually performed 80- 95 4-8 1- 5
W Fa m ily ped ig ree
berween 15 and 18 weeks' gestation. The risk of ~o = absent ~ glpbin chain synthesis
miscarriage associated with amniocentesis is ~. = .educed synthesis A family pedigree summarises a complex family
approximately 1 in 200. CVS can be performed m Hb A = a,~,; Hb A, = a,5, history LOto a sunple and concise format (Mueller
the first trimester, usually around 11 weeks' gesta- Hb F (fetal Hb) = =1' & Young 1998). The construction of an accurate
FIGUR E 6.3 Ultrasaund Image af fetus tn
sagittal section, with nuchal translucenc y tion. The risk of miscarriage associated with CVS family pedigree is a fundamental component of
TAB LE 6 .3 Haemoglobin and beta·tholassoemio clinical genetic services and of human genetic
measu rement marKed by calipers . is approximately 1%.
'#
Women's health: a co re curric ulu m
6 Hea lth edu cation b efo re and d uring p reg nan cy
research. Table 6.4 summarises corrunon pedigree Health maintenance

symbols and definitions, and Figure 6.5 gives an Questions
example of a pedigree of a patient with cystic Folic acid supplementation is recom-
c. carries a risk of miscarriage
mended for all women considering
fibrosis. pregnancy. Ideally It should be com- Comp lete the follow in g statements with d. Is more accurate if combined with a
me nced 3 months before conception th e correct answer.
blood test /'
Symbols Definitions and continued for at least 3 months . 1. Folic acid:
e. detects thalassaemia . ../
Smo king Is harmful at all stages of
a . is advised as Soon as pregnancy is
0 .0. 0 pregnancy, and strategies should be
_,e,. Male. fema le. sex unknown
Affected individuals
employed to encourage smokers
to quit.
diagnosed
b . is adVised in a dose of 5 mg per da y
for all pregnant women
4 . Individuals with thalossaemla minor:
a. are at risk of having a fetus with
thalassaemia major
~~ Carriers c . reduces the Incidence of /
References anencephaly In pregnancy b . require constant b lood transfus ions
JZ10 Deceased individuals Cuckle HS, Wald NJ, Thompson SG 1987 incidence of
d . is not necessary for women with
through their lives
Down's syndrome. British Journal of Obsterrics and epilepsy c. have a chromosomal abnormality
58 Stillbirth (write below the symbol) Gynaecology 94:387-402.
e. helps women with diabetes have d . have more than 50% norma l adult ..,.
p Pregnancy (write Inside the symbol) Hanrctty KP 2003 Obsterrics illustrated, 6th eeln . Churchill better glucose control . haemoglobin
Livingstone, Edinburgh.
~.~. Proband: an affected Individual 2. Smoking : e . are at risk of an affected pregnan cy
coming to med ical attention Hercberg S, Preziosi P, Galan P 2001 Iron deficiency in if their partner does not carry the
Independent of other family Europe. Public Health -urritioo 4(2B):537-545. a . reduces the chance of conception gene.
m embers
Jensen TK, Hjolland NHI, Henriksen TB er al 1998 Does b . reduces the chance of miscarriage
5. Cystic fibros is:
~D~O Consultand: an individual
seeking genetiC counseling/testing
moderate alcohol consumption afieer fe rtiliry? Follow-
up srudy among couples planning first pregnancy.
c. redUces the chance of premature
blrfh a. is more common In people of
British Medical Journal 31 7:505-510.
d. increases the growth o f the fetus Mediterranean descent
~ Spontaneous abortion (SAB) (If
ectopic. write ECT below symbol) MRC Viramin Srudy Research Group 1991 Prevention of b IS more common in people from
neural rube defects: results of the Medical Research e. reduces the risk of SUdden Infant
.......
..
death syndrome. northern Europe /
Allected SAB (write gender below Council Vitamin Srudy. Lancer 338(8760):131-137 .
Mo le/f"emofe the symbol) c. occurs as a result of extra
M ueller RF. Young ID 1998 Emery's elements of medical 3 . Nuchal translucency ultrasound : chromosomes
L;A Termination of pregnancy (TOP) genetics, 10th edn. Churchill uvingstone, Edinb urgh. a . is a d iagnostic test
d. creates neurologic a l abnormalit ies
Affected TOP (write gender below Newberger DS 2000 Down syndrome: prenaraJ risk b . is m ore accurate tha n
Mole/ Female the symbol ) assessment and diagnosis. American Famil y Physician amniocentes is e. is usually diagnos ed in the fetus by
62 :825-832. a blood test.
TABLE 6.4 Common pedigree symbols and def-
initions (From Mueller & Young 1998) Pitkin J, Peattie AB, Magowan BA 2003 Obstetrics and
gynaecology - an illustrated colour teXr. Churchill
uvingsrone, Edinburgh.
FIGURE 6. 5 Pe d igree o f a p a tient with cystic

fibros is
-4
/
Antenatal care
Edited b y Sandra Carr
Lifestyle issues in pregnancy Penelope Black and William AW Walters

Antenatal care - first trimester Stephen O'Caliaghan
Ectopic pregnancy, miscarriage Lijliana Milkovic-Petkoyic and Thomas Tait
Antenatal care - second trimester Warwick Giles
Antenatal care - third trimester Andrew Bisils
1
Learning objectives
Knowledge • discuss the effect of ectopic pregnancy

on future fertility
At the end of this chapter, the student
w ill be able to: Mfs~ ge
• discuss lifestyle Issues in pregnancy define miscarriage and the types of

miscarriage
F~ trimester
indicate the prevalence of miscarriage
summarise early embryonic and
placental development list the common causes of miscarriage
• discuss the minor complications of early describe the Invesllgatlons for first-
pregnancy and their management trimester vaginal bleeding and oulline
management options
• describe the clinical and laboratory
diagnoses of pregnancy Se~d trimester
oulline the role of first-trimester outline the management of second-
ultrasound trimester minor complications
describe the antenatal screening tests describe the maternal and fetal
performed at the first antenatal visit screening tests performed in the second
list the models of antenatal care trimester
E, c pregnancy outline the clinical evaluation of the
pregnant woman at each antenatal visit
• discuss the epidemiology of ectopic
pregnancy Third trimester
• list the sites of ectopic pregnancy describe briefly the physiological
discuss the pathophysiology of tubal changes in the uterus before labour
damage in ectopic pregnancy outline the management of minor
discuss the investigations commonly complications of late pregnancy
utilised to diagnose ectopic pregnancy summarise the health education
• oulline the emergency treatment for Information to be given in preparation
ectopic pregnancy for birth, breastfeeding and parenting
(Continued over)
•
7 An te na ta l c are
Women's health : a core curricul um
unpaid leave, is usually of 12 months' duration. At to inferior vena caval occlusion. Contact sports
• perform and interpret a urinalysis the completion of maternity leave, the employee is and recreational activity with an increased risk of
(Learning objectives continued) entitled to resume employment at the same level of falling should be avoided. Exercise may contribute
• perform a clinical o~stetr!c examination
seniority within the organisation concerned. In the to the management of gestational diabetes by
of a woman in the third trimester.
• describe the principle of the birth private sector, maternity leave entitlement varies increasing glucose utilisation.
plan considerably and the o rganisation's human
Attitudes resources officer should be approached for Occupational work
list the signs of commencement of
At the end of this chapter, the student detailed information.
labour. Evidence suggests that physically demanding work
should reflect upon : Additional entitlements for many parents
and prolonged standing are associated with preterm
Skills include the maternity allowance, family payments
pregnancy and birth as a physiological
and the baby bonus payment. Parental leave may birth and reduced birth weight (Berkowitz &
At the end of this chapter, the student process Papiernik 1993). Shift and night work, and high
also be available for parents to enable them to care
should learn how to: • the role of the health professional to cumulative work fatigue scores may also be associ-
for a newborn or adopted child. Paternity leave
provide support and education (paid or unpaid) of 1 week may be available for ated with preterm birth. However, long working
perform a pregnancy test hours and preterm birth are not associated.
• the role of medical screening in fathers at about the time of the birth of their child.
explain to a woman the physiologic~1 . Exposure to toxic chemicals and radiation in the
antenatal care
basiS of minor pregnancy complications work environment is best avoided during pregnancy.
and suggest management options • the opportunity afforded by pregnancy Seatbelts
to encourage women to Improve It is a legal requirement that all motor vehicle driv-
use the correct technique to measure general health and lifestyle. Sexual activity
arterial blood pressure ers and passengers, including pregnant women,
wear seatbelts. During pregnancy, the lap belt Variable changes in sexual feelings are normal in
should be worn low under the enlarging abdomen pregnancy, ranging from a significant increase to a
and over both anterior and superior iliac spines decrease in desire. While sexual intercourse is not
and the symphysis pubis. If a shoulder harness is contraindicated at any time during normal preg-
used, the straps should be placed so that they pass nancy, it is best avoided when the membranes have
* lifestyl e issues in
pregnancy
Birth and parentin g education
Antenatal education programs are provided in mosr
centres for pregnant women and therr support
diagonally across the body between the breasts. It
is important to avoid placing the lap belt over the
anterior abdominal wall and the underlying
uterus, as should an accident occur, the forward
ruprured prematurely or when antepartum haem-
orrhage has occurred. In women with threatened
miscarriage, it may be wise to advise against sex-
ual intercourse for several days after symptoms
people in the second half of pregnancy. Programs for momenrum of the uterus against the seatbelt at the and signs have disappeared.
Common clinical presentation primigravid women usually consist of ~ 2-hour ses- time of impact may result in trauma to the uterus.
sions over 6 weeks. The aim is to proVide educanon In particular, placental abruption and fetal death Die t
A 23-year-<>ld woman in the loth week of her about pregnancy, labour, birth, breascieedin.g and
first pregnancy attends the antenatal clinic may occur. A small increase in energy requirements occJ.Jrs dur-
early parenting. The courses include strategies for
with her husband to ask whether she needs to encouraging suppornve farruly relanonships and ing pregnancy (71-120 kcal per day). The birth
. alter her lifestyle In preparation for the birth of Air travel weight of the baby is related to maternal nutrition.
promoting healthy lifestyle b.ehavlOurs for pregnant
the baby. women and their farrulies (Kitzman et al 1997). Provided the pregnancy is uncomplicated, there is During famine, the mean birth weight may fall by
no reason for restricting air travel unless the 550 g. Protein requirements increase in the final
Social and psychological support woman is at or beyond the expected date of deliv- 12 weeks of pregnancy, with 12 g nitrogen being
ery. However, individual airlines have their own required for the growth of maternal and fetal tissue.
Health education for While it is logical to expect that social sUjJPort dur- Additional folate, riboflavin and polyunsaturated
restrictions, which impose an upper limit (e.g.
optimal pregnancy ing pregnancy should be benefiClill, there IS very lit- 36 weeks' gestation) for international flights. fatty acids promote fetal wellbeing. A balanced diet
Pre-conception counselling and antenatal <:are pro- tle definite evidence to support this concept. It has Pregnant women should consult the airline before rich in fruit and vegetables and containing three
vide excellent opportUnities for lIDprovmg the not been shown to prevent preterm birth or low ved making arrangements to fly. serves of dairy products each day is ideal.
health of women before and during pregnancy. For birth weight but may be associated WIth lIDpro
example, controlled trials have demonstrated that fetal growth and reduced lilCldence of pregnancy- Exercise Weig ht
behavioural strategies to stop smoking durmg induced hypertension in a high-nsk pregnancy. In the absence of medical or obstetric com plica- The average weight gain in pregnancy is 10-14 kg.
pregnancy are successful (Dolan-Mullen et al
nons, 30 minutes of moderate exercise a day is rec- Low pre-pregnancy weight «50 kg) increases the
1994) and that pre- and peri-conceptional folic Maternity leave for employees
ommended for pregnant women. After the first risk of intrauterine growth restriction (IUGR),
a .d supplementation can prevent recurrence of Government organisations provide materni1
trimester, exercise in the supine position should be while excess weight gain during pregnancy is asso-
f~~ neural tube defecrs (Enkin et.al 2000). Such leave, part of which may be on full or: reduce avoided to prevent supine hypotension secondary ciated with large r infants. Obesity increases the
interventions can have a flow-~n etfect m lIDprov- salary. In Australia, the £ull enm1ement, lilcluding
ing the health of children and ,amllies.
Wi
7 Antenalal core
risk of complications, including gestational dia-

betes, hypertension, dystocia and thromboembolic
Opiates
Maternal withdrawal from opiates is associated
* Antenata l ca re
first trimester
Clinical and laboratory diagnOSis
Most women suspect pregnancy when their men-
with spontaneous abortion, hypoxia, passage of strual period is delayed. The expected date of
disease after caesarean secoon. Welght-reducmg
meconium, FDIU and hyperactivity of the new- delivery is calculated as 40 weeks from the first day
diets should not be commenced or continued dur- Common clinical presentations
born. Therefore, maternal stabilisation on of the last menstrual period. If the menstrual cycle is
ing pregnancy, and a dietician should manage
methadone should be encouraged in opiate users A healthy 20-year-old woman seeks advice megular, this date may be inaccurate, in which case
extremes of weight control. because she and her partner have been trying early ultrasound detennination of gestation is more
during pregnancy. ta have a child and it is now 7 weeks since her reliable (±S days). Common early symptoms of
Alcohol last menstrual period . History reveals that this pregnancy include fatigue, breast tenderness,
Alcohol is teratogenic, and ingestion of large Amphetamines waman has epilepsy and has been taking anti- nausea ('morning sickness') and frequency of
amounts of alcohol causes the fetal alcohol syn- Amphetamine use in pregnancy has been associ- epileptic medication for the last 5 years. unnaaon.
drome characterised by pre- and posmatal growth ated with IUGR and placental abruption. A 36-year-old woman Is concerned about the Diagnosis of pregnancy is possible with highly
restriction, dysmorphic facial features and mental chance of having a child with some form of reliable pregnancy test kits, for use by either the
retardation. Ingestion of smaller amounts of alco- Dental care congenital malformation , because at age 40 woman or the doctor. The kits use a monoclonal
hol (twO drinks per week) reduces adverse fetal Recent evidence suggests that periodontal disease her mother had borne a child with Down syn- antibody to detect the presence (or absence) of the
effects while five or more drinks per week in pregnancy may be a risk factor for preterm drome who died soon after birth. beta subunit of human chorionic gonadotrophin
throughout pregnancy appears to be the threshold delivery and low birth weight (Offenbacher et al ' (HCG) and may be positive a few days after the
for increased risk of fetal anomalies (Ouellette et al 1996). These complications can often be prevent- first mIssed menstrual period. Formal laboratory
1977). There is no known safe level of alcohol ed by nonsurgical procedures such as professional testing may also be used to test the level of serum
intake in pregnancy. Development of the embryo, HCG in a quantitative assay if necessary.
teeth cleaning to remove plaque and local irritants.
Precautions should be taken to avoid invasive fetus and placenta
Smoking dental procedures and reduce any risks associated
Minor symptoms/complications
The blastocyst forms at the 32 -cell stage after fer-
An increased frequency of low-birth-weight with the administration of medications or diag- tilisanon and consists of an inner cell mass - the VlItUally all women experience some minor com-
infants, prematurity and spontaneous abortion are nostic radiation. Maintenance of oral health in precursor of the embryo - and the trophectO- plications of pregnancy, and for some women
well-documented, dose-related complications of pregnancy is helped by a diet high in protein, cal- derm overlying the embryonic pole, wIDch these symptoms can be most distressing. An aver-
maternal smoking. Other associations include pla- cium, phosphorus and vitamins A, D and C. mteracts WIth the uterin e lining to facilitate age of 24 symptoms have been found to be ex-
cental abruption, fetal death in utero (FDIU), implantation 7-14 days after conception. The perienced by pregnant women, the most common
premature rupture of membranes and sudden Pets being urinary frequency, fatigue, pelvic pressure,
first 8 weeks is. the embryonic period, by wIDch
infant death syndrome (SIDS) (Brandt 1987). msomrua and lower backache (Zib et al 1999).
Pregnant women should be advised that domestic arne the begmmngs of all the essential structures
However, the incidence of congenital anomalies The most dlStressmg symptoms of the first
cats might have toxoplasma infection, wIDch can are present. The neural plate begins developing
is not increased with maternal smoking. trimester are usually nausea and vomiting wIDch
be transmitted to humans through contact With dunng the 3rd week and the heart begins beating
are related to increased HCG and proge;terone.
infected cat'S faeces. Toxoplasma may be transmit- about 21-22 days post-fertilisation. These struc-
Drugs These are more severe in multiple pregnancy.
ted to the fetus and can result in mental retard- tures grow and develop in their complexity during
Relief measures include frequent small meals,
ation, seizures and b.lindness, and in some cases the fetal penod, from the 9th week until birth
Marijuana foods low m fat, eating dry carbohydrates before
infant death. Other common pets do not pose any (Lipson 1994).
nsmg, and oral vitamin Bl . When nausea and vom- \v-ll
The use of marijuana may be associated with serious risks.
Placental growth and development involve
growth of. the cytotrophoblast (individual cells),
lUng are severe, it is known .as hyperemesis grav 0 ... 1",\\
IUGR, an increased risk of prematurity and darum and can lead to Slgnificant dehydration IT -.;f.'I\T¥"'",u,
not treated appropriately with rehydration and ~ ~Vt
With mvaSlOn of the maternal spiral arteries to
delayed mental development in the newborn.
mcrease the maternal blood supply to the placenta
and branch 109 of the villous structure of the pla-
annemenc drugs such as metocloprarnide. The \0"
Cocaine ~rmCJples of management for all minor com plica- ~
centa to maximise the surface area for nons of pregnancy are to exclude more serious
Cocaine use has been linked to maternal medical maternal-fetal exchange at the terminal villi. underlying pathology, reassure the woman and
complications including stroke, seizures, acute . With the advent of modern molecular genetics, provide supportive therapy.
myocardial infarction and arrhythmias. Cocaine SQenasts are beginning to elucidate the mecha-
has also been implicated in IUGR, premarunty, OlSrns mvolved in the development of early fetal
spontaneous abortion and placental abruption.
Routine blood and
anatomy. JUSt how does a fetus know where to
Furthennore, prenatal exposure to cocaine is as- grow its eyes? Which is the head end of the body?
other investigations
sociated with necrotising enteroco.litis and abnor- ~ch IS nght and left? These are intriguing ques- At the first antenatal visit, a thorough medical,
mal behavioural development in the newborn nons (Sharpe 1999). famlly, obstetrlc, gynaecological and social history
(Cunningham et al 1997).
Wi
7 Antenatal ca re
Women's health : a c ore cu rr ic u lum
is taken and physical examination performed. The

Diagnostic tests
Chorionic villus sampling at 10--13 weeks involves
* Ectopic pregnancy Consequently, . risk factors include sexually
transrmtted mfectlOns, pnor ectopic pregnancy,
prIor tubal surgery, hormonal factors such as
principle of care is to identify a baseline so as to
monitor the impact the pregnancy may have on raking a transvaginal or transabdominal SamPle, diethylstilbestrol exposure and progestogens, con-
maternal wellbeing. It must be remembered that under ultrasound guidance, of chonomc villi for A 26-year-old woman presents with amenor- rraceptlve faLlures . (e.g. intrauterine devices),
genetic testing to identify chromosomal abnormal- rhoea and pelvic poln. mcreasmg age and cigarette smoking. Proliferation
the majority of pregnant women are healthy. The
ities and some hereditary conditions. Amniocentesis A young woman presents with bleeding In
of refluxed endometrial tissue arrested within a
purpose of antenatal care is to promote health and
is most commonly performed in the second early pregnancy. tube could provide the epithelial characteristics of
manage complications. Blood tests that are rou-
trimester and is described under second-trimester a uterine environment, and this is the pathophysio-
tinely ordered include full blood count (FBC), A pelvic ultrasound scan is performed at
care in this chapter. logical explanation involving endometriosis
blood group (ABO and Rhesus), red. blood cell 6 weeks' gestation and no Intrauterine gesta- (Hunter 2002). There is also an increased risk with
antibody screen and serology for syphihs, hepaDtls tion sac is seen.
Models of antenatal care assisted reproduction techniques (NF). .
B (and, for women at risk, hepatitis C), human Extensive investigation has been conducted at
and education A 35-year-old woman uncertain ot her last nor-
immunodeficiency virus (HIV) and rubella. If the cellular level to study decidualisation and
mal menstrual period complains of severe
these tests identify a problem, they enable treat- Women in Australia are able to choose different abdominal pain and collapses. Implantation in ectopic pregnancy (Lemus 2000).
ment to be given to improve outcome. For ex- models of care for their pregnancy and birth: home
ample, if red blood cell antibodies are detected in birth with a midwife or doctor, birth centre Diagnosis
the mother's blood during pregnancy, further attached to a hospital, shared care with family .
practitioner at a public or private hospital, team Ectopic pregnancy is frequently misdiagnosed at
investigation and appropriate treatment can
reduce the effects of Rhesus isoimmunisation. midwifery care or private obstetric consultant care. Epidemiology the mmal visit. At present, we rarely see patients
The role of the health professional is to present the who present m shock because of ruptured ectopic
A sterile mid-stream urine (MSU) sample is also Ectopic pregnancy remains a major health concern
options and discuss with the woman and her part- pregnancy. The main symptoms are delayed per-
collected and sent for culture and sensitivity, as for women of reproductive age and a common
ner those that best suit her individual needs. IOd, abnormal bleeding or pelvic pain, initially uni-
asymptomatic urinary tract infection is more cOm- cause of pregnancy-related deaths. In developed
lateral but It may become more generalised.
mon in pregnancy and may lead to pye\onephritls counm es, the mCldence of ectopic pregnancy has
Individual needs On examination, the patient should be assessed
if untreated. increased six-fold over the last 20 years, although
for signs .of shock, such as pallor, tachycardia and
Australia is a comple.x, multifaceted society. There ill recent years there is some evidence of reduction .
hypotenSIOn. O n abdominal examination there
might be unilateral or generalised guar~g and
are groups of women within our society who, for a The incidence of ectopic pregnancy in the general
First-trimester ultra sound variety of reasons, will reqwre speaal conslderanon populanon IS 1 m 200; in a high-risk population it
pentorusm. On vaginal. examination, there may be
Fetal imaging with ultrasound in the first trimester when they present for antenatal care. They may be can be as high as 1 m 30. With IVF, there is a risk
bleedmg, a closed ce rvIX, a small uterus for gesta-
is performed to establish gestational age, to illves- indigenous or from a non-English-speaking back- of ectopic pregnancy in 5% of pregnant cycles and
nonal age, an adnexal mass (with or without ten-
tigate vaginal bleeding or to screen for Down syn- ground. They may be very young, depressed, vic- of heterotopIc pregnancy (co-existing intrauterine
derness) and cervical excitation.
drome. High-resolution ultrasound, parucularly tims of domestic violence or soaally disadvantaged. and ectopic pregnancies) in up to 3% of pregnant
Currently, transvaginal ultrasound scan (TVS)
with a high-frequency transvaginal imaging probe, The history taken at the first antenatal visit should cycles (Lemus 2000).
and senal j3HCG determinations remain the two
is able to date the pregnancy accurately (±5 days) identify any factors that need consideration when most important diagnostic tools. The absell ce of an
and identify the presence of a fetal heartbeat from providing care for the individual woman so as to Sites mtrauterine gestation sac on TVS when ~HC G is
6-7 weeks amenorrhoea. This demonstrates a live enhance her care and her e."'qJerience of pregnancy. The fallopian tube is the most common site for above 1500 IU/mL is strongly associated with
fetus, whether the pregnancy is intrauterine or ectopic pregnancy (97%): 810/0 ampulla, 12% in ectopic pregnancy.
ectopic, and shows whether the pregnancy is sin- the lSthmuS, 5% fimbrial end, 2% interstitial seg- Clinical findings are associated with a higher
gleton or multiple. ment (cornual). Other sites include the ovary, probabIlity of ectopic pregnancy, even when
Early presentation for antenatal care
Ultrasound can also be used routinely as a cervL"<, broad ligament and peritoneal cavity. j3HCG and TVS are below algorithm threshold. In
allows accurate establishment of
screening test for chromosomal abnormality such gestational age, baseline health
these situations, findings of free fluid in the pouch
as Down syndrome (trisomy 21) by measuring assessment and timely lifestyle Pathophysiology of tubal damage of Douglas (POD) and adnexal mass on TVS are
fetal nuchal translucency, ideally together with modifications to optimise maternal useful. A f)HCG rise of at least 60% over 48 hours
Ectopic pregnancy is believed to be due to
first-trimester biochemical assay of the two hor- and fetal outcome. and progesterone values over 25 nglmL are pre-
endothelial tubal damage secondary to salpingitis,
mones: free j3HCG and pregnancy associated dictors of VIable pregnancy, but do not determine
disturbed mbal oocyte transport or proliferation of
plasma protein A (pArP-A). Such a test has an the site of pregnancy.
refluxed endometrial tissue arrested within the fal-
85-90% detection rate for trisomy 21 (and also lopian tube. History of salpingitis often cannot be
for some of the other major chromosomal disor-
Emergency trea tme nt
obtalned, . but deciliatlon is frequently found or
ders) and can be used as a population-screening there IS histologic evidence of previous salpingitis W hen a patient has haemorrhagic shock, she must
test for women who have been counselled and (Speroff et al 1999, Guyton & '-fall 2000). be operated on as soon as possible by the most
choose to have this test (Spencer et al 2003).
i:'
7 Anlenatal core
Women's health: a core c urriculu m
Suspected ectopiC pregnancy
Patient haemodynamically unstable
Deteriorating clinical Signs/unstable -
~HCG levels
failing/patient stable .
FIGURE 7.1 Unruptured tubal p regnancy (Reproduced wi th permission from observe
Belscher et 011997, P 172. plate 5)
shorter hospital stay, lower analgesic requirements

expedient method. Open laparotomy is often and quicker postoperative recovery compared
preferable, after securing IV access and blood for with laparotomy. Laparoscopic salpingectomy or
blood group, crossmatch, FBC and ~HCG, even salpingostomy can be performed. There is no dif-
before blood and fluid have been replaced. ference in the intrauterine pregnancy (IUP) rate
following these twO procedures if the contralater-
Management and implications al tube is healthy. Failure to completely remove
A:; diagnosis becomes possible at increasingly trophoblast and recurrent ectopic pregnancy is
earlier gestation, it is possible to observe the higher after salpingostomy (RCOG 2002).
ectopic pregnancy when indicated and await natu- In selected cases - e.g. asymptomatic patient, FIGURE 7. 2 Management of suspected e c topiC p regnancy
ral resolution. The success rate of expectant man- no free fluid in POD and small tubal ectopic on
agement is up to 700/0 in selected cases with low TVS, and low (lHCG - it is possible to give
~HCG, no haemoperitoneum and a tubal mass methotrexate, an antimetabolite that prevents the
growth of rapidly dividing cells by interfering with complex.. With the aid of methotrexate, a more Fertility outcomes
less than 2 cm. Rupture of ectopic pregnancy can
DNA synthesis. It can be administered systemic- conservanve approach has recently evolved. Other
still happen and expectant management has a poor If infertility has not been a problem, the rate of
ally or by local injection under TVS or laparo- forms of therapy for cervical pregnancy include
efficacy. Follow-up requires measurement of IUP followmg an ectopic is 85%, with 7.5% recur-
scopic guidance and has a 7+-84 0.0 success rate
(lHCG until it disappears, which might take up to emb.ohsation, Foley catheter tamponade and rence and 7.5% infertility. Future fertility is unre-
(Buster & Heard 2000, Sowter et al 2001). These
50 days. Operation is indicated as soon as there is SUction curettage (Tulandi & Sarnmour 2000). All lated to size of ectopiC, haemoperitoneum or tubal
patients require (lHCG follow-up.
deterioration in clinical symptoms/signs. Non-tubal ectopiC pregnancies are rare, and non-senslOsed Rh-negative women should receive ruptur,e. It is significantly affected by the presence
Today's surgical approach is by laparoscopy. standardisation in diagnosis and management is 250 IU (50 !-!g) of anti-D IgG. of penadnexal adhesions.
Laparoscopy is associated with less blood loss,
7 Antenata l ca re
Women's heolth: a c ore curriculum
On vaginal examination, the internal os of the Expectant management may be a solution for
embryo/placenta to develop normally. This is fol- WOmen in the first trimester. In a randomised con-
The patient should be involved in the selection cervix is open and often products of conception
lowed by haemorrhage into the decidua basalis, trolled trial, up to 80% of patients were managed
of the most appropriate treatment. She should be are present in the canal.
which causes necrotic changes at the site of pla- Septic miscarriage presents with fever, bleeding expectantly,. but they needed regular follow-up,
reviewed in a follow-up clinic and have appropri- centation. At the same time, there is a fall in
ate counselling regarding future fertility. Support and srgruficant tenderness in the lower abdomen and some soli needed surgrcal evacuanon. Medical
oestrogen and progesterone concentrations, caus- and uterus. evacuation is an accepted alternative using miso-
for the grieving process related to pregnancy loss ing decidual sloughing. All these changes result in
should be provided if necessary. . in complete miscarriage, products of concep- prostol (RCOG 2003).
vaginal bleeding and uterine irritability, leading to oon are passed and on pelvic examination the Women with recurrent miscarriages should be
uterine contractions and expulsion of the products cervix is closed. An ultrasound scan reveals an referred to specialised recurrent pregnancy loss
* Miscarriage
of conception.
As many as 50-60% of embryos miscarried in
the first trimester will have a chromosomal abnor-
maliry. Autosomal trisomies are the most common,
empty uterine cavity.
Missed or delayed miscarriage is often diag-
nosed when a first-trimester ultrasound scan
chrucs. Low-dose aspirin, heparin and supportive
~e are cornerstones of management. Cervical
illcompetence can cause miscarriage of a fetus in
the second trimester. Often spontaneous rupture
Common clinical presentations reveals an absence of fetal heartbeat. Clinically, the
involving chromosomes 13, 16, 18, 21 and 22 in woman loses the symptoms of pregnancy. On of the membranes occurs, leading to fetal loss.
A pregnant woman presents with unexpected 50-60% of cases, and with karyotype 45XO pres- Trauma to the cervix is the most significant risk
bleeding at 8 weeks' gestation .
exammaoon, the uterus is smaller than eXJlected
ent in 70/0 of cases. The prevalence of major chro- for length of amenorrhoea and the cervix is closed. factor. Diagnosis can be made if an ultrasound
A pelvic ultrasound scan in early pregnancy mosomal abnormalities in the general population For most women, the diagnosis will be clear shows a characteristic appearance of 'funnelling'
reveals no fetal pole within the gestation is 3% but in a parent with twO or more miscar- following history, examination, urine pregnancy and shortening of cervical length.
sac. riages it is up to six times higher. test and TVS. For some, it will be difficult to dis- Treatment usually consistS of the insertion of a
Other caUSes of miscarriage include factors such cervical suture, with bed rest and close observation
Fetal heart activity cannot be demonstrated on tinguish between ectopic pregnancy and early mis-
a transvaginal ultrasound scan performed at as age (paternal as well as maternal), uterine abnor- for signs of infection. Transabdominal cervico-
carnage, so quantitative estimation of serum
malities such as bicornuate/subseptate uterus, and an ISthmiC cerclage is sometimes indicated in the
an estimated 8 weeks' gestation. ~HCG is required in cases occurring early in the
incompetent cervix. Thrombophilias, antiphospbo- management of previous recurrent second-
first trimester. trlIDester loss and preterm delivery. Occasionally, a
lipid syndrome, immunological conditions (e.g. sys-
temic lupus erythematosus) and other diseases (e.g. woman may be managed conservatively with strict
Definition and epidemiology Ma nagement bed rest.
diabetes mellitus and coeliac disease) are also associ-
. Early pregnancy loss will evoke a range of emo-
in Australia, a miscarriage is defined as the eXJlul- ated with miscarriage (Rosevear 2002, Kutteh 2001, Early pregnancy assessment units provide care by a
oons ill different women and can significantly
sion of the products of conception before Salit et al 2002). Infections (e.g. toxoplasmosis, ure- suppomve, multidisciplinary team and have been
affect them and their families. Women need to be
20 weeks' gestation. This defiuition may vary in aplasma urealyticum, Chlamydia, cytomegalovirus, found to improve the quality of outpatient care informed of the available support and foll ow-up.
different countries. Miscarriage is now the pre- herpes simplex) and environmental toxins, such as (Nardo et al 2002). N on-sensitised Rh-negative Often the ome of presentation is not the appropri-
ferred terminology to abortion, which is reserved cigarette smoke, high-dose radiation and cytotoxic women reqwre 250 IU (5 0 ~tg) of anti-D IgG ate nme to counsel but the woman must be man-
for therapeutic termination of pregnancy. drugs, have also been implicated. wlthin 72 hours. If a live ferus is seen on ultrasound aged with empathy and reassured as far as possible.
Spontaneous miscarriage occurs in 1O-20°;\) of scan and the cervLx is closed, the woman is reassured After one rruscarnage, the risk of another is the
all clinical pregnancies, and perhaps as many as DiagnOSis and follow-up is organised. Patients with complete same as for the general population. After two mis-
60% of conceptions are lost. This equates to only nnscamage may need ~HCG follow-up. carnages, the risk is 25% and after three, 30%.
The classic clinical presenration is with lower
a 25% chance of successful pregnancy per ovula- Surgrcal evacuation of the uterus with suction
abdominal pain and per vaginam (PV) bleeding.
tion in fertile couples. The incidence of miscar- curettage was standard treaanent until recendv. This
With threatened miscarriage, the typical his-
riage for women aged 35-40 is 21 % and for option may be preferred for patients wh; have
women over 40 is 41 %. Eighty per cent of miscar- tory is one of vaginal spotting with minimal pelviC
?eavy bleeding or who wish to avoid the inconven-
riages are diagnosed between 8 and 12 weeks' ges- or lower back pain. On vaginal examination, the Ience of not knowing when a miscarriage will take
tation. Missed or delayed miscarriage is the failure cervix is closed. An ultrasound scan reveals a live place. Senous complications include perforation,
to expel the productS of conception after death of intrauterine fetus. cervical tears, mtra-abdo minal trauma, haemorrhage
the embryo. Recurrent miscarriage refers to three Inevitable miscarriage is characterised by lower
and mtrauterille adhesions. All at-risk women
consecutive pregnancy losses before 20 weeks of abdominal pain and vaginal bleeding. On vaginal undergoing surgical uterine evaluation should be
gestation. This affectS 1 in 200 couples, or 1 in examination, the lower uterus appears to be bal- screened for Chlamydia trachomatis.
500 pregnancies (Speroff et al 1999). looning, while the internal os is closed. ProductS of
Tissue obtained at the time of miscarriage
conception have not been passed. should be exammed histologically to confirm
Aetiology and pathophysiology Incomplete miscarriage presents with a history
productS of conception and to exclude ectopic
of increasing bleeding, cramping lower abdorrunal
Most spontaneous miscarriages result from the pain and passage of some products of conception. pregnancy and gestational trophoblastic disease.
death of the embryo or the failure of the
':5
7 Ante nata l c are
Women's health: a core c urri c ulu m
* Anten atal care -

second trimester
• Blood pressure Is checked. Normal blood pressure
Is accepted as <140/90 mmHg using the phose V
Korotkon sounds (disapperance of sounds) (Brown
a b
et 012000). ---'t-- _
• The woman is asked it the baby is moving regulorl y
Common clinical presentations and otten. She is asked to report sudden changes
' ..
in the fetal achlty. In the third trimester, she will tee I ---·::·h:·· .. ·
A woman at 26 weeks' gestahon In her first
the baby roll over and kick several times a day. ~ "'"
'y
pregnancy Is referred to the antenatal clinic by
her general practitioner for apparent slowing • symphysis-fundal height (SFH) Is measured (gener-
ally, fundal height In cm ±3 = weekS of gestation).
of fetal growth .
Fetal size, lie, presentation and descent.of the pre-
A 37-year-old woman at 16 weeks' gestation senting port ore assessed . Fetal growth IS evaluated
asks if her age poses any risk to her by comparison with previous SFH measurements.
The fetal heart rate is checked with a Pinard stetho-
pregnancy.
scope or Doppler ultrasound . FIGURE 7.3 (a) Progressive Incre ase of fundal height . (b) The lie a f the baby. Th is refers to the
A 22-year-old woman at 24 weeks' gestation • Urine is tested tor proteinuria to screen for Infection relationship of the long a xis ot the fetus to the u t erus: longitudinal is n ormal (Based o n Hanretty
presents to the antenatal clinic with a history of and preeclampsia. 2003. pp 59, 75)
a previous intrauterine death . • Information about pregnancy and motherhood Is
provided, and the woman 's ability to cope With the performed between 15 and 20 weeks will give a mal glucose tolerance then undergo a full 2-hour
A pregnant woman who has a long-term
transition and her need tor social support IS ,
history of essential hypertension presents to the 70% pick-up rate for Down syndrome, with a 5% formal glucose tolerance assessment.
assessed .
antenatal clinic at 25 weeks' gestation. false-positive rate. If the calculated risk is greater Most women will be offered an ultrasound at
BOX 7.1 Procedure at each antenatal v isit
than 1 in 250, the woman sho uld be referred for around 18 weeks' gestation to check the anato my
genetic counselling and amniocentesis to assess of the ferus and the number of feruse s, and to con-
fetal karyotype. firm the gestational age of the fetus. After 20
Follow-up antenatal care Amniocentesis is the removal of a sample of weeks, ultrasound is unreliable in confirming ges-
Antenatal care in the second trimester is based on amniotic fluid under ultrasound guidance. It is usu- tational age of the pregnancy. Ultrasound is also
monitoring maternal health and feral wellbemg, ally performed between 14 and 18 weeks. It is used to assess fetal wellbeing if there is any evi-
and providing education and support to the 1. Inspection - abdominal contour, operation offered to any woman at increased risk of chromo- dence of delayed fetal growth or other indicators
woman and her parmer. Care also alms to prevent, scars, striae, pigmentation, tetal movements somal abnormality, e. g. over 35 years of age. This of maternal/fctal compromise (see Chapter 8).
identify and manage any obstetnc and/or medical 2. Palpation procedure carries a 0.5-1 % risk of miscarriage. In some centres, women will have a FBC at
problems that arise, including SOClOeconomlC and • Fundal height. The uterus is first palpable at . In the mid-second trimester many women are 28 weeks. In Rh-negative wowen., an antibody
around 12 weeks' gestation, reaching the umbili- screened for gestational diabetes using an oral 50 g screen should be performed at 28-30 weeks and
psychological issues. . cus at 20 weeks. Thereafter SFH rises by 3-4 cm
In the second trimester of pregnancy, until glucose load with measurement of the blood glu- they should receive 650 IV of anti-D IgG at 28 and
In each 4-week period.
28 weeks ' gestation, a woman will have regular cose concentration at 1 hour. Women with abnor- 34 weeks if no anti-D has been detected.
• Fetal lie. Using both hands to gently compre~
monthly antenatal check-ups with her pregnancy the abdomen longitudinally, determine the lie o f
carer. Randomised controlled tnals m developed the long axis of the fetus in the uterus.
countries have shown that a decrease m antena.tal • Presentation. Using ooth hands, determine the
visit frequency is not associated with any neganve presenNng fetal part and assess descent Into the
maternal and perinatal outcomes. However, some pelviS. The one-hand Pawlic's grip is more
women feel less satisfied and their expectanons of uncomfortable for the woman.
care are not fulfilled (Villar et al 2003).. .. • Auscultation. Usten to the fetal heart over the
A comprehensive history taken at the first VISit area of the fetal shoulder. This area is deter-
mined by Identltying the posit1on of the fetal
will alert the carer to any problems. At each sub- back and limbs. The back Is telt as a smooth,
sequent visit, the woman is asked about her gen- firm elevation . Fetal limbs are felt by gilding the
eral wellbeing and fetal acnvlty. hands over the surface of the abdomen, seek-
ing the mobile Irregularit1es. The fetal heart Is
heard directly using a Pinard stethoscope or
Screening/investigations Indirectly using Doppler ultrasound. The normal
If no first-trimester nuchal fold translucency risk fetal Mort rate is 110-150 bpm.
assessment for Down syndrome has been conduct- FIGURE 7.4 A bdomi nal palpation (Based on Hanretty 2003, p 76)
ed, the woman should be offered maternal serum BOX 7.2 ObstetriC abdominal examination
screening (for ~HCG, AFP and oestriol), which if
'*
1 Ante n atal care
Women's health : a co re curricul'Jm
• Nausea and vomiting (usually resolving by early In

the second trimester, but may con~ nue) .
* Antenatal care
third trimester
The enlarging uterus can produce the following
symptoms:
• gastro-oesophageal renux due to reloxatlon of the
Physiology
Further breast enlargement occurs during the third
trimester and colostrum production commences.
• Con~ p~on due to Increased progesterone sphincter. The woman should be advised to eot
(smooth muscle relaxes in gastrointesMal tract). frequent, small meals, to ovoid caffeine ond spicy
The uterus contracts irregularly throughout preg-
Relief measures Include Increasing Huld and ~bre food and to toke antacids If severe nancy, but in the third trimester it contracts more
intake, exercise. mild laxatives or stool softeners. Common clinical presentations • Increasing difficulty w~h breathing due to enlarge- frequently in preparation for the labour.
• Varicosities due to progesterone-mediated smooth • A 25-year-old woman at 34 weeks' gestation In ment or the uterus. This can be especially evident Contractions commence as painless tightenings
muscle relaxation of the veins, Increased blood vo~ her first pregnancy wishes to discuss how she
at night. Sleeping in a supported lateral position but become more painful closer to the onset of
ume, stasis ond Increased pelvic pressure. Relief con help labour. The cervix undergoes a process of ripen-
measures include frequent posl~on changes, ele- will manage pain during labour and birth .
• oedema ond potenHol median nerve compres- ing. This involves breakdown of collagen so that
vation of legs , exercise , avoid ing lengthy periods of A 3D-year-old woman at 32 weeks' gestation In sion, leading to cor pol tunnel syndrome . Lower
standing, and support stockings . with the pressure of the amniotic sac and the pre-
her second pregnancy wishes to talk about limb oedema Is reloted to water retentlon ,
• Headaches, often worse In those women who have increased blood volu me and prolonged standing. senting parr, the cervix assumes a more anterior
having her baby naturally this time, as the
a pre-pregnancy history of migraine. Consider Reller measures Include wearing support hose and position in the vagina, becomes shorter (effaces)
previous birth was by elective caesarean
anaemia, hypoglycaemia. Relief measures Include regular exercise. Median nerve compression In the and dilates. As a result of this, women will notice
rest, hydr~on, simple analgesia and cold packs. section because the baby was very small. carpal tunnel by oedema may require physiother- an increasing amount of discharge or the loss of a
apy rererral and wrist splints
A 37-year-old woman at 41 weeks' gestation In discrete mucous plug.
BOX 7 .3 Minor complications o f pregnancy In the her firsl pregnancy presents to Ihe cliniC. She Is .. • supine hypotension due to aortocovol compres- The precise trigger for rhe onset of labour is
now 7 days beyond her expected dale of sion
second trlmester nor known but the following are important events
• postural hypotension due to obstructed venous
delivery.
return from the lower limbs
leading up to it. Oesrrogen promotes the develop-
menr of gap junctions between myometrial cells,
• urinary frequency due to pressure on the bladder.
Education • loin pain secondary to varying degrees of ureteric
thus facilitatin coordinated contractions in
The second trimester of pregnancy is often a time obstruction labour. estrogen r motes t e pro uction
when the woman is feeling well. :Morning sickness The third trimester of pregnancy is a time of • back and pelvic pain from the descent of the
of prostaglandins from the membranes. Another
has passed and she starts to fee l the baby move increasing anticipation about the. birth of the baby. feta l head and fhe relax oMan of pelvic ligaments. placental hormone, corticotrophin-releasing hor-
and experience the growth. of . the uterus, but It is important that those carmg for pregnant ReUef measures Include sleeping In the lateral mone (CRH), is produced in increasing amounts.
without the later physicallimltanons of the heavy women allow adequate space and time for. the position, massage, heat pocks and peM c rock The action of progesterone is removed, possibly
woman and her partner to voice all their quesoons exerc ise. through a change in receptor subtypes. Fetal mat-
gravid uterus. It is during the second mmester
that the woman co=ences parent educauon in preparation fo r birch. The principles of man- uration also seems to contribute to the onset of
BOX 7.4 Minor complications of pregnancy In the labour (Challis 2001).
classes. She is usually starting to explore what It agement remain to: third trimester
will be like to be a new mother. She may relate
stories she has been told by family and friends • monitor the progress of pregnancy . Preparation for birth
about birth and parenting. This can be a frighten- • provide advice, reassurance and educanon about
ing as well as joyous time. Each woman's expen- pregnancy, labour and planning for a parennng trauma. Pelvic fl oor exercises antenarallv are All women will have many questions about the
ence will be unique. Her background, culture and role, including factors influencmg the overall believed to reduce longer-term problems with anal signs of labour, the length of labour, what con-
social supportS strongly influence how she per- health and wellbeing of women and thelf families incontine nce, stress incuntinence and geni ral tractions feel like, pain llJanagement options, who
• identify women ar risk of maternal and fetal prolapse (Tindall 1991). There is also greater will care fo r them, or otller1toncems about labour
ceives her parenting role.
complications during pregnancy . emphasis on assessment of antenatal depression or based on their own pa~t experiences or those of
• manage any obstetric and/or medical problems posmatal depression. others. Every woman f.;hould be encouraged and
arising during pregnancy, mcluding soaoeco- supported to explore fhe changes occurring in her
nomic and psychological factors. Investigations body and her life during pregnancy, and to prepare
In the third trimester, antenatal visits will be for birth and parenthood. A birch plan facilirates
formightly from 28 to 36 weeks, and ~en weekly Many health centres will perform an FBC at the documenration of how the woman would Like
to 41 weeks. At each visit, the woman will have the 28 weeks' gestation and an antibody screen at her labour and birth care to be conducted. Writing
systematic assessment outlined in Box 7.1. Blood 36 weeks if the woman is Rh negative. There is these thoughts encourages her to think about her
pressure is of greater slgruficance m the third no good evidence to supporr the use of a routine expectations and makes them explicit for the mid-
trimester because this IS when preeclampSia IS third-trimester ultrasound scan, which should wives and doctors caring for her. A birth plan is
most lik~ly to occur (Brown & Whirworth19 99). be done only if fe tal growth problems are sus- usually written at around 36-37 weeks. It may
The focus of education moves to preparaoon for pected fr om the history or examination (Larsen document simple requests such as her preference
labour. One area receiving increasing attention IS et al 1992, US Preventative Services Task Force for analgesia or the presence of support persons,
the prevention and management of major perineal 1996). or it may make exp licit her wishes about medical
lit
7 An tenatal care
pregnancy loss - management. Online. Available: years prospe 've experience_ BJOG: an international
Enkin M, Keirsc MJNC, Neilson J et al 2000 A guide to
intervention, Once documented, this plan can be http://www.rcog. org. ukJguidelines. journal of obst ' d .ecology 110(3):281-286.
effective care in pregnancy and childbirth, 3rd edn.
discussed with the doctors and midwives cating Chapter 6, Dietary modification in pregnancy. Oxford
Rosevear S 2002 Handbook of gynaecology management. Speroff L, Glass R, Kase N 1999 Clinical gynecology,
for her. University Press, Oxford, pp 38-39. Blackwell Science, Oxford. endocrmology and infertility, 6th edn. Lippincotr,
A woman should be advised to stay at home until Williams & Wilkins, Baltimore,
Farquhar C, Jamieson M 1997 IntrOduction to obstetrics
the contractions ate regulat and becoming more fre- and gynaecology. Department of Obstettics and
Salir G, Younis J, Hoffman R er al 2002 Trombophilia is
quent, for example once every 7-10 minutes, She common in women with idiop~thic pregnancy loss and Tindall V 1991 Gynaecology - illustrated textbook.
Gynaecology, Univorsiry of Auckland/National Gower, London.
should contact her health service when the mem- is associated with late pregnancy wastage. Fertility and
Women's Hospital, Auckland.
Sterility 77(2):342-347.
branes ruprure, or if she is bleeding, experiencing Tulandi T, Sarnmour A 2000 Evidence-based management
reduced fetal movements or is feeling distressed. Haorerty KP 2003 Obstetrics illustrated, 6th edn. of ectopiC pregnancy. Current Opinjon in Obstetrics
Sharpe PT 1999 Homeobox genes and determination of
Churchill Livingstooe, Edinburgh. and Gynecology 12:289-292.
embtyonic body plan. 10; Rodeck C, Whitrle M (cds)
Hunter RH 2002 Tubal ectopic pregnancy: a patho- Fetal medicine - basic science and clinical practice.
US Preventative Services Task Fotce 1996. Guidelines for
physiological explanation involving endometriosis Churchill Livingstone, London. clinical prevention.
(review). Human Reproduction 17(7): 1688-1691.
Antenatal education prepares the Sowter M, Farquar C, Petrie K 2001 A randomised trial Villar J, Carta Ii G, Khan-Neelofur D et al 2003 Panerns of
couple for childbirth, breastfeeding Kitzman H, Olds DL, Henderson CR Jr et al1997 Effect comparing single dose systemic methotrexate and routine antenatal care for low-risk pregnancy. 10: The
and parenting . of prenatal and infancy borne visitation by nurses on laparoscopic surgery for the treatment of unruprurcd Cochrane Database of Systematic Reviews (The
pregnancy outcomes, childhood injuries, and repeated tubal pregnancy. British Journal of Obstetrics and Cochrane Library). Online. Available:
childbearing: a randomised clinical trial. Journal of the Gynaecology 108:192-203. http: //,,".\"W. update-sofrware.comlcochrane.
American Medical Associatioo 278;644-652.
Spencer K, Spencer CE, Power M, Dawson C, Nicolaides Zib M, Lim 1., Walters WAW 1999 Symptoms during
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and the newborn; an illustrated textbook, 3rd edn. 11:435-439. biochemistry in a one~stop clinic: a review of three Gynaecololgy 39(4):401-410.
WB Saunders, Sydney. Larsen T, Larsen JF et al 1992. Detection of small-for-
Berkowitz GS, Papieroik E 1993 Epidemiology of pretenn gestational-age fetuses by ultrasound screening in a
high-risk population ; a randomised conrrolled srudy.
birth. Epidemiologic Review. 15:414-443.
British Journal of Obstetrics aod Gynaecology
Brandt EN 1987 Smoking and «productive health. 99(6):469-474.
PSG Publishing, Littleton (MA).
QuestIon s b. Hepatitis B serology
Lemus J 2000 Ectopic pregnancy: an update . Current
Opinion in Obstetrics and Gynecology 12:369-375. c . HIV serology
Brown MAo Whitworth JA 1999 Management of 1. Which of the following statements Is
hypertension in pregnancy. Clinical and Experimental correct? d. Thyroid function tests (TFTs)
Lipson T 1994 From conception to birth - our most
Hypertension 21:907-916.
important journey. Millennium Books, Sydney. a . Behavioural strategies to stop e. Rubella serology '/
Brown MA, Hague WM, Higgins J et al 2000 smoking during pregnancy are
Nardo L, Rai R, Backos M etal 2002 High serum
The detection, investigation and management of
luteinizing hormone and testosterone concentrations
unsuccessful. 3. Which of the following statements is true?
hypertension in pregnancy: full consensus statement
do not predict pregnancy outcome in w omen with b. Social support during pregnancy a . All fetuses with Down syndrome look
(Australasian Society for the Study of Hypertension in
Pregnancy). Australian and New Zealand Journal of recurrent miscarriage. Ferrility and Srerility prevents preterm labour. abnormal on a scan at 18 weeks'
Obstetrics and Gynaecology 40(2);139-155. 77(2):348-351. gestation.
c . Air travel during pregnancy is
Offenbacher S, KatZ V, Ferrik G et al 1996 Periodontal contraindicated after 28 weeks' b. All cases of spina bifida will have an
Buster J, H eard M 2000 Current issues in medical
infection as a possible risk factor for preteon low birth gestation. elevated maternal serum alpho-
management of ectopic pregnancy. Current Opinion in
weight. Journal of Periodontology 67:1103-1113.
Obstetrics and Gynecology 12:525-527. fetoprotein (MSAFP) blood test result .
d . Government organisations provide /
Challis JRG 2001 Characteristics of parturition. 10; 'Creasy Ouellette E.M, Rosen HL, Rosman NP, Weiner L 1977 12 months' maternity leave. c. Most cases of Down syndrome are
Adverse effectS on offspring of maternal alcohol abuse detectable by first-trimester /
and Resnick, Maternal fetal medicine - principles and e. Treatment of periodontal disease
during pregnancy. New England Journal of Medicine
practice. WB Saunders, Philadel phia. shOUld be delayed until after screening with nuchal translucency
297:528-530. ultrasound.
Cunningham FG, MacDonald PC, Gant NF et al 1997 parturition.
RCOG (Royal Conege of Obstetricians and Gynaecologists, d. A scan at 18 weeks should be done
Wtlliams' obstetriCS, 20th edn. Appleton & Lange,
UK) 2002 Clinical green top guidelines: tubal Which of the following blood tests is
Stamford, Connecticut, pp 959-960. only on women who are at high risk
pregnancies - management. Online. Available:
not routinely performed at the first of fetal malformations.
Dolan-Mullen P, Ramirez G, Groff JY 1994 Obstetrics: a http://Www.rcog.org.ukJguidelines.
antenatal visit for all women?
meta-analysis of randomised trials of prenatal smoking e. Amniocentesis can detect the vast
RCOG (Royal College of Obstetricians and Gynaecologists, a. Full bload count
cessation interventions. American] ournal of Obstetrics majority of fetal malformations.
UK) 2003 Clinical green top guidelines: early
and Gynecology 171: 1328-1334.
'*
•
Women's health : a co re curricu lum
7 Anten atal care
4, Which is the most like ly diagnosis in a

woman with a quantitative flHCG of
a , Ser ia l measurement of maternal
weight is essential in assessing fetal
~hlCh of the following substances is
~;;~;ot associated w [fh the onset of c . Oestrogen
3000 IU/mL, an empty uterus on wellbeing , parturition? d . Gamma-amlnobutyric acid
transvaginal ultrasound scan and light
b . Psychosocial issues have little a. Corticotrophin-releasing hormone e , Oxytocin
vaginal bleeding? bearing on the provision and
a, A live intrauterine fetus outcome of management In the b , Prostaglandin
second trimester of pregnancy.
b, An incomplete miscarriage
c, Antenatal care in the second /
c , A pseUdo-pregnancy
d , An ectopic pregnancy
trimester aims to identity and
manage any obstetric or medical 1\+ D\I\...u..k- o~ ~ :
problems that develop during this
e, A delayed (missed) miscarriage ti me. ~ -e.J-t"nI 'Y"" fo.. 'l ~ roJ-f,.?
d . Ul trasound aHer 20 weeks is very
5, A 40-year-old woman who has had a
tubal ligation presents with a posit ive
pregnancy test and 7 weeks '
reliable In the calculation of the
gestational age of the fetus , CD rY\'l4~~~
amenorrhoea , Which of the following e, A maternal blood pressure of
statements is correct? 150/95 mmHg is normal.
~ Ce.k
a , This is a folse-positive test and the 8, With respect to screening tests in the
patient should be reassured, second trimester, which of the
b, The woman should have a following statements [s correct?
transvaginal ultrasound scan and a , Measurement of the symphysis-
quantitative BHCG,
c , The woman should be advised to
terminate the pregnancy,
/ fundal height is not a screening test.
b , Screening for gestational diabetes Is
not carried out In the second
d, The woman should be advised to trimester.
return in 2 w eeks for a repeat test c. An Rh-nega tive woman in whom no
and evaluation , anti-D was detected in the first
e , The woman is probably extremely trimester does not need to be tested / '
for anti-D at 28 weeks ,
pleased to be pregnant.
d , Materna[ serum screening may be
6, Which of the following statements oHered to assess the risk of Down
about spontaneous miscarriage Is syndrome .
true? e , Umbll[ca[ artery Doppler evaluation
a , It is commonly due to an inherited is a useful screening tool for
chromosomal abnormality, intrauterine growth restriction.
b . It occurs aHer fetal viability, I. e . Wh ich of the following is an essential

24 weeks' gestation. and routine port of the assessment
c. There is decreased risk if the woman during an antenatal visit in the third
is ove r 40 years of age , trimester of pregnancy?
d , It is most commonly due to sporadic a , Dipstick testing of urine

chromosomal abnorma lity. b. Weight measurement ../
e, It is frequently recurrent, c. Blood pressure measurement
7, Which of the following statements d . Che ck ing the amount of oedema in

about antenatal care In the second the lower limbs
trimester is correct? e, Assessment of amniotic fluid volume
WI
J
The fetus
Martha Finn
Learning objectives
Knowledge • critique the view that one can ha ve a
perfect baby every time
At the end of this chapter, the student outline the merits of a day-assessment
will be able to: service versus hospital admission
Fetal growth expla in the rele vance of ·t he cerebral
palsy statement.
discuss the importance of accurately
dating a pregnancy
describe the physiology of amniotic
flu id and the causes ot reduced or Skills
excessive fluid volume
At the end o f this chapter, the student
• list the causes of a small-for-dates and a should learn how t o :
large-far-dates tetus
list th e maternal and fetal causes of establish gestational age using
In trauterine growth restriction menstrual and ultrasound data
evaluate th e ro les o f palpation and ta ke a n antenatal histo ry a nd p erform
ultrasound in Identifying the small-fo r- an antenatal exami nation with
dates fetus particular reference to reco rd ing and
interpreting symphys is-fundal height
discuss the perinatal mortality and measurements
mo rbidi ty associated with intrauterine
growth ,estrlctlon listen to the fetal heart using a Pinard
stethoscope or handheld Doppler
discuss the importance of timing and
location of delivery explain to a woman the significance of
evaluate the Impact of intrauterine a fetus that appears small for dates .
growth restriction on the newborn, th e
child and later adult years
• describe the risks associated with
accelerated fetal growth Attitudes
Assessment of fetal wellbeing
At the end of this chapter, the stUdent
indicate the rates of stillbirth, cerebral should reflect upon :
palsy and b irth anomalies
• summarise fetal adaptations to acute the value of prenatal education and a
and chronic hypoxia healthy IifeSfyle in pregnancy
• c riticall y appraise the methods tor • the Impact of intense fetal monitoring
assessment of fetal wellbeing in n ormal on the wellbeing of the pregnant
and complicated pregnancies woman and her fam ily.
8 Th e fe tus
women 's health: a c o re curricu lu m
re~fncy such as anticonvulsants, warfarin,
*
below her gestational age in weeks. The liquor vol-
indicates the median and normal range of gesta-
. eta- . ockers and angIotensin-conve rting enzyme ume was normal throughout and the fetal umbili-
tion in weeks. This method may suggest a small
Fetal growth fetuS but it cannot differentiate between the phys-
mhibltors. Other
. al' f causes of fetal growth resrncnon
.. cal artery reSistance was also normal. The mother
sueh as Vlr m ections (e.g. rubella and cyromegalo- had a spontaneous onset of labour and deLivered a
i.I"i..i.i,i;ii,ii4.il.i@g,it#!j[.j,~. iologically and pathologically small fetus. Plotting
serial SFH measurements on a graph gives the vhlrusl)d bas well as chromosomal abnormalities healthy 2600 g baby at term. There were no
A pregnant woman at 36 weeks' gestation has s ou e conSidered. neonatal complications.
health professional and mother a better under-
a symphysis-fundal height of 32 em. Is this The finding of morphological abnormalities on The abdominal circumference is the single
standing of the growth of the baby (Fig S.l) .
baby small for gestational age and what are ultr.asound mcreases the suspicion of fetal aneu- most mformative meas urement of fetal size
An ultrasound examination will confirm if the
Ihe Implications for the mother and baby? baby is indeed small or large for gestational age:
plOldy. A sonographically normal fetus with earl - r~flecnng the size of the liver and its glycogen sup~
onset second -tnmester fetal growth resrnctlon . Y p y. An eval uanon of the ratio between the head
A pregnant woman at 32 weeks' gestation has physical variables of head circumference, abdomi-
may, h owever, have a 25% risk of aneuploidy. mcurnference and ,abdominal circumference may
a symphysis-fundal height of 36 em. What are nal circumference and femur length are plotted on
the standard 3rd to 97th (or 10th to 90th) per- The Rattern of fetal owth cannot be inferred mdlcate a relanve head sparing' effect, which is
the differential diagnoses?
from a sm . e measurement 0 e SIZe. owever due to preferennal cardiac output to the brain .
the growth-restricted fetus (asymmetric growt~
centile chartS. These measurements represent the
an. ev uanon 0 et we eing may help distin~
fetal size and thus one snapshot in time.
gmsh
all between
wth the healthy fetus and the poten- ~~tncnon). How:e~er, this feature may be absent if
An important objective of antenatal care is to mon- a y gro . -restricted fetus. Valuable information growrh-Impamng msult to the ferus occurs at
itor fetal growth and thus identify the fetus that is
The small-for-dates fetus may be gamed from assessment of liquor volume an earher gestanon when the fetus is incapable of
not realising its full growth potential (intrauterine When the pregnancy is judged clinically small for - the blOphyslcal profile score (BPS), 1elil cardio~ mounnng such a compensatory response (symmet-
growth restriction) or the fetus that is exceeding its gestational age, a search should be made for rocorsp11,Y and fetal um6mcal artery - reSlStanCe tiC growth restriction).
growth potential (accelerated fetal growth). Both physiological and pathophysiological causes. The (see sessment 0] fetal wellbeing).
conditions are associated with significant maternal mother's physique and ethnic background may Fetal growth may be observed only by serial Management of the
and fetal morbidity and mortality. suggest that a small baby may be of appropriate m::surements of fetal size at intervals of at least growth-restricted fetus
size for her. Pathological factors associated with ~eaIilikS. Anormal growth rate may be obseryc d in
Establishment of gestational age fetal growth restriction include smoking, hyper- y smaJJ; average and large letu~. In the While clinical practice places emphasis on the
tension, diabetes mellitus, autoimmune disorders pregnancy shown In figure S.2, the mo ther was s~all fetus, it is important to realise that any ferus
Acrurate establishment of gestational age is crucial and recurrent antepartUm haemorrhage. Growth
CaucaSian, 160 em tall and weighed 57 k wether of small, average or even above-avera ~
SymphYSIS-fundal height was consistently 4 c~ Size, may demonstrate a decline in growth (gro~
to identification of the small- or large-for-dates restriction has also been associated with alcohol,
fetus. The gestational age is calculated from the cocaine, opioid abuse and medications used during
first day of the last menstrual period. Menstrual
2
cycle length and recent oral contraceptive use
influence the reliability of this date. If the ultra- 50 0
I
sound estimation of gestational age, based on 38
I
crown-rump length in the first trimester or bipari-
45
90th cen11le 6
I ~
etal diameter at 20 weeks' gestation, is within 5 or

10 days respectively of the menstrual dates, the E 40
B
50Ih eenflle
loth cen~le
13
~
4
~
~
~
V
correct interpretation is that the ultrasound sup- E 35
g 32
7
.
~
portS the menstrual dates. Otherwise an amended B' ~ 30

1/ V - -3_
expected date of delivery may be calculated based
~
30 E /' ....,.V - - SO'Ue
C ~ 28 J .. - .. - ~'-
/' .cr
on the ultrasound date. " 25
c:
.
~ 26 o Fetus
1
';;; E
c
24
V /'
Screening for abnormal ~ 20 o /' /'
Q. ~ 22
fetal growth E < / V V
?; 15 20
/ /'
The uterine fundus is first palpable at 12 weeks' 18
10 /'
gestation, reaching the umbilicus at 20 weeks and
16
the xiphisternum at 36 weeks. Determination of
fetal size and growth by this method is, however, o 16 20 24 28 32 36 40 44 14
24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
prone to inaccuracy, owing to the variation in Weeks
Weeks
maternal bodily habitus. FIGURE 8.1 Assessment of fetal growth bY
M easurement of the distance between the serial SF H measurements (FrOm Llewellyn -Jones FIGURE 8 . 2 Normal a
JOW t h of a physiologica lly small fetus
uterine fundus and the symphysis pubis (sym- 1999, p 46 , Fig 6.16)
physis-fundal height, SFH) in centimetres (:t3 cm)
w;
-,I
Women's health : a c o re curriculum
8 Th e fe tu .
restriction) if exposed to an unfavourable Asian nulliparous woman with an SFH measure-

intrauterine environment. In the pregnancy shown ment of 29 cm at 32 weeks' gestation. Ultrasound 2
in Figure 8.3, ultrasound monitoring of growth confirmed a small baby. The liquor volume was ~
was commenced because of a bad obstetric history reduced (amniotic fluid index, AFI, 6 em) and the 8
with fetal demise at 35 weeks' gestation, due umbilical arrery resistance was high (>97th per- 36
~
to abruptio placentae. Clinically the subsequent centile). The mother was admitted to hospital and
baby appeared to be growing appropriately. An given steroids to promote fetal lung maturity. 134 ~
~
ultrasound examination at 34 weeks, however, Twice-weekly amniotic fluid measurements were g 32 V-

demonstrated no fetal growth in 4 weeks. On hos- low-normal (AFI 8 cm). Doppler measurements j 30
pital admission a day later, severe bradycardia were unchanged. Daily cardiotocograph record- E
V :,...-
~
--,.....
---"""""
~ 28
occurred, necessitating delivery by emergency ings were normal. Two weeks later, however, there ..
~ 26
./ V - ,~
caesarean section and neonatal resuscitation. The was no demonstrable growth, oligohydramnios V- ./ o Fews
~ 24
baby spent a week in neonatal intensive care but and absent end-diastolic flow on Doppler assess- o :,...-
.
/
:ll22 ./
subsequently did well. ment. The mother showed evidence of severe /
/' ./
If one snapshot in time shows the fetus to be preeclampsia. A caesarean section was performed. 20
truly small for dates but the fetus is surrounded by The baby weighed 1600 g, was hypogiycaemic at 18
V
normal amniotic fluid, is active, morphologically birth but required minimal oxygen supplement- .. 16
~
r-
normal, and has normal umbilical arrery resist- ation, fed well and rapidly gained weight. 14 I
ance, the mother may be reassured that the fetus A decision to deliver a growth-restricted fetus
~a~VD~~~RDM~38~3838~~U
appears healthy. A repeat ultrasound to assess must balance the risks of prematurity and con-
Weeks
growth may be performed a minimum of 2 weeks tinued fetal compromise in utero. While severe
later. The liquor volume may be evaluated more JUGR poses a significant risk for the fetus, peri- FIGURE 8.4 Fetal growth restriction In a woman with severe preeclampsia
frequently, as fluid changes are more dynamic and natal monality and morbidity is dominated by
may demonstrate a compromised fetus earlier. The gestational age at diagnosis and delivery. When
mother should be assessed for risk factors and her delivery is deemed appropriate, consideration Profound fetal distress warrants deliyery by emer-
gency. caesarean section. Lesser degrees of com- An expedited delivery, particularly if compli-
blood pressure monitored weekly. must be given to the timing, mode and location of
Growth restriction is one manifestation of the delivery. The gestational age and degree of pronuse and later gestation allow consideration of cated by operanve illtervention, may create con-
rnducnon of labour. SIderable anxiety. Neonatal complications may
preeclampsia. Figure 8.4 shows the case of a small compromise dictates the urgency of the delivery.
Deliverr of a pre term compromised baby lead to separation of mother and baby, and diffi-
42 should be ill a umt WIth neonatal intensive care. culty ill bonding. Every effort should be made to
In-u~ero transfer of a baby to such a unit should be illvolye the mother in the care of her infant
consIdered, as well as administration of exogenous mcluding feeding of expressed breast milk. Parent~
40
38
sterOIds to promote pulmonary maturity. may rncur significant exp~nses either travelling
36 ~
~
daIly to the neonatalrntensive care unit or staying

f34 ~
~
v
.-/ Impact of growth restriction away .from home in temporary accommodation.
i The finanCIal pressll!e to return to work may also
i
E
~ 28
32
30
6 V-
V-
Ov-
VV
/
V/
--.-
- -00Ye
- - --97'U1
The neonatal complications of intrauterine growth unpact on the family. Early involvement of the
reStrlctIOn lllclud,e antenatal or intrapartum SOCIal worker should be encouraged.
mtrauterrne hYPOXIa, WIth risk of fe tal death, and In the short term, other family members may
~ 26 --O---Feb.4 fetal distress rn labour requiring instrumental feel neglected. It IS unponant that siblings of the
~ 24
V ./
or 0peranve delivery or neonatal resuscitation. mfant be mcluded in the management plan. Older
o
:ll22
cf V V Neonatal hypogiycaemia may occur as the glyco- children ,may have been anticipating the new
< ~
/' V gen-depleted lIver fail s to maintain normogiy-
20 arnval WIth excitement and then acutely feel the
./ caeOlla. When pre term delivery occurs, additional
18 disappOIntment If the baby dies Or requires inten-
problems such as pulmonary immaturity further SIve neonatal care.
16 complicate neonatal life.
14 Long-term chronic childhood illness may be
Childhood complications include failure to
~a2VD~~~RDM~38~38.~~U stressful for the whole family. A supportive gen-
Lhnve, chronic lung disease and learning disability.
ow bmh weIght has been associa ted with later eral ?racnnoner and ease of access to specialised
Weeks
FIGURE 8.3 Intra ute rine g rowt h res triction of a 'no rm a l-size' fe tus (aBdult onset of hypenension and diabetes mellitus paediatrIC servICes are irnponant. Early recogni-
arker et aI 1993). non of and attennon to learning disability should
help such chIldren to maximise their potential.
Wi
8 The tetu s
Women's health : a core curricul um
8 cm. If this is found, an anatomical screen is per- 42

Prenatal education formed to exclude a gastrointestinal obstruction, 40
Prenatal education should promote a healthy which may occur anywhere from the mouth to the 38
lifestyle, involving diet and exercise, immunisation ileo-caecal valve and inhibit fetal absorption of 36 ~
~
against rubella, and avoidance of smoking, alcohol amniotic fluid . Anencephaly is associated with a
and recreational drug usage. During a preconcep- neurological inability to swallow. Placental or cord
K 34 0
~
~
/"
V
tion counselling session or fIrst antenatal visit, the haemangiomas may be other causative factors. No ~ 32
......V
~
/"
general practitioner has the opporrunity to re- cause is found for many cases of polyhydramnios. .! 30 , - - 3_
...... ...... - -50_
inforce these values, check immunity to rubella, Accelerated fetal growth may be identifIed by e
E
28 ,
~
...... .-/ I --0-_.

_ .. - 91"Al1o
advise folic acid supplementation and optimise serial ultrasound measurements (Fig 8.5). In asso- ~ 26
~
treatment of preexisting medical conditions. ciation with polyhydramnios, this should prompt 0
~
V ..... V
E 24 ,
One of the greatest risk factors for develop- investigation for diabetes mellitus or tighter 0
:822
:0 ......
ment of intrauterine growth restriction is a history maternal blood glucose control. Glucose crosses « / .....- ......
20
of a previously affected baby. The recurrence risk the placenta, and the hyperosmolar state induces ......
is 25%. If the growth restriction was severe fetal polyuria and production of fetal insulin, a 18 --
enough to warrant delivery before 34 weeks' ges- growth-promoting hormone. Polyhydramnios is 16 --
tation, the recurrence risk may reach 50% . Early associated with preterm labour, preterm rupture . 14
referral to specialist antenatal care and ultrasound of the membranes, cord prolapse, postpartum 24 2S 26 27 28 29 30 31 32 33 34 35 36 37 38 39 4D 41 42
confirmation of gestational age are important. haemorrhage and fetal malpresentations. Macro- Weeks
Clinical evaluation of fetal growth should be sup- somia is associated with intrauterine asphyxia, FIGURE 8.5 Fetal growth ac c eleration In a woman with diabetes mellitus
ported by serial ultrasound examinations in the obsuucted labour, birth trauma to mother and
third trimester to allow prompt recogrunon and baby, shoulder dystocia and caesarean section,
with its attendant maternal complications. The Management of the growth-restricted fetus after 24 completed weeks' gestation or weighing
management of fetal compromise.
fetal hyperinsulinaemia places these babies at risk is a balance between the risks of preterm delivery over 500 g up to 28 completed days of life. The
The large-far-dates fetus of neonatal hypoglycaemia. and continued fetal compromise in utero . Australian definition refers to births after
Figure 8.5 shows growth acceleration that Management of the large infant includes consider- 20 weeks' gestation and/or weighing over 500 g.
When the uterus is clinically larger than expected is associated with maternal diabetes mellitus. Poly- ation of maternal diabetes mellitus fetal Structural In developed counmcs, the perinatal mortality
for dates, the possibility of a big baby must be con- hydramnios was present from 34 weeks. The abnormalities associated with polyhydramnios and rate for babies over 1000 g is usually less than 6
sidered. The differential diagnoses include mcor- mother had previously given birth to three large an assessment of the safest mode of delivery. per 1000 births, whereas in developing countries it
rect dates, twins, polyhydrarrmios, uterine fibroids babies (>4000 g) by normal delivery with no ranges from 30 to 200 per 1000 births. Such vari-
or exuauterine masses. complications. Labour was induced at . 38 weeks'
A large-for-gestational-age fetus is defined as gestation. An obstetrician was present ill annclpa-
having a weight greater than the 95th percentile tion of shoulder dystocia. A baby of 4100 g was
for gestational age. The fetuS may be phYSIOlogI- delivered after a labour of 6 hours. The baby was
* Assessment of
fetal wellbein g
ation reflects the health of the general population,
access to and quahty of antenatal care, the inci-
dence of birth anomalies, and quality of intra-
parrum and neonatal care.
cally normal or may have accelerated growth put to the breast immediately and did not develop 1\vo per cem of children are born with major
(macrosomia), which is associated with maternal hypoglycaemia. malforrnauons (life-threatening or requiring major
diabetes mellitus or a congenital fetal abnormality surgery). Chromosomal abnormalities, single gene
(Beckwith-Wiedemann syndrome). Summary • A tetus Is determined to be small tor gesta- mutauons, and environmental and teratogenic ex-
Incorrect dates and twins can confidently be tional age on ultrasound. Is th is likely to be a
The clinical finding of a uterus that appears small posures account for 40% of major malformations.
excluded by referring to the morphology or or large for dates should prompt re-evaluation .of healthy, small tetus or a growth-restricted tetus?
earlier dating ultrasound scan. A fibroid or ovar- A pregnant woman at 39 weeks' gestation has Threats to fetal wellbeing
the gestational age and a search for maternal nsk
ian cyst can usually be seen at 18 weeks' gestation relt reduced tetal movements in the previous
factors. An ultrasound examination is performed Both maternal uteroplacental and fetal conditions
and may become larger as the pregnancy pro- to confirm that the fetus is truly discrepant for ges- 48 hours.
gresses. Polyhydramnios may be clinically sus- may cause an imbalance between fetal oxygen
pected if the abdomen is particularly distended tational age.
For the fetus identified as small for dates, fur-
demand and supply. Maternal conditions such as
and tense, and fetal parts are difficult to identify. hypertension or microvascular diabetic disease impair
ther evaluation of fetal wellbeing is necessary to
When the uterus is recognised as large for distinguish the healthy small fetus from the com- placental. perfusion, leading to lUGR. Fetal hyperin-
Perinatal mortality sulinaenua may also be associated with accelerated
dates, an ultrasound is performed to determine promised and potentially growth-restricted fetus.
fetal size suucrure and amount of amniotic fluid. Serial evaluation of fetal measurements at 2-week- The international definition of perinatal monality growth. Maternal hypethyroidism affects fetal
Polyhyd:amnios is defined by an AFI of more ly intervals determines the pattern of fetal growth. refers to stillbirths and neonatal deaths occurring basal metabolic rate by transplacental transfer of
than 20 em or a fluid pocket depth of more than
Wt
Women's health: a core c urri c u lu m
8 The fetus
antithyroid antibodies. Intrauterine infection rnay normal umbilical artery resistance more reliably
cause fetal anaemia (parvovirus). Isoirnrnunisation predicts that a growth-resrricted fetus is not
may also cause fetal anaemia. It is irnporran.t to mon- hypoxaemic. The positive predictive and negative
itor the fetal response to such threats and detect early predictive values of absent end-dias.tolic flow
signs of compromise. velocity for fetal death are 40% and 95% respec-
tively.
Clinical assessment One of the adaptive fetal responses to hypox-
of fetal wellbeing aemia is reduced cerebral resistance to blood flow.
This is a reflection of the redistribution of cardiac
Maternal assessment of fetal movements provides output preferentially to the brain and myocard-
a simple assessment of fetal wellbeing. UltrasOlwd
ium. Identification of decreased middle cerebral
evaluation of fetal growth, activity, amniotic liquor
artery resistance in the presence of increased
volume and fetal perfusion provides valuable clin-
umbilical artery resistance is consistent with fetal
ical information in a high-risk pregnancy or sus-
hypoxaemia.
pected fetal compromise. More detailed analysis
of fetal acid-base status and hypoxaemia may be Further fetal decompensation occurs when the
cardiac output falls. H ypoxaemic cardiomyopathy
made by invasive tesring.
results in fetal acidaemia. Doppler venous indices __
Amniotic fluid volume reflect ventricular function, and abnormal patterns
herald imminent fetal demise.
The volume of amniotic fluid re.tJecrs YIerjpr per-
fusion and the physiological processes of fail Fetal blood sampling
sWaIIOwing, fetal cardiac function and rsal fu lJc-
non. Reduced utenne perfUSion, secondary to Cordocentesis involves taking a blood sample from
nypertension, microvascular disease or placental the fetal umbilical artery to evaluate blood gases and
acid-base status. It may be of value in compromised
infarCts, results in redistributed fetal cardiac Out·
put. This leads to poor renal perfusion and low preterm fetuses, where perinatal mortality is domi-
renal output. Thus oligohydramnios suggests a nated by gestational age at diagnosis and delivery:
compromised fetus. Intervention on behalf of the very early preterm
Evaluation of liquor volume is one component fetus should cautiously be considered at the point
of the BPS, which considers fetal tone and move- where decompensation begins but before the blood
ment, fetal brearhing pattern and liquor volume. gases (determined by cordocentesis), cardiac func-
Scoring 2 for each normal variable, a healthy baby tion (determined by cardiotocography) and perhaps
will achieve at least 6/8 over 30 minutes' observa-Doppler venous indices have deteriorated too far.
tion. A still fetus with oligohydramnios is an omi- Fetal scalp sampling in labour is performed
nous finding. Fetal cardiotocography may also be where there are clinical signs of fetal compromise,
a component of a modified BPS . e.g. a non-reassuring fetal heart rate pattern.
t~tl Evaluation of fetal venous pH and base excess
Um bilic al arterial resistance - "'" \ \J 1..1\- aUows continuation of conservative management
or prompt delivery. Use of this modality has helped
Resistance to blood flow in the fetal umbilical to reduce, without neonatal compromise, the rate
artery may be measured by Doppler studies (Fig of caesarean sections amibuted to 'fetal distress'.
8.6). Umbilical artery resistance closely refleCts
placental villous resistance. Umbilical artery Cardiotocography
downstream resis.tance increases once approxi-
mately 30% of the villous vessels are affected. Doppler recording of fetal baseline heart rate and
Increasing flow resistance reduces diastolic flow variability is the basis of non-stress cardio tocO-
velocity in the umbilical artery, leading in the graphy. The baseline fetal heart rate falls with
extreme cases to absent or reversed end-diastolic increasing gestation and becomes more variable
velocities. with the later development of fetal vagal tone.
While absent end-diastolic flow velocity has There is insufficient evidence regarding the relia- FIG URE 8 .6 Feta l umbilica l o rte r D I
been shown to correlate with fetal hypoxaemia, bility, validity and suitability of electronic fe tal ~ Osp lta l) y opp er patterns (Photos courtesy Peter Farkos/RoyOI Darwin
Women's health: a core curricu lum
8 The fotu.
monitoring as a tool for assessing feral wellbeing, uteroplacental function, e.g. hypertension or dia- The International Cerebral Palsy Task Force
except in [Wo circumstances. A ferus with a base- betes mellitus, may also be thus monitored. ing difficulties - may reflect physiological irnma-
(MacLennan 1999) considered three essential cri-
line hearr rate within the normal range (110-150 tunty. Nevertheless, the document gives valuable
teria to be necessary to amibute the cause to Intra-gwdance to expert opinion when counselling in
bpm), moderate baseline fetal hearr rate variability Cerebral palsy pa~ hypoxia:
(6-25 bpm) and no decelerations is not at risk of this area. By defining intrapartum causes of cere-
Cerebral palsy, a nonprogressive abnormal control • evidence of a severe metabolic acidosis in intra- bral palsy, it should help to focus research on the
acidaernia (Fig 8.7). At the other extreme of fetal
heart rate patterns, a fetus with a bradycardia or
absent fetal hearr rate variability in the presence of
of movement or posture, develops in 2-3 per 1000
live births during the first years of life. It has long
partum fetal or
samples
mr early neonai'at' blood many antenatal causes of cerebral palsy and their
prevennon, ill addition to the prevention of dam-
persistent late or variable decelerations has evi- been associated with intrapartum adverse events. • earl agrng Intrapartum hypoxia, which has been the
dence of potentially damaging acidaernia. Recently, however, it has been recognised that .~~~~~~~~~~ mam emphasis to date.
The majority of the above tests of fetal well- about 90% of cases can be amibuted to intrauter-
being may be performed in a day-assessment set- ine events preceding labour, e.g. IUGR, fetal coag-
ting. This allows close surveillance of the pregnan- ulation disorders, multiple pregnancy, anteparrurn Health maintenance
cy, while causing least disturbance to the woman's haemorrhage, chromosomal and metabolic abnor- A healthy lifestyle involving diet and
family life. Maternal causes of compromised malities, coagulation disorders and infections. Weaker. criteria that together suggest intra- exercise and avoiding smoking
parrurn tllIung but by themselves are nonspecific alcohol and recreational drug ~se
include: prOVides a favourable environment
for fetal growth. Pre-conception
• a sentinel hypoxic event occurring immediately treatment of medical conditions
before or during labour optimises fetal growth and wellbeing .
• early evidence of multisystem involvement
early imaging evidence of acute cerebral abnor-
mality.
References
Implementation of the International Cerebral
Palsy Task ~orce guidelines is limited by the lack of Barke r D]p, Glud<man PD, Godfrey fG\.f er 0.1 1993 Fetal
nutntJon and cardiovascular disease in adult life.
resources !n smaller hospitals to ascertain the Lancet 341:938-941.
degree of metabolic acidosis and to perform early
neonatal brain imaging. The consensus document Llewellyn-Jones D 1999 Fundamentals of Obstetrics and
does not address the association between preterm gynaecology, 7th eeln. Mosb» Lo ndon.
birth below 34 ~veeks' gestation and cerebral palsy. Macwnan A 1999 A template for defining a causal
This IS a difficult area, as signs of neonaral relanonship between acute intrap artum eVents and
encephalopathy - such as difficulty initiating and cerebral pals}': internarional consensus stare-mem
International Cerebtal Palsy Task Force. British '
marntauung respiration, abnormal tone and feed- j\·ledical kumal 319,1054-1059.
d . It would be wise to consider early

1. A 22-year-old woman presents ot delivery.
34 weeks' gestation in her first e. She may have twins .
pregnancy. Her pregnancy appeors
clinically smoll for dotes. Which of the
following is correct? 2. Intrauterine growth restriction is
associated with:
a. Her dates may have been incorrect. /
b. She could have polyhydramnios. a . maternal weight loss in pregnancy
FIGURE 8.7 Normal ontenotal cardiotocograph pattern (Courtesy of Peter Farkas /Ro yal Dar win
c. A single ultrasound examination can b . fetal talipes equinovarus-
Hospital)
determine fetal growth.
-~ £)n aternal preeclampsia
,/
"·k
to
Women's health: a core c Uiri culu m

*9
Medical disorders in
c. A fetus with a normal cardio- .
d. reduced fetal umbilical artery tocograph is likely to be aCidotiC.
resistance
e. all of the above.
d. The use of fetal scalp sampling for pregnancy
acid-base status in labour has been
associated with an increase In Edited by Martha Finn
3. A 35-year-old woman with diobetes caesarean section rates.
mellitus is at risk of having:
e. All of the above.
a . a macrosomic baby
Hyperemesis gravidarum Regina Wulf
b . a growth-restricted baby 5. Which of the following statements
about cerebral palsy are correct? Anoemia Petra Porter
c. a traumatic delivery associated with Isoimmunisation Louise Komman and Helen Savoia
shoulder dystocia a. Cerebral palsy occurs In less than 5
Abnormal glucose tolerance Helen Lammi
per 1000 births.
d. a baby that succumbs to Hypertension Mark Brown
intrauterine asphyxia
e. all of the above.
/ b. About 10% of cases of cerebral
palsy may be attributed to
intrapartum hYPOXia.
Thromboembolic disease Petra Porter
4. Which of the following is correct in the c Severe metabolic acidosis In labour Learning objectives
. should be an essential criterion to
assessment of fetal wellbeing?
diagnose an Intrapartum event as
Knowledge outline a plan for the diagnosis and
a. Amniotic fluid volume reflects causal to cerebral palsy. management of a microcytic anaemia
uterine perfusion and the processes in pregnancy
of fetal swallowing, fetal cardiac
d. Intrauterine growth restriction may At the end of this chapter, the student
function and renal function .
imply a cause of cerebral palsy will be able to: Isolmmunisat/on
other than acute intrapartum
b. Isolated abnormal fetal umbilical hypoxia. Hyperemesis gravidarum identity the common antigens that ma y
artery Doppler resistance reliably cause haemolytiC disease of the
predicts a hypoxaemlc fetus . e. All of the above. indicate the prevalence of morning newborn
sickness and hyperemesis gravidarum
describe the pathophysiology of fetal
• discuss the differential diagnosis of anaemia and cardiac failure in
hyperemesis gravida rum Isoimmunisation
describe the Investigations required to describe the pathophysiology of
assess the severity of hyperemesis neonatal anaemia and jaundice
gravidarum
• outline the Investigations and
outline a management plan for severe management prinCiples of
hyperemesis gravida rum isoimmunisation
Anaemia • discuss prevention strategies, the value
define anaemia in pregnancy of screening and effectiveness of anti-D
immunoglobulin
indicate the pregnancy demands for
iron and identify dietary sources of iron, Abnormal glucose tolerance
folate and vitamin BI2 describe the physiology of glucose
describe the pathophysiology of homeostasis in pregnancy
anaemia in pregnancy define gestational diabetes mellitus
describe the common causes of describe the population at risk for
anaemia, their prevalence and gestational diabetes
management
• discuss the implications of abnormal
• outline the diagnostic tests performed glucose tolerance for the mother, the
to Identity the cause of anaemia fetus and the neonate
discuss the value of routine versus outline the principles of management of
selective iron supplementation gestational diabetes
(Continued over)
II.F
9 Medical d isord e rs in p regn a ncy
women's health : a core curr icu!u rn
(learning objectives continued) Ski lis

* Hyperemesis
gravidarum
increased thyroid-stimulating activity and elevated
serum thyroxine levels have been reported in more
than 70% of patients with HG. Hyperthyroidism
• discuss the Importance of maintaining usually resolves early in the second trimester, sub-
normal pre-pregnancy blood glucose should learn how to:
siding along with the hyperemesis. PSjCchosocjal
levels in women with established diabetes
clinically assess the degree of dehydration stress is not a cause of hyperemesis but can
in a woman with hyperemesis gravidarum A 30-year-old woman at 8 weeks' gestation Is
Hypertens ion
unable to eat or drink owing to severe nausea
affiavate It and should be taken into consideration
• define the subtypes of hypertension In perform and interpret a ward urine dipstick and vomiting. She fells dizzy and weak, passes in e overall management of the woman with HG.
pregnancy and discuss the clinical examination only small amounts of dark urine twice dolly Women who have experienced HG in a previ-
implications of each interpret blood biochem istry of a woman and is unable to look after her other child or to ous pregnancy or who have experienced nausea
• list the maternal risk factors for develop- with severe prolonged vomiting do any housework. She also experienced while taking oral contraceptives are more likely to
ment of preec lam psia nausea and vomiting In her previous suffer from HG.
counsel a woman regarding the
significance of hyperemesis gravldarum pregnancy.
describe the pathophysio logy of Physiology
preeclampsia take a nutritional history from a pregnant
outline the investigations performed to woman and offer appropriate advice. The pyloric glands of the stomach produce gasrric
about iron and vi tamin supplementallon secretions high in potassium (15 mEq/L) and with
assess maternal and fetal wellbeing in a Morning sickness
hypertensive pregnancy explain the role of postpartum passive
significant sodium content. The secretion from the
immunisation to the Rh-negative mother Nausea and vomiting are cornmon in early preg- parietal cells is isotonic but contains chiefly
discuss the statement that hypertension in
pregnancy, in particular preeclam~sia , is a who has no ant ibodies detected in nancy and are referred to as morning sickness, but hydrochloric acid. It also has a significant potas-
common cause of maternal mortality and pregnancy symptoms are restricted to the morning in only sium content (5-8 mEq/L). In the formation of
af perinatal morbidity and mortality explain to the Rh-negative mother the 2% of women. Up to 85% of pregnant woman are hydrochloric acid, sodium bicarbonate is rernmed
implications of a posllive anlibody screen affecied, and symptoms are commocly expen- to the extracellular fluid (ECF). C.!(!!,tinued vomit-
• outline a management plan for a patient
admitted with preeclampsia test in pregnancy ence from the 4th to the 12th week of Ereg- ing thus leads to aemia, hYE.0natraemia,
explain to a woman the value of a glucose n~. Although the symptoms may be traulITe- ~oraemlc alka losis an a decreass in FeE
Thromboembolic disease some, they rarely require investigation or dru& v Alkalosis shiftS more potaSSium into the
screening test in pregnancy
• discuss the significance of thrombo- ~eraa In general, first-trimester nausea has no cells. In adclition, the concentration of body fluids
counsel a woman with gestational increases because of insensible water loss with no
emboliC disease in pregnancy diabetes mellitus about her long-term a verse effect on the roWer or ferns.
• identify the common symptoms and signs health risks
replacement. In some patients who have been
of deep vein thrombosis and pulmonary Hyperemesis gravida ru m vomiting for a long period of time, the pyloric
clinically assess the woman who presents sphincter rela;'(es and large quantities of alkaline
embolism with hypertension in pregnancy Hyperemesis gravidarum (HG) is excWiye pq:g- duodenal contents are lost. These patients will
• outline the investigations used to Identify counsel a woman about appropriate nancy-related nau(;f and /gr vomiting that usually have bile in the vomirns.
DVT and PE In pregnancy therapy for deep vein thrombosis and prevents ad uate fo and fluid intake and is asso- Urine output is reduced. This occurs by hyper-
describe the management of deep vein pulmonary embolism in pregnancy. oate with ei t oss a mare t an 5% of body osmolar stimulation of antidiuretic hormone
thrombosis and pulmonary embolism in mass. It occurs in ess than 3% 0 pregnancies. secretion and reduced glomerular filtration, asso-
pregnancy Attitudes Symptoms usually begin at 4-6 weeks' gestation and ciated with reduced ECF volume. Urine specific
identify women who may need prophylaxis peak between 9 and 13 weeks. In 10-20% of cases~ gavity is incregsed. Initially the urinepH IS atka
for thromboembo lic d ise ase in pregnancy
or the puerperium.
symptoms may last the entire pregnancy. The inabil-
ity to retain food and fluids leads to de!tndration,
~6ecause the kidneys excrete bicarbonate in an
attempt to correct the alkalosis. As the condition
the value of indivldualisation of care for nutritional deficiency and metaboGc lIDb ceo p!:o~esses, however, the jlQtaSSium defiaens
each woman In pregnancy causes an ina ro riate acidifica .on of the urfue
Aetiology and the urine comes more acidic.
the maternal anxiety engendered by the
label of 'high-risk pregnancy ' The cause of HG is not well understood. Human
chorionic gonadotrophin (HCGl. which rises to a Clinical picture
the maternal guilt of having a condition
that may adversely affect the fetus. peak at 12 weeks' gestation and falls thereafter, The reduced ECF volume and hypokalaemia cause
bas been held responsible. The HCG level is ex- thirst, malaise, dizziness when tanding and ~
tremely high in women with molar pregnancies ~ ~ati0!1 is associated With postural
and twin pregnancies, conditions associated with hRr0tensJOn and fever. Hyponarraemi!, may cause
HG. High levels of HCG are also associated with ~s, convUl5iOm and reSplIatory arre t.
-
Iltt
\ 9 Medical disorders In preg nonc y
should be further investigated by microscopic exam-

ination of a midstream urine sample. A urine dip-
stick is used to check for specific gravity, ketones,
and the selective serotonin (5HT3) receptor antag-
onist, ondansetron, are most co I use an
have not een associated WI te ato enie e
* Ana emia
protein and urine acidity, as severe dehydration is AI " es suc as pow er (1 g
associated with high specific gravity and the produc- dally) and Vltamtn B. (30 mg pyridoxine daily) • A 32-year-old nulliparous woman presents at
tion of ketones. The haematocrit is increased as a have also proved to be effective and can be tried 14 weeks ' gestation to receive the results of her
result of a concentrated blood volume. T here are where oral therapy is possible. S stemic steroids Initial antenatal screentng blood tests. Her
blood eleCtrolyte changes, e.g. decreased sodium, (hydrocortisone, prednisolone) have e e haemoglobin is 90 gIl.
p~ chloride and ~ esium are common, as fully H.sed in patients f Of whom annemegc therapy
A 24-year-old woman presents at 29 weeks'
well as elevared'1iver, enwmes such as asparrate has failed. Parenteral therapy haS a role to play in gestaHon with tiredness. She is a vegan and
transaminase (AS 1j, alarune transaminase (ALT) severe HG.
has two young children at home.
or bilirubin. Overr jaundice is rare. Thyroid function It is imporrant to remember that a woman who
teStS should be checked in women with clinical signs has been hospitalised for a prolonged period with
of hyperthyroidism, in which an increased T4 con- HG, who is dehydrated and confined to bed, is at
centration and reduced thyroid-stimulating hor- increased risk of venous thromboembolic disease, The majority of hereditary haemolytic anaemias
mone (fSH) may be found. An ultrasound should be and tlJ.£Qmboprophyl~s (lffilZ-Wo!eCJJ lar-weit t and homozygous haemoglobinopathies are identi-
performed to identify a rwin or molar pregnancy. _. heoiif and compressIOn stockings) shoUld e fied before pregnancy. At the . t antenatal visit,
co~ensa: the most common cause of anaemia IS nutrltto .
Tre a tment der cases of nausea and vomiting in preg- CJc"caslonatIy heterozygous haemoglobinopadlfeS
nancy have not shown a long-tenn adverse out- and, very rarely, a panCytopenic bone marrow
In the eighteenth century, it was believed that HG come for the fetus. In sev . ed
was caused by a 'fullness of the vessels of the uterus' aplasia or leukaemia are identified. The ~
Diagnosis maternal naus v ttn and we
of nutritional anaemias are due to iron deficiency.
and it was treated by venesection. Today, once the erus IS at ris of &9wth restriction, whieh may
diagnosis is made, trea . 0 .
lead to preterm delivery and its complications. ft is rare today, with food forrification and vitamin
care with correction a both flu ' 01 supplemenration for prevention of neural tube
irn c deficienCies. Summary defeers, to see folic acid deficiency or the haema-
Hospitalisation is necessary in severe es. tological manifestations of vitamin Bu deficiency_
Adequate fluid, eleCtrolyte and vitamin adminis- Screening beyond the first trimester is directed at
tration will prevent life-threatening complications. identifying iron deficiency anaemia.
First-line management includes intravenous rehy-
m anon WIth normal saline or H artmann'S solution Physiology
WIth potasSlUm chlOride su pplementarion. It is
irnporrant not to correct severe hyponatraemia toO Plasma volume begins to increase by the sixth
Investigations rapidly, as this may also precipitate central pontine week of gesration, peaJdJ]g at around 30 weeks,
myelinolysis. Fluid and electrolyte regimens With a total of 1.2-1.3 litres extra by term. The
e oss 0 should be re-evaluated daily, based on serum urea erythrocyte mass mcreases more slowly and' pro-
tic! ta oscur and eleCtrolyte concentrations. A woman who has pomonately less than the plasma volume, resulting
As psVchological factors may influ- in a net dilutional effect. This is referred to as the
bo y a our ue to rapid fat oss and ketosis may been unable to eat sufficiently for weeks is at risk ence the severity of hyperemesis
be noted. Excessive salivation (ptyalism) with con- of significant malnutrition. V~it~";!;
m~in~ s~~,IOiOj~ gravidorum . early adaptation to the phYsiological anaemia of premqnQ'. The lowest
srant spitting is found in many women. The urine tion, es eciall of the water-s e vitamins su pregnancy and a pos itive outlook pregnancy haemoglobin (Hb) occurs at 25-26
is usually dark, and urinary frequency is reduced as amm I, IS lIDporrant to Rrevent evelop- should be encouraged. weeks' gestation. A haemoglobin less than 110 gil
to two to three times daily, as the body tries to ment of werrucke's encephaloE!athy. in the first trimester or less than 100 gIL in late
retain as much water as possible. Oral lIwd and food should be withheld for second and third trimesters should be considered
Symptoms of hyperthyroidism are similar to 48 hQurs and then a bland carbohydiate diet cOm- as anaemia and investigated furrher.
those of normal pregnancy (heat intolerance, pal- menced WIth small and frequent meals. Antiemetics Mild agaemia, although a marker for poor
pitations, tiredness), but the presence of goitre, are tndlared tor S~ptoIllS that are inr:;:;lctable nutritional status, rarelfuhas untoward effects dur-
tremor and signs of eyelid lag or exophthalmos despite adequate hidranon. t hey shoUld be iJruL ;f ~egnancy. When e haemoglobtn IS 60 70
should alerr to the possibility of associated hyper- witl£:caunon, especiaIIy dUring the first 10 weeks of , ~e mother is at risk for high-ournut cardiac
thyroidism. n
pregnancy. necessary, melowest effecnve dose IS
failure and extreme tati~T'" At these levels the
Symptoms and signs of a urinary tract infection administered. Metoclop rarnide, phenothiazines
1'eWs'is at the lower limit ~ adequate o"lgen;tion_
9 Modlcal disorders In preg nancy
women's health: a core curr ic ulu m
Screening for anaemia

with the beta-thalassaemia trait have a 250/0 prob-
ability of propagating a major thalassaemia. This is
a transfusion-dependent condition that has high
* Iso im munisa ti on
A full blood examination (FBE) estimates haemo- Common clinical presentations
morbidity and mortality. Parents should be given
globin concentration, platelet and white blood cell A woman presents with an Inevitable miscar-
the option of prenatal diagnosis.
counts. In addition, the red cell size (mean corpus- riage at 10 weeks' gestation. Her blood group
cular volume, MCV) and the red cell Hb concen- Sickle cell syndrome Is Rh(D)-negatlve.
tration (mean corpuscular Hb concentration,
MCHC, and mean corpuscular Hb, MCH) are It is important to screen all high-risk ~oup s, such A woman presents to the antenatal clinic at
as black people of A1ncan Orlgtn, , ans, Saudi. 27 weeks' gestation. The routine antibody test
calculated. . performed at 26 weeks' gestation showed a
Microcytic anaemia (MCV <80 femtolitre s ArabIans artdivfediterranean eo Ie, or sickle cell
traIt. SICkle ce . soluble titre of 1 In 128 of antl-Rh(D) antibodies.
(fL)) is commonly found in Iron defiCiency
Further questioning reveals that atter a previ-
anaemia and thalassaemia. Provided the platelet
ous ectopiC pregnancy she had not received
and white blood cell count are normal, the first Rh(D) Immunoglobulin. There Is no record of
investigation of microcytic, hypochrorruc (low an earlier antibody titre in this pregnancy, as
MCHC) anaemia is directed at Identifymg \ron she was travelling overseas In the earlier
deficiency, by estimati pg sepJI~ ferpryn concentra- weeks of her pregnancy.
tion. Tests of serum iron and \ron-bmdin~g~
rare mfliienced b dietary mtake and pre an ,
an us are not recomm n e . erum er-
riM IS nsmpaJ (especuiIly when the M CH IS very Approximately 170.0 of Caucasians are negative for
low, with a riilldly depressed MCV), haemo obm the Rh(D) arttigen and are termed Rhesus negative
electrophoresis is performed to Iden carner (Rh(D) negative). This blood type is rare in people
statesof haemoglobinopathies. . of Asian or Australian Aboriginal origin. Rh(D)-
A macrocytic anaemia (MCV > 100 fl.) ~s asso- positive individuals may be heteroz)'gous or.~
ciated with folic acid and vitamin B12 dettclenCies. homozygous for the D antigen. A heterozygous, ( f ,
Anaemia associated with macrocytic red blood father has a 500.0 chance of passing on the D anti- f (I
cells (RBCs) and hypersegmented polymorphs Thalassaemia gen. If a w oman is Rh(D) negative and her partner 'l
should be investigated to detennme erythrocyte Alpha-chain haemoglobin production is under the is heterozygous, each fents bas a 50 % chan ce of ,CfJ·
folate levels. Serum B12 levels are difficult to mter- control of four genes and beta-chain produ~on being Rh(D) positive or Rh ipl peg3 ~. ••
pret in pregnancy and are commonly phYSIOlogi- under the control of only twO genes, one inhented M ore than 40 dillerent red cell antigens have
cally low in the second half of gestatlon. from each parent. Thus thalassaemia may have been reported to cause haemolytic disease of the
major and minor forms. The major fonns are ferus/newborn (HDN) . However, o.!llx 3gri-R h (Q.),
Iro n -deficiency a naemia usually identified before pregnancy as severe trans- anti-Rh(c) and 3nrj- Ke l! cause seriolIS feral prob-
fusion-dependent anaerrua. The common . -
Summary lems. Other antibodies (Rh E, C, e), Duffy (Fya),
Women are prone to iron deficiency, which is
aggravated by menstrual loss and short intervals
. efe resul ' e unde d The most common cause of anaemia in pregnancy tGcId aka) and Lutheran (Lua) are common but
between pregnancies. In the non-~regn.ant state, .either alpba or beta sbaLJli.. Un . . is nutritional deficiency. With changing migration usually cause only mild to moderate HDN .
uses an uru:natched excess of the other leadin patterns throughout the world, it is important to
approximately 1-2 mg elemental . \ron IS needed
mem(lU)e e an mcrease e e ~ - screen for haemoglobinopathies. Pathophysiology
each day. An additional 2-3 mg \ron per day 1S
ity and reS111ring.JO a c orne emo ~c anaenua. ~ During pregnancy, fetal cells may cross the placenta
needed in pregnancy (apgror4 atelv 900 mg m
total per pregpanf)' The ad tionaJ \ron IS used
T he populanons most affected Y beta-& ilas
and enter the maternal circulation, exposing the
saemia minor are from the Mediterranean regIOn,
both to increase e maternal red blood cell mass mother to 'foreign' red cell antigens that the ferus
where the carrier rate may be as high as 1 m 7 llldi- A healthy diet generally meets the
(400-500 mg) and liver stores (250-300 mg) and has inherited from the father. This fetomaternal
viduals . Alpha-thalassaemia minor is more com- physiological demand for Increased haemorrhage (FMH) is most likely to occur at deliv-
for fetal haematopoiesis. mon in sub-Saharan Africa and Southeast Asia- ~ iron in pregnancy. Oral supplement-
Oral iron is absorbed in the stomach and duo- ery (60% of pregnancies) but may also occur spon-
women with bo th the alpha and beta tram, ee g- ation may be considered to maintain
denum, in a mildly acidic medium. Thus enteric-
n1.hf: taneously during pregnancy and in association with
coated or sustained-release iron preparatlons are
inefficient. Iron absorption is inhibited by antaCids
nancY js generally well tOlerated .
iC@jiifjed as £}rner It ISjffipera rjy e
father of~e
that:-
mot e r A
. d also be screened With. hae . 0 -

maternal iron stores .
threatened or complete miscarriage, after trauma
and after invasive procedures such as amniocentesis,
and enhanced by ascorbic acid, and therefore Iron chorionic villus sampling (CVS), external cephalic
is beg ral ~en °0 20 empty stomach . The iron ~varr:
g 0 Ul concentration an aem 1-
trophoreslS. s is Im portant because twO peop e version (ECV) or abruptio placentae .
;J;fe for absorption is termed th e elemental \ron.
'0
9 Me dica l disorders In p regnanc y
Exposure to foreign fetal red-cell antigens may d

result in the development of maternal antibody. 1.0
fetal cells in maternal blood, is used to determine
Development of isoimmunisation deBend.s. on a the volume of FMH and thus the dose of anti-D
0.7
number of factors, indudiIlg the anagentClty of ""a that should be administered after sensitising
tl:ie anagen, the dose of antigen to whiCh the 3. 0.4 events ill the second and third trimester and after
mother is exposed and the responsiveness of her E
<: 0.3 Severelyaffec ed delivery. Anti-D immunoglobulin should be given
--.;
as. dose to the sensitising event as possible and
immune system, and ABO com,anbiliry between
the mother and the ferus. (D) IS the most ~ 0.2 ~-- .... -----.......... Within 72 hours. It may still have an effect up to
'6 9-10 days after the event.
immunogeruc ot the red-cell antigens. A single preg-
~ 0. 1 -----.. --. Administration of Rh(D) immunoglobulin to
nancy with an Rb(D)-positive, ABO-compatible <:
t» 0,07 Moderately affected ------- all Rh(D)-negative women who have not devel-
fetus initiates immunisation in about 1 in 6 Rb(D)- '0
'6 0.05 oped anti-D antibodies at 28 and 34 weeks' geSta-
negative women.
Antibodies of the immunoglobulin G (w;i).. "
~ 0,03 non and after each sensitising event reduces the
class are act;i.vely transferred from mother to fetus.
0 development of sensitisation to less than 0.20/0
0.02 Normal '. (NHMRC 1999).
The anl0unt of antibody transferred is small in the
first 12 weeks of pregnancy, increases slowly
between 12 and 24 weeks and thereafter increases 33 35 37 39 41 Health maintenance
exponentially until te=. HDN occurs when the Maturity (weeks)
life span of the infant's red cells is shonened by
the action of a specific antibody derived from the FIGURE 9.1 Optical density of a mniotic fluid In the ~l1e~jgz~~t~%~8~;t?4~f;rere
~Iven ~~~_
mother by placental transfer. Antibody-coated red
cells are removed from the circulation by the fetal
liver and leading to anaemia I he illcreased
prediction of hoemolytic disease of the newborn
(Bosed on Symonds & Symonds 2004, p 59. Fig 4.16)
s ou d be
ftSM~&gi~t i €h
weeks' ~estatIO!1 . This considerably
bre own 0 aemo 0 U1 resu ts in ingeased Preventio n of Rhesus reduces In t1Sk of Isolmmunisation .
pigment in the amniotic fluid. Anti-Kell antibodies isolmmunisation
appear to work differently, bY causm anaemia ri-
maril via su ression of
ra er an ~ aemo ~IS.
III mUd ises of RNathe ferns may be born
ucnon
* Abnormal g lucose
tolera nce
without major clinical problems, and simple post-
natal observation of the mfant may be all that is
required. In other cases, phototherapy or an Common clinical presentations
exchan~transfusion ma~ be required for ~~ When screened at 28 weeks' gestation, a
h}'.llC,rb bmaemta. EarL QUShof severe :Ce 33-year-old primigravida has impaired glucose
rna res@t ill te@ anaemia in utero which le~
increase e 0 oeisis (enlarged
~.~o~::~~~~~~~~~~§e~n~~~iY~
ine transfusion can be pe orme Intrauterine
tolerance.
A woman gives birth to a 4500 g baby. Whot

" \ liver an spleen), cardiac decompensation and transfusions are usuauy stopped around 34 weeks' are the Implicati ons for the mother ond
'""'" ~ h:;drops fetaljs (so-called immune hydrops) with gestation and the fetus delivered at 36-37 weeks. In subsequent pregnancies?
ascites, pleural and encarclial effuSions and~-
0,
\dL
~
~amruos. ntreate us results '
deaai. The affect on the erus of jsoimmunisation
tal
less severe disease, where the maternal blood tieres
do not rise above 1 in 16, or where the aD 450
results do not require additional intervention, deliv- • threatened or spontaneous mjscarriage, ~~ Epidemiology
~'\lI\rt cisWiD.y increases in severity with subsequent preg- ery is usually planned for 37 weeks' gestation. stye procedures, trauma, placental abruption
nancies. (increased risk of F~ Gestational diabetes mellitus (GDM) is defined as
Noninvasive methods of determining fetal
anaemia are increasingly being researched. The • routinely at 28 a nd 34 weeks' gesra&K>n carboh drate intolerance of variable severi with
Investigations most promising appears to be the peak systohc routinely ~ty if the baby is Rh(D)- onset durin e .
The presence of re! Ifll antibodies.t n m~ternal flow in the middle cerebral anery. Liver length, pOSlt!ve. In Australia gestational diabetes is fo~nd in
blood is deteged b_ a, _ indirect ano JpbUlin test spleen perimeter and fl0'.·' velocity changes in 6-8% of all pregnancies. There is an increased risk
The dose of anti-D given must be sufficient to
(lAn. Antibody levels are monitored by either other fetal vessels have all been reponed m women WI th a famil y history of djabet4i, a~-
remove all fetal cells from the maternal circula-
titration or quantitation. Once the titre eXceeds (Divakaran et al 2001) . sto of estational d ' c~
tion. The Kleiliauer-Betke test, which identifies
hypen eosion, e ore pregna;cy, older
.- cytv-(,o~ ~~ ~\
~~ ~AAhj l~ 1~, D'''_ _
~I.U'< ~ \. '"
. ., .1' """"""",I ( L ~
Ct'l1 I 1M~",,\ ~"""'- f
CJI'vt q.), ~~'" :L L'f"), '7 ~
I
Women·s health: a cor e curricul um
9 Medic al diso rders In p regn a ncy
maternal age, a previous magosgmjc infiJlt or develo ~ment of raised baemnocri r wd neopalil' Diagnosis
Wlexplained fetal demise. Some ethnic groups (e.g. hi'Perb'irubinaemja. _ nn a!jties in babies of WOmen wi th pre-
indigenous Australians, Pc:!:::an and Indian Admissions to neonatal intensive care WlitS If a screen test is positive, a confirmatory test is pregnancy diabetes. In all women with abnor-
women) are at pamCularly ~sk of developing occur more ofren and perinatal mortality is reqUired. Common diagnostic testS include either: mal glucose tolerance in pregnancy, fetal growth
GDM. should be assessed clinically and by regular
increased. Neonatal complications include hypo-, • ~ 75 g glucose tolerance test that yields a fast-
glycaemia and hypocatcaemla, the latter bemg ultrasound to Identify growth restriction or
Ing glucose greater than 5.5 mmol/L or a
Pathophysiology attributed to reduced parathyroid hormone syn- 2-hour result of greater than J.-;nmollL
accelerated growth. Fr eks onwards,
cardlo" c a h , be er
Normal pregnancy is characterised by hyperplasia thesis. Compared with infantS of similar gesta- (Hoffm~ et al1998). A 2-hour cut-off level of ,as
9 mmo'!~ IS used in New Zealand. t ere IS an Increased rlS 0 sudden intrauterine
of pancreatic beta cells, increased insulin secretion tional age, infantS of mothers with diabetes have
fetal death. However, the cJinical effectiveness
and insulin sensitivity in early pregnancy, followed less surf~ctant production and are at increased risk • A 3-hour 100 g glucose tolerance test, taken
of thIS approach is not weJl established.
by a progressive increase in insulin resistance. of respiratory distress syndrome. after .overnight fasting and carbohydrate load-
Induction of labour rna be c ' red after 38
Placental diabetog~c bormones, such as growth mg, IS more commonly used in the United
States. wee s gestation In women with 0 0
hOnnone, progesterone and corticotrophin, lead Signs and sy mptoms tro e " , VI ence that peri-
to changes in maternal carbohydrate metabolism natal mortiih1y IS Increased in the presence of
during pregnancy. These hormones rise linearly A woman with gestational diabetes is usually Therapy
asymptomatic and diagnosed after screening for weJJ-controJled gestational diabetes.
during the second and third trimesters ill orCJef..u, Good glycaemic control is important in labour.
sup~owing ferus consrandy with sufficiwt the condition. Alternatively, she may have symp- '
toms of hyperglycaemia (polyuria, polydipsia) or a Lower insulin requirements are common in
n~ - glucose and am;;o ac~. The mot.Mr labour, and hypoglycaemia should be avoided.
~ from carbobydiaL tg _ w!:!abfjIWTI, large-for-gestational-age ferus.
Elecrroruc fetal monitoring is advisable.
utilisinr. free fatty acids, triglycerides and ketones Close neonatal fo Uow-u is iill artant arti-
Screening
fanue . .
~rmal pregnancies, blood glucose levels fall There is controversy regarding which women
e a: or e eteenon 0 emia and
:.:,splratory stress syn orne. Breastfeeding IS
by 10-20% owing to ' increased storage of tissue should be screened and how to screen for gesta- acdvely eHEolliaged.
glycogen, increased peripheral glucose utilisation, tional diabetes. Some guidelines recommend uni-
decreased hepatic glucose production and fetal Prog nOSis
versal screening of pregnant women, and others
glucose consumption.
suggest testing only high-risk groups. Approx- Most women become euglycaemic after delivery
In estational diabetes, there is gr-eater insul ' ,
resi rure m sec e
imately one-third of women with gestational dia-
betes will be missed if risk factors alone are used to
as somatomamrnotrophic hormone produced b; ..
p~ Hyper ycaemia is associated with an the placenta has a short half-l ife.
. increase in maternal and fetal complications. The guide screening. Women with abnormal glucose tolerance
maternal same!.e of gestational diabetes include The optimum time for screenin is 24-2 have a 30-70% increased risk of recurrent gesta-
an mcrease risk of pregnancy-mdu ed hyperten- weeks' estanon, w en insulin resistance increases. tional diabetes, ,the higher rate being reported in
sion and preeclampsia, premature delivery and t e present orne, ere is a ac of high-qu ty the non-CaucasIan population . Higher pre-preg-
caesarean seenon. evidence regarding important health outcome nancy weIght and a, hIstory of a large infant are
Women wuh pre-pregnan~ diabetes have an measures related to screening for gestational dia- assocIated, Ith an Increase d risk of recurrence.
increased risk of fe@ congen! abnormatities, in betes. The Australasian Society for Diabetes in The nsk of developing type 2 diabetes meJlirus is
particular cardiac detects and neuraJ rube deteers. Pregnancy (Hoffman et al1998) recommends uni- up to 50% over the following 5 years. There is
Later UiItuences on me tHus depend on the degree versal screening. emergrng eVidence thar the incidence of obeSity,
of maternal hyperglycaemia. An oral glucose challenge test performed at insulin reSIStance and diabetes is increased in the
FetalJlyperglycaemia stimulates hyperinsulin- offsprmg.
24-28 weeks' gestation is used to screen for gesta-
aemia, which leads to stora e of excess energy and
aces erate gro . S IS maru es S as mago-
tional diabetes. Two variations are described with The
W~)[Denla
2r~~, ~~~endati~~ f screen
~: f VEt; : pbetes -at
positive resultS:
somla, With resuTting increased rates of shoulder 6 weeks postpamun and ths! rg cgntinue to
dystoCla. and birth trauma. • a serum glucose level greater than 7.8 mrnoVL section screen tor diabetes at least every two years
Polyhydramnios IS caused by hyperosIDplar 1 hour after a morning nonfasting 50 g glucose (Hoffman et aI 1998). Women who have had ges-
fetal 01 ria and may precipitate reterm labour. load tational dIabetes should maintain ideal body
e mcrease c rate an 0 en • a serum glucose level greater than §Jl. mrnoVL Fetal monitoring weIght and exercise regularly to decrease the risk
requirementS may partly :=rlain e !perease risk 1 hour after a morning nonfasting 75 g glucose An ul of future diabetes , There is no strong evidence that
or llltrauterme asphYXla:tiey also lead to tlie load. gestational diabetes predisposes to a later risk of
hypertensIOn.
I'F
9 Medica l d isor d ers in pre gna nc y
Women's hea lth : a c ore curricu lum
accompanying evidence o f maternal cerebral, but once preeclampsia has begun it runs a pro-
Contraceptive advice should be given in the Type of Characteristics
renal, hepatic or clotting abnormalities, or fetal gressive course until delivery.
puerperium, and women should be advised to hypertension
De !l~VO trt~2ttitl§I~!l arlsln~
growth r estriction.
plan future pregnancies with careful attennon to 1. Preeclampsia Clinical assessment
Offer 20 weeks' gestatlo n, In developing countries, preeclampsia remains
good pre-conception blood glucose controL rmorl'Hng Fo normal within 3 one of the most common causes of maternal death Preeclampsia is detected initially in most cases by
monmspoi!Od@tD and a common cause of death in young women. the presence of hypertension arising after the
and ane or more or: Death may occur from acute hypertensive crisis, 20th week of pregnancy. It does nor occur before
Health maintenance p~a - ~3()() mg/dafr
spat urine albumln:creOflnn e
mkam£Ti' acute pUiIDOnary~edema, acute
ure, 'ver failure, haemorrhage or co::.:a~,."
o _ __
the 20th week, except in the rare case of hyda-
tidiform mole. S~s are not always present,
In women with diabetes mellitus, nor-
ratio (ACR ) ~30 mg/ mmol or but may comprise severe headaches, convulsions.
malisation of blood glucose levels d ipstick proteinuria persistenHy
Ii'i1Iie developed workI; maternal mo .ty is now
before pregnancy reduces the risk of uncommon, although occasional cases still occur s~e, re eated visual scotoma (all manifesta-
~3 gIL
fetal congenital abnormalities and despite the best possible management. Perinatal tions of cere r lnvo vemenc), severe epjga§qjc
facilitates optimal control during Rena/Insufficiency - pl~ or right upper quadrant pain (reflecting hepatic
creanmi'ie ~1;I!l ~ mollL mortality is of the order of 20-35 per 1000 cases.
pregnancy. Identification of abnormal ischaemia With pOSSi ble subcapsular haematoma
glucose tolerance in pregnancy ~as Uvw distiase - AST >50 IU/L
and/or severe epigastric/right of the liver or even li ver rupture), ~ (due
lifelong implications for a woman s to acute renal failure) , bleeding ~use d by dis-
upper quadrant pain
general health. se minated intravascular coagu \:tion (DIC::) ,
Neurol0fl.'cal Qr51~b2~i- -
convulsions (eclampsia); lower abdominal ~ain ca used by abruptio-pTa-
hyperrenexla with clonus; centae" re duced G I wgyemen n or fetal denuse.
*
S' g hegdgches with hyper- -rIi'most cases, however, clinicians must search
re for evidence of maternal or fetal abnormalities in
Hype rtension Haema/olog/cal dlsturbances preeclam psia. Routine h sical examination
0 : sho uld include assessmeot 0 e 0
haemo~
Common clinical presentations fe e ra e, e etecnon a epl!lastric or ri~t
2. Gestational De nova h~ensl o n after
A primigravida presents In the antenatal clinic upl'er quaarant tenderness, and assessment ott:e
hypertension 2 weeKS' eSlanon~ 1
at 36 weeks' gestation with 0 2-<:1ay history of a~...QI!'Ler eature o f
multi Ie re an connective tis- reflexes, parucUlariy Identification of clo ous as a
headaches, a blood pressure of 160{1 05 and preecfgmgs o , re~ sue or ers a esl ear re ancy sysro c P warmng SIgn of unpendlOg eclampSia.
2+ proteinuria . no rmal wtthln 3 months post-
p~
> mm g, ck race an pass! m
boptlilias. Smokiflg appears to reduce e llkeb-
om- In general, only a few laboratory tests are
required for the full assessment of preeclampsia
Two days after a normal delivery of her second
3. Chronic h15tcr01' developing preeclampsia but babies of (Table 9.2). Fetal growth is best assessed by
baby, a mother feels nauseous and unwell,
and proceeds to have a tonic clonic seizure. hypertension smokers tend to be small for gestational age. Test Significance
a . EssenHal BP ~ 140 mmHg systolic and/or Underlying renal disease also increases the risk
A 38-year-old woman with chronic high blood hypertension ,,90 mmHg diastolic ~ when there is preexisting r enal impairment, Hoemoglobln Haemolysls: bleeding
pressure o n antihypertensive medication wants ceoti on or in the nrst half of Hoematocrit Haematoc rit , 0.40 renects plosma
hypertension or proteinuria. The placenta appears
to know what medication Is safe to take during pr~rran<N' W1TI'!a ar- volume contraction
en secondar1§use or evi- to be the culprit in causing p reed ampsia, with
pregnancy. dence of WHire:coar hyper- other maternat organs such as the kidrieys perhaps Platelets Platelet count < 150 x ]09 is abnor-
tension mal, probably due to Increased
being amplifiers of the disease process.
plotelet ocHvatlon
b . Secondary H~Cill!ilgll gl.li! to renal or PreeclamJsia is characterised by the patho-
Creatinine Plasma creoHnine ,,90 ~mol/L
hypertension a renal d isease physiologic triad of: reffects Impaired GFR
Definitions TABLE 9.1 Cla ssific ati on system fO I h y pe rten - Uric acid Plasma uric acid ~0 . 35 ~mol/l
H ypertension occurs in about 10% of pregnancies sive pre gn an c ies renects Impaired rena l tubular func-
and is defined as an absolute blood pressure Hon
greater than or equal to 140/90 nunHg. It IS clas- Hypertension in pregnancy Aspartale AST , 50 IU/L Indicates hepatic dys-
sified as follows (see also Table 9. 1) : function in preeclampSia
The development of elevated blood pressure after Proteinuria A s~gt wlgmlilgW Utig~ cltu Ig;tir;n:a:e-
• arising de novo during pregnancy (gestational 20 weeks of pregnancy without evidence of mat- atinlne ratlo e Fn~~
hypertension or preeclampSia) ernal organ dysfuncti on is known as gestational creQflHioe In I
• present befo re pregnancy (chronic, usually teln excreHon.
hyp ertension . Preeclampsia also refers to hyper-
essential hypertension) . TABLE 9.2 Laboratory In v e stigation of
tension d evelo ping in the second half ? f preg-
• preeclampsia superimposed on chrom~ hyper- p reeclampsia
nancy, but this more serious disorder . mcludes
tension.
lit
Women's health: a core curriculu m
9 Medical dis o rders in pregn ancy
ultrasound, and fetal wellbeing by a combination • inability to control blood pressure in a subsequent r.re~ancy. Women who have
oTCaraTotocography and ultrasound assessment of inadequate letal grgwth. presented at or beor?S weeks of gestation may Health maintenance
bio~:fiKal profile and utenne mea resIStance. It have a highet risk of recurrence. Early presentation for antenatal care
slio be stre sed that none of the assessments of AntihYJ1ertensive m edications are usual ly
fetal wellbeing provide any long-term certainty given if e systolic blood pressure IS persIs- . The traditional view has been that preeclamp- facilitates identification of chronic
about fetal outcome. tently ~ao mmHg a1lti

Oi diaseotOmSl!re
~o mm g, aIthough t~ choice 0 the exact
sIa IS not assOCIated WIth long-term health risks for
the mother, although gestational hypertension _
hypertens ion and risk factors for
development of preeclampsia .
Regular antenatal care allows early
blood pressure level at which treatment . is particularly when recurrent - prediCts a greater
Eclampsia likehhood of later essential hypertension.
detection and management of the
required remains controversial. For such chronic often asymptomatic hypertensive
treatment, several agents may be used, However, it is now thought that long-term cardio- disorders of pregnancy.
including methyldft};a, o~re nolol, labetalol and vascular and cerebrovascular risks are increased in
clonidine as hrst- e agents. ~ hen addltlonal women with preeclampsia or geStational hyper-
treatment IS reqUIred, hydralazine, nifedipine or
prazosin may be added. Angiotensin-converting
enzyme (ACE) inhibitors, angiotensin II (~
receptor antagonists and ~ are ~y
tensIOn.
Gestational hypertension * Thromboembolic

d isease
a~ the first two groups cause a fetal
hypotension syndrome and diuretics reduce an .- Common clinical presentations
already impaired maternal blood volume.
HELlP syndrome Blood pressure ~170/110 mmH re uires acute
gestation In her third pregnancy for routine
HEllP syndrome (haemolysls, elevated liver treatment er to revent mate oke antena tal review. During the consultaHon she
enzymes and low platelets) IS a subcategory of an~r e ampsla. IS setting, in~s complains of a swollen . sore left leg. .
preeclampsia. Although sometimes regardedas a hy r azme or mtravenous labetalol are most com-
separate entity, HELLP simply refers to a severe mo@y used. o@ IiiJedipme 15 al 0 usefUl. One week after an emergency caesarean
form of preeclampsia in which the hepatic and MagnesIum sulfate is the dru~hoice for section under general anaesthetic for fetal '
co nvulSion prophylaxis. It is a stered to distress. a 25-year-old woman presents to the
platelet abnormalities dominate. Clinicians should
continue to look for all the other potential those \~omen who have already bad a conYUl- emergency department with breathlessness.
complications of preeclampsia in such women. sion an IS otherwise reserved for women who A 34-year-old woman presents to her general
have severe ttIfi'ptomatic preeclampsia, hyper- pracHtroner for advice about her next preg-
Prevention ~Ia or 0 er diIIj@ evidence of cereOraJ Chronic hypertensio n nancy. During her third pregnancy, she was
involvement. d iagnosed with deep vein thrombosis and
Unfortunately no set of tests has reliably predicted In most cases, this is due to essential hypertension treated with low-molecular-weight heparin unNI
the development of preeclampsia. Low-dose a.nd, unlike preeclampsia or gestational hyperten- 6 weeks postpartum . .
Postpartum m anagement
aspirin reduces the risk of developin~reeclamp ~I~n, It IS apparent in the first half of pregnancy. It
~ but apprOlamately 100 women ne thiS treat- Recovery should be anticipiued over 5-7 days fol- IS unp ortant to exclude 'white-coat' hypertension
ment to prevent one case (Knight et al 2000). It is lowing - delivery in most women. OccasIonally, with 24~hour ambulatory home blood pressure
best reserved for women considered at highest panents may take up to 3 months for all the fea- Thromboembolic disease encompasses thrombot-
morutormg before making a certain diagnosis of
risk; such as those who have expenenced a tures to resolve, and a few patients will have essential hypertension. IC events (deep vein thrombosis - DVT
generally of the lower limbs, superficial throm~
~ious fetal loss due to preeclampSIa or who proteinuria that takes up to a year to disappear The main risks of chronic hypertension in
have prevlOus0 re;i1llred very earty de!ivery completely. pregnancy are : bophlebitis and thrombosis of other venous
because gf t hiS g]wrWr - systems such as hepatic or portal veins) as well as
As~s~~~~~~~~~~~~ fetal growth resrriction embolic phenomena, both venous and arterial
months os artum i ato . ressure
Treatment sh ave returned to normal within 3 months. • accelerated maternal hypertension (pulmonary embolus - PE, cerebral and other
If it oss not, t s s ou prompt a seare or • superimposed preeclampsia (in about 25% of end-artery systems). This chapter discusses only
underlying essential or secondary hypertension. cases). DVT and PE and their relationship to pregnancy.
Urinalysis and urine mjcroscooy should be nor- P~on= embolism is a mabor cause of
mal, certainly by 12 months postpartum, if not Wire ;! rnriljr;r, and bVi mdE are major
• progressive evidence of maternal gcva n dys- n
before. this is not the case, a pnmary underly- contributors to maternal morbidity. Pregnancy,
fu~ worserung renat or hepatic function, ing renal disease should be sought. DVT and PE are closely linked, as pregpancy is a
worsening thrombocytopenia, development of As a general rule, preeclamosia or gestational rothrom botlc state WIth an increase in coa 1-
neurological symptoms or signs hypertension will recur in about 15% of women [Jon actors, eVI ence 0 0 asmino-
gen activation, and impairment of yenous retur. p
..-
9 Medical disorders In pregn a n cy
in the lower limbs. Pregnancy may be associated Pulmonary embolism after consultation with a haematologist. Patients References and further reading
with other risk factors, imrnobilisation (hospitali- Without a c10ttrng tendency usually have postpar-
sation) and surgery (caesarean section). tum prophyl3.XJ.s but not necessarily antenatal Cousins L 1987 Pregnancy complications among diabetic
prophylaxis. women: revieW 1965-1985. Obstetrical and
Deep vein thrombosis Gynaecological Survey 42(3):140-148.
The prevalence of DVT is less than 3 per 1000 preg- Prophylaxis without DVT Divakaran TG, Waugh J, Clark TJ et aI 2001 Noninvasi ve
nancies. Thrombosis often startS in the calf but only techniq ues to detect fetal anemia due to .red blood cdJ
TbromboEfog,hv w with heparin in £!3!gpaocy alloinununizarion: a systematic review. Obstetrics and
thrombosis above the knee produces dots large mQ be o$r;;C;; ummen WIthOut a hiStory of Gynecology 98:509-517.
enough to create a significant risk of pulmonary DVT/PE who have a thrombophilia or possibly a
embolism. Alone, superficial thrombophlebitis in strong farruly hiStory. Some obstetric units offer Hod M, Orvieto R, Kaplan B 1994 Hyperemesis
the leg or thigh is unlikely to generate aPE. prophylaxis post-caesarean section for all patients gravidarum: a review. Journal of Reproductive
Medicine 39:605 .
DVT occurs with e uaI Ere uen in each whereas others offer this intervention only wher~
. ester but other rIsk factors coexist. Hoffman 1., Nolan C, Wuson JD et aI 1998 Gestational
Ri,tJ$..factors may h.e considered in two grQ'1PS: diabetes mellirus - management guidelines [consensus
DVTs occur in the e eg or ater y. is sug- ~le and a~le. The former include statement], the Australasian Diabetes in Pregnancy
gested by signs and symptoms that include pain, maternal age over 35 years, high Parity, ~: SocJ<ry. Medical Journal of Australia 169:93-97.
swelling, oedema, heat and redness. As swelling is a persona:t or £3illlly hiStory of throm1Josls, _
Knight M, Duley 1., Henderson-Smarr D], King JF 2000
common symptom in late pregnancy, it has poor bophilia syndrome or malor surgery. Av~e Ann·platelet agents for preventing and treating
sensitivity as a sole symptom. Unilateral or early- nsk factors that demand arrenoon indu~ preeclampsia. In: The Cochrane Database of
trimester bilateral swelling should be taken seriously. ~n, Immobility, pree~lampsia and r;:,a~ok Systematic Reviews (rhe Cochrane Libtary), issue 2:
In re an there should I w res old Intercurrent liifecoon or Illness. Multiple ns CD000492. Online. Available: http://www.update.
factors fiiitlier Ihtrease an individual's risk of somvare.comlcochrane.
for eJ<! u n . iagnostic investigations are the
same as for non-pregnant panents except for the thromboembolism, and prophylaxis should be Langer 0, Conway D, Berkus M et aI 2000
value ot the D-difiler test: the D-diriier IS usuany cOrISidered. .
A comparison of glyburide and insu/in in women with
elevated In pregnancy and especially postparnun. gestational diabetes mellirus. New England Jourrul of
Ultrasound - usuaJIy compreSSlOn Ultrasound - is Heparin Medicine 343 (16): 1134-1138.
e Low-molecular-weight heparip is becgmipg tb e NHMRC 1999 Guidelines on the prophylactic use of Rh D
stanfod anticoa@l4iit used during pregnancy immunoglobulin (anti·D) in obstetrics. Online.
~a In the noo-pregnant state. It is..wgrs expell- Available: http ://www.health.gov.au/n/unrc.
slve 9ut regtllres little monitorin~and is assocj<u:-
Queenan J 1999 Management of Rh-immunized
ed .lYlth a reduction in the side eeets comwpolJl pregnancies. Prenatal Diagnosis 19:852-855.
seen~th untracoonated he~.e. o§.t eoporo-
~ om60cytog;rua and be . Symonds EM, Symonds 1M 2004 Essential obstetrics and
gynaecology, 4th edn. Churchill Livingstone New
~~ ,
The risk ot thromboembolism is

increased in pregnancy. cabi mu,st
b~ laken 10 address avoid a e
tacrg!s such a s immoclIi$gfj on,
Inre li on and dehfcdrallon, which
p rdmo te venous s asis and platelet
activation. Prophyl axIs should be
consIdered in indivIduals c onsIdered
at Increased risk . There shOUld be a
loW IhresMold for Inyestjggljpo pf
venous I romboemboJism a n d
prompttrealmen t .
...
It..
Women's health: a core curriculum 9 Modic al disordors in p reg nonc y
Questions b , Is managed with

iron per day -
¥a mg elemerJ.Ial
~
@ n creases perinatal morbidity .,/' 11 , Therapy for pulmonary embolus In
d , can be prevented / pregnancy:
Select the correct answer(s), 12\15 characterised by low seru n V '
r;l associated with an increased a, is commenced using ther;!lpeutic
1. Which of the following are Important In V ferritln, ~aesarean section rate, -V'" doses of warfarin ./
the investigation of severe hyperemesis d. commonly causes a macrOcyti /
gravidarum? /. anaemia 9, Preeclampsia: /
@ AurinedipstiCk examination ~~ _ e. is associated with increased fetal a, is characterised by convulsions ./' c. itially involves intraVenous / '
(§) Haematocrit ./' ~M-~",",) loss , b, should be treated with aspirin in all . /
unfractionated heparin
(9 Thy roid function tests ~\RI"~roJ(!"", \so

patients d. always requires the addition of a / "
Which of the following statements
d. HCG estimation /' regarding isolmmunisation is true? Pc\;s defined as hypertension plus . / vena caval filter
G
~~I _
An ultrasound examination VI""""\J#J'f,
, W-Qol(.) Ib.\AII Rh(D)-negative women should
I V have their red-cell antibodies
/ \ : Iorgan Involvement In pregnancy
e . with heparin puts the fetus at risk as ~
d, is always associated with growth./' It crosses the placenta.
2. Which of the following are recognised
checked at 26-28 weeks' gestation , / restriction of the fetus
complications of hyperemesis b. h(D)-negative women who have o n e . can be safely treated with ACE / 12. Thromboprophylaxls in pregnancy
ectopic pregnancy should be given .' inhibitors. should be:
gravidarum? /
Rh(D) immunogobulin,
a Dehydration 10, Deep vein thrombosis In pregnancy: a , offered only to women with a history"'"
. V c, A woman who is Rh(D)-negative / of pulmonary embolus
esophageal bleeding (with no red-cell antibodies) and \AcXPa, occurs in 1 in 100 pregnancies ../
~
, Intracranial bleeding gives birth to an infant who is Rh(D)-
b. is diagnosed with D-dimer ../ ered when there are multiple ris k /
... positive does not need anti-D
immunoglobulin, fC:I may be treated with low-molecular· , / '
,""w eight heparin c.
f ctors
Iv en to patients with a ./'
d , If an Rh(D)-negative woman's ./'
hrombophilia syndrome ../'
partner is Rh(D) positive, the babY"" d, is always associated with a .,,-
3, Physiological anaemia of pregnancy: wil l certainly be affected by HDN . thrombophilia syndrome ~ @ With SUbcutaneous heparin
a. esults from Increased plasma ./' e , he disease process is likely to be e . is treated for 12 weeks w ith w~. e, with low-dose warfarin , ./'
olume more severe if a woman has had
b, results from decreased RBC mass . /
antibodies In her previous
pregnancy,
~~ b~~
c. is greatest at term /'
7, Gestational diabetes: ~\\) f- V/~'f\ \J ~~ r,
d, results from decreased plasma
volume and Increased RBC mass
/'
a, occurs In 25% of pregnancie J ~ ~'\\- _(u-Avw- '
G )esults from decreased iron stores, """ ( 9ma y recur in subsequent .,/'
pregnancies
4, Microcytic anaemia: 01ncreases the risk of preeclampsi /
~
a. results from low vitamin B12 . / f treated, Improves maternaY-
urvival
b. has an MCV >100 fL '/ ./'
, ccurs more frequently in women /
c , requires further Investigation with
with a higher body mass index . /
serum Iron and Iron-binding
before pregnancy.
capacity ~i\."V\ ' .
d . esults from Iron deficiency ,./"/ 8. Abnormal glucose tolerance during
pregnancy:
e, causes significant fetal morbidity,
~ccurs because of increased ins;:!Ln
5, Iron deficiency in pregnancy: / ~(eslstance V
a, results from increased maternal RB @ ncreases the risk of later type 2 ./
mass diabetes '"
ItA
Infections in pregnancy
Michael Humphrey and Ajay Rane
Edited by Vivienne O'Connor
Learning objectives
Knowledge Other infections
summarise the eHects of other common
At the end of this chapter, the student infections on the mother and fetus/
will be able to: neonate
• discuss the time sequence of fetal • outline the diagnostic procedures for
organ development In relation to each infection in pregnancy
possible teratogenic Influences
describe available tests to confirm fetal
Rubella Infection
describe the consequences of maternal outline management options for each
rubella Infection in pregnancy Intection
discuss the Importance of pre- Chorioamnionitls
pregnancy counselling, antenatal
screening and primary prevention by oulline the aetiology of preterm
vaccination prelabour rupture of membranes and
preterm labour
Hepatllts B
list the common causative organisms tor
list the modes of transmission of chorioamnionitis,
hepatitis B
• describe the consequences of maternal Skills
hepatitis B Infection
• describe the serological tests for
should learn how to:
hepatitis B
• outline a management plan for an • explain to a pregnant woman the results
infant at risk of hepatitis B of rubella and hepatitis B antibody
screening tests
Urinary tract Infection
instruct a woman how to collect a
• state the significance of urinary tract midstream specimen of urine.
infection (UTI) and asymptomatic
bacteriuria in pregnancy
explain the predisposition to UTI in Attitudes
pregnancy
describe the clinical and should reflect upon:
microbiological diagnosis of UTI
outline the management of UTI in the maternal anxiety engendered by an
pregnancy uncertain prognosis, particularly when
tetal or neonatal infection may not be
• list appropriate antibiotics used for evident for several weeks after maternal
treatment of UTI in pregnancy exposure,
\ NV\ 'tf
10 Infecl lons In pregna nc y
Women's health: a core curriculu m
* Rubella
Impact/outcomes
If a woman believes that she may have been
exposed to the 'wild' rubella virus in pregnancy, she
Time period
0-2 weeks
Susceptibility
High rate of lethality
Usually not senstlive
Events
From fertilisation to complete implantation of blastocyst
In endometrial stroma
Uteroplacental clrculo~on established
should have paired sera examined 10-14 daYs 3-8 weeks Organogenesis Embryonic development In a cepholocaudal fashion
A pregnant woman Is concerned because a a~ looking for a ch3llge in rubella IgM and IgG Rme of greatest susc epHbllity Susceptibil ity stgrts with ayes and brain , then movin
child at her doughter's preschool has a rash . antibodies (lgM rises 7-10 days after primary infec- ac1 ; Ss own peak o f towards lower limbs g
A woman discovers that she Is pregnant shortly tion). As laboratories may use different types of susca AgePifS causing serious defects Include viral Infeetons
rubella antibody testS (enzyme-linked immunosor- qlcohol, maternal diabetes, med!cgt1ons '
after being vaccinated against rubella.
bent assay - EUSA, haemagglutination inhibition 9-40 weeks FunetonaJ maturation Fetal development can be affected by agents such as
and immunofluorescent antibody assays), it is wise Suscepltblllfy decreases alcohol or clggrette products
to test the paired sera together in the same labora- Effeas depend on dose a nd duration of exposure
Epidemiology tory. Rubella immune serum globulin does not
TABLE 10.1 Fe tal susceptibility to damage during development
appear to be a useful post-exposure prophylaxis.Jn
*
Rubella is a ribonucleic acid virus causing a
v ess assoaate Wl a e macular the event of a s~cant rise in rubella antibodIeS
rash. It commonly occurs ill childhood but can withill the fuSt lU weekS of Dreftang.. termina- inf..:,cnous Datie ; the patient with chronic he~t Uri na ry tract infecti o n
tion of pregnancy shoUld be offete to e woman. ons~d the pL-ant woman most likelY to q~_ s-
cause fetal abnormalities if it occurs in a woman at
less than 115' weeks' ~estation. Vaccinaoon IS usu- IDlt the mfecnon to her baby. Vertical transmission
Cammon clinical presentations
*
a1.Ifcarned out ill ch dhood. While rubella vacci- IS less likely when the anti-HBe antibody is found.
nation should be avoided during pregnancy, the A pregnant woman presents·with high fever. dysuna
recorded cases of accidental vaccination of women
He patiti S B Impact/outcomes and frequency, rigors and uterine controetons. .
in early pregnancy would suggest that the li:ts. Infection may produce a variety of clinical states A pregnant woman has recurrent urinary tract
attenuated virus in the vaccine is not teratogenic. varymg from ~ severe systemic icteric illness t~ Infections ond is found to have asymptomatic
A pregnant woman is found to be an asympto-
asympt0m.anc mfection, and resulting in a spec- bacteriuria.
matic carrier of hepatitis B. raising questions of
Pathophysiology trum of disease from full recovery and long-term
possible transmission to her baby and to
If a maternal viraemia occurs during the first mununlty to progressive liver damage and an
health core professionals.
a'ii'esrer of pregnancy (viraemia occurs 5-7 days mfecnve carner state. It does not a~pear to be ter- Pathophysiology
after exposure), there is an approximate 20% risk of ato!';1ms but fetal loss can occur, as WIth any other Urinary tract. infections are more common in
feb e I.llness 10 pregnancy. women than m men, owing to the shorter female
rransplacental fetal infection le a $ ous=ge Transmission of this deoxyribonucleic acid (DNA)
or to one or more con*,erutal ab~tles. r he"fat- virus is predominand;l via sexual or blood (via urethral length, whIch makes bacterial contarnina-
ter may IOvolve eyeJectS leadiIlg to vision loss,
Management non of the urethra and bladder a common occur-
injecting drug use) contact and by vertical trans-
hearing loss, cardiiC"defuctS, intellecruafdI.Saljility N~wborns at risk of vertical ttansmission of he a- rence With sexual activity. The majority of urin
mission to the neonate. tract mfccnons are due to Escherichia coli ary
and befui'y!ouraI abn ormalities (the congenital tms B should b$ Efven nepanps 1$ Iwwppe glbb-
rubella syndrome). iVGteu"r jofectjoo in later uIin (HEIGl within 12 hours of birth and a The combination of decreased ureteri~ muscle
Diagnosis
pr~ ns;y has a lower incidence of fetal problems, subse uent course of active he and s Bva~cination tone and peristalsis, altered bladder tone and
e.g. thrombocytopenia and vasculitis (the expanaedThree antige,!).s are measurable in ass~ation with shou e commenced wit lD o ur mcreased bladder capacity (due to the high levels of
congenital rubella syndrome). The maximal risk to.the hepatitis B virus: the ~ (HBeAg), the b,fuE; Breastfeeding is not contraindicated under progesterone and rela.--..:in. in pregnancy and to
the fetuS occurs in the ~t weekSif§,~:cy,
8 core antigen (HBcoreAg), and the surface antiv.en m ese CIrcumstances. uretenc compresSIOn by the gravid uterus at the
ana armost
is nonexistent1)x 16 weeks~ gesr;r;ox;.(HBSAg). pelvIC brun) leads to u . stasis and vesicoureteric
A positive test to the surface antigen (HBsAg) reflux. Conse uencl , e re ant wo gil
Signs and symptoms denotes ~t or present contact with the virus, and nsk
tra .
of bo tomatIc an .
c~
.
the anti-HBs antibody is found m unmune and Universal. vaccination programs should
Infection with the RNA rubella virus usually pro- all but eliminate congenital rubella
immunised individuals. Unlike the HbsAg, which is
duces a mild febrile illness with a fleeting rash and are of major importance in red'uc-
associated with the viral protein coat, the e antigen
1~-14 days atter exposure. 109 the Impact of hepatitis B on the Signs and symptoms
(HBeAg) and the core antigen (HBcoreAg) are asso- neonate. Pre- re non e vaccination
ciated with the viral DNA The H&oreAg is USIl- Presentations vary from a severe febrile illness with
Natural history sh re
alll. confined to infected hepat~and is rarel.Y and wom ilistrertebral angle and suprapubic tenderness to
lmmuni follow io a rubella infection is u uall found in se~ and the ann - core antibody is tQ..Cllbe lla dl!rj o g pregnancy should be e . ncling of SIgnificant bacteriuria in an asyrnpto-
~e ong..an c · 00 vacclOanon programs are usuaJ]y the ~o appear in an infection. The find- offered postpartum Immunlsaft on. manc mdivldual. The most cornmon presentation
ing of ~Ag in serum often denotes the h.ig];!Y
e most cost-effective means of preventing the consiStS of frequency, dysuria., urgency and nocturia.
congenital rubella syndrome.
10 Infections in pregnancy
Diagnosis * Varicella zoster virus VZV =q~~ in the Seriparrum period sho!!ld
begixen
eriCOUraged.
va
and reastfeeding should be * Cytomega lovirus
Common clinical presentatio n
*
A pregnant woman who Is not Immune to
varicella zoster virus has Significant contact A pregnont chlldcare worker asks about the
with a child who develops the rash of chicken- Pa rvovirus 8 19 consequences of contact with a child Who Is
pox 1 day late I. known to Chronically excrete cytomegalovirus
In her urine.
Management • A fetal death, secondary to the development

Treannent of any pregnant woman with UTI should Pathophysiology of hydrops fetalis, occurs after a minor mater-
nal febrile illness. Pathophysiology
include advice about ~ fluid intake .and ~ The varicella zoster virus (VZV),. which causes
Ce~ (250 mg or y 6-hourly), ~ chickenpox and herpes zoster (shingles), ~ Cytomegalovirus (CMV) is a member of the her-
toin (50 mg orally 6-hourly; best tolerated rn the risks for both the mother and the feros if infeCtlon pes virus group and is the virus most freQuemly
~olide form) or amoxicillinJ~otasSlUm clavu- occurs dUTIn¥ pregnan~ The usual rncubauon Pathophysiology transmitted to a feI!!S. Illf.;,crious CMv max.,be
l~te.J.2501125. mgoratiy 8-houry) are the most penod IS 10- 4 days, Wl infecoVIty lasont.from. Infection with parvovirus BI9 causes a cornmon fo~nd in wine" s~~ blood, := sem,!!1 and
app ro~riate anoblOocs, and should oe contmue~ 1 to 2 days before the rash appears un@ an esions childhood febrile illness known as fift breast mill<, and rh s eddiiiiOf ~rus may rake
for at east 10 aay:;. 1 fie rising i denc; of E. co!t
reSIstance to amoXlcillin makes an rnappropn-
ate anoblooc to use ruane, UDJess the orgarusm IS
known to be sensitive. .
-
are crusted.
Im pact/outcomes
e
drome .
ema infectiosum or s a syn-
orne rop et spread leads to symp-
toms 4-20 days later and, classically, the illness
place Intermittently, WltbOiltanY detectable si,l2!s
and Without causing symptoms.
Symptoms and signs

PregIlant women presentin~ with a seve(e febrile lasts 1-3 weeks wjth a cbamgerjsdc rcd ra§h l1fi
. ess and ossible sepocaerrua sha uldlJe treated the cheeks and a lace-like rash on the trunk au
d
m rn a lliiiEs that may tade and reappear. Up to one-third
oTaaUits with this infection are asymptomatic,
Diagnosis
Parvovirus B I9 IgG and IgI\1 antibodies measure-
ments will show a rise in titre in the presence of
infection.
-
Impact/outcome
Primary CMV infection occurs in 1-3% of ~regnant
Management wmIlen. andis US~y asymptomatic. It IS, owever,
Impact/outcomes the most impoltan use or COD enital viral infec-
No treatment or vaccine is available. .' . 4 ecnOlL ~
Subsequent to the sue
in
shoul
e
esta
a ro am of re
e
eatment of UTI dur-
Management Outcome /impact
risk 0 e
infectiog maY lea to a gene
rh~ wirh an SAM nsk 0 compllcat1ru16
'7
infecoon in
recurrence . A varicella-seronegative pregnant wOII,lan \1{ho within the first few years of life, Indu~ h~g
"'OC'CaSi'onally, recurren! infectjQn~ make propby- has a sl .{icant e osure to VZV mEe ~ISlOn = M!tm@' and vatyJ,ng degre_ of=---
laxis a~ODriate Wlth rutrofurantorn (50-100 mg s ou e oHered zoster unmune J? 0a (ZIG) tal retardation. Alternatively, rhe infant may be
oraJIy ~ynor dle remamder of tln!-pregnancy. within 72 hours of exposure. Varlce a~se~oneg ~ with no symptoms at birth, and subse-
atIve pregnant women who have a slgmflcant quently may deVelop hearing and mental or coordi-
Health maintenance exposure to VZV and do not receive ZIG, or nation problems. There appears to. be little risk of
who have risk factors for severe adult dlsease, CMV-related complications for women who have
The association between urinary tract should be considered fur prophylactic Ora ', ac:y-
infection and preterm labour is been infected at least 6 months before conception.
c~ Pre gnant women ;to ,develop yap cella
sufficient to warrant mlcroblolo~ical
examination of a midstream urine pneumonia Qt.p,her compcatlo ns of VZV (e.g. Management
specimen in the event of any urinary ha1iTIorrhagic rash, neurolOgical SignS) s~
sympfomatology. Asy,!,pton;atrc ge offered intravenous a9,c1ovlI, as sh,?uld preg- In rhe event of a CMV-specific antibody rise in a
bacteriuria should be Identrfled of fhe nant wo men receIvmg systerruc comcosterOid pregnant woman, amniotic fluid viral culture and
first antenatal visit. therapy who develop otherwise uncomphcated fetal blood antibody testing have been used to
VZV infection. Babies born to women WIth attempt to diagnose fetal CMV in fection, but nei-
ther test is reliably accurate. &, more th::~ 50% of
Women's heallh: a coro curriculum
10 In fe c tion s In pregnanc y
feruses are unaffected by intrauterine infection and

there is nQ known curative or pr0;fjylactic treat- is appropriate; clindamycin 600 mg intravenously,
men;, tegrlinaoon of pregnanCJ:, in e IDscance of given slowly 8-hourly, can replace the amoxicillin
pnmary maternal infection is controversial. and metronidazole in women hypersensitive to
penicillin.
* Toxopla smosis Outcomes Ur ent delivery of the baby should be consid-

ered: vagill IS e, as caesarean sec-
nonin ese CIrCUmStances may lead to serious
intraperitoneal sepsis.
Common clinical presentation
A pregnanl velerlnary nurse quesllons Ihe
safety of conlacl wilh cols. Symptoms and signs
These may include maternal fev" and/or
~ fetal tachycardia, uterine pain and ten _
:jJt: Health maintenance
Women known to be at risk of giving
birth to a baby with GBS colon isation
Pathophysiology ~~ Pf'~ labour and ~ or puruJem shOUld be treated with intravenous
amn10_ -- . ---- antibiotics In labour; potentially this
means thai 20-30% of labouring
DiagnOSis women will be exposed to antibiotics,
with the ~Isk that this Will lead to on
Full blood examination reveals a leuk~osis with a increase in the incidence of antibiotic-
Ma nagement neutroph jlia, and a cervical swab reve .targe num- reSislant bacteria .
bers of le~~es and pathogenic pacteQ!!, with an
Treatment of the carrier State is not successful absence? Ctobacilli. Occasionally, microscopy
in eradicating the organism. The incidence of neQ- and culture ot ammotic fluid obtained by amnio-
Impact/outc ome ?x
natal disease is sigpificantly reduced iprr3P?,!,J?" centesis may be needed to confirm the diagnosis. Further reading
anti blogCi : intravenous Gasta"we pe pJCdhn
2 x 106 u, followed by 1 x 106 U 4-houdy until Impact/outc ome Freij B], South MA, Sever]L 1988 Maternal rubella and
dslli:;ry; or clinctamycm 906 mg 8-hourly or e:rytli-
the congenital rubella syndrome. Clinics in
Prevention
rornycin 500 mg 6-hourly in the event of pemcillin
hypersensitiviry. In the absence of a rapId dia!;00s-
tic test, the current a roach to the use of
seS emia ~ the feros, preterm
ae
r
Chorioamnionitis ma'y cause pneumonia and/or
and ~I;I,
septicimia in the mgther. ere is eVl ence
that chorioamnionitis i a risF factor for cerebral
Perinatology 15(2) :247-257.
Heuchan AM, Isaacs D 200 1 The management of varicella-

zoster virus exposure and infection in pregnancy and
the newborn period. Australasian Subgroup in
parrum antiblottcs IS to treat orne whose
• The mo$u is at risk of significant postpar- Paediatric Infectious Diseases of the Australasian
babIes are at en n reterro labour.
rum endomC1J1!J!;" Sociery fot Infeerious Diseases. Medical ]oumal of
prolonged ru&; rure of membranes, kndWIi CBS car- Australia 174: 288- 292.
~ fever ill our).
Managem ent Vierorian Medical Posrgraduate Founda tion Therapeutics
* Group B Streptococcus * Chorioamnionitis

Aggressive antibiotic therapy is used to treat Commicree 1997 (on behalf of the Vierorian Drug
Usage Advisory Co mmittee) Anribiotic guidelines, 10th
chi5noamnionitis as soon as the infection is diag- edn.
nosed, and the antibiotics should be continued
after delivery. A combination . of gemamr!;,in Wong SF, Chan FY, Cincotta RB, Tils. M 2002 Human
Common clinical presentation Some days after prelerm prelabour rupture of
(~day intravenously as a sin e dose), parvovirus B19 infecrion in pregnancy: should
amoxicillin (1 g mtravenous y - ourly) and screening be offered to the low-risk population?
A pregnanl woman wilh previously membranes and maternal fever, a woman Australian and New Zealand Journal of Obstetrics and
me2".oructaZole (500 mg intravenously 12-:hourly) Gynaecology 42(4) :347-364. . .
documented Group a Streptococcus (GaS) develops fever, abdominal pain and uterine
colonisation wishes to minimise her baby's risk contractions, and a fetal tachycardia develops.
of neonatal GaS disease.
Pathoph ysiology
Epidemiology
Between 10% and 30% of wo men are asympto-
ma~y colOlllsed With Group B Streptococcus mem ranS§,.
I"~
women 's health : a c o re cu rriculum
c, should have a caesarean section to

Preterm b irth
Questions minim ise the risk of vertical
transmission of hepatitis B Regina Wulf
Select the correct answer(s).
r'd.\h ould have a program of hepatitis
1. A woman who consults her doctor \.:.;..a Immune globulin and active __ Ed ited by Martha Finn
after discovering that she was hepatitis B vaccination within ..r
Immunlsed against rubella 3 weeks 12 hours of birth to minimiSe the risk
after conceiving should be offered: of vertical transmission of hepatitis B
a . termination of pregnanc/y e . should be given acyclovir during

labour to minimise the risk of
@ eassurance vertical transmission of hepatitis B.
c . paired rubella IgM and IgG
antibody titres 2 weeks apart 3. Urinary tract Infections in pregnancy
are common because :
d . an 18-week gestation anomaly
a. Immunity is reduced in pregnancy
scan Learning objectives
b . the glomerular filtration rate is
e . chorionic villus sampling. reduced in pregnancy
2. A woman who is HBeAg positive: c . the vaginal bacterial flora become Knowle dge describe the investigations to confirm
more pathogeniC in pregnancy the diagnosis
a. should be isolated from her baby at At the e nd of this chapter, the student
birth to minimise the risk of vertical d. reduced bowel mobility leads to an list the investigations to screen for
Increased Incidence of gram- will b e ab le 10 : infection
transmission of hepatitis B
negative bacteraemio outline a plan of management for the
Pre/erm labour
b . should bottle-feed her baby to
minimise the risk of vertical
~ inary stasis is increased in mother and fetus
transmission of hepatitis B V~egnancy. . / define preterm birth
• desc rib e the outcomes for the
discuss the importance o f prematuri ty to fetus/neonate .
perinata l mortality a nd morbidity
• li st the causes of preterm birth
Skills
discuss the diagnosis of preterm labour
At the en d of this chapter. the student
outline the investigations and sh ould learn how to:
management options for preterm labour
discu ss the role of taco lysis and Counsel a woman about the risks of
corticosteroids preterm labour and its management.
Pre term prelabour rupture of the
membranes (PPROM)
Attitudes
• define PPROM
• discuss the prevalence of spontaneous At the end of th is chapter, the student
rupture of the membranes and the should reflect upon :
prevalence in preterm births
• the significance of preterm birth for
list the causes of PPROM families and soc iety.
Women's health : a co re curricu lum
11 Pre lerm b irth
* Preterm labou r neoplasia) is associated with an increased risk of

cervical incompetence.
If the diagnosis is unclear but the clinical pic-
ture suggests threatened preterm labour - e.g.
costeroids is administered (two injections of beta-
methasone given 24 hours apart). Corticosteroids
Common clinical presentation trregular utenne contractions and lUldilated or
Consequences of preterm birth effacing cervix --:- prediction of labour is impor-
should be administered with caution to women WIth
The ma jor risks of pre term birth include ~ tant. One predicove test is based on detection of diiibetes mdlitus, as thIS may prec!pltate sliiIiificant
gestation with irregular uterine contractions .
fibronectin, a glycoprotein produced by the chori- hrer!ycaemla.
Her previous baby was born at 24 weeks' death due to eXtreme illlffiaturtty, and rejpiaatoD'
distress syndrome, as the lungs are un er evel- orne cells and released when the interface between ~ use of prophylactic antibiotics for prema-
gestation and died a few hours after birth. ture labour without ruptured membranes has been
Postmortem examination was not performed . oped and surfactant is deficient. The developing the chorion and decidua is interrupted, either
investigated in a large multicentre ITial, the ORA-
fetal organs, particularly the brain and bowel mechanIcally or owing to infection. Detection of
CLE II srudy (Kenyon et a! 2001). Although there
mucosal are susceptible to hypOXIa. III the late sec- fibronectin has a poor positive predictive value for
was a reduction in maternal infection, it failed to
Ond trimester and early thlrd trimester, the delivery within 14 days (less than 40%) bur the
negative predictive value is as high as 97% and this demonstrate any benefit Or harm with respect to
vascular subependymal plate below the cerebral neonatal outcome.
ventricles is particularly sensitive to changes in may be useful in determining the need to transfer oco! 'c ents su
oxygen tension, and these fragile vessels may bleed the woman to a tertiary referral centre. cated or tene
into the ventricles, causing ventricular dilatation on. ey are e to success e
and scarring. Developmental arrest of the rapidly Management
"CeniiCar dilatation' Or if preterrn
growing bowel mucosa leads to necrotising entero- Unfortunately, therapeutic agents designed to sup- I our occurs early in the second trimester. They
colitis. press labour have not been effective in prevention of may act by beta S)'ID"bathetic agonist activiry (salbu -
The preterm baby has relatively low stores of preterm bmh (delivery before 37 weeks' gestation). taIIiol or ntoanne), y reducrng myometrial inrra-
Risk factors fat and without this insulation is prone to The management of threatened pretenn labour is cellular calcium levels (calciwn channel blockers
~E.2:$S!l!;~' In the pre term infant, the tmmature therefo~e auned at prolongmg the pregnanCY to such as nifeclipine), by smooth mUScle relaxation
Preterm labour is preceded by spontaneous rupture stores, leading to ~ allow mne for adiIllnistration of corncosteroids (glyceryl trinirrate) or i.illiibition of prostai:landjc
of the membranes in one-third of cases. It is thera- to The mother. 10 treat [lJe undeclymg cause and to producuon (mdomeiIi'acin). Despite being predomi-
peuticall, induced in the maternal or fetal interest ow tr the mo er 0 e a cenITe. ~ta 2 agonises, the sympathetic agonises are
in another third (e.g. in the presence of hyperten- I" Suppression of labour IS con IT e owever assoaated WIth the severe maternal side effeces of
sive disorder or fetal growth restriction). The cause where continuation of pregnancy may prove dele: tachycardia, pulmonary oedema and myocardia!
of up to one-third of pre term labours is unknown. to mother or fetus, as may occur in the case infarcoon. Maternal anxiery, tremor, hypotension
~ir[ad~tion.
th~e~~~~~~~~~~~~:i~~~ 7
Women at increased risk of reterrn labour are placental abruption, chorioarnnionitis or fetal and hypokalaemia are also co=only experienced.
f:
those w 0 ave a distress.
Particular care needs to be taken if :; ~
Cortico teroid adminisITation is desjgned to ex.l§pni condipoqs,. e.g. bearCdis or
a neonatal unit creates a distance between the promote fetal lun!! ma~:~~ stimplati on pf mulaple )lEegnapcy. Ntfedi~lDe 15 as ective in
mother and her new baby. Every effort should be ~veolar cells to prOOuCl' _ • __ t, a surface ten- short-term sugll~~~ ~ lour as nrod%ie "SUt
made to involve the mother in the care of her sLOn-[owenng agent, which will allow optimal lung wiailess severeJide ;ifern, and haS secom~ the
infant to promote bonding. expansLOn after delivery. Administration of cortico- drug of liiSt choice,
steroids berween 29 and 34 weeks' gestation has ."Women who present with cervical dilatation
Diagnosis been shown to halve the incidence of respiratOry dis- WIthOut utenne conrractions or rupture of the mem-
tress syndrome and its sequelae of neonatal death branes rna
and intraventricular haemorrhage. Steroids ar~ most ce
se consIdered for erne en cervical
e. owever, s carnes e ris 0 mem rane
ner to leon. beneficja! if delivery has not occurred wit h; 4~ pe oration and subsequent chorioarnnionitis if the
hours of adIl1iI1istratlOn or u~ to 7 days pOst-admin- cervix is very thin and the membranes are bulging
~ I here IS now evi ence that the use of through a dilated cervix.
repeated doses of corticosteroids can have the
ad~erse effect of .fetal. growth restriction, with up to Proph yl axis
25 Va reducoon m birth weIght, and reduction in
bram weIght and head circumference (National Preven= of prereun hju b is di ffi~ but e s
tion regarding a healthy lifestyle and pepmpr effrr-
Institutes of Health 2001). Myelination of pyra-
~dal ITaces and other myelinated nerves may be ave ITearment of iD1ecuon rnay play a role. In
Impatred. Insulin reSIstance may be induced and a w2IT?en who nave l1aa a hiStory conslstent with
reduced cortisol response at the age of 3 years has cemcaJ mcoms;renc(j ;r9ett!a$c cem@ cer-
been observed. Nowadays, a single course of corti- cllli e may be pegnne a U Q' 8esta~n, once
a live fetus has been visualised on ulITasound. In
'EE
11 Pre te rm b irth
Women's health : a core cur riculum
preterm PROM, as the reduction in amniotic fl uid The interpretation of an elevated leukocyte
women who have an increased risk of cervical restricts lilllb aria Chest movements. count and C-reactive protein can be difficult in
incompetence, transvaginal ultrasound may be use- preterm births pregnancy, as they are physiologically elevated.
ful ra measure cervical length and predict preterm Diagnosis Fetal hean rate monitoring may identify fetal
birth. A shortening cervix may prompt the insertion compromise due to cord compression or infection.
of a cervical cerclage. The diagnosis of preterm PROM is based on the
Aetiology Cardiorocographic recording is unfortunately less
history, physical examination and identification of
reliable in very preterm pregnancies, as the central
Prognosis Spontaneous rupture of the membranes at term is amniotic fluid. In 90% of cases, the patient's his- nervous system is still immature. The relatively
usuauy caused by a narurat weaJ<erung ot the mem- tory alone is correct, but urine leakage and later physiological development of the parasympa-
An accurate assessment of gestational age, taking increased vaginal discharge may be mistaken for thetic system results in a greater sympathetic sys·
menstrual and ultrasound data inra consideration, is branes or by the force of contractions. In ~
essential. This will determine the likelihood of via- p@M; an iriHatdiMEOt i piUe~ weakens the preterm PROM. tem influence with higher fetal hean rate and less
c.l:iorioamnion. Bacteria and macropllages prOduce To confirm the diagnosis a steri le sllcmlum variability in the preterm infant.
bility, and hence suitability for resuscitation, and the
examination IS performed. Digital examination
prognosis for the infant if born at an early gestaTIon. protease, phospholipase, elastase, cytokines and If expectant ;;;rcgemem is chosen, the w~
eicosanoids, which lead ra uterine irritability, cervi- Should be avoided, as this increases the risk of is nospltaJiSed ancorticosteroids and anrik .
The paediatric and obstetric team should deade if
delivety at the current hospital is safe or if transfer cal ripening with membrane weakness and rupture. infection. ~ol of liquor cannot be identifie ~ a . erO! ave teD sho':Y!Uo
ra another centre is more appropriate. This will A previous histOry of pretenn PROM is the mOst a IS from the osterior forrux an improve fetal outcome by reduang the mCldepce
depend on the progress of labour, the availability of common risk factor for reterm PROM. smeared on a s e. is owe to and then
Ofli y:wt me:rrafie S!ease mtraventIicular
neonatal intensive care support, and expernse 1Il the CervtcovaguuTIS ue to s transDll c- examined under a light microscope for the appear- Memo age an necrotlSrng enterocolitis in the
management of very preterm babies. Preterm labour , a e w c ance of feming, which is characteristic of amni- event of preterm labour. Steroids have not been
is a highly stressful event for most parents. ococcus is strongly associated with otic fluid. Another method employs nitrazine, an shown to increase the risk of fetal or maternal
Counselling about the possible neonatal outcome of P . Uf1Ilary tract ection may to altint that c'tinges colour from renow to blue at a infection. The effectiveness of steroids has not
the fetus and the discussion of management options c orioamnionitis if the woman becomes septi- p above 6. As the vaginal pH dunng pregnancy been assessed in the very preterm fetus.
is 4.5-5.5 and the pH of amniotic fluid is about
is very important. caemic. Cc;rvical incompetence, polyhydramnios
and mul1l.le PlIfanClesaISo preref'se to weak- Ul nim~jne wi". cbange.j o ft Recent .evidence. has shown that the ~
If It co mes 10 anTIbIOTICS IS benefiCial 1Il preterm PRO even if
* Preterm prelabour
rupture of me mbranes
ening of e me ranes by pressure e ecr. Cigarette
s~ diinng pregnancy IS be\leved t o co:~
~ tbeJDemhrane jnteeQry thrQugh effe_~
carbon monoxide. The association between low
contact With arnmonc £Jill.
positive resuI
Lscmen ~, ' e .
ommately, ~
a occur from contamination
bacterial vaginosis, an ~ , as they all increase

es 0 va en on et al
socioeconomic StatuS and preterm PROM probably the vaginal pH.

Common clinical presentations reflects the presence of one or more of the above Ultrasound examination can be helpful to Prognosis
support the diagnosis in the presence of oligo-
A 35-year-old woman presents at 29 weeks' risk factors. Ax less than 24 weeks' gestatio ~ the outcome is
hydramnios and to confirm the fetal presenta-
gestation with a history of waking up In a pool
tion. A finding of normal liquor volume, how- usually poor. Pulmonary hypopasia as a conse-
of Muid. She hod two previous preterm deliver- Sequelae of preterm PROM quence of madequate alveolar growth and in utero
Ies at 36 and 34 weeks' gestation.
ever, does not exclude a diagnosis of ruptured
of preterm PROM is chest compression in chronic oligohydramnios
membranes.
A 22-year-old woman presents at 32 weeks' ges- leads to poor oxygenation. In survivors ener-
tation In her first pregnancy feeling generally Management alised develo mental dela , dela ed motor
unwell. She describes a constant malodorous ogment, cere ~riit p y and chIomc lung dise.ase
wetness far 5 ·days. The baby Is less active than Management will depend on w tational .ffiie, the rnafn0ccur as oog-term problems.
usual. On examination. her blood pressure Is presence of iIlfection, and fetal and maternal welJ- cases where preterm PROM occurs very
110/65, temperature 38.4·C and her abdomen b3. At 34-36 weeks' gestaTIon, de4yerv may J?e early in the second trimester and is likely to be
soft but mildly tender. Speculum examination apnriate as a balance between fetal maturity associated with in utero fetal death or chronic
reveals a closed cervix and a pool of liquor In an e nsk of infection. oligohydramnios, termination of pregnancy may
the vagina. The liquor has an offensive odour. At less than 34 weeks' gestatign agd in the be considered and the parents need in-depth coun-
The baseline fetal heart rate is 180 beats per absence of SignS of maternal or fetal infection or selling.
minute. cord com ression directed Overall, the risk of expectant management
must not be underestimated and close observation
can make the difference between a healthy moth-
Prelabour rupture of the fetal membranes (pROM) er and fetus or high maternal and fetal morbidity.
is defined as ru turf of membranes that oc Parents should be involved in decision making
reterm pre our ruo- after counselling by a senior obstetIician and a
or preterm PROM) is
lij
Women's health: a co re c urricul um
paediatrician. The management of preterm PROM

is still controversial and more research 15 needed to
optimise outcomes.
References
Kenyon SL, Taylor DJ, Tarnow-Mordi W 2001 Broad-
specaum antibiotics for spontaneous preterm labo ur:
the ORACLE II randomised trial (ORACLE
Coll aborative Group). Lancet 357(9261):989-994.
* 2
Maternal and perinatal mortality
Gerard Gartlan and Clement Chan
Health maintenance Kenyon SL, Taylor DJ, Tarnow-Mordi W 2002 Antibiotics
Attention to oral hygiene and avoid- for pretc:rm prelabour rupture of the membranes: Edited b y Lucy Bowyer
ance of STis minimises the risk of short-term and long-term outcomes (ORACLE
chorioamnionitis and preterm labour. Col.laborative Group). Acta Paediatr Suppl
91(437):12-15_
Narional Institutes of Health 2000 Antenatal corticosteroids

revisited: repeat courses - consensus development
co nference statement, August 17-18. Obstetrics and
Gynecology 98:144-150.
RCOG 1999 Antenatal corricosceroids to prevent

tospiratory distress syndrome. Royal Co llege of
Obstetricians and GynaecologistS Guidelines 7,
Leaden.
Learning objectives
Knowledge Skills
will be able to : should learn how to :
d. exclusion of parents in deCision /
Questions making , as this can be very /
Maternal mortality take an obstetric history, with attention
stressful
Select the correct answer(s). to areas that may affect maternal
e . emergency cervical cerclage. define direct, indirect and incidental health
1. Preterm birth is associated with : maternal mortality
break bad news
~
_ drug abuse /' 3. Common risk factors for preterm PROM compare the maternal mortal ity rates In
are: different regions of the world interpret the grass findings of a
pregnancy ultrasound scan
b. ervical dilatation withou V a. previous preterm birth "", list the main risks of pregnancy to the
mother detect a fetal heartbeat with a Pinard
contractions / Ci\ b. oligohydramnios /\1"" stethoscope or fetal Doppler device.
describe preventative management to
c. reduced fetal movements '" f' ~L C sexual intercourse /'
"Iv- ;~R'<I'o~ . .." reduce these risks
€ ) ntracranial haemorrhage / /~~~~Ci garette smoking during pregnancy describe the physiological changes of Atti tudes
~sPiratory distress syndrome. e. dyskaryosls an Pap smear. / pregnancy that may adversely
influence the health of women with pre-
4, The following may be part of the existing disease should reflect upon:
2. The management of preterm labour
~
agement of preterm PROM '
• discuss areas of obstetric care where • the respons ibility of managing a
Includes. a . trauterine transfer if nOMOnatal 1- improvements can be made pregnancy
~ccurate estimation of fetal ,,/" eds are available .."" discuss improvement of care tor women
. • the foct that every pregnancy carries
gestational age X admlnistration of antibiotiCS only If with high-risk pregnancy
some risk to the life of the mother
& dmlnlstration of Intravenous "f. p- ~J there ar~ signs of Infection Perinatal mortality
~l'f ~t(~~ ~7 ./~' ounseiling
the varying standards of obstetric care
antibiotics ..,. define stillbirth, neonatal death and In the world and the high maternal
c admlnistralion of repeated courses use of corticosteroids / ' vi' perinatal mortality mortality rate in developing countries
of corticosteroids xpectant management. indicate the perinatal mortality of • the impact of a maternal death on
developed countries family, friends and medical personnel
• list the major causes of perinatal the impact of perin atal death on a
,rtaHty. mother and her family.
.Ii
12 Materna l and perinatal morta lffy
Women's health : a co re curriculum
It then remains fairly constant until term. Blood

* Materna l mortality e.g. heart disease, diabetes mellirus and ~ Triennium Total Maternal Maternal
-
confinements deaths mortality ratio pressure usually falls slightly in the second
disease. (per 100,000 trimester and then returns to normal levels in the
In some countries, including Australia and New confinements) third trimester. Durin labour cardiac ou ut rises
Zealand, details of a third group - incidental 1964-66 667,649 275 41.2 b e- a our eve s thus
A multiparous woman In spontaneous labour deaths - is collected for statistics but excluded placing a considerable load on the m~ocardium.
at term becomes shocked and dyspnoeic In 1967-69 713.064 237 33.2
from international comparisons. Incidental mater- The increase in blood volume and cac q ac output
the second stage of labour. nal deaths ace those occurring during pregnancy 1970-72 790,818 244 30.9
Two weeks after delivery a woman Is read- but to which the pregnancy has not contributed 1973-75 726.690 137 18.9 Number of deaths
mitted with leg pain , followed by a sudden significantly, e.g. road accidents, malignancies. 1976-78 678.098 106 15.6 Cause of death By
episode of chest pain, shock and death specific Total
6 hours after admission. Maternal mortality in Australia 1979-81 682.880 98 14.4
cause
1982-84 713,985 94 13.2
A 35-year-old -primigravida , 8 weeks
pregnant. The main causes of direct maternal deaths in CardIovascular disease 10
develops lower abdominal pain·. which does Australia (1991-96) ace given in Table 12.1. The 1985-87 726.642 86 11.8
Cardiomyopattw 1
not settle with paracetamol. Four hours later principal causes in eaclier decades were haemor- 1988-90 754,468 96 12.7
she loses consciousness and dies. rhage, infection and preeclampsia, but blood trans· Myocardial Inforction 1
1991-93 769.253 84 10.9
fusion, oxytocics and antibiotics have reduced th~. Card iac arrhythmia 1
1994-96 767.448 100 13.0
Pregnancy~nduced 1
TABLE 12. 2 Moternal deaths In each triennium . hypertenSion
Number Australia. 1964-96 (From NHMRC 1996. P 21)
Rates and definitions Cause of death
of deaths Preeclampsia 1
Maternal mortality in Australia and in countries of 8 incidence of haemorrhage and infection. Improve- Dissecting caronary artery 1
P.lILmonary embolism aneurysm
similac social and medical background is approxi- ments in the health of the general population,
Amnioftc ftuid embolism 8
mately 8-10 per 100,000 births. The rate is a antenatal care and awareness of preventing direct Mitral and aomc valvular 2
measure of the quality of obstetric care for the Preeclampsla. prognancy~nduced 6 disease
causes of maternal mortality have resulted in a sig-
mother. hypertension nificant fall in maternal deaths (Table 12.2). As a Eisenmenger's syndrome 1
World Health Organization (WHO ) figures EctopiC pregnancy 5 result, indirect deaths, pacriculacly from heart dis- Septol defects 1
-
(excluding incidental deaths) for other regions ace: 5 ease, have become more prominent (Table 12.3).
Sepftcaemia Infec:tlon 2
• Southern and eastern Europe: approximately Termination of pregnancy 3
30 per 100,000 Physiolo gical changes during Pneumonia 1
Ruptured uterus 2
• Southeast Asia: approximately 60 per 100,000 p regnancy Sepffcaemia 1
• Africa: approximately 940 per 100,000. Prima!:X e2!!Eartum haemorrhage 1
Supervision of pregnancy requires appreciation of Cerebrovascular disease 2
Spontaneous abortion 1 the changes in maternal physiology and the poss-
Comparison between countries depends on accu- Cerebral haemorrhage 2
rate statistics and similar definitions. T~ Plac,!;,ta pra2.:as 1 Ible nsks when there is preexisting maternal dis-
Suicide
ease. 2
defines maternal morcali as' e death of a Placental abru.!2l!,on 1
w2 man w e pregnant or within 42 days of the Blpolor mood swings 1
Intracranial haemorrhage 1 Cardiovascu lar system and blood
terrrunanon 01 pregnancy, irrespective of the dura- Postpartum depression 1
1 composition
n on and rhE site or the pregnancy, from any cause Ruptured artery MIscellaneous 4
related to or aggravated by the pregnancy or its ThrombOHc thrombo~e2nla 1 The plasma volume incteases by 50% from the 6th
management' (WHO 1993). Su0 deaths can be to the 34th week of gestation and then remains Ruptured artery 2
Thrombocytopenia 1
classified as: fairly constant until tene. The red cell mass Diabetes 2
Ana~!!§lg;u:I~
1 increases continuously through pregnancy and is
• direct deaths resulting from obstetric complica- Tolal Indirect deaths tram 20
46 r<used by 20-35% at term, resulting in a relative all causes
tions of the r egnant state, e.g. e~Jit;L, Tolal
haemoclilution. Total blood volume increases ro Note. Each death has been attributed 10 a single couse as
mromboembo m, postpartum haemorr ge, Nole: Each death has been attributed a single couse. os
decided by the relevant state or terrttofV maternal mortalty
40% above non-pregnant levelS. Iron reqUIre- decfded by the r vont state Of teffltoly maternal mortc'lty
ruptured uterus - committee. In a ;Cnffl.cant number. mult1p6e tactors were present ments also Increase because of tile increase in red c Ol'TYT'dtee. In a slgnlftcant number. muffip6e factOf'S were prec..ent.
indUect deaths resultin~ from preexisting dis- cell mass and fetal consumption. TABLE 12.3 Indirect maternal deaths by
ease or disease that eve loped dunng7the TABLE 12.1 Causes of direct maternal deaths principal cause. Australia 1994-96 (From
. Cardiac output statts to rise early in the first
pre~an~ bur w~ch may have ~~~ a~a in Australia 1991-96 (From NHMRC 1996. P 22) tnmester and at 24 weeks has increased by 40% . NHMRC 1996. p 23)
vat~by1fie Pl1YslOloi§l meetS Jw;mancy,
1"
12 Matarna l and pari natal mortality
Women 's health: a core cu rri c ulu m
Health maintena nce neonates from 400 g birtb weight, or of at leaSt 20 rates, with the neonatal deatb rate decrease being
Ilred jspgses t 9 cardiac fai lure jn the }¥gw an w jth weeks' gestation wben birtb weigbt is unavailable the more marked. Figure 12.2 grve the main causes
underlying cardiac disease. The development of Antenatal patients must be assessed as well as neonates up to 28 days after birth. ' of permatal mortality in WeStern AuStralia. The
anaemfa in pregnancy further increases the work- carefully and women with high-risk preg-
nancies (e.g. those with heart disease, three main causes are similar in all States, but a
load 0 the heart. diabetes, renal disease or pregnancy- Rates and prevention in Austra lia nanonal report using the more recently introduced
"toag\ilauon factor production is increased in induced hypertension) referred to Tbe AuStralian perinatal mortality rate decreased AUStralian and New Zealand Antecedent Classi-
Rre specialist units. Adequate facilities for . from 22.6 per 1000 births in 1973 to 8.5 per 1000 ficanon of Perinatal Mortality is not yet available.
delivery and the care of mothers should births ill 1999 (FIg 12.1), This fall can be attributed Tbe development of neonatal intensive care
be provided according to their risk.
to a combination of lower fetal and neonatal death , services bas been largely responsible for the
Careful postpartum observation and
early ambulation are important in all
women, with prompt intervention to man-
age abnormalities such as postpartum 25r-----------------------------=========
haemorrhage, deep vein thrombosis,
puerpenum. e me an! pressure 0 e uterus puerperal depression ond psychosis. 20
on mE m:n: ve.ins and illtenor vena cava further
a§&ravates venous stasIb produces oedema in the
l~ and increases the nsk of tfrrombo-em botism.
Renal and endocrine system
Renal plasma flow and giomem la [ fi ltration rate
* Perinatal m o rtality
increase early in pregnancy, rising up to 30%
above pre-pregnancy levelS by rrud-pregnancy and
A woman at 32 weeks' gestation reports that
then remaining sta!ile for the remamder of the
~~73~--~19~7;6--~1~97~9~~~;---~~--~~~--L-----L-----1-~
she has not felt fetal movements for 3 days.
pregnancy. G IL!;!u;co~s!.!ie~~l5i.lo.il~Uu.ll.lo!;;.I.I.:~.w.~1lS
pregnancy, WI relative resistance to insulin. An ultrasound at 28 weeks' gestoNan reveals an 1994 1997
LevS[ or adrenocomcOtroPIC hormone (ACrB) abnormal fetal heart and evidence of fetal Year
and unbound cortisol are increased. Thus preg- hydrops. . _. - - Fetol deaths -0- Neonatal deaths Perinatal deaths
nancy IS a prodiJhefiC State. A newborn baby becomes cyanotic with
FIG URE 12.1 Fetal neonatal and . t I
feeding . Sul livan 2001. p 37'. Reproduc e d !::'fI~~ a ,death ;~~es In A ustralia . 1973-99 (FrOm Nassar &
rml SSlon 0 e A ustralian Insti tute of Health and We lfare)
M ental state
P ~OI dDlClthl, modmod WI'IIffIek:I c kJl:all'lcct1on, Wemlln Au.l1* 1999

Definitions
~~-----------------------------------
25
~~ -------- ----------------------------
WIthin 28 so (WHO 1993).

erma mo ity is a measure of the Standard
of obstetric and neonatal care in a community, and
analysis of the causes directS attention to areas that
need better care, The Australian Bureau of Statistics
and other countries with a low perinatal mortality
~~~~ E2 ~;i ~ The mai n c a uses a f perin a tal mo rtali t y in Western Au strallo, 1999 (Based on Gee &
rate use a wider definition of perinatal mortality
than the WHO. In Australia, the definition includes
. W"'-o)
-7
~~ ~,~~~J -) ~~
~;;¥\n ~~\\k '7/400~
1,,'1 V'J'f\1wt >tI OOO~
/1M>
-
A+J!) -;,- 19 ~ ~ ~~'or\ ~f. ;;, l-%~ ~
~ ~. }c :fJ ~~ W'( \.0 1-~ ' ~ \o;y~
~ \,..,'y 0--. . ~\ "'..,.~ ($h\1 ",-,(\"'\,...) , ~
-, ~~ \"t\. 1IV\e' 0 ~ ~'\~
~c.. ~ >8" ~) -
decrease in neonatal deaths associated with pre-

mature birth. However, the prevention of prema-
all mothers. Many abnormalities are not necessarily
fatal, making a decision about continuation of the
labour and delivery
pregnancy difficult for the mother and her advisors.
ture labour still offers wide scope for reducing
perinatal mortality. Perinatal deaths can be further
Improvement in intrauterine procedures, neonatal Edited by Beverley Vollenhoven and Martha Finn
management and operations will save some of these
reduced throu renataI counselIm materna!"
babies, but fetal abnormality will continue to be a
an etal ScreenIpg, an Wlprovemenrs to care or
WO=men with hi -riSk pre anCles. Pre-concep- major cause of perinatal mortality. Normal labour Andrea Barkehall-Thomas
tion a VIce s 0 ill U e genetIc counselling and Prolonged and dysfunctional labour Andrea Barkehall-Thomas
testing, immunisation against rubella and treat- References Active management of labour Roslyn MacKenzie
ment of preexisting disease (e.g. HIY, syphilis), Buist A 1997 What's new in postpartum depression. Operative vaginal delivery Andrea Barkehall-Thomas
together with strict control of diabetes mellirus Resource Dlanual 5, resource unit 144. Royal Prolonged pregnancy Nader Gad
Ausualian and New Zealand CoUege of Obstetrics and
and administered drugs.
Antenatal care should ensure avoidance of ter- Gynaecology.
atogenic drugs and subStances, and adequate man- Gee V, O'Neil MT 2001 Perinatal statistics in Western
agement of diseases acquired in pregnancy such as Australia: seventeenth annual report of the Western
toxoplasmosis and varicella. Women with high-risk Ausualian midwives, 1999 - notification system.
pregnancies (those with cardiac and renal abnor- Department of Health, Penh. learning objectives
malities as well as diabetes) should receive optimum Nassar N, Sullivan EA 2001 Australia's mothers and babies,
antenatal care, sometimes in dedicated antenatal 1999. Perinatal Statistics Series no. 11 AIHW cat. no. Knowl edge Operative vaginal delivery
clinics. Intrapartum deaths and morbidity may be PER19. Australian Institute of Health and Welfare,
• Indicate fhe local prevalence of
reduced by better fetal monitoring techniques, Canberra. At the end of this chapter, the stUdent operative vaginal delivery
with both current equipment and furure improve- be able to:
W ill
NHMRC 1996 Report on m",ernal deaths in Australia, list the indications for each type of
ments. 1994-96. Nation"l Health and Medical Re.earch operative vaginal delivery
As a result of increased screening for fetal abnor- Normal labour
Council.
mality using genetic, biochemical and ultrasound define labour • describe the risks associated with each
techniques, early termination of some pregnancies WHO 1993 Geneva inrernational statistical classifiGltion of mode of operative delivery for mother
will lower the incidence of babies born with abnor- disc'ase5 and related health problems, tenth revisio n, describe the stages of labour and fetus
malities. However, termination is not acceptable to vol 2. World H ealth Organization, Geneva. Prolonged pregnancy
outline normal progress of labour
review the maternal physiological • define the terms post-dates pregnancy,
changes in labour post-term and post-maturity
• describe fetal adaptations to labour • discuss the fetal effects of prolongation
of pregnancy
describe the options for pain
management during labour present a plan for management of
2. Which of the following are prolonged pregnancy.
Questions major contributors to perinatal
• outline the various models of care and
options for place of birth
1. Which of the following are the main mortality?
Abnormal labour
~
Down syndrom7 e
causes of maternal mortality in Sk ill s
developed countries?
-I-
list the likely reasons for the failure to
b . Prematurity progress adequately In the first and At the end of this chapter, the student
. Pulmonary embolism . / should learn how to:
second stages of labour In nulliparous
b Amniotic fluid embolism \I'" c Unexplained intrauterine
and multiparous women
care for a woman during the birth of
death ./
c Haemorrhage ~ outline a plan for management of slow her baby
d. Syphilis infection progress in a nullipara and a multipara
d. reeclampsia , /
e. naesthesia 'I- 0 aemo Philia ..,. Active management of labour
demonstrate the use of a partogram
demonstrate the mechanism of birth
describe the principles of active using a doll and pelvis .
management of labour
explain to a woman the risks of
critically appraise this model of care prolonged labour
(Continued over)
'IE
Women's health: a c ore cur Ficulum
13 Lobo ur a nd d e livery
(Leornlng objectives continued) Attitudes Process progress of the labour accelerates to a minimum
establish the date of delivery using At the end of this chapter, the student of 1 em dilatadOn pH Hour III the nullipara.
menstrual and ultrasound data should reflect upon :
. The sece d stage of labour cap alsg be d~ed
• counsel a woman about the risks of a the range of women's attitudes towards birth mto two p es:
pregnancy that Is more than 42 weeks'
gestation different women's responses to medical 1.
intervention in labour.
• describe the methods of induction and
discuss the associated risks to the mother
and fetus.
Duration
Surprisingly the 'normal' duration of labour
* Normal labour care facility will have a policy that must be fol-
lowed when monitoring progress and maternal
1. F~ stage: from the onset of labour to full cet-
VI dilatatj on
2. Se~d sTilge: from full dilatation to delivs;r of
remains poorly defined and hotly debated.
Difficulties arise with the definition of the onset of
labour and appreciation that the lengths of both
Common clin ical presentations and fetal vital signs in labour. ~daby the first and second stages of labour do not have a
normal (Gaussian) distribution. Thus median and
3. stage: delivery of the p lacenta and mem-
At an antenatal clinic,nulliparous woman
0 b~ interquartile ranges more appropriately describe
asks how long her labour will be. Ti ming the distribution than parametric methods (mean
In the nulliparous woman, cervical shQqe~g, and standard deviation). The latent phase 13§\s
The vast majority of women will be delivered by
A womon hovlng her first boby telephones known as effacem ent, is followed by dilatanon, !found 8 hgurs on ayern ge, and adequate progress
to soy that she Is hovlng controctlons every 7 days beyond the due date, although in some
whereas they commonly occur together in the in the active phase for the normal labour is con-
3 minutes ond osks if she is In labour. instances this will be as a result of medical mter- multiparous w oman.
venti on in the pregnancy. Approximately 7% of sidered to be 1 em per hour in the nullipara and
~ A multlparo arrives In strong lobour and wonts The first stage of labour can be divided into
babies are born be fore 3 7 weeks, and less than 2% 1.5 cm per hour in the multipara. The activUrlih,ase
to know If she con hove on epldurol. two phases:
are born later than 41 weeks. of labour lasts on avc.raf 8 hours for tile n para
1. ~ phase - a gradual process of efface- E
an:!! hours for [he wnJjparp
Mechanisms m~pd dihtatWD I e duranon of labour can be demonstrated
Definiti on 2. ~ phase - from dilatation of 3 em, the visually by a graphic representation of the progress
of labour, called a partogram (Fig 13.2). This doc-
uments the maternal and fetal observations in con-
,~ ~~ ~
res e antiCI- junction with cervical dilatation and station of the
pate outcome 0 norm a our is e vaginal presenting part. The partogram can be used as an
birth of a full-term, live, healthy infant to a healthy aid to evaluating the progress of labour.
mother. Giving birth is a most significant event 10 The duration of the second stage is influepced
a woman's life. As health professionals, we must by the clioice of anak esla. 1he woman with a
respect the significance of labour and birth for the gooa e iduraJ bJoCk;;TI be unaw
woman and her partner. moment ea reaches
When labour begins the woman will report floor and thus
uterine activity that progressively increases in fre- lafi ~ urge to push. It is advisable to allow eXtra
quency, duration and intensity until she JS havmg
\/'0/
timetor the head to descend (first stage) before
regular, rhythmic contractions every 3-4 mmutes, encouraging the woman to push. The mean d!.l.t.a-
each lasting 60--90 seconds. This mayor may not tion of th econd sta e of labour for - .
be accompanied by spontaneous rupture of the min tan e (median 45 mins
membranes. I range 27- 7 6 mins) and 100 minutes withB.
Clinical history, abdominal e~%:9~ arul.. epidural (median 82 IQ range 45-134 mins), and
vaginat exalIti:na4if1etermige Whecll1't lab\l!!r fo rihe'" multipara 20 minutes without an epidural
haS co=enced: 1 e progress of labour is moni- (median 13 mins IQ range 8-22 mins) and nearly
tored by the fTequency and duration of contrac- FIGURE 13.1 Cervical effocement and 60 minutes (median 33 mins IQ range 17-70
tions the descent of the fetal head mto the pelVIS di latotion in the nullipara (Based on Farquha r
& Jamieson 1997. p 55. Fig 6.10) mins) with an epidural (Paterson et al 1992,
and ilie dilatation of the cervix. Each hospital or Saunders et al 1992).
"t
13 l a bou r a n d del ivery
Traditionally, the second stage is considered Pain management options

REG
prolonged atfer 2 hours In the nUllipara and during labour
NO SUR·
NAME
Bun OAT< II? AUG SPECIAl INSTRUCTIONS after I hO'Uir-;p the mJ] 't~a. 1his li~ex
194216 Eo.O _.. _Q.AWL _ ___.._ .. flUSBAIJD TO B~ WITfl Wlj::r teiided by 1 hour for women with epidural anal- The perception of pain varies for each woman and
eRST
F.N.
0
SfimA AGE 25 PAAITr._ CL.__..__._...__...
,
2 ] ~ s , 7 8 9 10 II 12
TflROUGflOUT H[R LABOUR
,. IS 17 18 21 ,., rn
~ [he absence of fetal distress, the duration with each of her labours, The response to labour
CONSULTANT 190
IJ 16
" 20 22 2J
,80?O oItlie second stage is not significantly associated pain depends not only upon the afferent pain
,,'" impulses but also upon her emotional, social and
'80
DR H. SMYTHE 170 with the risk of low neonatal Apgar score or
160
'so I '"so admission to neonatal intensive care, but there is culrural expectations. A significant proportion of
.....
HEAAT
14()
130 ,, 40
JO aLJ increased risk of maternal postpartum haemor- women experience severe labour pain but care
RATl 120 I
,'"'0 rhage and pyrexia as tIme etapes and the risk of providers can neither quantify an individual's pain
110
, nor choose for her what analgesia, if any, is appro-
ICO
90
JlO
90 infection is doubled after 4 hours (Saunders et aI
110
199'2). Current management approaches aim to priate; hence, analgesia in labour remains the
I~ ~ 70
'" achieve a balance between attempts to improve the woman 's chojce.
1here are many methods of pain management
-
....= I I I I I I I I I I ~I I I I I I I I I I I I I I I rate of spontaneous delivery, particularly in the
for labour, and they vary significantly in the degree
JO I nulliparous woman, and avoiding maternal mo[-
bidity and thus allow second stage labours of of intervention and the physical effeCts upon the
woman and her fetus,
/
....J~
up to 3 hours duration, in the absence of fetal
/ N on-pharmacological meth gds, such as contin-
...... distress.
uouSfuaternal 5l!QPpn in labour, maternal posi-
01
.... '" .. ...... ...... ~
~
tioning and movement, ~e and ~, ~e
". '. "'- been evaluated with controlled studies and have
ft.1 demonstrated not onl y benefits in pain scores and
I 18 I. 11
" 17 10 22 2J 14
analgesic requirements bur also enhancement of
labour progress, reduced medical intervention and
improved maternal satisfaction . They have the
advantages of avo iding maternal and fetal drug
effeCts, ease of commencement and cessation, and
Ma ternal phy sio logica l changes low cost. Acupuncture and hypnosis may also be
during labour uscfui.
Other complementary therapies such as hom-
Active labour is hard work and the systemic mater-
eopathy and aromatherapy may be used in child-
nal changes reflect this. T he maternal heart rate
birth bur their beneficial effect remzjns uncertain.
lIOJ 100 and respiratory rate rise, the cardiac output,
190 '90 Transcutaneous electrical nerve stimulation
180 '0) peripheral vascular resiStance and blood pressure
170 '70 (TENS) is a promising therapy with a scientific
'60 16. rise, and catecholamine secretion increases. For basIS for pam rehef via the gate theory of pain, bur
ISO
'40 '40 some women with preexisting or acquired medical in a recent meta-analysis it appeared to provide
IJO ';0
'lD "D diseases, the superimposed demands of labour may only limited, if any, significant analgesic effect
ItO :-"
100: : "'
100
be detrimental to their health. (Carroll et a11 997).
90 90
80
70
110
70
Pharmacological methods of pain relief are the
60 Fetal physiological c ha nges traditional Western medical approach to alleviat-
""""" Il NI '" during labour ing pain in labour. N itrous oxide is widely avail-
1.~"U' ~ I
GlUCOSE Nf able, inexpensive, non-toXle and has the benefits
T[~lUI.! S"" 6" ge' The healthy fetus is able to tolerate the repetitive
of being pati ent--controlled and self-limiting, and
o r 2 ] • S 6 7 9 9 10 II 12 I) ,.. IS 16 17 18 ''I 10 11 12 lJ 24 but intermittent Interruption to oxygenation that
producing rapid onset of analgesia without pro-
oCSIrs WIth uterIne actlVlty. In the healthy fetus, longed effeCts on the fetus. An additional benefit is
ultrasound revealS a dramatic reduction in breath- that nitrous oxide has no effect upon uterine con-
ing and limb movements during labour. ~_ tractility. Systemic opjoldS are also often prescn5ed
FIGURE 13.2 Example o f a p artogra m (From Llewe llyn-Jones 1999 , p 73. Fig 9.1 ) chemicall~ the well fetus maintains a normal cord Tor pam in labour: si~ are those typical of
atteri~ p until Jle second sta.u.. opioid drugs, in~uding nausea and sedation.
'ei
Women 's health: a ca re c urric ulum
13 la b o ur a n d d elivGry
=~I an:e: h~ ~~~ administration ~ Models of care

inte : tor n:uCLs; sigp of opiojds
local anaesthetic via a fine catheter placed LP the In Australia, most women give birth to their baby
lumbar epidural space pro~des excellent pain re!jcl. in a hospital setting, with a small number of
The ma'or dis es to this include ~ women choosing a home birth. Within a hospital
mot r 1:i oc ade which limits or rev a- setting, women may choose various models of care
including team midwifery, shared care with a gen-
tion, e need for continuous eta monitoring, ~ Aetiology
eral practitioner, or a medical model of care
"iD1r! maternal hYd'0tenslOn, non-reassuring fetal including private obstetric care. Delivery for
heart patterns an the loss of bladd . : n, women with low-risk pregnancy may be at home,
requirin indwellin urin . Addinon- in a birth centre or in a hospital.
ally ere appears to e a small prolongation of,rbe
duration of the !ahour (or an LPcrease LP oxytOC19
use) as well as increased rates of igST IWe?taLddjv-
~. Caesarean delivery .f ates iF; ~9t JPcreased _
Epidural use is aIso assoaated WIth mcreased rates
* Prolonged a nd
d ysfunctional labour
of maternal fever 01 uncerthlri aetiology. -
• norm - ized fetus with unfavourable diameters
Mech a nism of b irth A nulliparous woman at term presents on presenting (e.g. OCClpltO-pOstenor,
2 successive days 24 hours apart with palntul • normal-sized fetus with cpmpou nd presg;lta-
regular uterine activity and unchanged I). tisIJl. thereby enlarging thel functional diam-. ,f
Positi o ns fo r delivery partially effaced cervix. eters presenting "" rtICol,(t~~D"
If all is proceeding well, the woman may cboog A nulliparous woman In labour progresses to lar~e fbtus -tUvI
feta a normalities (e.g. hydrocephalus).
h;=M0sition for delivery. She may c?oose to give 7 cm , but 4 hours later there Is no turther
cervical dilatation. A clinical history and examination allow an
b' on the bed, on ~fQWs, ~idine' 19 a ~
ported squat Or' on the ~ . A nulliparous woman with on epidural has
assessment of the cause of dystocia (prolonged or
been tully dilated tor 3 hours.
dysfunctional labour).
Dia g nosis
Sacral pmmontory
The partogram is the mainstay for identifying pro-
Definition longed labo ur and arrest of labour, by visually
demonstrating progreSS over rime.
Outcomes
nullipara and 16
o mg y, some au ors c ate the duration
of the latent phase from the first assessment at
admission, in whi ch case a duration of
more than 8 hours is considered prolonged.
FI GUR E 13.3 The 'Id eal ' obstei ric pelv is (Base d o n llew ellyn-Jones 1999, p 56, Fig 7,3) Historically, the limits of normal for t;h,e
active ph ase of labour have been deIlneatedas
13 l a b o ur o nd de livery
Management * Acti ve manageme nt

of labour
The accegted rate of 1 cm per hour cervical
dilatanon in nulliparae was originatl y derived by
Fnedliian rn 1955, as this ~resented the slowest
prolonged labour and a low caesarean sectioD
rate (Bohra et al 2003).
Individual components of active management
1 ~ of labours. A line is drawn on the partogram of labour have been evaluated by randornised
to highlight this rate of progress. Dujardin et al contwJled trials. A Cochrane review showed tbat
A 26-year-old woman expecting her first baby (1992), have shown a significant increase in rounne amruotowy sh0rteps labgur by 1 2 hgurs
presents In labour at 4 em dilatation. Two hours neonatal resuscitation if this line is crossed. (Fraser et al 2002). Another Cochrane review
later, there has been no progress . . , It must be emphasised that this active JIllIn- showed .that one-to-one care in labour is assocj-
agement applies to nullifarous rather than to ated With decreased caesarean section and
muln arous women, as t~e causes of abnormal epldurat rates, decreased A ar scores below 7 at
Active management of labour is a concep t origi- lab£.ur I er 10 t ese two groups an e m ter· 5 mlOUteS an ess ostnata at
nally described by O'Driscoll in 1969 at the ventIon of oxYtoCin IS less sate rn a multiparous 6~ 0 nett .
National Maternity Hospital in Dublin. It was \voman a due t6 lHtfeasSd riSk or titeHHe rupture. . Acnve management of labour has been prac-
designed to prevent prolonged labour and applies In a nulliparous woman, the likely causes of tised around the world with varying success.
principally to nulliparous women in spontaneous abnormal labour are, 10 order of GesuenS)': Some question an approach that identifies 45%
labour with a singleton fetus and cephalic presen- 1. inefficient uterine action of nulliparous labours as abnormal, requiring
tation. Over time, the definition of prolonged " augmentation with oxytocin. While the majority
2. persistent oCCIp ito-posterior positioQ o£ the
labour has changed from more than 36 hours in fetus of studies of active management of labour have
1963 to more than 12 hours in 1972. On aver- 3. cephalopelvic disproportion. demonstrated a shortened length of labour (circa
age, maternal morale in labour deteriorates after 2 hours) and reduced rate of women delivered
6 hours and rapidly declines after 12 hours. The Conversely, in a parous woman the ljkely after 12 hours «5%), reports of secondary Out-
reduced caesarean and instrumental delivery ca ~e: come of caesarean section rare have been variable
rates that resulted from this management 1. obstructed lab o l1f
(Tabowei et al 2003, Sadler et al 2000). In South
approach in Dublin have been a fortuitous by· Africa, a randornised trial showed significantly
2. ?crsi~ent occipiro-posterior position
product which has prompted other institutions to fewer caesarean sections in those managed with
3. rnefficlenr uterlOe acnon (r~ in a multipara).
adopt active management of labour in part or selected principles of active management of
whole. ocin au ents inefficient contractions labour than in those who were managed expec-
The key components of active management of and encoura es = 0 0 e eta ea , so that tantly (pattinson et al 2003). This flOding is par-
l~are : the vertex reac es e pe vic oor an rotates to ticularly relevant in a region of high HIV preva-
the anterior position. Thus, oxytocin in the nulli- lence. In this study, artificial rupture of the mem-
• antenatal education para overcomes two of the most likely causes of branes was deliberately avoided to minimise the
definition of the onset of labour ~bnortnal bbour, but must be used with caution risk of vertical transmission of HIY.
rncrease. • one-to-one l(ersonaJ care 10 labour in the multipara and gnly wbeg obstDlcred labour
routine amruotomy and early use of oxytocin has been excluded. If this measure fails, delive[Y
Summary
. If there are correctible factors, a prolonged
for slow progress (less chan 1 cm per hour IS by caesarean section. The retrospective diagno- The total package as practised in Dublin achieves
lab our may progress to a vaginal delivery, or
increase in cervical dilatation). SIS IS that of cephatopelvic disproportion in this the aim of avoiding prolonged labour in nulli-
labour may become arrested with or without fea-
tures of obstructed labour. An arrest of labour Antenatal education prepares the woman for labour. parous women, with the advantage of compara-
occurs when there is no further cervical dilara- labour. In a nulliparous woman, onset of labour At the National Maternity Hospital (NMH) in tivel y low caesarean section rates. The application
non des ite aChievm adequate uterme acnvity is defined by full effacement and commencement Dublin, 63% of nulliparae were delivered in of acnve management of labour varies from place
WIt oxytocin stimu an on. , of cervical dilatation (at least 1 cm dilatation). 6 hours with 93% delivered by 10 hours to place, as different centres implement selected
there IS arrest of descent of the ead, progressive The use of a partogram to monitor progress of (O'Driscoll et al 1993). By comparison, 50% of components according to their own philosophy of
caput and iii pp idlilg, and pOSSIbly me appearance labour prOVides a Visual ald for both the woman muloparae were delivered in 2 hours and 90% by labour and staffing resources.
of materna! feller, tachyc~rdla and haematuria. ~her care-wets. It I!n~~~ ete~tl'IO/l of clille 6 hours. In 1993, the rates of caesarean sections
LaOcili"r arrest :md obstrucnon require delivery by otaelivery as well as aertlOg sow progress. and instrumental deliveries at the NMH were 50/0
-
caesarean secnon. Progr:essive cervical dilatation is the most objR:-
nve and re ia means 0 assessm
st sta e of labour w hile escent
ro ess in
e al
and 10% respectively, with 45% requiring aug-
mentation with oxytocin . More recently a
prospecnve observational study in Dublin re-
escri es pro~ ess in the second stage. evaluated active management of labour and
re~ar vagm examrnanon is essentiaL found similar outcomes of a low incidence of
If;
Women's health: a core curri culum
13 Labou r and d elivery
* Operative vag ina l

delivery
Maternal
• Maternal exhaustion/Inability to push because
• The mother-to-be has been Informed of the
procedure.
01 dense motor blockade • The woman has been posltloped sultgbly
• Prolo nged second stg ae (e.g. stirrups or footplates, with the end of the
Common clinical presentations bed removed).
• Coexisting medical c onditions that
con fTdlndicore signihcont maternal effort, • Full dilatation of the cervix is confirmed,
A nullipara has been fully dilated and push'ing
e.g. severe preeclampsia, maternal • Ens o sem ent of the (etg' heSl,d has occurred (the
for 2 hours and is now too tired to continue. cardiopulmonary or neurological disease maximum diometer of the skull has passed the
pelvic inlet) .
A multipara has been pushing for 15 minutes. Fetal
The head Is not In view yet and the fetal heart • Non-reassuring fetal stgWs (e.g. abnormal • The membranes are ruptured .
falls to 60 bpm and falls to recover. cardiofocogra ph , a b ruptio placentae, cord
prolapse, acidaemla Identified on fetal scalp
• A nullipara with severe preeclampsia Is fully sampling)
dilated, the head is 3 cm below the ischial • Assistance with the birth of the second twin
spines (+3) and the maternal blood pressure Is • The b ladder Is e m pty - catheterise If necessary.
180/110. You wish to expedite delivery without BOX 13.1 Indications for an operative vaginal • Ania l~isla needs have been considered -
maternal effort. delivery sp no epidural/pudendal block: especigllY fpr
,. fo~s.
• CogsjdergtjgD has b eeg glyen to episigtgmy _

the patient population. Recent Australian data m are likely with forceps than with ventouse.
Defini tio n for low-risk primiparae demonstrated a forceps BOX 13 .2 PrereqUisites for an operative
An oPerative delivery is an gbstGvje ipteryepry on d elivery rate of 10.50/0 and a vacuum dehvery vaginal delive ry
in the second stage o f Jahg llr t9 aSsist WJtb the bIrth rate of 6.8%. FIGURE 13.5 Ve ntouse cups for anterior and
a e bab b the u f the force s or vacuum ex- posterior p ositions of the occiput, trac tion cord
tracto r (ventoug ) whep there i§ Asru O[ & telltial Instrument design forceps may be J.Wid for ditea OA deJiyeWS from and tractio n handle (Reproduced with permisslo
compromise to the health of the mother or e fetus. the mid-cavity, the Wri e force s suit an outlet fro m Beischer et 01 1997, P ~ 7B, Fig 47 .10A)
The three main types of forceps used in Australia deJi:£wr and the Kielland are or r eps
are the Neville-Barnes, Kielland and Wrigley for- deliveries (Fig 13.4).
Inc idenc e ceps. They all have a pelvic curve and a cephalic There are a significant number of different ven-
The operative delivery rate varies significantly curve, and are designed WIth a handle, a shank rouse cups available: metal, soft silicon, rigid plastic,
depending upon the instirution, the operator and and a blade with fenestrations. The Neville-Barnes reusable or single-use. All have a round cup
attached ro a section of suction tubing which is con-
nected to a manual or electric pump. Some cups suit
KleUand's forceps
both OA and rotational deliveries (e.g. Kiwi cups)
~i
l. 1=:1 I while others have separate anterior and posterior
cups (e.g. Bird cups). The major modification suit-
able for posterior cups is the site of attachment of
'''00 [ the rubing to prevent compression against the
maternal tissues and lass of suction (Fig 13 .5).
i'J e'.lille-8ornes fo rceps
Sho nk [
Indi c ations and p re requisites
Lock [
The indications and prerequisites for an operative
vaginal delivery are given in Boxes 13.1 and 13.2. Contrai ndicatio ns
Shoulder [
Some contrainrucations apply for both instru-
Types of Instrumenta l delive ry ments, others for one or the o ther.
Handle [
• M~ - the fetal head is engaged and the
station is less than 2 cm below the ischial Both
spines.
FIGURE 13.4 Forceps parts and some commonly used forceps (Based on Symonds & Symonds • Fetal Station abOye the ischia ' spines
• L~ ty - the station is at least 2 em below • Any expectation of significant cephalopelvic
2004, p 192, Fig 13 .16)
the ischial spines, but the head has no t dispropornon
Wom en's health: a c ore c u rri c ulum
13 labou r and delivery
Forceps Ventouse appearance of a newborn baby who has dry,

cracked skin coated with meconium, overgrown
Maternal Lower genital tract t~ GenUgl trgct traymg IAU cpmmqn; nails, abundance of scalp hair, little vernix or lanu-
m o re likely I! Cgcy!x or ygg lcgl wgll mens . An amendment may be made to
Perineal trauma go hair, well-developed palm and sole creases and
trapped under vento use cup e account of longer or shotter cycles. Twenty
Anal sphincter djs!uptlon/f~1 loss of subcutaneous fat. Only 10--20% of pOSt-
Incontinence term babies show any of these signs. per cent of women, however, have uncertain dates
PostpgrtllW hgemgrrhgge secondary to
or experience irregular or prolonged cycles. In
blood loss from trauma/episiotomy Pathophysiology these women, early ultrasound assists in accurate
establishment of gestational age (see Fetal growth,
Fetal Facial bruising Scalp abras.!gps Post-term babies are twice as likely as term babies to Chapter 8).
Cephalhaemgtgmg c e;5halhaemgtomo weigh more tIlaii 4 kg. I hus mothers of these babies '\- .~
Facial ne rve palsy Subgolea l haematama are at illcreasect nsk of proloqzd labour, operative Clinical assessment at 40 weeks :. ~~~~) 'NAI.J
Intracranial haemorrhage Intrac ranial ho emorrhage deilvrot' and posrpartUID tJae!!urhage. Careful clinical assessment of the pregnancy at 40
Pro onged pr~ancy is associated wjth an
-
Skull fracture
TABLE 13.1 Complications of forceps and ven to use delive ries

increase In penna mortali~. Pan of this increase
is ;rue to con~lmtaJ abnormijities. which are more
weeks' gestation is undertaken to identify c~
oons that may warrant early delivery. These fac-
tors may mdude previous poor obstetrIc history or
corrunon ill ese babies. A woman carrying an
tIl Lw.,t . anencepJlaJJc ferus typically may not labour spon-
complications m me current pregnang': for exam-
ple, preeciame;:la, diabetes mellitus, chronic renal
Forceps The choice of instrument depends upon the taneously until 43 weeks' gestation.
disease, recurrent pyelonephritis, antepartum
individual circumstances of the patient, and the The 0 er main cause of increased erinatal hae morrhage or illtrauterine growth restrlctIon.
Indication to avoid an episiotomy, e.g. ~
experience and preference of the operator. mottali ro ongeC! Inaucnon of lebour tg betore 41 weekS; gestation
anticoagulatipn
in a healthy pregnanCY confers no advantage to
Ventouse mortier or terus.
Non-vettex preseruations, e.g. breech/face Antenatal education should prepare .~\J.
Sigii!Iicant prematurity <34 ws;e~ women for the experience of labour Management options at 41 weeks:' \ ,,\t.S\
and birth and inform them obout the If clinical assessment at 41 weeks is ngrm a! tb~ VtJN
Complicati ons available' choices, including options
for analgesia . induCtIon of labour betore 42 weeks should be "":'in . .1A.
ol1ered to die mother. Compared to conservative ~..... ..
The complications of force ps and ventouse deliv- management with close fetal surveillance, a policy
ery are outlined in Table 13. l. of induction reduces the risk of perinatal death in
Compa ri son of fo rceps
and vento use
* Prolonged pre gnancy normal babies. This has been demonstrated in a
meta-analysis of 19 randomised trials (Crowley
1995). There was only one death among more
than 4000 women in the induction policy group
• The forceps have a lower failure rate.
A woman who has reached 42 weeks' compared to nine deaths among a similar number
The vento use IS less likdy to cause significant in the conservative group. Five hundred induc-
gestation, confirmed by early ultrasound,
wishes to await spontaneous onset of labour tions were needed to prevent one death associated
and hove a natural birth. wjth prolonged pregnancy. This policy also result-
ed in a small, but statistically significant, reduction
A pregnant woman at a gestation of 40 weeks
in the caesarean section rare and a decrease in the
and 2 days presents to the antenatal clinic. She
incidence of meconium-stained liquor.
is very anxious being stili undelivered and
wishes to be Induced.
The woman should be allowed to make iW
informed" decision about induction of labour. If
she deCldes a mdUCtIon of tabour before
~~~~~~~~~~~~r-
'''f
·.
Women's health: a cor e curri culum
13 La bour a nd d ell ery
IndIcation 0 2 Eltzschig HK, Lieberman ES, Camann WR 2003 Regional

anesthesia and analgesia for labor and delivery. The
Dilatation Less than 1-2 em 3 em New England Journal of Medicine 348 :319-332.
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Farquhar C, Jamieson M 1997 Introduction to obstetrics
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New Zealand Journal of Obstetri cs and Gynaecology cdn. Mosby, St Louis.
Summary 31(1): 31 -36.
The more accurate the estimate of the geStational Dujardin S, De Schamphcleire I, Sehe H, Ndyiaye F 1992
Paterson CM, Saunders N St G, Wadsworth J 1992 The
age, the lower the LPo dence 01 prolonged preg- Value of the aleC{ an d action lines on the panogram.
characteristics of the second stag. of labour in 25,069
nancy and thus unnece l nEion Of Illad- singleton deliveries in the North West Thames Health
Lancet 339: 1336-1338 .
ve ent preterm .e ·very. It is important to rea Region, 1988. Journal of Obstetrics and Gynaecology
99:3:-7- 380.
·.
Women 's health : a c ore curriculum
13 Labour a nd d el/very
Patti nson RC, Howanll GR, Mdluli W et al 2003 Journal of Obstetrics and Gynaecology 3. Which one of these statements about G
/
The most likely reason for slow
Aggressive or expectant manage men t of labour: 99 :381-385. normal labour is correct? progress in a nulliparous labour Is
a randomised clinical trial. BJOG: an r In efficient uterine action .
International Journal of Obstetrics and Simkin p, O'Hara M 2002 Nonpharmacologic relid of pain p. The average duration of the latent
Gynaecology 11 0:457-461. during labor: syStematic reviews of five methods. phase of labour Is 2 hours. b ' <ne-te-one care in labour has been
American Journal of Obstetrics and Gynecology
tt.'For the primigravida, adequate ~own to reduce the duration of
Peisner DP, Rosen MG 1985 Latent phase of labor in 18 6:513 1- 159. labour. ;.
pregress In the active phase of
normal patients: a reassessmeoc. Obstetri cs and
Smith CA, Cyna A./VI, Crowther CA 2003 CompLementary labour is cervical dilatation of
Gynecology 66:644-648. 6. Which one of these statements obout
and alternative t herapi~ fu r pain managem ent in 2 cm/h .
operative delivery is correct?
Riley M, Halliday J 2001. 2003 Births in Victoria labour. In : The Cochrane Database of Systematic
/ - The average duration of the active
1999-2000. Perinatal Data Collection Unit, Victorian Reviews (The Cochrane library)_ Online. phase of labour for the multigravida a . Five per cent of low-risk nulliparae
Government Departmem of Human Services, Avai Lable: http://www.upda te-softw.re.com/cochrane. Is 10 hours. require an Instrumental deli very.
Melbourne.
Symonds EM, Symonds 1M 2004 Essential obstetrics and @ he average duration of second . / b . Wrigley forceps can be used for a
Robern CL, Tracy 5, Peat B 2000 Rates for obstetric gynaecology, 4th edn. Churchill Livingstone, stage of labour for the null ipara '" rotationa l delivery.
in tc rvt: lltio n ~Ill ong priva te and public patients in Edinburgh.
without an epidural is 60 minutes. C)M ed ical conditions affecting the
Australia: population-based descriptive srudy. British
Tabowei TO, Obora VO 2003 Active management of e. The purpose of the parto ra h is to. mother's abi lity to push are an ~
record uterine contractio~s . p~
Medic,l Journal 321:137-141.
labour in a district hospira! setting. Jo urnal of indication for a forceps delivery.
Obstetrics and Gynaecology 23(1):9-12. d . In a low-risk nullipara, an
Rosen MA 2002 itrous oxide for re lief of labor pain: a
systematic review. American Journal of Obstetrics and 4. Which one of these statements about L. Instrumental delivery should be
Vacca A 1992 Handbook of vacuum extraction in obstetric
Gynecology 186:5110-226. prolonged labour is correct? ., conducted atter 30 minutes of
practice . Hodder and Stoughton, Lo ndon. 6:"w pushing.
~, he action line on the partogram
Sadler LC, Davison T, McCowan WE 2000 Wucocks ], Philips K 1997 Obstetrics and gynaecology. prOVides a visual cue for abnormal""'V e . The use of the ventouse Is
A r. ndomised controUed trial and mero-analysis of
~
Churchill Livingstone, New York. rogress of labour. \/ contraindicated for rotational
active management of ;"bour. BJOG 107: 909-915. delivery.
Wo rld Health Organization 1994 Maternal health and safe An abnermal pelvis shape is the
Saunders N Sr G, Parerson CM, W.dswonh J 1992 motherhood programme. World Health Organ ization m ost likel y reason tor prolonged 7. Whic h one of these statements about
eomra! and maternal morbictiry in relation partograph in management of labor. Lancet labour in the nul lip ara . operative delivery is correct?
to the length of the second scage of labour. 343:1399-1404.
c . Fa ilure of descent w ith p rogressively a. A forceps delivery can be
Increasing caput and moulding is a conducted appropr iately withou t
feature of normal labour. any ana lgesia .
d. The. use of o xytocin a ugmentation is b . A forceps delivery is safe when the
Similar for the nullipara and the fetal head Is above the iSChial
Questions 2. Which one of these statements about multipara . spines .
analgesia in labour is correct?
1. Normal active labour is associated
~ The most common cause of slow 0,:he membranes must be ruptured
with wh ich of the following maternal 0 EPIdurai analgesia may be
p rogress in a nullipara is InefficlenW before an instrumental dellver:'''~
associated with a 10w-grad V l,J'"'"
physiological changes?
maternal pyrexia . uterine action . V be performed .
a. Heart rate increases, respiratory d . A vente use is the instrument of
rate Increases and peripheral ,.t5. Nitrous oxide reduces uterine activity. Which of the following statements cho ice to. deliver a fetus of less than
vascular resistance falls. c. Epidura l analgesia does not affect about active management of labour 34 weeks' gestation .
the rate o.f instrumental delivery. are correct?
b . Heart rate , respiratory rate and e . The vento use is associated with
o cardiac output are unchanged .

Cardiac output , blood pressure and
catecholamine secretion all rise. \/'"
iT." Non-pharmacolog ical methods of
pain re lle.f such as baths , massage
and continuous maternal support
@
a . The principle aim is to reduce the
caesarean delivery rate .
EarI Y amniotomy allows visualisation
more maternal trauma than the
forceps .
have not been shown to have any 8. Which one of these statements about
d . Cardiac output and catecholamine effect upon maternal pain scores . of the liquor and augments labour./ operative delivery is correct?
secretion increase, blood pressure c. The. action line on t he partogram
foils. L One-to-one care in labour is a. Forceps and ventouse have the
associated with an Increase in Indicates a cervical dilatation rate same maternal and feta l
e. Oliguria. analgesia reqUirements . of 2 cm per hour. complications.
Women's health: a cO'a c urr ic u lu m
* 14
(9The vento use requires less analgesi q / b. Prostaglandin-ripening of the cervix
Specific obstetric emergencies
at delivery and is associated with / is safe in grandmultiparae.
less pain postpartum. Nadia Badawi, Michele Batey, Jonathon Morris, Michael Nicholl
0 · mniotomy is an effecti~ method
c. The ventouse may be used for
delivery with a face presentation .
Vof inducing labour. V Edited b y lucy Bowyer
0 .terine rupture is a risk assocjpted
d. There is no limit to the number of with induction of labour. ../
traction efforts that can be
attempted with a ventouse delivery. G Electronic fetal monitoring is
recommended for women on
e. Episiotomy 15 unnecessary with
9.
forceps delivery.
A 28-year-old woman with uncertain

(\1.,&
'
'I oxytocin infusion
11 . tephanie's LMP was 01.02.2004. The

first trimester ultrasound m e asurement
menstrual dates presents at 41 weeks'
gestation, as determined by ultrasound of fetal crown rump length (CRL)
suggested a fetal gestational age of
assessment at 20 weeks. Her
8 weeks and 6 days and a D e stimated
Learning objectives
pregnancy appears to be progressing
normally. Which of the following date o f delivery (FOP) Of 12 11 04. A p-
statements are correcn later morphology scan su r ested a Knowledge describe the signs that may indicate a
gestational a~e of j 8 wee s a nd 6 cord prolapse
I'6'\The pregnancy couJP be at 42 days and anbb of 16.iT .04. Wh ich
\.7 w eeks' gestatio V At the end of this chapter, the student describe the effect of cord prolapse on
of the ,o iiOWlilg Sldi Ql ii t§nts are will be able to: the fetus
6)rhe pregnancy may not be post-date. c orrect?
c. Urgent induction of labour 15 ~ aegele's rule gives on expected V Antepartum haemorrhage outline a management plan for the
patient who presents with cord prolapse
advisable. ~date of delivery of 08.11 .04. discuss the aetiology and differential
tdl The risks of prolonged pregnancy I ® :he second ultrasound Is more diagnosis of antepartum haemorrhage Fetal malpresentations
\./ a nd induction of labour should b eJ
discussed with the woman.
accurate than the first for 'f- describe the assessment and describe the possible fetal
malpresentations in labour
estimating gestational age. management of a woman presenting
~ Conservative management may be ( 9he first ultrasound examination with antepartum haemorrhage discuss the complications of fetal
considered, with close surveillancV supports Stephanie's menstrual dotes. malpresentation
outline the emergency management of
until spontaneous onset of labour.
@ Stephanie should be offered urgent a patient presenting w ith life- discuss the management of each
Induction of labour if undelivered threatening antepa rtum haemorrhage malpresentation
10. Which of the following statements
about inducing labour are correct? on the 10.11.04. Primary postpartum haemorrhage (PPH) Shoulder dystocia
td:\Cervical ripening with prostaglandin & here is Increased perinatal ._. . / define primary postpartum describe the clinical presentation of
V may be required for a c e;.VIX with a mortality if Stephanie is undelive ~ haemorrhage and indicate Its shoulder dystocia
Bishop score of 3. V after 42 weeks' gestation. incidence list the risk factors for shoulder dystocia
"i- summarise the physiological • describe the complications associated
adaptations of normal pregnancy in with shoulder dystocia
anticipation of PPH
outline the appropriate management of
01 ~ /l \ , critically appraise active and
physiological management of the third
a woman with shoulder dystocia.
stage of labour
l2. (\I ... V list the risk factors for PPH
S kills
describe the emergency management At the end of this chapter, the student
of severe PPH should learn how to:
Umbilical cord prolapse
take a relevant medical history from a
• list the conditions predisposing to cord patient presenting with antepartum
prolapse haemorrhage
(Continued over)
It¥
Women's health: a cor e curri CU!l..!m
14 Specific obste tric emerce ncies
(Learning obiectives continued) Attitudes

corticosteroids at less tbag 34 weeks' gestation] in
describe the general condition of a post- At the end of this chapter, the student case-premawre deJiyeqr js reTlired .
partum woman and accurately record should refiect upon: If bleeding settles with expectant management,
postpartum blood loss , blood pressure and the patient should be observed in hospital for at
pulse rate the need to appreCiate maternal risk factors least 48 hours. Approximately 60% of patients wjl!
palpate a postpartum woman's abdomen, for obstetric emergencies and to prepare a have wgher bleedio8 after the initial episode.
plan of management before labour Traditionally patienrs were observed in hospital for
and accurately record size and tone of the
uterus and any deviation from the midline the need to call for immediate assistance the remainder of the pregnancy, but more recently
in obstetric emergencies studies have shown no difference berween inpatient
• perform emergency resuscitation measures
In a simulated major antepartum • the impact of primary postpartum haemorrhage and outpatient management in terms of materna! or
haemorrhage. on the mother-infant relationship. minor L.. moJor -.-l neonatal morbidity, with outpatient care achieving
huge cost savings and bener patient acceprability
FIGURE 14.1 Pla cen ta proevia (Bosed on (Wwg et a! 1996). If outpatient management is tp
Farq uhar
& Jamieson 1997. p 107, Fig 13 ,2) be COnsidered the Qi6rnr should be cQPose"cd
*
about the risk of recurrent bleedin shou .v
usually in the upper two-thirds of the uterus, more .' Presentation cl I ve a e one and the
Antepartum often posteriorly. At 20 weeks' . n the - mean 0 rerum to the hospital imme
haemorrhage centa is low-l in in a rm(lmatel 5
b Y term slruanon as resolved in 90%
The classil!dlit~t!tn:
painls;s va_~--EL_lIl_ j u 1a.le
t
;lacr J.Onet~
ta
LO. PL Placental abruption
from minor to . e-threateniJlg. Some p atienrs also
o~ (Comeau et at 1983) . this apparent pla-
cental migration is due to the differentia! growth
cte"1t9
bJee '
yrsifue contractjORs or]jpiihdlty. the
usually stops spontaneou y
A patient presents In the third trimester of preg- of the lower uterine segment compared with
nancy with a small amount of vaginal bleed- re omes out the cy.
the remainder of the myometrium. The blood flow Bleeding is thou r to e assoaated with the
Ing ofter sexual Intercourse.
through the placenta is enormous, reaching deve/opment and thinning of the lower uterine
A patient is brought In by ambulance at 500 mUmin at term. Following delivery of the segment, which results in disruption of the placen-
36 weeks' gestation, having hod a massive baby, the uterus contracts and rapidly decreases in tal attachment.
painless vaginal bleed at home. She Is size, leading to separation of the placenta.
. hypotensive and tachycardic.
Diagnosis
A known hypertensive patient presents at Placenta praevia
32 weeks ' gestation with abdominal pain and If the materna! and feta! conditions are stable,
Placenta praeyia is implantation of the placenta in ultrasound should be performed. Transabdominal
rigidity, and vaginal bleeding, thelower segment of the uterus. I he wadence IS
A patient has recurrent moderate vaginal
bleeding throughout the third trimester of
Un 100 blctfjii. Rli[ fiicwp; lIlclude previous cae·
sa~an seaioo, in vitro fertilisation, mUinpancy,
ultrasound is llsed initiall~ d has
93% . Transperine31 or tr ae an
accura¥,: of
n1rrasol'n%in
fUIther increase accll!;as;y. The rate of placenta
Presen tation
from clinically
'. pregnancy. maternal age oyer b years, and t~ an? ~e praeVla greatly depends on the gestation at which
USe The most important of these IS prevIOus cae- the ultrasound is performed. Digital va .
~an section. After one caesarean section, the risk ina ' uld .
is reported to be 1-40/0, while after four or more prae;ia has een excluded by ultrasound.
caesarean sections it is 10% (Clark et a! 1985).
Four types of placenta praevia are described Management
(Fig 14.1):
cen u eru .
• 11.ES.I (marginal) : placenta encroaches on e
Th~ost common presentation of abruptio,>is
JOWei e t t rea e mte s
mild wana! bleediog, with or without ptenQr
• ty~ (minor): pia a! contractiorIS and a normal fetal heart rate, which
os;out does not coyer it
occurs WIth partial abruptiQIl. Major placental
• ~ (major): placenta partially coveye
aDrupnon may aJsOi£{ese~t with DIe. In such cases
in~os .;;=?i....."lr4r:;,.:;...;~;.:;::;:;::;:,7I'~d, even to the em nt the sigrIS are va iilleeding. bleeding from
The placenta! site is where the conceprus ~ (major): placenta completely covers the ':.:::~.w!;UI.~~~~Wi1~ in early gestations. vpnep uncture sites and brujsing. Fulminant DIe can
isp1ants [nCO the endometrium. ImptaTIta60n 15
----
internal os. given to administering occur Wldilil 1-2 hours of a complete brupnon:
It.!
Women's health : a c ore cu rriculum 1d Speci fi c obstetric emergenc ie s
* Primary postpartum
haemorrha ge
• the constriction of uterine blood yessels in the
A patient who has had a complicated labour
~02§!fJ.e~g9X~Sge, placental bed by myometrial fibres
and delivery has excessive blood lass • lo~ and general coagulation systems.
onl v"~ t In the c ase of
vi;'P5T"619tqlgQ mixod haem-
Immediately fallowing delivery.
IN 048,ge orrhage there will Failure of one or both of these
amoun t of
retroplocantcl
be some vaginal A pa tient who has delivered In the community
bleealng c nd
clot, couslng perhaps po.uoge
(planned home birth or born before arrival) is
a lDIIW o f c lot.s. bU' e lso a being transferred to 'hospital by ambulance
u~ build-up of some
clot behind the with excessive blood loss shortly after delivery.
placenta.
On the postnatal ward the morning after the
birth of her baby. a patient states that she Is
feeling dizzy and light-headed.
Th(omboplost\ru
releo:5ed from ttre
bock of the p lacenta
Into the maternal
ci rc ulation moy result
Epidemiology
In dlnemlnated
I ntrO\lO ~lJlor Postpartum blood loss is a physiological conse-
coa gurotlon (Ole) . quence of delivery. Blood loss is often underc:sti-
mated at both vaginal and caesarean deliveries.
Best estimations are that loss following vaginal
delivery is approximately 500 mL and following a
caesarean delivery 1000 mL. Pcwnaqum haemor-
FIGURE 14.2 Classi fication of placental rha e is define d as blood loss of <000 mL
abruption (Based on Pitkin et al 2003. p 37. durin and a er c evere IS
Fig 2) defin ed as b 00 ~100 0 mL A pti.wol.IT
PPH occurs within the fust 24 ours following
tissue destruction releases thromboplastins, which delivea_ PPH is potentiatIy iife-tllf~atening and APH - bklOd between OvetdlJteruton Of
activate the extrinsic coagulation pathway.
Bl eeding fro m the has an incidence of 5-15% worldWide. It IS still """,","""'~Iet1M>gwllh / Ule,,,,clwlns.
re Tac tion. Mov olio be pofytIydrorm6ol)
lower genita l tract one of the main causes of maternal mortality in osoodoled _ conganitol Inhlb/n notmol
Diagnosis botll developed and dexc;Jgping cpllon-irs detect and eXC8Sllve .----, ute,.,. r. raclten
Additionally, PPH is associated with significant bIe~ l o'ge _ loJ

silo (mUltiple
materna l mmbjdiry, including anaemig, prolonged Abtold cen --t~~!JJ ~)bIeeds
hospil! stay, lactation difficulties, pituit~ infarc-

Intart... with
conTract tv ""',.
~ aemorrhagic shock, coagu!.opay, renal
~t (acute tubular necrOSIS), com!l-, the GtCI'ld ~
t "", 01 PPH",
.....-J7- CIoI ~ utame
cavity prevents
need for surgical intervention, anaesthesia, inten- may hove mote musde refraction
tlbfOUltlSsue
sive or high-dependency care; and the loss of """ uf'edne wal
Full bIoddet due fO
future reproductive capabiliry if hysterectomy is dlJI'.... hledoelv
required to control the bleeding (NSW Health 011.,.,......",. wtl""
blood !tow (10m
Department 2002). ~~f't ~f""1Si~ plOce ntal bad
f'G'h.mslo rnot'l
Management / ~Sle.- V ctcu60flon.
Management varies depending on the maternal pathoPhYSiOI~~Y._~~t~;~r\! 00110 c&lVbt causes

h1~ pail. corvlal ""'-,
Int 'eres wtIfl
and fetal condition, gestational age and cervical With re an ~e~';tdrogrc Increase to bloo shOck and prevents
ContlOctlon
odeou90to U1eme
retroc-Iton
examination. Major placental abruption is an Avoidance of drug use and smoking
in pregnancy reduces the risk of FIG URE 14. 3 Main c auses of ute rine o ton y
obstetric emergency. ImrneCliate delivery, usually placental abruption.
by caesarean semon, IS reqUITed both to save t1ie (Based on Pitkin el 01 2003. P 60, Fig 2)
.t.'
Women's health : a core curriculum ~w.~ -\-(Q.II\j~~\OIl'\
14 Spec ific obs te tri c e m ergen Ci es
rr-~--.A-
Clinical findings Compensation Mild shock Moderate shock Profound shock replacement of blood loss. Other causes include gisr), anaesthetist, haematologist, intensive care
delay in the recognition of coagulopathy and delay specialist, operating theatre, laboratory and inten-
Blood loss 900 mL 1200-1 500 mL 1800-2000 mL in the recognition and control of traumatic bleed- sive care staff. Ongoing monitoring is required,
1~ ~ 30-35% ing. Concealed blood loss in the uterine cavity, WIth replacement of blood and elorting factors.
Blood pressure Nil Minor (postural) fall Marked foil Profound fall intra-abdominally or retroperitoneally, may lead The urine output must be monitored to determine
(systolic) 80-100 mmHg 70-80 mmHg 50-70 mmHg to substantial underestimation of total blood loss. fluid balance.
To correct Ii ovotaemi c ·talloids normal . In some cases, laparotomy with ligation of utile-
Signs and Minimal Weakness, ,:,nxiefy, Ta~a,re~. Co~ depressed saline or H artmann s so utJon s 0 me and/or mternal iliac arteries is required. lLthis
symptoms ±tachycardla, slow c~m y skin pollor, m9n1a1 state, gjo. fads, hysterectomy will be requued lD order to
capillary renn, ±Oii9Yl!a oJjgudg. h4lJ,Qar, ~Ia,
Circulatory a(Wf if control the blood loss. Anglographic embolisation
untr4tffild of utenne vessels has been reported in some series
to avoid the need for hysterectomy. In rare cir-
TABLE 14.1 Correlation between clinical findings and deg ree of shock in primary postpartum cumstances, widespread bleeding in association
haemorrhage with a consumptive coagulopathy may necessitate
abdominal packing and/or angiographic embolisa-
tion post-hysterectomy.
trauma, rupture or inversion (NSW Health Manual removal of the placenta may be necessary.·
Department 2002). Fundar massage may sometimes be necessary to
ensure adequate uterine musele contractility. Health maintenance
Abnormalities of coa ation account for on!
1% . D C may occur as a conse- Ante nata l ed ycgtio n sbg!!Jd Inform
quence of PPH. Risk factors far DIC include Signs and symptoms women abo ut excessive postParlum
preeclampsia, fetal dsi!6 tp litera, sev~e IOGiiop blood loss and the be~ ~~ ~l ~~
acJl1' mdh1tmenf 0 Cr:
loge
plaCeIitii1'aliruption and amniotic fluid embolism.
Evidence
-
of 10 our an reasHeeding .
.
An Iron-rich d ie! sh ou ld be a regular
part of every woma n' s il1e.
Prevention
Antenatal detection and correctian of anaemia is
imparrant (Prendiville et al 2002). The ~
mana e ent of the third sta e of Ja .
1. For an atopic vrep 's uterine massage, bi man-
uaT" compression and O~ocic
used. Prostaglandin ha FlJ
ctrugsmay be
IS us7 cl to con-
tr'OTSevere PPH caused by uterine atony that is
* Umbilic al cord prolapse
most eft PPH. unresponsive to oxytocin, ergometrine or uter- Common clinical presentations
inc udes the use ofcGffiPhylactic oxytocic ageplIj ine massage. PGF2a is usually given transab· Cardlotocographic monitoring of the fetal
with aetvery, and and control of dominally into the myometrium. heart shows an acute change In heart rate.
traction to e e e ve a te ace 2. If the lacenta is retained st be cemov d
PliyslO OglC or expectant management employs At 27 weeks ' gestation, a woman comes info
none of these interventions. O,,:ytoOO is the agent hospital saying her membranes have ruptured
of choice for prevention of PPH. The usual pro- spontaneously and that she can feel
something hanging out of her vagina.
phylactic dose is 5-10 units 1M or 5 units N
slowly as the anterior shoulder of the baby is deliv-
ered. Ergometrine maleate is not recommended
for routine prophylaxis because of its significant
Diagnosis
adverse effects profile. Cord £rolapse occurs when the umbilical cord
~ beyond the presenting part through the
Other third-stage management issues cervix and into' th.e n ea (Fig 14.4). Umbil-
Ical cord prolapse IS diagnosed either when the
Management of established PPH mother notices that '99ps pr cord spend r6rouah
Significant causes of maternal mortality and mor- me mtroirus or when an attendant feels cord in
bidity associated with PPH include delay in the advance of tne presenting part at the time of a vagi-
correction of hyp ovolaemia and inadequate nal examination. Cord tolapse should be ex<;lud-
ed as the cause of fetal eart rate decelerations as
4",,-l\ Iot~v il'l.~t'OJ
<: v ~\~ ~~~"'(,~';\(t;
14 Spec iti c o bstetric eme rgencies
women's health: a co re cu rriculum
NO/mal Molposillon COP)
pressure on e via a en.

T s proce ure should be performed in hospital
gen ca ere IS no e ective with the addition of uterine tocolysis. External
reglOn anaesthesIa, a rapid general anaesthetic is cephalic version successfully rotates a breech to a
FIGURE 14.4 Cord prola pse (Ba se d on Pi tkin et necessary. Senior neonatal personnel skilled in cephalic presentatlon in 40% of nulliparou s
al 2003, p 62. Fig 2) resuscitation should be in attendance. The person ~ and 80% of multiparous women. It should
responsible for preventing cord compression be performed III a cen tre that bas the resourcesro;
soon as they are detected by fetal hean auscultation should remove his/her examining hand from the Immediate caesarean section ill case ot fetal dis-
or electronic fetal hean monitoring. vagina only after the baby has been delivered. Me'presentation (8res:::h) ~Q/pr e.sen to r1on (StIoufdlH)
tress dun ng [he procedure. 1he morbidIty associ-
Even with prompt obstetric manal?~~: ~e ated With thiS procedure Is low.
There are a number of ide tifia
for umbilical cord pro apse. These include preterm mortalitffIOom cord prolapse may bUi ljiPh ;s fIGURE 14. 5 M alpresentotio n and malpositio n
(B ased on Pitk in et 01 2003, P 53 , Fig 4)
. SometilDes vagmit breech delivery occurs
prelabour rupture of the membranes, malpJ'benta- 30%. eIther because of maternit preference or the diag-
nosIs of breech presentation is not made in suffi-
nons (such as transverse lie, oblique lie an reech
presentation), a hi£!; presenting part, u~
abnormalities (such as fibroidS), twin preW-MCJ,
polyhydtarnruos, fetal abnormality and 15 ymg
* Malpresentations
cient time to perform a caesarean section. In these
instances, vaginal breech delivery should be per-
formed by senior obsretric staff, with paediatric
ptacenta. these coiidinons predispose to cor pro- staff ill attendance. An3Pisiotorny is ysually per-
lapse, since the presenting pan is not closely Expecting her third baby, a mother complains formed. The legs, bUttocks and abdomen are
applied to the cervLx. When the membranes rup- ot excessive tetal mobility. Upon examination, allowed to deliver spontaneously. The shoulders
ture the umbilical cord can slip past the presenting the tetus Is in a transverse lie. Breech presenta tion and arms of the fetus may be delivered by rotation
part of the fetus and present at the cervix, or actu- of the fetal trunk. Following the delivery of the
When examining a woman In labour. a mldwlte Breec~ presentation happens in approxi mme ly 3%
ally prolapse into the vagina. It is estimared to shoulders, the fetal head should be delivered by
is concerned that she does not palpate the of delivenes at term, but is more common in
occur in approximately 1 in 800 deliveries. fleXlon ill a controlled fashion either with the use
tetal head as the presenting part. prcterm than in term labour. It oc~ wbeg the
fetal buttockS present III the birth canal, and may of forceps or manually.
Management be further classified as:
Transv e rse lie
~resentation of the ferus (Fig 14.5) ~ • frank (extended) breech: the fetus has flexed
A transverse lie occurs when the long axis of the
~ed as any tetal presentanOp gther tban vertex. hips and extended knees
fetus is perpendicular to that of the mother. W~
The mOSt common malpresentation is the breech • complete (flexed) breech: the ferus has flexed
the ferus IS !P a rragsyerse~~ ~ ':,n~ ~~~
presentation. However, other abnormal presenta-
tions include transverse lie, shoulder presentation,
hips and flexed knees
• footling breech: the fetus has one or both hips
viiiiillly. If labour isaUow,;a ;n:;;;m; ;;h a
and knees extended so thar the feet of the fetus ferus in a transverse lie after rupture o~ ~e mem
fac e presentation, compound presentation and
branes, either te umbilical cord may prolapse Qr
brow presentation. are presenting.
Malprsrenratip ps put the fetus at increased risk
me fetal shoUl er may become firmly impacted in
the maternat pelVIS. 1£ attempts to perform a
of inumber of com lications. These include ~
panum e ess, perinar death and umbiltcal versIon of ilie ferns to a ton@tudiriat lie WIth a
cor pro pse. The moilier who has a ferus in m.al- cepfullic presentation are not successtul, a caesar-
presentation is more til<e\Yto be subject to operanve ean section IS necessary 10 order to deliver the ferus.
1'4
Women's health: a core curricu lu m 14 Specific obstetric emergen·:;i es
• diabetes obstetric, paediatric and anaesthetic staf~ should

• inStiii'iiieiitai vaginal delivery be called immediately, The woman should be
• prolonged hiSt and second stage of labour transferred to a dorsal lithotomy position, ~i
• short marernal Starure siotomv performed and Jlentle downward traction
maternal obssity. applied to the fetaI nead. n
de!tvery is not
achieved; there ere a n umber of manoeuvres that
FeWi risk mcro" are: can lie attemQljed, but no more than 30-60 sec-
• fetal macrosomia onas shoUld be spent on each manoeuvre.
• post-date pregnancy 1. First, the woman's hips should be flexed and l._ _
feq anomalies. the maternal thighs positioned ooro the mater- V'e.t \(
nal abdomen (McRobeq's ma p OPl1Yt,e). In ",\~_f. '"
addition, suprapUtiic pressure should be 1?os,hO
applied to dislodge the antenor shoUlder of the
a. Menta-anterior - delivery possible b. Menta-posterior - delivery Impassible fdiE-rrom the symphysis pubis. Gentle down-
ward traction should be applied [0 the fetal
FIGURE 14.6 Face presentation (Based an Pitkin et 01 2003 , P 53 , Fig 5) head together with these manoeuvres .
2. Should these measures Dot result ig deHyw:- of
the baby, the accoucheur should reach t te
Face/brow presentation delivery of a persistent brow oresentation is not the 0 e erus in an
po~,b1s. and a caesarean section is requjred. -
A face presentation occurs when the fetal head is .~~~~~~~~~~w-
hyperextended so that the occiput is in contact
with the fetal back and the face of the fetus is the
presenting part (Fig 14.6). Such a presentation is
diagnosed during a vaginal examination. When
* Shou ld er dystocia
3. of
the feral face presents, the chin, mouth and eyes

After d elivery of the fetal head, the shoulders 4.
are palpable. Fetuses with a face resentati.
do not descend and the fetal head is retracted Yic
b del ivered va u back into the birth canal. The chi n does not
s~,
clear the perineum.
1 n a brow cresentation (Fig 14.7), the fetal If Done of the above manoeuvres bays i'ccPIfl-
head remams between full extension and full flex- pHshed delive~ an attem~t can be made to ~
ion so that the biggest diameter (the mento-vertex) Ma nagement erately fiam Jr ~be d a",c1 gt tIle fetuS by o r =g
presents. A brow presentation is usually diagnosed DiagnosiS the anterior clavicle a~t the maternal sym-
by vaginal examination only when labour is well
Shoulder dystocia is an ob tetric emergen8', It has phYSIS pubis. OccasIOn y, wnere noneOf the
established, Under most circumstances, a v~al measures IS unsuccessful, two further manoeuvres
been demonstrated m popu!anon-based Studies that
have been described: symphysiotomy and replace-
the incidence is approximately 1 in 750 deliveries.
ment of the fetal head followed by caesarean sec-
Shoulder dystocia is characterised by ~
tion . These are rarely used and may not salvage
in .£kIjyerjps the rbO'ddeq o f the baby wb;g they
what is, by this stage, a desperate situation.
become i~ ~ the maternal bon~~elvis
after deliv;;rvJZJelOad. The antenor sho er of Re fe re nces
the fetus impactS on the maternal pubic symphysis,
Christoffersson M, Rydhstroem H 2002 Shoulder· dystocia
with the posterior fetal shoulder on the sacral
and brachial plexus injury: a population-based study.
promontory. When this occurs, further maternal Gynecologic and Obstetric Investigation 53(I)A2-47.
ex~sive efforts and tracnOD on the rera! head are
una Ie [0 deliver the tetus. Clark S, Kooning> P, Phelan J 1985 Placema previa/accreta
and prior cesarean sectioo. Obstetrics and Gynecology
Risk factors and complications 66 .89-92.
Maternal risk factors for shoulder dystocia are : Comeau J, Shaw L, Marcell CC, Lavery JP 1983 Early
FIGURE 14 .7 Brow presentation (Based on placenta previa and deli very outcome. Obstetrics and
Pitkin et 01 2003, P 53, Fig 6) • shoulder dystocia with a previous birth Gynecology 61.577-580.
"# I
14 Speci fic obstetric 6' m ergencle~
Farquhar C, Jamieson M (eds) 1997 lnrroduction to Pitkin J, Beattie AB, Magowan BA 2003 Obstetrics and
~undal pressure helps to deliver the

obstetrics and gynaecology, 2nd .dn. Department of gyn.tecology - an illusrrated text. Churchill e. is not considered an obstetric
Obsterrics and Gynaecology, University of Livingstone, Edinburgh. emergency.
AucklandlNationa! Women's Hospital, Auckland. ~ abY.
Prendiville WJ, Elboume D, McDonald S 2002 Acrive
6. Which of the following is true of
HoErneyr GJ, Hannah ME 2003 Planned caesarean section versus expectant managemem in the third stag!:: of
shoulder dystocia? 7. Which of the following Is true of a
for term breech delivery. In: The Cochrane Database of labour. In: The Cochrane Database of Systematic malpresentation?
Systematic Reviews 3 (The Cochrane Library), Reviews 1 (The Cochrane Ubrary). Online. Available : a. From the time of delivery of the fetal
CDOOOI66. Online. Available: http ://www.update- http://www.update-software.com/cochrane. a. It decreases the chance of
head to delivery of the fetal body caesarean section.
software.com/cochrane. 15 minutes can elapse before the'
NSW Health Department 2002 Framework for prevention,

Wing DA, Paul RH, Millar LK 1996 Management of the
symptomatic placenta previa: a randomized, conrro[led
fetus becomes hypoxic. @t is aSSOCiated with a higher risk of
cord prolapse.
early recognition and management of postparrum trial of inpatieot vs o utpatient expectant managem ent. b . houlder dystocia Is more common
haemorrhage (pPH). Circular 2002199, 7 November. American J ouma! of Obstetrics and Gynecology In mothers with diabetes mellitus. c. A breech presentation means the
Sydney. 175:806-811. fetus cannot be delivered vaginally.
c. Shoulder dystOCia is more common
with normal delivery. d. A transverse presentation means the
fetus can be delivered vaginally.
d. Sho.u lder dystOCia does not Occur
with a normal-sized baby. e. A malpresentation means that the
fetal face is presenting.
Questions d. Primary PPH does not occur with

caesarean section.
1. Which of the following is most e . Primary PPH can occur anytime in
characteristic of placenta praevia? the first 6 weeks postpartum.
a. severe abdominal pain 4 . Which of the following is true of
b. disseminated intravascular primary postpartum haemorrhage?
coagulopathy
~rimary PPH cannot be prevente o!.
c. Intrauterine fetal death
b. Primary PPH is most ef/ectively \"
0 painless vaginal bleed prevented by the expectant
management of the third stage of
e. small bleed at the time of rupture of labour.
membranes.
~ ISk reduction can be achieved by
2. Which of the following should not be the routine use of prophylactic
part of the initial assessment of a oxytocic agents.
patient with antepartum
d . Primary PPH Is always characterised
haemorrhage?
by hypotension and tachycardia.
a. abdominal palpation
e. Primary PPH does not occur as long
~ Vaginal examination as the uterus is well contracted.
c. ultrasound
5. The management of established
d. coagulation stUdies primary postpartum haemorrhage:
e. cardiotocograph. a . always involves blood transfusion
and the use of other blood products
b . ideally Involves colloid solutions for
primary postpartum haemorrhage?
the correction of hypovolaemla
a. Blood loss postpartum is usually
overestimated . c . does not involve inspection of the
lower genital tract
b. Primary PPH Is a rare obstetric event.
rd't: onslsts of initial assessment and
~ imary PPH is sti ll a major cause of '-.)reatment followed by more dire cted
U aternal mortality. in terventions
*15
The newborn
Paul Craven and Nadia Badawi
Learning objectives
Knowledge Skills
w ill be able to: sh ould learn how to:
describe the cardiorespiratory changes • assess a newborn baby 's Apgar score
that occur in the transition from fetal to
neonatal life • perform an examination of the newborn
describe the care of the newborn in the accurately weigh and measure the
first 48 hours newborn
discuss the problems of the premature discuss Immunisation schedules and the
baby use of growth charts v,. ith parents
describe the features of Down syndrome • perform neonatal resuscitation and

examination on a mannequin.
outline the immunisation schedule
planned for the first year
describe the neonatal screening tests Attitudes
discuss the impact of the newborn on At the end of this chapter, the student
the family and community. should reflect upon:
• the factors Influencing a woman's

decision whether or not to breastfeed
the multidisciplinary team involved In
the care of a neonate
the dramatic change a newborn baby
brings to the life of a couple or a family
the Impact of a sick newborn baby
upon the mother and the family.
If'
Women's health : a core c u rriculum
15 The n ewb orn

You ore osked to perform 0 routine Head 33-35.5 em In
doy 3 check on 0 neonote before dlschorge. circumference. Moy be length 51 cm
covered with lanugo (fetal Weight 3.5 kg
A term boby born by emergency coesorean hair) which will c ome out.
section hos 0 resplrotory rote of 80 breoths per +--____ Eyes dry. The newborn boby
seldom weeps.
minute at 1 hour of oge.
Sclero Is otten blue o f birth.
A boby is Joundlced on doy 4.
The blood sugor of 0 boby born to 0 womon

with dlobetes mellitus meosures 1.5 mmol/L.
Pulse (apex beat)
120-140/mlnute
Definitions and problems Feeding Stump of umbilical cord fled

or clamped. It should
Of around 245,000 babies born in Australia each Early establishment of feeding after delivery is obliterate In 3-4 days, and
year, the majority are born at term (37-42 weeks' desirable, and breastfeedin& is most successful if separate in er-9 days.
gestation). Approximately 7% are born prema- mother-infant suCktID~ be~ W1ctUn an hour of" In the moles, testes should
turely at less than 37 weeks' gestation and 1.5% at bIrth. Breascteeding s oule gm III the delivery have descended into the
less than 32 weeks' gestation. A baby born at more swre and then be continued and supported when scrotum by term .
than 42 weeks' gestation is described as post-term. the mother is moved to the posmatal ward.
limbs are worm and well
The average term bab wei 3500 is 5 Although breastfeeding is optimal for both mother rounded. The whole skln
Ion and and baby, some mothers choose to feed their should rapidly become
infants artificially with formula milk. Feetbg pin, .
should be re ted b emand i.e. as the a
FI G URE 15, 1 The normal newborn baby (Based on Hanretty 2003, p 356)
Temperature c ontrol
Strict attention should be paid to temperature con- Postn a tal care
trol because newborn infants can rapIdly become
hypothermic. Neonates have a large surface QU'a
to body mass ratio and od y a little brown fat to
Changes to the generate heat. Wants lose heat from evaporation,
condUCTIon, convection and radiation. ~
cardiorespiratory system retained by ing infants well !acin them in
warm
rents.
-Unce babies are warm, ~ink and normo-
glyca~ffilc, they shQuld &; ty w ed and ~eir
lengt , wei~ht and bead circumference recor ed. Neonatal resuscitation
f1i ey shaul then be transferred to the posmatal
ward or discharged home, depending on parental Although the majority of infants are weU at
choice and the medical stabiliry of both the birth and stable enough to transfer to the POSt-
mother and the newborn infant. natal ward, approximately 5-18% of otherwise
normal newborn infants require some form of
Itk
Women's health: a core curric uf u m
15 Th a n e w born
CH t..f/... '\
Apgar scores
genetic cause of the dysmorphism. Thorough docu-
Ductus arteriosus 0 mentation of features is essential for accurate
Colour White Blue Pink
diagnosis and effective communication with genetic
specialists.
Heart rate Absent <100 >100
left lung
Respiratory None Irregular Regular Down syndrome
effort
Tone None Reduced Normal
Reflex Irritability None Reduced Normal Reno. t presents WI lOcreasmg equency as
TABLE 15.1 Apgar scores fo r neonates maternal ;t:e mcreases. An IIlfant born with
Down synome may be recognisable by certain
Pulmonary trunk characteristic fearures. These should be identified
by the day 3 ch«ck. Such fearures inclUde ~_
+-----Heart
nem e ic . ds, a flat r CiE'ut, a ~ge tongue,
SLn e . a1mar crea~es an marked ypoto@.
ecogrunon 0 t ese feamres IS unperanve both
-1'--- - - - - Aorta for making a diagnosis and for further investiga-
nons of the aSSOCiated morbiditie of Down syn -
dr~e, which mdude:
Examination of the neonate
• hearing deficits - 60-80%
~: i dney All newborn infants admitted to either the neona- • co!!S,eruta! hean disease - 40-50%
tal nursery or the postnatal ward require a thor- • intesonat abnormalities (especially duodenal
ough postnatal examftnon. ThiS 15 r~ atresIa) 30-34%
performed on day 3 ~ life and aims to Identify • cataracts - 3%
cornmon patholOgies 10 the newborn period. Of • hFyroidism - 15-20%
major concern are ductal dependent ~a rdiac at antoaxJal instability - 15%.
2 ns ,. dysplastic hips, SPLnaJ anomalies and
anogerutal anomalies. There are a multimde of Other COrnmon syndromes identified in the
other common anomalies that should be identified neulborn period include Edwards' syndrome (tri-
and managed appropriately. To identify anomalies somy 18), Patau's syndrome (trisomy 13), and
accurately, a thorough systematic approach to velocardiofacial syndrome (a micro deletion of
newborn examination should be taken. This chromosome 22).
includes:
Internal Iliac arteries
Newborn screening
• p~ of the anterior and posterior
FIGURE 15.2 Changes in fetal circulation at birth (IVC, inferior ve na cava ; SVC , superior v ena f2 tan«ll.e and slillY"e lines The newborn screenm test is desi
cava: degree of oxy genation shawn In circles) (Based on llewellyn-Jones 1999, p 29. Fig 4.2) i entificatig D of Dorma' facja! fea nlres for tr ata e etabolic d '
• palpation gf the hard aDd 59 ft ra'aIe New om screening tests are free ut not compul-
resuscitation, and only 50% of these can be pre- achi.eves a score of 8, with a maximum possible • examination of the chest and cardiovascular sory. Each year the Newborn Screening Program
dicted from the history. Every delivery, therefore, score of 10. ~ poor Apgar score at 5 minutes gives abdommal and gerutouri systems ' tests over 90,000 babies in New South Wales and
detects about 90 who need urgent assessmem and
so:-m:~e~IIl~·tdi]ca~tljO~n~o~f:.t~
h,e~n~e~ur~o~d~ev~e!3l~o~pE:m::ie~njj;t~aI:il0ut-
should be attended by a person skilled in delivery • ex mati of for disloca' reloca-
tion upon Onolani and Bar ow manoeuvres treatlnenr.
and resuscitation. cO,me a e III ant an cal
(Fig 15.4) Common conditions that are screened for are
An indication of the need for neonatal reslls-
citation is given by the initial Apgar score at
a ran on to extraut e.
ear gw e es have been established for • examination of tbe limbs, $5, ~e and~_ pbdJJIketonun~
rol m and ~snc
J!ky), con~enital hxoothy-
rOSIS. PKU IS a rare condition.
1 minute after birth (Apgar 1953). The physical neonatal resuscitation by the International Liaison The examination is com%nJ,d by accurately g ot-
condinon of every Want born in Australia is eval- Committee on Resuscitation (ll.COR), and there IS tInS-the Wili/lt,
head CIr erence and l~ of
If it is detecte by newborn screening and the baby
uated 1 minute after birth and the Apgar score currently a strategy to develop a program of IS given a diet low m phenylalanine normal growth
the infant on an afpropnate cenrile chan.
recorded in the notes (Table 15.1). The rFtuation mandatory ttaming for those involved in the care and development will Occur. Untteated PI<! I can>
. If a number 0 anomanes are Identified in the
is~peated every 5 mmutes until e IIlfant of the newborn. es severe neurolOgical impairment. Co~
mfant, this raises concern over a syndromic or
nypotbyrOldism aHem about i Ln 3500 babies and
11:1
Women's health: a core curri culum
15 Th e nawbo rn
Normol Breathing impaired Not impaired

Signs in
first minute
Breathing Breathing
Breathing
shallow stopped ofter NO breathing
1
First breath
regular
Within
or regular first breath
Usually In first
Never breothed
seconds few seconds
Heart rate > 100 >100 > 100 <100
Periphe ral
perfusion
FIGURE 15,4 Examination of the hips of a

newborn Infant (From Pitkin et 012003, P 81 ,
Fig 3)
results in inadequate thyroid hormone, which is

essential for nonnal brain developmem. If the con-
din on IS detected early and adequately treated, a
child will develop nonnally. Cystic fibrosis affects
1 in 2500 babies and is characterIsed prInClpaJly by
pancreatIc and respiratory dysfunction. Early diag-
nosis and treatment are irnponanr for the future
prognosis of the disease.
Immedlafe reocf1ons
In addition to newborn screening all infa
I CaRtor gdvgnced resyscttator (ARNB) have their bearin formal! assessed b au . m-
II Administer OOSfc resusCTraHOn
I.e . ~ an are 0 ere ':TIDlurusaoon as s own in
I) Position t~1i:. t;!~b.- TaEfe 15.2. The Ausrraian Standard Vaccination
11) venfllgte WlfhJace
mask Schedule is recommended by the National Health
iii) Ap ex erna cardia
tt hea < n ~p~or
and Medical Research Council (NHMRC), which
or has sought to reduce the number of injections
Unanticipated meconium Watc ar given at each immunisation session through the
0) Symmetrical chest movement
use of new combination vaccines (NHMRC
-
I Suck gyt mouth as soon OS heWIs
b) Onset of regular breathing
delivered 2002). Immunisation is not compulsory, bur access
c) Improvement of heart rate, perfuslon ,
Coil for advanced resuscitator of
colour, movement and tone to child care benefits and some child care services
the newbOrn boby Iv) Consider naloxon~e_ _ _ _ _ _ __ --, may be influenced by the immunisation status of
the child. Age Vaccine
III Place bab y flat or slighMy head·down
Birth He.£2!!!jU.
IV Suck out mouth and gg.se <..i;r1onths DTPa-nepofilis B, Hib, OPV
V G i~ by funnel If no improvement. further aclion
~months DTPa-nepatitis e, Hib, OPV
Administer advanc ed resusc itation by ARNB
I.e. ~onths DTPo-hepafffis Band OPV
i) Trochee' 'NI [batten and ventilation
ii Externgl GO rd lp c cgrnp'AS# on 12 montns MMRand Hib
Iii) D~lf necessa ry Prema ture Infants DTPa dtphthe no . tetan us, ac ellular p ertussIs
OPV oral poliomyelitis
Despite the best efforrs to suppress labour, prema- MMR meosle:s, mumps and rubella
turity accounts for the majority of neonatal prob- Hib Ho emophUus Innuenzae 8
FIGURE 15.3 Al gorithm f o r neonatal resuscitation (From lIe we llyn·Jones 1999, p 82, Fig 9.17) lems. Preterm infants have a survival rate inversely TABU 15.2 Austrollan Standard Va ccination
proportional to their gestational age. At 24 weeks' Schedule
":8
Women's health : a core c urric ulum
15 The newborn
W g'
.~ ve
OCQ1TS in 20%of infant:; horn at less than ~£i require a health cbeck at 6 weeks of at
w ·ch time the health of both mother and c . d is 2. Premature infants:
10 weeks' gestarjon (Disability Online 2004) and
~o/mln.
a normal respiratory rate of
can have devastatin neurolo· cal conse u ces, noted in the parent-held health record, Subsequent a. will mostly surVive at 24 weeks'
their severity eing equ to t e seventy a j)i consultations, health checks and vaccination sched- gestation.
G are susceptible to hypothermia.
all infants born at less than 30 weeks' gestation, ules are also recorded in the parent-held record. b. are unlikely to develop
ru:ZO% Will have cerebral ¥ilf, up to 5.Q1!uyill
have a flnecific learnwm diffi ty, 1% will 6eregis-
intraventricular haemorrhage.
./
-
c. develop jaundice secondary to
tered b· d and 5% . be deaf. Parents should be advised against phototherapy.
smoking in the home to minimise the
Taki ng the baby home risk of neonatal lung problems and
sudden infant death syndrome.
In Australia, some infants are born at home but most
are born in hospital settings. Those born in hospitals
remain for varying periods, depending on gestation,
birth weight and associated morbidities. As a rough References
guide, parents of preterm infants are told to expect Apga r V 1953. A proposal for a new merhod of eV:1l u.a tio n
their baby's discbarge to coincide roughly with the of the newborn infant. Current Researches in
initial due date. Te . annal! remain in hos- Anesthesia and Analgesia 32:261-267.
pital between 6 hours and 1 we
e amv a any t in the home is onc of Disability Online 2004 Premature babies.
Available: http://www.disability.vic.gov.a ui
the most profound changes to lifestyle that a family dsonlineidsartid es.nsflpageslPremature_babies.
will ever experience. Problems the parents may have
to cope with include sleep deprivation, breastfeed- H anretty KP 2003 Obstetrics illustrated, 6th edn. Ch urchil.l
ing dilemmas and society's attitudes to this, financial Livingstone, Edin burgh.
consrraints as one partner often ceases working,
Llewellyn-Jones 1999 Fundamentals of obstetrics and
posmatal depression and sexual diffirulties. gynaecology, 7th edn. Mosby, London.
Suppou for t h e faqlily once they have been dis-
charged from hospital is supplied by a nlWlber of NHMRC 2002 The Australian Standard Vaccination
services. Community midwjxe5, co=unirv health Schedule 2000-200l. In: T he Australian Immunisation
c~ and gegeral practitioners provide excellent Handbook, 7th edn. National Heal th and Medical
Research Council.
support and pnmary care tadlities for these families.
After cfucha[ge, jt is recQmmended that the bahy be NS W Department of Health 200 1 New South Wales
reviewed at the early childhood cenerd; whicb will mothers and babies 200 0. NSW Departmen.t of Health
often orgaruse a home visit WIthin e fust (public H ealth Division), Sydney.
wee a owmg e om OSplt . The gen-
Pitkin JP, Pe.artie AB, Magowan BA 2003 Obstetrics and
er praCtItioner proVl es primary health care for gynaecology. Churchill Livingstone, Edinburgh.
both the mother and the baby. .All newly discbatged
Qu e sti ons b. is macrosomic If the baby weighs

2500 9 at term.
Complete each statement w ith the correct k ' ls premature If born at 32 weeks'
answer. V gestation .
1. A neonate : d. w ill only feed several hours atte v
a . is premature if born at 37 weeks' birth.
gestation. e. should be fed every 6 hours.
*16
Routine management
of the puerperium
Edited by Sandra Carr
Norma l puerperium Sandra Carr

Care after caesarean delivery Michael Humphrey
Puerperal sepsis Sandra Carr
Seconda ry postpartum ha emorrhage Jan Dickinson
Genital tract trauma Christine White
Learning objectives
Knowledge Secon dar y p ostp artum haemorrhf!g e

( PPH)
At the end of this chapter, the student define secondary postpartum
will be able to: haemorrhage and indicate its
prevalence
Normal p uerpe rium
list the common causes of secondary
• describ e the physiological changes of PPH
the puerperium
oulline the management options for the
• discuss the establishment of successful c ommon causes of secondary PPH
breasHeeding
Gen ital tract trauma
describe the assessment of the mother
• list the causes of gen ital tract in jury
before discharge
describe the d ifferent types and
oulline the role of the 6-week degrees of episiotomy
postpartum health check
discuss the ro le of episiotomy In
Care after caesarean delivery childbirth ,
list the common complications of
caesarean section
• describe prophylactic interventions to Skills
minimi se these complications
discuss the management of pregnancy should learn how to :
follow ing caesarean section
Prob lems of th e puerperium • assess the amount of vaginal blood loss
and a woman 's haem adynamic statu s
• define puerperal p yrexia
counsel a mother before discharge
list the risk factors for development of about her own health and caring for
pu e rperal sepsis the baby
• list common sites of infection and palpate the postpartum uterus and
oulline management of each infection rec o gnise the stages of involution,
(Continued over)
"*
16 Routi ne m o na gement o f th e p uerPerium
,'Jamen's health : a c ore curriculum
symphysis pubis and uwbjIjq's. By 2 weeks. it is no their family doctor. Pelvic floor exercises assist in
longer palpable abdominally. By 6 weekS the the healing and reduction of pain.
(Learning objectives continued)
uterus has returned to close to "itS pre-premant
s.s. The term uteru we ighs approxImately Cardiovascular system
Attitudes moo g, but involutes to 50-60 g by 6 weeks post- In the first 24 hours, the mother's baseline pulse
At the end of this chapter, the student delivery. Uterine contractions under the influence... rate drops b,' about 10-15 bpm and her tempera-
should reflect upon: of oxytocin are ohen paiIlfui 6Jterpains) and may ture may be slightly elevated. This is investigated if
rt: q ~e aiia1g§@. it persists or becomes significantly elevated. Blood
the sociocultural Influences on childbirth The mtemar 0 of the cervix is closed b the
and breastfeeding
volume decreases and viscosity increases to pre-
sec e vagJna, gaments a e uterus, pregnant levels. Smooth muscle tone of vessel
the impact of puerperal Illness on the muscles of the pelvic floor and separated rectus walls improves and cardiac output reduces. There
experience of childbirth muscles return to close to their pre-pregnant state is an increase in the leukocyte count during labour
the gravity of serious postpartum with time and exercise. The decidua is shed aDd and in the first 24 hours postpamun. Evaluation of
haemorrhage. appears as lochia (postpartum blood flow). Lochia the haemoglobin concentration is important if
consists of blood; leUI<o es and dwaual "Fa;- there has been significant postpartum blood loss.
m_ . . y ng t oehia rubra) for 3 or 4
The physiological, hyp ercoa~ble state of preg-
days, changmg over the next 10-12 days to pale
nancy persiSts u to 6 wee 0 artum and
brown (lochia serosa) and finally to yellowish
* Normal puerpe rium

\. Process of Involution white (lochia alba). Typically, between days 7 and
14 postpartum there may be a transient increase
in vaginal blood loss, due to shedding of the pla-
increases
Urinary system
om oem olic ·sease.
Common clinical presentation cental site scar. The endometrium regenerates in

2 weeks, but it may take up to 6 weeks at the for-
A woman has delivered her first baby. She
mer site of the placenta. In general! postpartum
enquires about the physica l changes she
can expect to experience over the next
blood flow ceases by 4-sn weekS po~artum
(medJaO 30 days). I fie totat volume IS about 250
6 weeks.
mL External pads are useato ao orO the 10Cliia.
!tiS important to report any increasing 10ssLclots Bow e l fu nction
or maloaorous disCliarll.e.1 as It may mrucate
The puerperium refers to the 6 weeks durin infeC1'lon Or retamed proJucrs of conception.
w ' aw siolo .call retu
pregnant state. These c t es are a result of the Ovarian func tion
withdrawal of pre~CY OnTIones. The puer-
perium connnues t eslgnihcant tranSIUOn that Ovarian function returns after about 10 weeks to
pregnancy has begun. For many couples, it is n~t die non-lactating woman but may return as earlY
until these early days and weeks after theIr baby s as W weekS p&EpaHum. In lactating women, 1 Breastteedlng
birth that they begin to fully understand their new o§lanon my De detaVed for 8-16 months. All . . .
women need to consIder contracepnon frelM' The se~ond mb~~m of 10bstpartumtfdi care is to
role as parents. . ' ~--", 2 4 weekS postpartum as~lst e esta ent 0 reas ee ng. ~
The midwife is the primary care-gJver durmg ________ . , milk meets aU the infant's nutrWlllliLll"&.,ds in the
the early puerperium, and the family medical prac-
titioner supports later puerperium care. For
----14
_ _ _+6
_ _-+8
Perinea l tra uma hist 6 monthS of tJe and rem];;; ; ; ...
fom! ror a fUrther 6 months. Breast#pwr;..s
!:;
I
women who have had a homebirth, a IDldwife will T~ including second-degree tears or episiot- agamst irifecnollS thrOUgh specific and nonspecific
visit them each day for about 10 days. If a woman tOffile5, heals within 2- 3 WSeks Women need to immune factors 10 milk and has !:~g-tM mgse-
has delivered in hospital or in a birth centre, the keep the penneum clean and dry. It is important to quences for metabolism, deyerm;!!!.!:~und ~
length of stay will range from 6 hours to 5 days, aVOId constig:!!;ion and report increasing pain, ~- latei'" w file. For the mo eastfeedin aids
with the majority o£ wo wen gging hgrne 3 days nal ctJ¥C!lai"ge or malodour, as these may be signs of involunon, reduce risk of e I eI
after birth. - mfeCtlon. ~ cancer and e a . icy
~
itor the rocesses £ o re ric ioyo pn rnlli-
main aims of pos~artum ~ ~ r~ tp
establi;h
FIGURE 16.1 Normal In volution : fundol hei gh t
"WOr;;en may need lubrication with intercourse if
they experience any diScomfort durmg the first
(NHMRC 1995). Current rates of breastfeeding in
Australia are approximately 80% at birth 600/0 at
breas etsg an assist the development 0 Qar- b y doys ofter delive ry 6 weeks. If this discomfort persists they should see 3 months of age and 40% at 6 months of age. The
ennng s s and abiIines.
!"
Women's health: a core cu rriculum
16 Routine management o t tho p u erperium
prevalence of women breastfeeding at 3 and baby feeds more frequently. The mother may
6 months is less than the national target of 80% activity and any ongoing medical concerns such as
perceive this as a sign of insufficient supply but diabetes. She is encouraged to discuss her experi-
(ScOtt & Binns 1999). should be reassured if the baby is well-hydrated ence of pregnancy, labour and birth and identify
and gaining weight. any issues of concern. The importance of her fam-
Milk formation Neonatal roblems may cause breastfeeding ily and wider social supports are emphasised.
arISe g
Six-week postpartum visit
Each woman is referred to her local child health
corrununity nurse 1-2 weeks after going home and
to her family medical practitioner 6 weeks after
birth. At the 6-week visit, the family practitioner
checks the welfare of both mother and baby. The
process of involution is checked and a cervical
smear performed if necessary. The mother-part-
ner relationship is discussed, the need for contra-
ception explored and any medical condition clini-
cally evaluated. The baby growth and develop-
ment is assessed, immunisation schedules are
planned and the parent-infant relationship is dis-
cussed.
Ejection (let-down refle x)
, Preparation tor home After a caesarean section, a woman's experi-
Sucklin& leads to o~ocin release from the pos- ence of the posrpartwn period is differem from
ten or ~!tu!tary, resutmg III contraCOon of rwo- The third principle of postpartum care is to facili- that of a Woman who has had a vaginal delivery.
epiclle .al cells, forcingIDilk Into me iadlte[ous tate and support the early transition to parenthood For some ....:omen, the experience can impact upon
ductS and leading to eiecoon of milk. The ~cin and prepare the mother for discharge. Factors that their perception of self and mothering. They may
alSO causes urenne contractions and involution ' influence a woman's early adjustment to parent- require opporrunities to discuss and reflect on
hood include her past experiences of parenting, these feelings.
health status, her experience of birth and expecta-
tions as a mother. Other factors influencing the Health maintenance
parent-infant relationship include the level of sup-
Antenatal education, reinforced by
POrt available to the mother from her parmer, midwifery assistance in the early
family, friends and commtmiry, indigenous and puerperium , assists the development
culrural influences, social background, financial of good parenting skills .
position and physical home environment. These
factors should be considered in a holistic approach
for each new mother. '
During the postpartum hospital Stay, the care-
giver provides guidance, advice and education
directed towards the mother's need to care for her
baby physically and emotionally. Through this
process, the mother develops confidence, prepares
for discharge and identifies available commtmity
motions.
resources. Each care facility should have policies
Common problems and procedures for discharge of mother and baby
that include asseSSment and discussion of the
mother's physical and emotional wellbeing. The
mother is advised about uterine involution lacta-
f iGURE 16.2 Establishing breostfeedlng (Bosed tion, urinary and bowel function, healing ' of the
on Fraser & Cooper 1971, Fig 40 .7)
permeum, contraception, resumption of sexual
,g.,
Women 's health : a co re cu rri c u lu m
16 Ro utine managemen t Of th e p ue rperium
* Care after requires rransfusion is not conunon, and may be

associated with injury to the uterine vasculature.
operation of choice, as this scar is less likely to
rupture in subsequent pregnancies than the longi-
augment labour. Obstetricians are, however
caesarea n delivery Damage to the bladder is possible, especially in the tudinal incision in the body of the uterus (as
increasingly advising women to attempt vaginal
presence of scarring from one or more previous cae- birth in these circumstances.
performed in the classic caesarean section). There
Common clinical presentations sarean sections. Such an injury does not usually have If th ta develo s on the anterior lower
is little evidence that different operative tech-
long-term sequelae if promptly recognised and niques, such as single- versus double-layer closure
A 35-year-old nulliparous woman has a caE>- appropriately repaired. Continuous bladder drain-
sarean section for breech presentation.
of the uterus, alrer the risk of postoperative wound
age is instituted for several days postoperanvely. complications (Enkin & Wilkinson 2003
Four days otter a caesarean delivery. a woman Most complications occurrin in the u eri- WIlkinson & Enkin 2003). '
has a temperature of 38°C and on InHamed um ar te WI ever. ll:~~e......_ .....= "" Deep vein thrombosis can be migim~by
wound site. ours, the source 0 a eve ' . .karefuIS handling of the woman's legs during and
tract 1Il eetlon, mtrauterine sepsili. or se~ afrer the operation to minimise endothelial injurY,
In the antenatal clinic. a 32-year-old woman
requests an elective cae sa rean delivery for the
lung coIIapse. Par31yoc ileus is unusual1Ollo\ving and .by attention to . good hyclTaoon and early
.birth of her second child. Her Hrst baby was caesarean section . mobilisauon. There IS evidence that graduated
barn via emergency caesarean section Fexer associated with a wound infection" IS compression Stockings are useful in minimising the Health maintenance
because of failure to progress In labour and obvious after 3-4 cia and IS assOCIated V.'1th incidence of deep vein thrombosis in hospitalised
increasing lower abdo " an !£l: ,. Good hydroll'jln , egWi nwbil!SQ~n
fetal d istress. patients and that this prophylactic procedure is anOpjJYsio!bergpy minim ise toe
thema surrounding the wound. Full-thickness more effective when used in association with other postopergliye complications Qf
wound disruption is rare . Wouud.infection is mpre prophylactic techniques, such as intermittent calf vef'l"ous throm boembolism and chest
likely in women who are obese~ when the caesa!- compression devices and/or low-dose heparin in ~ .
Common com plications of ean seetlon occurs after obsrn'd'lH;I gF IOltQ- (Aroaragiri & Lees 2003) . This evidence is not spe-
caesarean section I Uf, or were there is difficulry in estab-
cific to pregnancy and caesarean section, and the
*
g wo un haemosrasis. . . trials in pregnancy have insufficient power upon
Caesarean section i a major abdominal operation, Fever associated with deep vei n thrombOSIS 'S whic h to base reconunendations (Gates et al 2003).
aSSOClat d with a smarr matemaI moi'cill nsk, genei-aJly not as high as that associated with sepsis Pue rpera l sep sis
inrraoI'.eraove riskS of haemorrfuiH and~e cta and can tenderness IS usually elicited. D~ Management of future pregnancies
to otbi r abQomrnopelvlc VIscera, Shorr-term rISks Ji&asound jnvesngatlon ot blood fl ow in the after caesarean section Common clinical presentations
of wound and urinary tract s~s and ~bO venous system of the leg will usually provide a
e~sm, and long-term risksOf scar deliiscence, A woman presents with a 38 .5' C fever 4 days
diagnosis in this cim lmstagce. A p u1wouacy ycoo_ Most of the twentieth century was dominated by
atter a caesarean delivery.
placenta praevia :ffi'(! acreta 1I1 fUrcre pregnapCies.lation-perfusion scan should be considered if the the dictum 'Once a caesarean, always a caesarean'
1 he lIlodenee of cfieSecom~tions is higher D2£Pler exa/Illllation is p~tive. (Cragin 1916). However, the increasing incidence A woman presents with fever. offensive lochia
in noo-elective 0mratioos. It IS 01Jt to separate of caesarean section throughout the world (with and a tender uterus 48 hours otter a prolonged
the mortality ns ot caesarean section from the ProphylactiC interventions to reduce rates exceeding 25% in many countries) has led to labour and vaginal delivery.
mortality risks of the pregnancy complications that incidence of compl ic ations increasing medicolegal and political pressures to
lead to emergency caesarean section (e.g. signifi- aim for vaginal birth in subsequent pregnancies,
cant preeclampsia). The mortalitY risk of a healthy UnLike most intra-abdominal major operations, especially if the indication for caesarean section is
woman havin~ a plaruied elective pnmarv g esac.: there is no evidence that withholding oral fluids not recurrent. Successful vaginal birth afrer cae- Puerperal sepSis
ean seenon un er reglOnat anaesthesia is onld'thmar- afrer uncomplicated caesarean section decreases sarean section (VBAC) occurs in 30-70% of
ginlilIy abOve that assooated Wit'ti vagmaI b . the risk of postoperative complications such as women who undergo a trial of labour, although
GeneraI anaesthesia 1I1 pre an paralytic ileus (Mangesi & H ofmeyr 2003) . there is great variation in the number of women
with a er n s 0 on com ns. There is e~e that using prophylactic ano- willing to try lab our. T he c;s!WplicniliRs of
Co e maJonty 0 caesarean se . ns biotics at caesarean secnon reduces the UlCldence of attem ted VBAC, including uterine ru and
are now per orme er s an or e idural ena omemns and wound Weenons b more than fe oss, mUst ance a t the hi
an e use 0 e-nee e tee ques IS 50 0 .v caesarean orexc essive lood loss, uninten e
associated with a low incidence of 'post-spinal' se~ons.. rnaill & H ofmeyr 2003). Single-dose bla er an bow I ecnoD an omboembolic
headaches. Other complications, such as jntra o-w regImens of both am~ and £irs~-&em:r.aOQn disease related to repeat caesarean section tone
. e!Ira-du ral intecnons, fiaematomas and neurolog- cee.halosporins have s1milar effi caQ'. iR
rPdUqng et al 2000, Lydon-Rochelle et at 2oon. At the
ical injuries, are rare. postoperative segsis (Hopkins & Smaill 2003). . beginning of the twenty-first century, the evidence
tnrraoperabve morbidirv is relatively uncom- Caesarean section with a transverse UlClSIOD m for the safety of VBAC is unclear, especially when
mon m expert Jllll1dS. Excessive blood loss that the lower uterine segment is recommended as the
oxytocin or prostaglandins are used to induce or
Mg.;
Women's health: a core curric ulu m
16 Routine manog emen l at the p uerp e rium
rate from sepsis rise to one woman in four or five subsequently be transferred to the infant
of those giving birth (Loudon 1986). (although there are wide variations). The in..fuut Clinical signs and symptoms
In the late 1800s, streptococcal organisms were suffers adverse effects sllfb as diarrhgea and COD- Postpartum haemorrhage most typically Occurs in
demonstrated in pus from wound infections. In snpa~n, due to the acnon of antibiotics on the the second week post-delivery (40% of all cases)
1879, Louis Pasteur identified the haemolytic neonatal gastrointestinal tract. In the early puer- when the placenta! site scar is being shed and is
Streptococcus in the blood of a woman with puerpenum.' acomprehenslve assessmenr is required to uncommon after the ftrst 4 weeks postpartum (5%
peral sepsis (Adriaanse 2000). When Joseph Lister, ascertam if It IS safe for a mother who is breast- of cases) (Dewhurst 1966). On occaSions, the firSt
learning of Pasteur's work and the germ theory, feeding to take a specific medication (Hale 2002). menstrual penod after delivery may be misinter-
began to apply antiseptic principles to the practice preted as a secondary PPH, as this menstruation is
of surgery, there was a dramatic fall in postopera- Wound infection ofren anovulatory. The volume of blood loss is not
tive deaths from infection (Lister 1870). It took usually severe but is associated with haemodyna-
Infection is more commonly seen in caesarean ser-
nearly 30 years for 'Listerism' to be universally mlc compromise in 10% of cases.
tion wounds around day 4 or 5 post-delivery but Bef?~ discharge the woman s~ld
accepted by medical practitioners. By the end of be informed abollt tb e signs Qf Subinvolution or abnormalities of involution
may also occur at clle site of epIsIOtomy ano per-
the nineteenth century, the need for obstetric asep- puerperal iI:lLilction to allow early are clinically recognised by a large sofr uterus and
ineal tears. The woman complains of fever, red-
sis was well appreciated. recognition and prompt
Today, in AuStralia, deaths from puerperal sepsis dfnin~, inflammation and discomfort :iroUncG1iC management.
a parulous cervix, and may result from retained
woun (Hum--pJlfey 1999). The wound will appear placenral tissue or uterine infection. Attention to
are extraordinarily rare (the overall maternal mor-
~ed and there may be assOCiated offensive ' the SignS of endometritis is importanr. Clinical
taliry rate is currently about 0.1 per 1000 births; Weep~ows of secondary PPH are fresh vnm;;r
lo~ A swab and smear of clle wound should be
Donnay 2000), but infection and fe er are not rare, Ii eeding of greater than 100 rnL and crampin~
and the microbes causing them are common. It is
notew however, that only the use of incr;
com lex antibiotic re' ens controlS clle rates
sernto micro];logy. Anti~ !ieraqU hQula
be commepce ~ for geDlta act
Urinary t ract infection

ecnon. ~
)
* Secondary postpartum
haemorrhage
abdommaI pam.
I he necess~ investigations include a full
bloo d count, bood group and va~al swab"'STor""
mo~ry. culture ana sensitiviry:Jt w ay be neceS?ary JP
Ureteric dilatation and vesico-ureteric reflux cross-match ..b!god, depending on the degree of
Risk factors sio OS! y assOCIate Wl p regnancy m e unnary blood loss.
tract decnon common p0Stparrum. I he woman Fourteen days after a normal vaginal delivery. Ultrasound allows visualisation of the uterine
Risk factors for puerperal sepsis include:
presents With dVSwla, fever and doudr' malodorous a woman presents with an abrupt Increase In ~'Organised blood dots may reseDible placen-
prolonged rupture of membranes resulting in ~.s:. A midStream oT9jtbsrsr 5pegme~e vaginal bleeding associated with lower ta! nssue sODographically, and in 10--15% of C§eS
an asceriztiHg irikEtloH S ould be coTIeged. Antibiotic theWlY SJ;11tlhe abdom inal pain . On physical examination. she u}tr:=und .will Incorrectly report retained placen-
fre~uent use of urin ~ cathetS] commenced and high fluid intake encouraged. bas a fever or 38"C. a palpable. tender uterus · tl=llSSue Wlthin the uterus (false-positive rare) . The
p rO onged labour, WI lllc;!.ased interveIlli.on and tresh blood clots issuing tram on open f se-neganve rate lot ultrasound in this setting,
and more vagmat examinan o;!i Thromboembolism cervix.
however, IS very low. An atonic uterus, without
assisted birth (vacuum or forceps delivery with Ten days after a normal voginol delivery at retamed placental tissue, usually has an enlarged
epIsiotomy) - - term. a woman is transferred to the emergency endometrial cavity on ultrasound (>2.5 em antero-
vaPi!£al lacerations room via ambulance with severe vaginal posterior di~meter). Ultrasound may ide ntify
postpartum haemorrhage bleeding. ute nne rOlds or arteriovenous fistulae which
• caesarean secnon. may be associate Wl
The most common causative organisms are
Groul< B Streptococci, Staphylococci, Gonococci, • Excessive bleeding after shedding of th e placen-
coTtforms and other Dowel flo ra (Lewis 1984, ta~r _
McCormick 1947). Transmission of drugs in breast milk • Idiopathic subinvolution
The clinical diagnosis is based on a history of
It is generally agreed that medications penetrate • Retained placental tissue and/or membranes
labour and delivery, and presenting symptoms that • Endometritis
milk more during the first four weeks than in
usually reflect the site of infection. A full examina- • Coagulopathy
marure milk, although there are exceptions. In
tion of the woman is required. ·Tra~
the breastfed newborn, the infant must me tab-
olise and eliminate the drug. In the case of many • Uterine nbrolds (rare)
Genital tract infection
antibiotics! the oral bioavailablliry is such that • Cervical ca~ (rare)
The woman presents with fever and malaise, generally es t an 1% of t.h e maternal die
offensive lochia that may be purulent or bloody, wiII Ultimately nd Its way mto the milk and
BOX 16.1 A etiOlogy ot secondo ry PPH
'tf
Women's health: a core curr icu lum
16 Routin e m anageme nt of th e p uerpe rium
Management Preventative strategies

farms the central perineal body. The ischiocaver-
There are three basic strategies in the management nosus muscles cover the crura of the clitoris and
of secondary PPH: traverse in part along the medial margin of the
• ascenain the aetiology of the bleeding ischiopubic ramus. The triangulated ligament is a
• insogate a medlc31 or surgical management two layered fibrous sheath situated between the
plan to treat the bleeding symphysis pubis and the superficial transverse
reSUscitate m cases of excessive blood loss. perineal muscle. Laterally it extends to the ischial
tuberosities. The deep transverse perineal muscle
It is imponant to take the whole clinical picture is a thin sheath of mixed muscle fibres lying
into account to avoid overdiagnosis of retamed between the superior and inferior fascial layers of
tissue as a cause of secondary PPH and thus to the urogenital diaphragm (Fig 16.3).
minimise urmecessary surgery. Infeenon Witham
The levator ani muscles form a sling to suppon
retained placental tissue is optimally managed
the pelvic organs. They originate from the symphy-
medically with antibiotics. If delivery was by
sis pubis, laterally from the ischial spine and pos-
Breastfe edjn" has long-term health teriorly from the coccyx. Fibres cross over in the
A full gynaecological history and examination Is be ne/lfs for both mother and baby. It midline, encircling the vagina and blending with
required. On examination, the follawlng may be m ini mises costpartum haemorrhage the reCtum. The levator ani is divided into ileo-
faund : an d p romo tes uterih e IiI Obluflet't,-- coccygeus, pubococcygeus and puborectalis pans.
Infant immu y and es s ment o f
General and abdominal
th e on e ee n mo er an y. Portions of tbe levaror an i that maY be directJy
• Uterine enlargement and/or tenderness affected in deep secopd-deu ce laceratiOns alld
• Fever, tachycardia episiotomy include- aq
• Occasionally haemodynamic compromise
• the pu~s, which comprises the most
Speculum examination
• Bload and/ar necratlc placenta In the cervical
canal
• Cervical dilatatian
* Genita l tract trauma
medial and inferior portion. It attaches to the
central perineal body and the external anal
sphincter to fonn a sling around the anal canal.
• Purulent or affenslve vag inal discharge • the pu bococCXi:!'us, which is continuous with
A pregnant woman enquires about how she the puborectalis, but slightly more lateral and
may avoid episiotomy or perineal trauma dur- superior to it. It forms a sling between the sym-
BOX 16.2 Clinical examination signs In Ing birth. physis pubis and the coccyx.
secondary PPH
• Two hours after delivery, a woman complains
of excruciating vulval pain. On Inspection, one
The uterus can be divided into:
• Intravenous line insertian (Iarge·bore cannula) labium maJorum is grossly swollen and dis-
coloured. • the upper uterine segment
• Volume replacement wijh crystalloid/colloid
• the lower uterine segment
• Blood transtuslon If haemoglobin <80 g/dL - One week postpartum, a woman states that
• the cervix.
fresh frozen plasma, cryoprecipitate and platelet her p erineum Is red, swollen, painful, and there
Intusion may be required is d ischarge from the gaping wound .
• Intravenous oxytocin (10 IU), followed by an Intu- BOX 16.5 The uterus
sion of oxytocin (30-40 unit> In sao ml crystallOid
solution at 125 ml/h)
• Ergometrine 250 I'g IV If there Is continuing heavy Anatomy of the genital tract
bleeding
The bulbocavernosus (alternatively bulbospongio- Three layers of muscles in the pelVic Hoor support
• Intravenous broad spectrum antib iotics the pelvic organs:
• Operative exploration of the uterine cavity and • Uterine perforation (3%) sus) muscles form a thin, flat loop partially encir-
• superficial muscles
lower genital tract under anaestheSia , once sta- • Hysterectomy (1%) cling the vaginal orifice before passing forwards to
• triangular ligament
bilised • Asherman syndrome (rare) the clitoris. The superficial transverse perineal
• deep muscles.
muscles pass from the ischial tuberosities to the
BOX 16.3 Management of se v ere secondary BOX 16.4 Complications of surgical centre of the perineum. This is the point of arrach-
postpartum haemorrhage postpartum evacuation of the uterus BOX 16.6 The pelvic floor
ment of many other muscles in the pelvic floor and
'.
'il
Women's health : a co re curri c ulum
16 Routin e man 0gernent of the Puerperium
transverse perineal, bulbocav=osus, central directions:

perineal body, and posten or margin 9£ th~p the labium majorurn. The bl.o_,; o;;..
dl~o.::;ssrr-";""'''
transverse Illuscle and""uro enita! dia hragrn. A 1. The mediolateral eEisiotomy is the most com- haematoma ma be considera
dee second-d . the mon. The incision starts at the midpoint of the hypovolaemia, s oc an severe anae~a. If the
pu ore s and pubococcygeus muscles. fourchette and is directed laterally at a 45° haematoma IS extensive or continues to extend, it
3. ~ degree - the te~extent .~~u~ me angle to the right or left of the midline of the will require evacuation under general anaesmesia
who e of the perineal bgdy a n _ LVQ v_ any perineum. Mediolateral incisions are per. or regional analgeSia.
PaUgt the eXTernal anal sphincter.. formed in a vascular area.
4. Fourth degree - the tear extends mto the anal 2. The median episiotomy is a vertical midline Rupture of the uterus
Perineal lacerations or rectal mucosa. incision in a vascular watershed area. It maybe
This mostly occurs during labour and may be
Perineal lacerations are classified according to the associated with less bleeding but carries the ~ attributed to:
srructures involved. They are commonly disun- Episiotomy of extension into~.
guished by four degrees: This is the surgical incision made to enlarge the • rupture of a previoys classic or lower uterine
Vaginal lacerations caesarean section scar. A dehiscence may cause
1. F~t d~grbn-laceration of the yaginal mucosa, vaginal outlet durmg childbirth. It IOvolves:
little bleeding.
penne s ' or fourchette only, but not of the These are tears of vaginal mucosa and underlying
• perineal skin.and subcutaneous tissue tissue. They may occur on the posterior vaginal • Spontaneous ruf ure follO Wing obstructed
unJerlymg muscles of the perineal body. .
• postenor va . al wall laBour DY cephal nelyje di§prgponi on or .QJAk
2. Second degree - laceration of the vaglA~ wall or along one (unilateral) or both (bilateral)
• b ocavernosus muscle sides of the vagina. presentation. The rulIDJre is accompanied by
eEi?ie!iIr;' perineal skin and muscle of the superfiCIal ttan verse ;ferineal muscle
penne ody, whiCh may be slight or severe but P, 3 bleediIlg, haematuria and collapse.
puoococcygeus mJ'sd~ Vulval trauma r;auma (latJogeruc r - - -
does not include the external anal sphincter.
The muscles involved are the superficlal The : cision may be made in one of two main Vulval trauma includes grazes or tears of the inter. The role of episiotom y
nal surface of the labia minora, clitoris or urethral in obstetrics
area. The tears may be unilateral or bilateral. The
Vagina
most sev~e ~:Qrrh ~c QCCJlrs with those Until the late 1980s, routine episiotomy was
myalyi n g e ; ~al W Anterior episiotomy believed to be protective against severe perineal
(deinfibulation) may be performed for women trauma, pain, dyspareunia and incontinence.
who have undergone female circumcision (infibu- However, recent studies comparing routine epi-
lation). siotomy with a restrictive use of the procedure
Urogenital
dIaphragm ischiocavernosus clearly demonstrate that episiotomy does not
muscle Cervical trauma achieve this protection. A systematic rcviPw
Inferlor ramus
--
of Ischium unequivocally supports a restrictive use of this
prbcedure (ReIifrew 1998).
ischial Indications
tubero ~ty
Absolute indications for e!isioto:y include ~

distress, Were the bjqh De TIs to _e hastened and
where me ~erineum is obstruging me progress of
Pude ndal the w-esennng parr Relative indications incl~e
PUbocOCCygeJ
s
vessels muscle le~ato r pre term birth, assisted birth, breech delivery,
am Vulval haematomas
Illococcygeus s1i:OiiJ:aer dystocia, mater'iiaT (car'diac) clisease,
rnt!SC':le These develo fo to a blood femaIe genitaTcircl!mci~n and prev!ous tlill"a or
They are most commonly associate wim oulli ar- fourth degree tears.
Externa l ana.
sphIncter icy, episiotomy an operauve delivery. They may
1'Ti'll.,isc le
deVelop W1tliout laceration of t1te superficial tis- Complications of
Coccyx sues.. The haemarom: cXZde:elo~ ra~y and j~ genital tract trauma
re~y diagnosed b_ e_D"raoo_ J2~_ and the
The sho~term complications of genital tract
FIGURE 16.3 The ana tomy of t he perineum (Based on Hanretty 2003. p 411) appearance of a tense, fl uctuant swelling covered
trauma include permeaI pall4 woun d infectio~
by <!!scoloured skiD, exte~g downwards into
and breakdown, and anaemia from excessive
'fk
16 Rou ti ne management o f the puerperium
Women's health: a core curric ulum
Enkin MW, Wukinson C 2003 Single versus two layer McCormick CO 1947 A tex tbook on pathology of labor, the literarure. Breasrfecding Review 7(1):5-16.
blood loss. These problems may interfere with sutur~g for dosing the uterine incision at Caesa.rean the puerperium and the newborn. M osby, St Louis.
the mother's ability to care for her baby. L~_ section. In, The Cochrane Database of Systemanc Smaill F, Hoimeyr GJ 2003 Antibiotic prophylaxis for
term complications include chromc permeal am Reviews (The Cochrane Library), issue I. Online. Mitoulas LR, Sherriff JL, Hartmann PE 2000. Shorr- and cesarean section. In: The Cochrane Database of
. .' an ~ Available: hnp:/IW\,-w.update-software.com/co chrane. long-term varia tion in the productiun, COntent, and Systematic Reviews (The Cochrane Library), issue 1.
wi consequ n composition of human milk fat. Advances in Online. Available, http / iwww.update-
incontinence (faecal and flams) With ItS atten . t Experimental Medicine & Biology 478 :401-402.
Fraser DM, Cooper MA 2003 Myles .rextbook fot . software. ~om!cochrane.
psyctJ{;logical effects. Relationship difficulties midwives, 14th edn. Churchill Livmgstone, Edinburgh.
due to dyspareunia have been reported to lead to Nl-\NlRC 1995 Dietary guidelines for children and Stone C, Halliday J, Lumley J, Brennecke S 2000 . Vaginal
marital breakdown. Gates S, Brocklehursr P, Davis LJ 2003 Prophylaxis for adolescents. AGPS, Canberra. births after caesarean (VBAC) , a population srud y.
venous thromboembolic disease in pregnancy and the Paediatric and Perinatal Epidemiology 14(4):340-348.
early posmatal period. In: The Cochrane Database of Prendiville W], Elboume 0, M cDonald S 2002 Active
Systematic Reviews (The Cochrane L,brary), ISSue 1. versus expectant management of the third stage of
WHO 1998 Evidence for the ten steps for successful
Health maintenance Online. Available: htrp:/lwww.update- labour. Cochrane Ptegnanc)' and Childbirth Group. In:
breasrfeeding. World Health O rga nization, Geneva.
softv.rare.com/cochrane. The Cochrane Database of Systematic Reviews (The
AnteQQtgl p erineal m assage may Cochrane Library), issue 4. Online. Available:
hrrp:/!W\,~v.update-sofrware.comlcochrane.
Wilkinson CS, Enkin MW 2003 Perireneal non-closure at
mTriim ise genital Irac! trauma In Hale TW 2002 Medications and mothers' milk, 10th edn.
caesa rean section. [0 : The Cochrane Database of
labOUr. Attention to good wound Pharmasoft Publishing, Amarillo.
hy g~e promotes nealing an't! ovoids Renfrew MJ, Hannah W, Albers L, Floyd E 1998 Practices
Systematic Reviews (Th e Cochrane Library), issue 1-
lQ'i'ig:Term complications. that minimise trauma to the genital tract in childbirth, Online. Available: hrrp:l/www.update-
Hanretry KP 2003 Obstetrics illustrared, 6th edo. Ch urchill .
a systematic review of the literature. Birth software.corn/cochrane.
Livingstone, Edinburgh.
25 ,143-160.
References Recommended reading
Hopkins L, Smaill F 2003 Antibiotic prophylaxis « gimens
Adria.nsc AH, Pel M, Bieker OP 2000 Semmelweis, the and drugs for cesarean section. In: The Cochrane Scotr JA, Binns CW 1999 Factors associated with the Perineal Repair. Clinical 'green rep' guidelines. Online.
comb.t against puerperal fever. European Journal o f Database of Systematic Reviews (The Cochrane initiation and duration of breasrfeeding: a review of Avai lable: hrrp :iiw"'""'.rcog.org.uk.
Obstetrics, G)'necology and ReproductJ vc B,ology Library), issue 1. Online. Available: hrrp :/lwww.update-
90:153-158. softw"are.com/cochrane.
Ale.xandcr J, Thomas P, Sanghera J 2002 Treatments for Hoveyda F, MacKenzie IZ 2001. Secondary posrpartUm
secondary posrpa rtUm hae morrhage. Cochrane haemorrhage : incidence., morbIdity and current
Pregnancy and Childbirth Group. In: The Cochrane managem ent. British Journal of Obstetrics and
Database of Systematic Revie,",'S (The Cochrane G ynaecology 108 :927-930. Quest ions c. The transition of lochia rubra to
Library), issu~ 4. Online. Available : hrrp :/lwww.update- lochia serosa
software.com/cochrane. H um phrey M 1999 The obstetrics manual (revised edn). Which of the following influences the
initiation of lactation? d. The closing of the internal cervical
M cGtaw Hill, Sydney.
Am aragiri Sv, Lees TA 2003 Elastic compression stockings os
for prevention of deep veIn thrombosIS. In : The Lewis M 1984 Doctors, midwives, puerperal infection and
a. Increased levels of prolactin and
progesterone post-delivery ~alpation of the descent of the
Cochrane Database of Systematic Reviews (The the problem of maternal mortali ty .in late nineteenth uterine fundus /"
Coch rane Library), issue 2. Online. Available, and early tw'enrie.m ceDrury. OCca5lOnal Papers on b. The length of labour
hrrp:/Iwww.update-software.comlco c hrane. M edical History, Aust L85-107.
flC\lncreased levels of prolactin and 3. Which of the following is good
Cragin EB 1916 Conservatism in obstetrics. New York V w ithdrawal of progesterone post- / advice for a woman who has had a
Lister J 1870 The antiseptic system of treatment in surgery.
Medical Journal CIV(I):1-3 . delivery caesarean section for breech
Lancet 2: 287.
presentation?
d. The desire of the mother to
De CoSta CM 2002 The contagiousness of childbed fe ver: a Loudon I 1986. Deaths in childbed from the eighteenth breastfeed her baby k ]':"\n a subsequent pregnancy, it is /'
short history of puerperal sepsis and irs treatment. century re 1935. Medical History 30:1-41. '--1mportant for the woman to attend " ,
Medical Journal of Australia 177 (11/12) ,668-671. e. Return of progesterone and
oestrogen to pre-delivery levels early antenatal care and discuss
Lydon-Rochelle M, Holt VI.., Easterling TR, Martin DP the proposed mode of delivery
Dewhurst CJ 1966 Secondary posrparrum haemorrhage. 2001. Risk of uterine rupture durmg labo r among with the obstetrician.
Journal of Obstetrics and Gynaecology of the Bnnsh . .vomen with a prior cesarean delivery. New England 2. The process of involution is usually
Commonwealth 73:53-58. Journal of Med icine 345(1):3-8. monitored by which of the following? b. It is important to avoid intercourse
a. The return of ovulation and for 3-4 months after caesarean
Donnav F 2000 Maternal sur;ival in developing countries, MllJlgesi L, Hofmeyr GJ 2003 Early compared with delsyed menstruation, signifying the process section.
what has been dom:, wh at can be achieved in the next oral fluids and food after caesarean section. In: The is complete
decade. International Journal of Gynaecology and
c . A repeat caesarean section is
Cochrane Database of Systematic Reviews (The
Cochrane Lib rary) , issue 1. Online. Available: b . Ensuring the woman is able to pass necessary in a subsequent
Obstetrics 70(1):89-97.
hnp:/lwww.update-so ftware.comlcochrane. urine post-delivery pregnancy.
(Continued over)
g_t,1 '1..
Women 's health : a core curr iculum
*17
The psychological
7. A second-degree perineal tear does
d. A fetal malpresentation is highly
likely to occur again in her next
not include which of the following
structures?
experience of pregnancy
pregnancy.
a . Bulbocavernosus muscle
Jonathan Rampono
e . Home b irth would be a safe option
in her next pregnancy. G Anal sphincter ./
c. Vaginal mucosa Edited bV Sandra Carr
4. Which of the follow ing statements d . Transverse per ineal muscle
about caesarean sections is not true?
e . Perineal skin
a . Reg ional analgesia is preferab le to
general anaesthesia. 8. Which investigations would you order
for a woman with a mild secondary
,'b.l Medication is given before :t postpartum haemorrhage?
'V caesarean section to increase
gastric pH. a . Full blood count
~ Maternal morbidity rates are the b. Blood group Learning objectives

same for vaginal birth as for ~"" c. Vaginal cultures
aesarean delivery. ~ ~ ~ ~ d. Ultrasound examination of the
caes~ean ~ Knowledge outline the management options for
d. ower uterine segment uterine cavity each of these mental health problems
sect ion is practised to reduce "f I9.\AII of the above / At the end of this chapter, the student • d iscuss the public health Im plications of
complications in subsequent -.;:;,r. will be able to : postnatal mental health problems .
pregnancies . 9. Which of the followi ng may speculum
examination of a woman with a Psychological experIence
e . Caesarean delivery is associated moderate secandary postpartum
with on Increased risk of venous haemorrhage show? • discuss women's emotional changes Sk ill s
thromboembolism when compared during pregnancy
a. Blood clots In the cervical can al
to vaginal delivery. indicate the prevalence of depression At the end Of this chapter, the student
b. Cervical dilatation and anxiety in pregnancy
5. Which are the most common clinical c. Clinical signs of severe endometritis
signs of endometritis? discuss the social and cultural issues help a woman recognise normal
d. Bleeding from a vaginal tear affecting the transition to parenthood anxiety during pregnancy and when to
a. Secondary PPH
~" of the above ./ outline the antenatal assessm ent of a
seek further counselling
b. Uterine tenderness and vaginal woman's risk of depression use a screening tool for depression
bleeding 10. Advice for a woman with a second- during and after pregnancy.
Psychological/ps ychiatric dIsorders
~~terine
degree perineal tear should include
tenderne5- pu rulent lochia which of the following? describe the common psychiatric
V~nd fever ./ a. Avoidance of Interco urse for disorders of pregnancy
Attitudes
d. Subinvolution and secondary PPH 3 months • discuss the effects of antipsychotic
e. Lower abdominal pain and dysuria b . Reassurance that the wound will be medication on the fetus At the end of this chapter, the student
healed in 6 weeks should reflect upon :
• outline the management of
6. Which of the following does not c. Avoidance of constipation, as the psychological/psychiatric cond itions in
Increase the risk of puerpera l sepsis? tear has involved the rectal pregnancy the multiple factors Influencing a
sphincter woman's experience of pregnancy
a. Prolonged rupture of membranes Postnatal mental health issues
d. Delay in starting pelvic floor • the impact of a psychiatric disorder on
b . Frequent use of urinary catheters exercises until 2 months postpartum indicate the prevalence of mental a woman and her family
health problems In the puerperium
c . Assisted birth - vacuum or forceps .t.\EncoUragemen t to keep the area the influence of psychosocial stressors
r.::::J clean and repo rt to the doctor if describe the common mental health on the development and exacerbation
@ pr imiParit y / there is any pain, increaS~ng :;;our problems of the puerperium of psychiatric disorders .
or discharge from the site/
e. Caesarean section
Women's health: a core curri c ulum
17 The psychological experience of pregnancy
* The psychological
experience
While some women welcome the physical
changes of pregnancy in terms of its symbolism
and sense of womanhood, for many the changes in
Mother Father Mother Father
the response of the woman and partner to the preg-
nancy. This can be supplemented by encouraging the
Common clinical presentation

During her antenatal visit at 34 weeks'
body shape and size can be disconcerting. This is
particularly so for women with a preexisting eat-
ing disorder. Women hold a clinician's opinion in
high regard and this provides an OppOrrurllty for
?--cf woman to share some of her experiences of preg-
nancy at each antenatal VISit. Early administration of
the Edinburgh Postnatal Depression Scale will assist
in screening for risk of depression. Attendance at
gestation, a woman appears quiet and offers
appropriate reassurance and validation. antenatal education and exercise classes may facili-
no Information about her adjustment to
pregnancy. She tells you that she wishes her If a woman has had negative experiences in her Baby tate the woman's exploration of her feelings in
mother were stili alive. childhood, her fears about her capacity to be a respons~ to the changes of pregnancy. It is also the
good mother may manifest indirectly during preg- FIGURE 17.1 The mother-baby-father dinioan s role to encourage the woman to reflect on
relationship
nancy or the posmatal period. suppOrt mechanisms during pregnancy and assist
WIth suggesnons of how to develop these networks.
Depression and anxiety Social, emotional and mother-baby-father relationship shown in Figure DepreSSIOn IS more likely if a woman has a past
during pregnancy cultural issues 17.1 are the relationship between the mother and or family .history of depression, an unsatisfactory
Contrary to common myth, pregnancy does not Immigration and multiculturalism in Australia has her baby, the relationship between the father and relanonship With her own mother, a perception of
provide a 'protective umbrella' against depressive had an unprecedented influence on the manage-' the mother-baby dyad, and the perception of lack of personal support - especially from her
and anxiety disorders. There is a significant rise in ment of pregnancy and the postpartum period. It many men that they are 'triangulated out' by the partner, diffimlty conceiving and holding preg-
the incidence of depressive disorders in the post- would be difficult for any clinician to have a func· mother-baby relatIOnship. These relationships can nanoes, medical problems, ongoing social stresses
natal period and new evidence that they occur tional awareness of all the culrural issues. be proacnvely dIscussed with the couple during or a range of unfinished personal and psychologi-
the pregnancy. cal busmess. The diagnostic features and criteria
even more frequently during pregnancy. It has However, the consistent themes mentioned by
been found that the incidence of depression is patients of different cultural backgrounds include , Selma Fraiberg introduced the concept of for. depreSSIOn and aIL'(iety are the same in the
50% higher at 32 weeks' gestation than at 8 weeks the desire to be understood, to be respected as ghOSts m the nursery' (Fraiberg 1975). This refers pennatal penod as at other times.
to the hidden influences that exist behind the real- For a number of women, distress and concern
postpartum (Evans et al 2001). individuals and to have access to good communi-
Depression in pregnancy is sometimes missed cation channels (often through interpreter ser- Ity of the mother, the baby, the Cot and the blan- com~ound the joys, wonder and expectation in
because the symptoms may be attributed to the vices). Professional interpreters will often explain kets. The 'ghosts' are the encoded memories of the the first trImesrer. Distress and concern may be
physiological changes of pregnancy. Women may the background to a relevant cultural issue if they woman's own mothering, her relationship with secondary to blOlogJcal, psychological and/or
also choose not to volunteer symptoms of mood are requested to do so. her,mother and father, her projections of her part- SOCial factors such as changes in role, lifestyle and
disturbance at a time when they are expected to be ner S p atte~ of relanonship with her new baby, mdependence. These processes of adjustment
'blooming', and clinicians may fail to probe suffi- The family hermemones of her parents' relationship and the need to be carefully distinguished from clinical
ciently for symptoms. proJecnon of her fears and/or hopes for her own anxIety disorders or depressive disorders.
A Woman having her first baby may not have fully relanonship. AU of us have an 'instincti,re' per- Pregnane/ 'loss is not a rare event. Some
Emotional changes of pregnancy
grasped the dynamics of changing from a couple to specnve on parentmg, which in most cases is based wo~en .vlew early miscarriage as sad and regret-
a family, and negative consequences may emerge on a combination of genetic encoding and our table Without experiencing much additional dis-
As well as being a time of great joy, pregnancy is in unexpecred relationship issues in the postnatal own memones of being parented. tress, but it may have a profound PSYcholOgical
often a time of worry and uncertainty. A woman period. Despite the number of books available on For many women, these memories are valuable Impact on other women. It is important for the eli-
may have concerns about the baby's wellbeing, pregnancy and motherhood, many couples reach and positive, and enhance the relationships with maan to understand the woman's loss and to
possible abnormalities, her capacity to cope with parenthood without adequate preparation. therr baby and their partner. For other women, demonStrate empathy.
and enjoy motherhood, and the potential and Up to 30% of pregnancies are unplanned. The there IS a range of consaous and unconscious con- . Fet:ti bonding is often quite prominent .in the
probable changes that it will bring to her life, such reality of pregnancy and adjustments to pregnancy cerns, fears and even dreads linked to these ghosts first trImester. It tends to become stronger around
as her perception of self, her relationship with her and parenthood can have unsertling effects (Niven ill the nursery. Many of these issues surface during 18 weeks, WIth the detection of fetal movements
partner, and the change in her employment and 1992). Some women's ambivalence may even lead the posmatal penod. Irunal explanation, reassur- and visu~isation of the baby on ultrasound. For
financial status, including becoming financially them to consider termination of pregnancy. An ance and, ill some mstances, referral to a specialist the baby s father, bonding with the ferus usually
dependent on her partner. A woman may be unplanned pregnancy can be quite poignant post- may be indicated. occurs later than for the mother.
exposed to the extremes of prediction: an ideal- panum, when the mother absorbs the wonder and It is important to have heightened awareness of
ised concept of the wonder of motherhood - or a innocence of her newborn. mental illness m the third trimester, as for 50% of
series of 'disaster stories'. Clinicians must offer A 'conventional' couple consists of three enti- ~anagement of Psychological Women With posmatal depression there is evi-
prospective mothers a balanced and integrated ties: the woman, the man and their relationship. ISsues in pregnancy dence that the illness started in pregnancy.
view of the changes that occur in pregnancy and in The arrival of the frrst child brings many layers of An' . . The use of medicanon in pregnancy is complex.
unportant first step IS to take a comprehensive
the puerperium. complexity to this. The prominent themes of the social history at the first antenatal visit that includes In the 1990s, SIgruf!cant information was obtain-
ed In relatIon to the safety of antidepressants in
t.uE
17 The psychological experience of pregnan c y
pregnancy and during breastfeeding. Data continue Depression lamotrigine is used in the management of bipolar Denial in both women and clinicians may cause
to emerge, and expert advice should be sought to mood disorder and, so far, appears to have a lower unnecessary distress and psychopathology.
Depression is more common in pregnancy than in rate of congenital abnormalities thah the rwo pre- It is bener to screen for psychological and/or
help the couple make an informed decision about the postnatal period. In man) women, the first
the use of medication during pregnancy and breast- vious agents. If a woman needs to remain on these psychiatric disorders during the pregnancy rather
symptoms of clinical depression emerge. ill the anti epileptic drugs through the first trimester of in the postnatal period. Screening is achieved by
feeding. third trimester. The clinical symptoms mclude pregnancy, it is recommended that she use high- clinical interview and administering tools such as
anxiety, tearfulness, perceived inability to cope, dose folic acid supplementation before conception the Edinburgh Posmatal Depression Scale. This
Health maintenance depressive ideation, slowing of psychomotor func- and in the first trimester. This may help to reduce allows for open discussion to enable exploration
tion, sleep disturbance and early mOrnillg waking. the incidence of spina bifida. of emotional wellbeing or distress.
Women should be encouraged to Some symptoms of depression, such as sleepless-
share their experiences of pregnancy Depression in pregnancy and the posmatal
at each antenatal visit and at
ness, loss of appetite and libido, can be masked by Effects of medication on the fetus period has its roots in biological, psychological
antenatal education classes. the physiological changes of pregnancy and the and social factors. Effective intervention involves
adjustment to the posmatal penod. . In the second and third trimesters, all psychoactive
an approach involving all three of these areas.
A valid., reliable screening tool- the Edinburgh medications cross the placenta. The concentration
Posmatal Depression Scale - is available for both of antidepressants in the fetal circulation is esti-
* Psychological and
psychiatric disorders
the antenatal and postnatal period (see Box 17.1,
p 208). This questionnaire asks the woman specific
questions about her level of enjoyment, at1X1ety,·
mated to be 30-900/0 of the maternal concentra-
tion. Understandably, most women are concerned
about this. Clinical trials of children whose moth-
Health maintenance
Early administration of the Edinburgh
Postnatal Depression Scale can assist
fear, happiness and potential for self-harm. A score ers took fluoxetine or a tricyclic antidepressant in early identification of risk factors for
of 12 or more suggests borderline or probable pregnancy found no difference in intelligence quo- depressive illness.
Common clinical presentation depression (Cox et al 1987). tient, language development or a range of behav-
A pregnant woman at 19 weeks' gestation has
ioural tests after 7 years of follow-up (Nulrnan et
a past history of depression, for which she was
treated with Sertraline. She scores 18 on the
Edinburgh Postnatal Depression Scale: she
licked 'not very otten' in response to question
Schizophrenia
There is evidence to suggest that unplanned preg-
nancies in women with schizophrenia are more
common than in the general population (Davi.d et
al 2001). Emerging evidence suggests a potential
risk of behavioural and/or cognitive problems in
children whose mothers had untreated depression
and/or anxiety disorders during pregnancy. These
* Postnata l mental health
· 10, which asks about sulcldalldeotion. al 1998). Women \vith schizophrenia do not have factors need to be discussed in detail with women Common clinical presentation
an increased risk of relapse during pregnancy if plarming a pregnancy. A new mother complains about chronic sleep
they are well before pregnancy. Abrupt cessation of many antidepressants may problems due to a colicky baby. While
There is no conclusive information about the cause a discontinuation syndrome in adults. As these examining the baby, you note that the mother
Anxiety disorders antidepressants cross the placenta, the possibility of
safety of older antipsychotic medications in preg- is storing out of the window or fiddling with her
Anxiety disorders often emerge or re-emerge dur- nancy. However, during many decades of use, they a neonatal discontinuation syndrome should be con- hands. Her answers to questions tend to be
ing pregnancy. There is almost certainly a hor- have not been associated with an increased risk of sidered when counselling patients. There is little monosyll abic.
monal basis to some of the anxiety. Assessment, congenital abnormalities. There is insufficient evi- data on this subject, but babies of mothers taking
appropriate reassurance, cognitive behavioural dence to give reassurance regarding the safety of antidepressant medication have been observed to
therapy and social changes should be consldered newer antipsychotic medications in the fIrst 'twitch' for 24--36 hours a few days after birth.
before the use of medication. Benzodiazepines trimester of pregnancy. The use of antipsychotics and mood stabilisers Postpartum blues
should be avoided in the first trimester as they in pregnancy is best managed by a specialist.
may have teratogenic effects, in particular devel- Bipolar mood disorder Serum lithium levels tend to fall during pregnancy, About 800/0 of women experience postpartum
opment of cleft lip and palate (Altshuler et al secondary to the increase in the glomerular filtra- blues, or 'baby blues', on the third or fourth day
1996). Antidepressant medications such as selec- This is affected by hormonal fluctuations such as tion rate (GFR), and can then rise rapidly at deliv- after delivery. Many women become tearful, fret-
tive serotonin reuptake inhibitors and noradrena- those that occur in pregnancy, resulting in ety in relation to fluid and eleCtrolyte changes and ful and anxious at this time. The blues may con-
line reuptake inhibitors can be of value if med- increased risk of affective dysregulation and mood the change in GFR following delivery of the pla- tinue for up to 2 weeks but usually resolve within
ication is required. At this stage, none of these disorders. Medical management is comple..x in the centa. Levels of antiepileptic drugs can sometimes a day or rwo. SuppOrt and reassurance are valuable
agents has been directly implicated in terato- fust trimester of pregnancy. First-trimester expO- drop owing to changes in hepatic enzymes. during this time.
genicity. Some have been shown - m studies sure to lithium increases the risk of cardiovascular
with fewer than 350 participants - not to anomalies ten- to rwenty-fold (Cohen & Altshuler Management principles Postpartum depression
increase the risk of a baby having a congenital 1997). The antiepileptic drug sodium valproate IS
The clinician must understand that a range of psy- This occurs in around 140/0 of women. The peak
abnormality. This evidence can give only limited associated with about 5-80/0 inadence of spma bl-
chological and/or psychiatric disturbances will period of onset is 3-4 weeks after delivery but it
reassurance to women about the use of anti- fida. The use of carbamazepine is associated with
a lower risk of spina bifida. In the United States, Occur in a number of women during pregnancy. can occur any time in the first year. In retrospect,
depressants in pregnancy (Kulin et al 1998).
Women's health: a core curr iculum
17 The p sych oi ogical E.·Q eri&nce of pr egna ncy
some women have been depressed during preg- posmatal visit. Postpartum. depression may be this proactive management has significantly better
nancy and this becomes more apparent postpar- treated by counselling, cogrunve therapy or med- David S, Crawford AM, Breier A 1998 Prolactin levels in
outcomes for children in terms of emotional olaozapine versus typical and atypical anti psychotics.
tum. A further 120/0 of women suffer symptoms of ication (Evans et aI 2001). and/or behavioural consequences (Niven 1992). Schizophrenia Research 29 (1-2): 153.
subsyndromal depression that is not classified as
depression by standard mternatlonal crltena but Postpartum psychosis Evans J, Heron]. Francomb H, Oke S 2001 Cohon srudy
may have ongoing damagmg effects on the mdi- Health maintenance 01 depressed mood during pregnancy and after
Postpartum psychosis occurs in about 1 in 100.0
vidual her family and other relatlonshlps. women (Kendall et al 1987). Posmatal marna Women with a history of psychiatric childbirth. British Medical Journal 323:257-260.
Th~ symptoms of posmatal depression include emerges in the first few days postpartum and IS disorder are well advised to discuss
anxiety, tearfulness, perceived inability to c.ope and often rapid in its evolution and flond ill Its presen- the benefits and risks of continuing to Fraiberg S 1975 Ghosts in the nursery: a psychoanalytic
poor mothering skills (although the baby IS usual- take Psychotropic medications in the approach to the problems of impaired infant-mother
tation. Active and efficient intervention is impor- antenatal period or While they ore relationships. Journal of the American Academy of
ly well cared for), depressive ideation, slowmg of
tant for the safety and wellbeing of both the breastteeding. Child Psychiatry 14(3):387-421.
psychomotor function, sleep disturbance and early
mother and the baby. Ideally the woman is man-
morning waking. Risk factors for developmg
aged in a specialist mother-and-baby unit staffed .by Kendall RE, Chalmers L, Platz C 1987 The epidemiology of
depression include obstetric complicatlons, a past puerperal psychosis. British Journal of Psychiatry
a multidisciplinary team, including a psychiatrIst, References
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Cox et al1987). Midwives and child health nurses pressants appear safe in full doses and pheno- of psychiatric illness during pregnancy and postpartum
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drowsy or does not feed well. Lithium IS con- COX J, Holden], Sagovsky R 1987 Detection of postnatal
woman's emotional state and mood at the 6-week depression: developmem of the ten item Edinburgh Nulman I, Laslo D, Fried S et aJ 2001 Neurodevelopmenr
traindicated while breastfeeding. of chilc:lrtn exposed in utero to treatment of maternal
Posmatal Depression Seale. British Journal of
The Edinburgh Postnatal Depression Scale Psychiatry 150:782-786. malignancy. British Journal of Cancer
In the past 7 days:
Public health implications 85(11): 1611-1618.
1. I have been able to laugh and see the funny If 14% of women develop pastpamun depression.
side of things . and a further 12% of women have significant dis-
2. I have looked forward with enjoyment to things. tress in the first year after delivery, the effects of
3. I have blamed myself unnecessarily when this depression and distress will potentially affect
things went wrong . Questions
the dynamics of many families. Wide~reachmg e. Less than 5% or women develop
4. t have been anxious or worried for no reason . psychological intervention and support 15 of SIg- postpartum depreSSion.
1. Which of the following statements is
5. I have felt scared or panicky for no good nificant value. For some women, this begms WIth correct?
reason. creating a forum for ventilation and debriefing of 2. Management of the Psychological
6. Things have been getting on top of me. their birth experience. Regrettably, some women a. DepreSSion in pregnancy is not experience of pregnancy Includes
which of the following?
7. I have been so unhappy that I have had have a traumatic obstetric history or an expenence common because of the protective
difficulty sleeping. quite different from their birth plan. For many umbrella of pregnancy. a. A comprehensive social history at
8. I have felt sad or miserable. women, having a baby may cause a range of emo- the first antenatal visit
b The incidence of depression is 50%
9. I have been so unhappy that I have been crying . tions and conflicts to surface. SOCIal support, sup- . higher in the third trimester than in b. Encouraging the woman to share
10. The thought of harming myself has occurred to port of parmers and practical help during the the early postpartum period. her experiences of pregnancy at
me. extremely busy and tiring posmatal penod are each antenatal visit
The answers Include a choice of: yes, most of the time; yes,
c. DepreSSion in pregnancy is not
important. related to the emotional changes c. Early administration of the Edinburgh
some of the time; not very often; no, nevef. Response
categories are scored 0, 1. 2 and 3 according to the Proactive anticipation and management of and needs of women in Postnatal Depression Scale to screen
increased severity of depressive symptoms . emotional, psychological and psychiatric disorders for risk of depression
pregnancy.
in pregnancy and the posmatal period are of great d. Encouraging the woman to reflect
BOX 17 . 1 The Edinburgh Postnatal DepreSSio n value to women and their families in the short d. DepreSSion in pregnancy should be on and develop Support
Scale (Adapted from Cox et 01 1987) actively managed with medication mechanisms during pregnancy
term. In the long term, there is clear evidence that and hospitalisation .
e. All of the above
Women 's health: a core curri c ulum
5. Whi c h of the follow ing symptoms

Inferti Iity
3, Which of the following are risk factors
would alert you to a possible
for postpartum depression? diagnosis of major depression? Michael G Chapman and Una Conway
0 , A past history of depressive 0, Pervasive feeling of low mood and
disorder loss of quality of enjoyment of the Edited by Lucy Bowyer
b . A family history of depressive day
disorder b . Difficulty going bock to sleep In the
middle of the night
c . Lock of support
c, Undue tearfulness
d . Obstetric complication
d . Unexplained changes In appetite
e. All of the above
e, All of the above
4. Which of the following statements Is
true of the Edinburgh Postnatal 6. Which medications have been shown to
Depression Scale? be safe to use with caution and informed
a. It can be used in the antenatal

consent in the antenatal period? Learning objectives
period as well as the postnatal 0, Selective serotonin reuptake
period inhibitors
Knowledge Attitudes
b , It has not been widely validated b . Benzodiazepines
At the end of this chapter. the student At the end of this chapter. the student
c . It Is difficult to administer c , lithium will be able to : should reflect upon :
d , Mood stab ilisers
d , It is a diagnostic tool
indicate the prevalence of infertility the impact of inferti lity on a couple
e, All of the above
e, All of the above list the common aetiologies of female the complex ity ot Infertility
and mole Infertility investigations and treatment ,
discuss the investigation of the infertile the medicolegal and ethical issues of
couple surrogac y. women w ithout male
partners. donor gametes and c loning.
discuss treatment options for common
causes ot intertility,
Skills
At the end of this chapter. the student

obtain a comprehensive history from on

infertile couple
• explain to a couple the basics of
infertility investiga tions
outline the treatments for common
causes of Infertility.
jltl '4'
18 Infertility
Women's health : a co re curriculum

A young couple has been trying to conceive
* History and
examination Normal
Volume
2-5 mL
Concentration
>20 mlllion/mL
Motility
>50%
Normal torms
>30%
for 12 months with no success. Azoospermia No spe rmatozoa seen
A 32-year-old woman and her 34-year-old

A detailed history from both parmers can reveal Oligospermia
partn'er have had extensive fertility potential problems. Infertility is a stressful Sit- Mild 10-20 mllllon/mL
Investigations. A diagnosis of 'unexplained uation and so a ful~ mcluding occu- Moderate <5-10 mllllon/mL
infertility' has been made. pation f~es and the im£.i!ct of the failu~e Severe <5 million/mL
t~ceive is worthwhile. Frequency of sexual Asthenospermio Decreased
intercourse, timing and other problems involving
Teratospermia Decreased
*
interCourse should be explored with both parmers.
In the male, specific features in the history
Epidemiology shoufcf"beSOught including sexu"ilY .transmltted TABLE 18.1 Normal and abnormal qualities of semen
di~~ and mll;!!lPs as an adult; opeIanons such as
Infertility is defined re to conceive after
repair of in~al hermas and o~hldope?cy; drugs
a e ' d 1 ths 0 un . e. such as an~ents, b~ta blockers . and spermatogenic failure of unknown cause. Recently Tubal patency
Ithin this time frame, the natural rate of ~oncep
exce~1i()l. Examination ~rura1la genetic causes related to deletions in the Y chromo- Tubal patency needs to be established.
tiQn in a woman under the age of 35 years IS more sho~ld be performed to assess the size and consis- some have been documented. H ysterosalpingography involves the introduc-
th~ tency of the testicles, as well as the presence of the The postcoital test involves aspiration of a
During the second year of attempted conception of radiopaque material through the cervix
vasa deferentia and/or varicocele. sample of cervical mucus around the time of ovu- into the uterus and the fallopian rubes.
tion, some 50% of couples will conceive sponta- In the female, normal fearures of ovulation lation, within 6 hours of intercourse. The test is Intrauterine anatomy and rubal patency can be
neously. In each subsequent year, the. chance of include a re lar menstrUal cle, midcycle pam, somewhat controversial, as many factors other documented. Hysterosalpingography has the
success declines. Treatments for miertility produce chan es in vagig isc arge, premenstrUal sLmp- than mucus hostility can influence a negative advantage of being an outpatient procedure,
success rates greater than these background rates toms art pnmary dysmen~ea. The past re ro- result (lack of sperm motility) , e.g. infection or although it is poorly tolerated because of pain- It
of conception. . . ~ve his!QD' should be documented.. ere may incorrect timing. provides no information about problems occur-
Infertility is divided into pnmary (no prevIous
be predisposing factors for pelvIc infeenon, such as ring elsewhere in the pelvis, i.e. adhesions or
pregnancy) and secondary (previous pregnancies).
sexu~ rransmined infections the use of an Female endomerriosis. There is a small risk of introducing
There are different causes In these two groups: intraurerine device or previous pelvIC surgery.
e.g. male factor infertility is less likely in secondary Ovulation or reactivating pelvic inflammatory disease.
Symptoms suggestive of endometriosis shoUld a.tso Laparoscopy with dye instillation is performed
infertility. be explored, such as secondary dysmenoIrhoea It should be established that ovulation is occurring under general anaesthesia. A laparoscope is intro-
* Pathophysiology
and dyspareunia. Examjnation should Identify sec-
ondaryJl'x]1?1 delleIQ~nt, eVIdence .of. pe1vlC
inflamma~ory disease (PID) or en_dometnosls.
regularly. duced through a periumbilical incision to \'isualise
The easiest single test for ovulation is ~ the anatomy of the pelvis and reveal pathology,
ment ~f serum progesterone taken around 7 d~ such as adhesions, endometriosis and ovarian dis-
forIOwmg oVulan on (mldluwll). n the cycle is ease. Tubal patency is assessed by observation of
* Investigations
irregWar and the timing of OVulation is difficult, the spillage of methylene blue dye through the fal-
serial samples should be taken. Values greater than lopian rubes, after ,instillation of this dye through
3Q*"omclLI are indicative of Oyulation. the cervix. Laparoscopy is often performed
Male B~ bodY.1l:wperarure cbarts can reflect ovu- together with hysteroscopy, which may show
Other causes include: in~e i.tm;!9- Semen should be analysed afrer 3 days' abstinence lation by documenting t~ 0 SOC rise in tempera- intrauterine pathology such as adhesions, polyps
tence retrogr~on and anti-sperm anti- from ejaculation. The sample must be brought ture between the follicular phase and the ImeaL or fibroids .
p~e. Tiley are useful in defining cycle length and
b~ in rhef~e - cervical factors, including
anti-sperm antibodies, and severe endometngil.S..
Some 20% of patients are found to have no obVI-
ous abnormalities and are categorised as haVing
promptly (within 1 hour) to the laboratory. The
standard criteria for normal semen analysIs are
given in Table 18.1. ,
If the specimen is subopnmal, the test should
gmng an indication of the days in which ovulation
may have occurred.
Serial monitoring of luteinising hormone levels
* Treatment
unexplained infertility. be repeated after 4-6 weeks before a final assess- identifies the preovulatory surge of this hormone. Male
ment of quality is made. For abnormal speClmens, Ultrasound can be used to monitor follicular The major change in the management in infertil-
serum follicle-stimulating hormone (FSH) and growth and formation of the corpus luteum. ity in the last decade has occurred in the ability to
testosterone levels should be tested. Severe unpalC- Laparoscopy allows direct visualisation of the cor- deal with men with poor sperm quality and even
ment of sperm quality is predominantly due to pus luteum in the second hali of the cycle. azoospermia. Cold showers, wearing of loose
''Ii
Women 's health : a core curriculum
18 Inl e rti llty
fertilisation. Reversal of clip sterilisa~;::~ai~ The tr~nd has ~een to legislate more definitively to
the one area jn iYtl lt5 bJ b a! SlJrgery isCwhile. Reference
aVOid extreme c:ases: In all slruations, one gener-
rQ'F has now been used for more than 20 years ally agreed pnnclple 15 to protect the furure inter- Pitkin J, Pearue AB, Magowan BA 2003 Obstetrics aod
and results in pr-!Uancy rates hi~er than 25-35% est of the child. !lYIl.aecology: an illustrated colour text. Churchill
pe~ accor g to panent se eenon. The pro- LIVlDgstOne, Edinburgh.
cedure was primarily developed to bypass tubal
disease. However, its application has broadened Heolth maintenance
Further reading
substantially with the evolution of ICSI and its use When planning a family, women
in unexplained infertility. IVF involves induction should be aware of the influence of For information on the management of the infertile
of multiple follicles with subcutaneous FSH injec- ageing on fertility. couple, see the website of the Royal College of
tions and the collection of multiple oocytes under ObstetriCians and Gynaecologists in the UK at
Chlamydia - a sexually transmitted http:// www.rcog.org.uk.
ultrasound control. Fertilisation with the partner's disease affecting fertil ity - can be
sperm then occurs in the laboratory. One or [WO prevented by the use of condoms.
embryos are replaced transcervically into the uter-
FIGURE 18.1 Intr acytopla smic sperm injection. ine cavity after 48-72 hours. The major complica-
The egg is held by a suction pipette (left) and tion of IVF is srtfCcant ovarian hJ(pecstimuiation
the sperm In/ected Into the cytoplasm . (From syndrome, whic occurs ~ < 1% of cases.
Pitkin et 01 2003. p 133. Fig 5) Cfomiphene bas been shown tObe helpful in
unexplained infertility, but intrauterine insemina-
underwear, variS2£ele obljtaation and hormonal tion (IUI) is now the treaanent of choice. IUI suc-
strategIes have been shown to be of nQ...significant Questions
cess rates are in the order of 15-20% per cycle in 3. Which of the following semen
bet. The development of intracytoplasmic women under the age of 35 years. If IUI has failed, parameters is considered abnormal?
sper~niecrj Qn (ICSn (Fig 18.1) in :;action
1. What chance do a healthy 29-year-old
IVF can be offered. Cervical factor and anti-sperm woman and her 35-year-old partner a . Volume; 3 mL
WIth In n tro fertilisanon (IVF) has-eaa. SJlZ;- antibody infertility is poorly understood and diffi- have of conceiving In the next 12
cessliiI treatment in severe cases of male faeror cult to treat. Spontaneous pregnancies do occur months? . b. Sperm denSity; 21 mil li on per mL
pr.Ql:ilaiis. Intrauterine insemmagon may help and assisted conception may be useful. a.50% 0 0tllity: 40% L )SD 'I.)
mild oligospermia
Female
In women with polycystic ovarian syndrome or
* Medicolegal and
ethi ca l issues
b.60%
c . 70%
~ 80%
d . Morphology: 32% normal forms
e. Sperm antibodies in seminal fluid :
negative
/
hYRothalamic ameDorrh~a, mductioD of ov\!!g.- e . 90% / 4. Which of the follOWing are possible
tion improves the chance of conceptIOn to As reproductive medicine adopts the latest techno- complications of IVF treatment?
alIjlQst normal rates, provided the couJ1le~ logical advances in cell biology and molecular 2. What is the major reason for a decline a . Multiple pregnoocies
fo r 6-1 2 m ~nths. Clomiphene citrate is used in genetics, the potential for treaanent with manipu- /n fert ility with maternal age? b . Ovarian hyperstimulatlon
p'olycystic ovarian synorome at a dose of 50 mg lation of gametes and their genetic make-up opens a. Reduced frequency of intercourse syndrome - - - -
for 5 days in the eady follicula r phase of the a Pandora's box of ethical and medicolegal dilem-
me ~ t[l!al qrc ~ ClomiEhene increases FSH mas. Conservatism clashes with progressive exper- b. DecreaSing semen quality c. Psychological trauma
pr~ by acting as an anti-oestrogen at the imentation. A number of achievable treaanents are @ Reduced oocyte quality d . Low-blrth-weight babies /.
pituitary level. Response to treatment sbould be
measured by midIUteaI serum progesterone to
banned to varying degrees by different jurisdic-
tions, both in Australia and internationally. Tbese
d . Impaired hormonal environment I e l of the above
confirm ovulation. Other ovulanon mductloD include the use of donor gametes in single women e . Ageing of the uterus
agents sUitable fo r hypothalamic problems with 'social' infertility, and pregnancies in women
include gonadotrophins and gonadotrophin- over the age of 50 years. The use of a surrogate to
releasing hormone (G'n RID. They should be carry the child of a woman who has lost her uterus
prescribed only in specialist units. Compli- or is medically unable to carry a pregnancy is a
cations of ovulation induction include multiple minefield for the lawyers : it is banned by some
pregnancy and ovarian hyperstimulauon . governments, legalised by others and unclear in
Tubal surgery ii now rarely undertaken, since the remainder.
its success rates of only 20-30% compare Many of these issues pose personal questions,
unfiivourably with the success rates of in vitro whicb clinicians have to deal with individually.
tlE
*19
Unplanned pregnancy
and termination /
Paul Duggan and Jeffrey RObin~
Edited by Martha Finn
learning objectives
Knowledge explain options to a woman

considering termination of a confirmed
At the end of this chapter, the student trisomy 21 pregnancy at 18 weeks'
will be able to: gestation.
outline the geographic variation in

termination rates Attitude s
appraise the complex issues influencing
the wide variation In termination rates At the end of this chapter, the student
• describe the principles of counselling
for a woman who requests termination the effect of unwanted pregnancy on
of pregnancy different aspects of women's lives
describe the surgical and medical the Impact of termination of a
options for termination of pregnancy trisomy 21 pregnancy on the parents.
and the possible complications of these
procedures.
Skills

• calculate gestational age using

menstrual dates and ultrasound reports
perform a urinary pregnancy test
instruct a woman in the use of
postcoital contraception
explain options to a woman requesting
termination of an a-week pregnancy
fi'
19 Unplanned p re gnancy a nd termin ation
continuation of the pregnancy would be injurious Australia (1969) and Western Australia (1998) and
(including postcoital contraception), and atti-
tudes ro unplanned pregnancy and pregnancy to the mental health of the pregnant woman. There oWUlg to hberal judicial interpretation of existing
are no grounds to perform termination of preg- law UI other states (e.g. the Menhennit ruling
A woman with an unplanned pregnancy termination. nancy for SOCIal reasons and there is a residential Vlctona 1969, the Levine ruling New South w'al
requests termination of pregnancy. When a woman requests termination, the prac-
reqUIrement, whereby the woman must have 1971). es
titioner should establish the reasons for the
A woman with a planned pregnancy requests request, the woman's concerns and her under- reSIded ill the state for the previous 3 months. Abortion law is an area of great confusion and
termination of pregnancy for a fetal anomaly standing about termination of pregnancy. It is The law covenng termination of pregnancy does uncertarnty. In most instances the legal meaning of
that has been discovered by routine antenatal not apply to non-vIable pregnancies such as ectopic key terrns (e.g. 'in good faith' and 'mental health')
important ro discuss available options, including
screening. treatment of the underlying maternal or fetal con- pregnanCles, IIllScamages and hydatidiform moles. has not been tested. Western Australia is the onl
dition and the most appropriate termination prostate that legally permits abortion on request (pr:-
Australia Vlded specific counselling is undertaken) without
Pregnancy termination rates vary widely between cedure for the individual, with its attendant risks.
countries and within the same country at different Care must be taken to ensure that legal require- T~mination of pregnancy has become more acces- the need to determine medical grounds for the
times. For example, following liberalisation of the ments are met. Sl e as a result of changes in the law in South request. South Australia is the only state that allows
law in 1969, termination rates in women aged
15 -44 years in South Australia have risen from
6 per 1000 in 1970 to more than 17 per 1000
in 1998. Throughout the world, it is estimated
* Termination of pregnancy Number Rate per 1000
women aged
15-44 years
Rate per 100
estimated total
pregnancies
that 44% of terminations are performed illegally. Termination law
Estimated termination rates Ln countries where The term 'abortion' is the legal term for termina- China 7,930,000 26.1 27.4
termination is illegal may be as high as in countries tion of pregnancy in Australia and New Zealand. Hong Kong , 1996 25.000 15.1 27 .9
where termination is legal (Henshaw et al 1999; Most terminations are performed at the request of India, 1995-1996 566,500 2.7 2.1
Tables 19.1-19.3). Complication rates requiring the woman for psychological reasons, not for a
hospitalisation are significantly higher in countries fetal anomaly. Laws are different in each country Ireland' 4,900 5.9 8.9
where termination is illegal (Henshaw et al 1999; and within Australia in each state and territory. Japan, 1995 343,000 13.4 22.4
Table 19.3). Published data is available for South Australia, Russian Federation 2,287.300 68.4 62.6
The reasons for the geographic variation in where terminations may be performed to safeguard
termination rates are complex and not clearly the physical or mental health of the woman or Vletnam*- 1,520,000 83.3 43 .7
defined . Important factors may include social, when there are genetic defects or malformations • Irish
... women
Excludes a obtainln
stl t9 doverse as te~mlnatlon, as It IS Illegal In Ireland
political, religious, economic and legal roler- of the ferus. In South Australia, about 97% of n e ma e 500,000 pflvotEHector procedures
ance of sexual intercours e between unmarried terminations are undertaken on the grounds that ~~BLE Abortion statistics 1995-96 from selected countries
1 9.2
couples, th e availability of contraception ere data Is considered to be incomplete
Rate per 1000 Rate per 100

Number estimated total Number of Rate per 1000 Rate per Number of Rate per 1000
women aged
15-44 years pregnancies abortions women aged 100estimated women women aged
15-44 years total hospitalised for 15-44 years
22.2 26.4 pregnancies complications hospitalised for
Australia 91,900 complications
67.5 61.9
Belarus 155,700
15.5 22.0 Bangladesh 1995 730,000 28.0 18.0 71,800 2.8
Canada 106.700
15.6 20 .5 Brazil 1991 1,444,000 40.8 29.8 288,700 8.1
England & Wales 167,500
6.5 10.6 Colombia 1989 288,000 36.3 26.0 57,700 7.2
Netherlands' 22,400
16.4 19.1 Egypt 1996 324,000 23.0 15.7 216,000 15.3
New Zealand 13.700
18.7 25.2 Mexico 1990 533.000 25.1 17.1 106,500 5.4
Sweden 32,100
22.9 25.9 Nigeria 1996 610 ,000 25.4 12.0 142,200 6.1
USA 1,365.700
Philippines 1994 401,000 25.0 16.0 80,100 6.1
• Residents only
TABLE 19.1Abortion statistics 1995-96 from selected countries . es t
TABLE193B .
estimates of abortion statistics from countries where abortion is Illegal
where data is considered to be complete (From Henshaw et 01
1999)
fIt
Women's heallh: a core curriculum
19 Unp la nned p reg n a ncy an d termlllOlioll
termination solely on the grounds of a serious fetal which to judge the effect of liberalising abortion try to ascertain why this failed. Is the woman
anomaly up to 28 weeks' gestation. Practitioners laws on non-fatal sepsis. centa praevia, and delivery. of a low-birth-weight
aware that postcoital contraception is available?
mUSt know the law that applies in their own region. Unfortunately, in the developing world septic baby. The nsk of pre term birth lIlcreases with th
What future contraceptive options would be best
illegal abortion is a major cause of maternal mor- number.of terminations of pregnancy (or SPontan~
for her? Be alert to the possibility that the woman
New Zealand tality to the present day. eous nuscarnages) a woman undergoes. Most
could be acting under duress (usually pressure
women who decide to terminate a pregnancy do
Abortion law is dealt with in the Crimes Act 1961
and itS amendmentS. Two certifying consultantS
who are appointed by the Abortion Supervisory
Comminee must see the woman and sign the cer-
* Pregnancy termination
from a partner or other family member). Consider
the need for screening for sexually transmined
mfecnons and cervical dysplasia. If the woman is
ambivalent or needs help to resolve uncertainty
not suffer from major depression as a result.
Medical termination
tificate. The New Zealand law states that abortion Access about her opoons, conSIder referral to a social The antigro/iesq;roQ& wilipristop.e..(RU486) has
is legal in a case of a pregnancy of not more than 20 Access to termination services varies throughout worker. Accurate pregnancy dating is important been widely employed in Europe for medical ter-
weeks' gestation where the obstetrician believes that Australia and New Zealand. Larger urban centres and is best done by ultrasound scan. Arrange for a mination .o f pregnancy and wote best in comb i-
the continuance of the pregnancy would result in have specialised clinics with dedicated staff. second medical opinion if required. nat;!,on .WIth a pmsraSI2J;tdin. (e.g. rrusoprostiJ).
serious danger to the life or to the physical and Women may self-refer directly to these clinics. ApprOXImately 80% of first-trimester pregnancies
mental health of the woman or girl, or that there is Women in rural and small urban communities do Suction curettage or
will be successfully terminated this way. This
a substantial risk that the child, if born, would be so not have access to specialised clinics in their own dilatation and curettage
:nethod IS effecnve before 6 weeks' gestation by
physically or mentally abnormal as to be seriously community. Confidentiality is important to all lIlduClJ1g a nuscarnage. Mifeprisrone is not cur-
Surgical termination of pregnancy by suction curet-
handicapped. Very rarely, a termination is done women seeking termination of pregnancy, and this rently available in Australia.
beyond 20 weeks when it is believed that it is nec- tage or dilatation and curenage are the only reli-
can be a problem in small communities, where the
essary to save the life of the woman or to prevent able methods available in Australia. Suction curet-
woman may know hospital or clinic staff. Some
serious permanent injury to her physical or mental tage is the preferred method, as it is considered to Second-trimester termination
women choose to be managed in a major centre
health. COWlSelling, though often practised, is not a b~ easier and have a lower complication rate than Dilatation and evacuation
for this reason.
legal requirement in New Zealand. dilataoon and curettage. This is a day procedure
The majority of terminations in New South
Wales are performed in the private sector (includ- and can~e done under local, regional or general Suction termination is not safe or effective beyond
ing holders of healthcare cards, predominantly anaesthesIa. Ultrasound scanning to guide the pas- a?out 13 weeks, although surgical termination by
Ethics of abortion sage of the suction catheter and to confirm com- dilatation and evacuati &E u to about 18
low-income women), reflecting access difficulties
Moral and religious issues are a maner for indi- in the public sector in that state. In contrast, in plete evacuation of the uterus may be performed. wee gesta sate an e ecnve 1Il s
vidual conscience. Medical practitioners in South Auscralia most terminations are performed Prostaglandins (e.g. misoprostiL) can be employed handS and with appropriate instrumentS.
Australia are not legally required to perform abor- preoperanvely to make cervical dilatation easier The cervix needs to be widely dilated for D&E.
in the public sector. Recent data shows that hun-
tions or to refer women for abortion. dreds of Auscralian women crave! interstate each and safer. Women will bleed for 1-3 weeks after This is often achieved by preoperative use of
the procedure and should have minimal pain.
* Septic abortion
year to access termination services in different
states, there being a net movement from
Queensland, Tasmania and the Australian Capital
Territory to New South Wales and Victoria.
Immediate short-term co . .
intracervical laminaria (a desiccated seaweed
include product), which is inserted several hours before
end~, retained Pci0rauCtS, uterine pe ora- the procedure. There is a higher risk of perfora-
non and ItS sequelae, an illure to rermilll'te the non of the uterus in second-trimester D&E. Most
Serious infective complications may occur with a pr"gnancy. EndQroen:itis (with or without retained hospitals offer medical termination, as skilled sur-
termination of pregnancy (legal or illegal). Gas First-trimester termination produCtS) is relatively cOllliPon and usually pres- geons available to perform D&E are scarce.
gangrene causing multiple organ failure is a signif- ents WIth exce .' in and . P~
icant cause of death from this condition. Regardless of the reasons for the request, this is an phylacnc ann IOnCS ven re or durin the Medical termination
Maternal deaths from septic abortion at the extremely distressing situation for the woman. proce e may re uce the rate of endometritis.
Royal Women's Hospital, Melbourne, declined History-taking and examination must be per- Senous consequences from endometritis are rare. Medical termination using pr~ (e.g.
from 188 deaths berween 1939 and 1947 to formed sensitively and non-judgmentally. In some cases, return to theatre to evacuate mlsoprostil, dinoprostone) induces' on in
12 deaths berween 1951 and 1959, 2 deaths Determine clearly the reasons for the woman's retained produCtS is required. Uterine perforation 60-80% of cases at firSt anempt, but it can be a
berween 1960 and 1969 and 1 death berween 1970 request. In most jurisdictions, medical grounds are IS an uncommon but potentially serious complica- slow process, sometimes taking several days. Rates
and 1979 (Ranen et al 1985). It is incorrect to necessary for the request to be granted. Very occa- non, as small- or large-bowd injuty or injury to of retamed placenta requiring manual removal are
assume that this decline in serious sepsis in Australia sionally, the request is based on a mistaken major pelVIC vessels can occur. Failure to terminate high (over 40%). A second anempt after a few
is mainly due to liberalising of abortion laws, which assumption of teratogenic risk, which could be IS more likely to occur if the procedure is done days wIll usually follow a failed first anempt. If the
did not occur in Victoria until 1969. Presumably, managed by reassurance (e.g. that exposure to a before 6 weeks' gestation. Rarely, termination fails second anempt fails, alternative methods include
general improvementS made in women's health, substance perceived to be unsafe is in fact harm- because It IS . not realised that the pregnancy is intra-amniotic installation of hypertonic saline,
improved antibiotic therapy and safe surgical evac- less). Seek advice if there is any question that the ectopIc. MedIUm to long-term complications are urea, or prostaglandm F transcervical infusion
uation of infected intrauterine tissue were the main pregnancy could be the result of a sexual assault. 2cv
uncommon and may include depression, early of oxytocin or PGF through a Foley catheter,
responsible factors. There is no Australasian data on Enquire what contraception, if any, was used and 1a
pregnancy loss due to cervical incompetence, pla- D&E, hysterotomy or hysterectomy.
ffj
Women's health: a c o re c urric ulum
* Summary
Most terminations in Australia and New Zealand
References
Cico N 1999 Abortion law in Australia 1998-99. Research
paper I, Law and Bills Digest Group, Department of
Genital prolapse
are done on mental health grounds. Laws are dif- the Parliamentary Library, Parliament of AUstralia
ferent between and within countries and access to Canberra. ' Paul Duggan
termination of pregnancy is not uniform in the
same country. Termination rates to Australia and Henshaw 5K, Singh 5, Haas T 1999 Tbe incidence of
abortion worldwide. International Family Planning Edited b y M artha Finn
New Zealand are slmilar to those in other Western Perspectives 2S (Supplement):S30-S38.
countries. Serious hazards from termination of
pregnancy are rare except in countries where ter- Ratten GJ 1985 Changes in obstetric practice in our time.
mination of pregnancy is illegal. Australian and New Zealand Journal of Obstetrics and
Gynaecology 25(4):241-244.
Health maintenance
All women should have ready access
to effective contraception. including
,
emergency contraception .
Periconception use of folic acid reduces
the incidenc e of neural tube defects.
Good preconception control of
diabetes mellitus and avoidance of Knowledge
teratogeniC substances in the first Attitudes
trimester min imise the risk of congen- A~ltl hbe end of this chapter the student
ital malformations. WI e able to : ' Aht the end of this chapter, the student
s ould reflect upon:
• recognise uterovaginal prolapse and
diSCUSS the trea tment options. • the inflUence of uterovaginal prolapse
an a woman 's self-esteem.
Skills
Q uestions c . Failure to terminate pregnancy is
Impossible . Aht the end of this chapter, the student
s ould learn h ow to :
1. Termination of pregnancy in Australia d. Perforation of the uterus during
and New Zealand is mainly requested suction curettage is a trivial
for which of the following reasons? perform a Sims' speculum examination
complication .
a. Genetic anomalies in the fetus or perform a bimanual pelvic examination
e. Most women bleed for at least a
embryo week following termination . Counsel a woman with uterovaginal
b. Pregnancy resulting from rape pro!apse regarding her treatment
options.
3. Which of the following is correct
. c. Teenage pregnancies regarding termination of pregnancy In
d. Pregnancies in women over 40 years the second trimester?
old
a. Termination for a serious fetal
e . Mental health reasons anomaly is common.
b. Suction curettage is the safest
2. Which of the fallowing is correct method of termination o·v allable.
regarding surgical termination of
pregnancy in the first trimeste r? c . Prostaglandins are commonly
employed to induce termination.
a . Legal abortion is required for
ectopic pregnancy. d. Reta ined placenta is rare.
b. A termination procedure must be e . Prostaglandin termination takes as
done by a specialist gynaecologist. long as D&E .
**4
tji
/
Women's health: a core c u rriculu m

20 Genital prolapse
* Applied anatomy and Hydronephrosis resulting from ureteric kink.

ing may Occur in more severe forms of uterovagi. the appearance of a lump or bulge at the vaginal
A 48-year·<lId woman presents with an
uncomfortable 'dragging' sensation In her
physiology nal prolapse. Urin~tention due to d~s.cenLof
entrance (Fig 20.2). Often there are associated dif-
ficulties with bladder- or bowel-emptying and/or
vagina. the bladder base below the urethra may also occur.
The uterus and vagina are mobile and distensible urinary and faecal incontinence. Rectal prolapse
Rectal prolapse,-naemorrhoids and faecal inconti-
with connective tissue suppons predoffilnantly or haemorrhoids may also be present. Men-
nence are sometimes seen in association with
Uterovaginal prolapse refers to abnormal descent comprised of smooth muscle and collagenous struating women may report difficulties with
uterovaginal prolapse. Not infrequently, a multi-
matrix. DefectS in connecuve ttssue followmg insenion of tampons. Many women report low
of the uterus and~. The mostCommon grad- disciplinary approach involving gynaecologists,
ing system defines grade 1 uterine prolapse as pregnancy, surgery or from inherited connecuve back pain, which may be due to other causes.
physiotherapists, continence nurse advisers, urolo-
descent of the cervix at rest to above the level of tissue disorders may all result 10 vagInal prolapse. Prolapse may affect a woman's desire to have sex-
gists and colorectal or general surgeons may be
The cord-like round ligament, the relanvely ual relations. Ulceration of prolapsed epithelium
the introitus, grade 2 as descent to .the lntrOltus required to optimally manage complex cases.
and grade 3 as descent beyond the mtroltus (FIg dense infundibulopelvic ligament and the thin may occur and result. in discharge or bleeding.
2.0, I). There is, however, a poor relattonship
between prolapse grading and symptoms. The
terms cystocele, rectocele and ente rocTJe~e
broad ligament attach the uterus to the pelVIC Side
wall. The relatively strong uterosacral ligament
and loose para cervical tissue attach the cervix to
the sacrum and to the pel vic side wall. These
* Risk factors
Parity and birth weight have been consistently
Other causes of vaginal discharge and post-
menopausal bleeding need to be excluded.
Prolapse in young nulliparous women raises the
possibility of connective tissue disarders.
prolapse of the ant.erior vagi nal w;J14 pnsrenor
va~al wall and vagmal vault respecuvely. attachments comprise peritoneal folds, connecuve reported as independent risk factors for prolapse. Uterovaginal prolapse is best identified using a
tissue, nerves, lymphatics and blood vessels. The The incidence increases with age, postmenopausal Sims' speculum, while examining the woman in
* Prevalence and uterosacral and infundibulopelvlc ligaments may

be surgically attached to the vaginal vault to ald
status, smoking, chronic lung disease and obesity. the left lateral decubirus position.
incidence
A Scandinavian survey of randomly selected women
in the suppon of the upper vagrna followmg a
hysterectomy. .
The levator ani striated muscle group prOVides
* Clinica l eva luation * M anagement
The typical sympto ms of prolapse include a drag- Management options are tailored to the individual
aged 40-6.0 years reponed symptoms of pelVIC the principal suppon of the pelvic floor .and IS an
ging or bearing down sensation in the vagina and woman. These options include strengthening
heaviness in 15%, the. presence of a genual bulge In important suppon of the lower vagIna. T he
exercises for the pelvic floor, intravaginal oestro-
4% and use of fingers in the vagina or on the pen- pudendal nerve supplies motor fibres to the leva-
gen supplementation, vaginal packing, vaginal pes-
neu~ to assist defecation in 120/0 (Eva et al 2.0.03). tor ani and is at risk of lnJury from pregnancy and saries or corrective surgery. It is appropriate to
An Australian survey found that 9% of womel! ~5D childbinh, as are the bony attachments and muscle give reassurance in all cases, as prolapse is not a
years of age had had at least one prolapse repalr and fibres of the levator ani. Strengrherung of the leva- life-threatening condition,
9% had current symptoms of prolapse. Over 1.0% tor ani muscles by specific exercises has been Potentially reversible risk factors should be
reponed difficulties with defecation and 5% vagrnal shown to improve symptoms of prolapse and identified and managed (obesity, constipation,
laxity (MacLeI1llan et al 2.0.0.0). incontinence. chronic cough related to smoking, asthma or cys.
tic fibrosis, oestrogen deficiency).
Pelvic floor exercises

These can be effective, but exercises are not likely
to reduce prolapse that has extended beyond the
introitus. Vaginal oestrogen supplementation may
enhance the effect of pelvic floor exercises in POSt-
menopausal women. Long-term compliance \\~th
pelvic floor exercises may be poor. Involvement of
a physi.otherapist 'Or cantinence nurse adviser may
be helpful if the woman is having difficulty with
o . Grade I : descent of the cervix 0 1 b. Grade 2: descent to the i n~ c. Grade 3: descent beyond the pelvic floor exercises or has related bladder or
rest to above f e level of the Introitus Introitus - the vagina is c omple tely bowel problems.
ev~a cystocele , rectocele and
enterocele are also prese nt
FIGURE 20.2 Vagi nal wall pralapse (cystocele) Vaginal packing
FIGURE 20 .1 Uterine pralapse (Based an Mackay 1990, p 347, Fig 23.14) presenting at the Int ro itus (Photo courtesy Paul
Duggon) Chafing and ulceration of externalised epithelium
occurs in neglected cases and may be managed by
i*t
20 Gen ital p rolapse
Women's health : a core curricU lUm
r;:.ea~t. Other contributors to sexual dysfunc- References

vaginal packing with cotton gauze liberally ~~n, mcluding lo.~o, relatiOlWP problems Boyles SH, Webe r A;"I, Meyn L 2003 Procedures fo I ·
smeared with oestrogen cream. The prolapse is 10 . arnmat~-a: conditions of the vulva and vagin~ organ prolapse in the United States, 1979- 199;. pe VIC
reduced by the pack, which should be replaced ana pSY,.chO gi91 influences, must be considered. AmeCican Journal of Obstetrics and Gynecology
188(1):108-11 5.
*
daily. Ulceration managed in this way will respond
in 2- 3 weeks, when definitive treatment (pessary Eva UF, Gun W, Preben K 2003 Ptevalence of urinary and
or surgery) may then be undertaken. Prophylaxis Summary fecal mcon tlnence and symptOms of genital prolapse .
for venouS thromboembolism must be considered, women. Acta Obstetcicia et Gynecologica Sandi " in
Uterovaginal prolapse is a common condition that 82(3):280-286. o>\!ca
as these women are usually elderly and frequently mcre~es In preyalegce with age Pregnanc;y and
immobile. childbirth are lIDPOnant risk factors. Magagerneac Mackay EV, Beischer Nt\, Pepperell RJ, Wood C 1990
IS tailored to the individual woman. It should IUusrrated textbook of gyriaecolos)', 2nd edn. WB
vaginal pessaries Include reassurance and may include ~r SaundersfBailliere T Uldall, Sydney.
An appropriately selected and fitted pessary (Fig e~~t, oestrogen supplementation, v~l MacLennan AH, Taylor AW, Wilson DH, Wilson D 2000
p~, pessarles or s~. A multidisciplinary The .prev:il.ience of pelvic fl oor diso rders and their
20.3) should reduce the prolapse and not affect
approach IS usuaIly worthWhile. relanonshtp to gender, age, parity and mode of
either partner's en joyment of intercourse. deli very. BJOG : an [ntemanonal Journal of Obsretrics
Pessaries need to be removed, washed and re- and G yuaecology 107(12) :1460-1470.
inserted periodically to minimise ulceration of . Health maintenance
vaginal epithelium and prevent incarceration Pelvic floor exercises help maintain O lsen AL, Smith VJ. Bergstrom JO, Colling JC, Clark AL
pelvic floor function . Avoidance of 1997 EpidemIOlogy of surgically m.maged pelvic organ
(every 3-6 months is sufficient fo r ring pessaries prolapse and urmary incontinence. Obstetrics and
but may be insufficient for pessaries that have a obeSity, constipation, chronic cough
and heavy liftin g minimises pelvi c floor Gynecology 89(4):501-506.
large surface area in contact with vaginal epithel- dysfunclion.
ium). Pessaries may increase physiological vaginal
discharge and rates of anaerobic vaginal infection.
Supplemental vaginal oesttogen therapy for post-
menopausal women may minimise these problems.
Questions c. A pessary Is unlikely to manage this
Surgery problem satisfactorily.
1. Which of the following is correct in a
The principles of surgery for uterovaginal prolapse 55-year-old woman with prolapse of d. This pro blem will respond best to
are to correct the anatomical defect, to maintain the anter ior vaginal wall presenting at vaginal oestrogen re placement the r-
sexual function and to treat associated urinary and the vaginal entrance? apy.
bowel dysfunction. Traditional surgical repair a . The woman has almost certainly e . The Le Fort operation (vaginal oblit-
involv~ va&i£al hvsteregamy, midline suturing of had a hysterectomy. eraHon) is the first procedure of
v~ fasaa and excision of redundant vaginal b. The woman will almost certainly chOice .
epithelium - an operation that has changed little in have urinary stress Incontinence . 3. Wh ich of the following is correct?
the last 100 years. Many newer operations have
c. Sexual Interco urse is not advisable . a: There Is a d irect relationsh ip
been described that utilise vaginal, abdominal or
laparoscopic techniques. Long-term randomised d . Th is problem will respond best to between the severity o f prolapse
vaginal oestrogen replacement ther- and the severity of sym ptoms.
data are required to properly evaluate these tech-
niques. In some instances, the woman's own tissue r apy. b . Prolapse does not occur in young
is inadequate for a satisfactory repair, so synthetic ~, e . vaginal pessary may satisfactorily nulliparous women . .
mesh and/or slings are utilised. Non-absorbable syn- ([;;\ treat thiS problem . . c. Prolapse causes stress incontinence.
thetic materials could potentially provide a more ~~ Which of the following is correct In a fit ~o men with posterior vaginal wall
durable repair but are associated with complica- I 70-year-old woman prese nting with com- prolapse may have to place a
tions, including chronic infection or rejection in plete prOCidentia. a deficient perineal finger In the vagina to assist with ~~')t...'.
bowel evacuation. ,"\0 ~ (~':,
b o dy and absent retropubic shelf?
10-300/0 of cases. New materials hold promise for a
reduction in these complication rates. Procedures
that obliterate the vagiJlal cavity (e.g. Le Fort) can
FIGURE 20.3 vaginal pessories: A - large ring
pessory; B - medium ring pessary; C - shelf
a . The woman is too old for surgery.
b. Pelvic floor exercises will c orrect the
e. Sexual enjoyment is likely to Improve
su bstantially following prolapse
t ~~
\'
p essary (Photo courtesy Peter Far kas/ROya l
be performed relatively quickly under local anaes- Darwi n Hospital) prolapse . treatment. 11 .." .
thesia and may be appropriate in selected cases.
7
*f'
V
Incontinence
Paul Duggan
Edited by Martha Finn
Learning objectives
Knowledge • Instruct the patient how to perform

pelvic floor exercises
At the end of this chapter, the student explain what Investigations may be
will be able to: performed upon a urogynaecology
referral.
describe normal bladder function
indicate the prevalence of urinary and
faecal incontinence in the female
population Attitu des
describe the different types of u rinary At the end of this chapter, the student
incontinence should reflect upon :
discuss the aetiology, investigation and
management of urinary and faecal the impact of Incontinence on a
incontinence woman's life
• critique the view that a multidisciplinary incontinence as a social as well as a
approach is more effective than medical/surgical Issue.
medical or surgical treatments in the
management of Incontinence In
women.
Skills
AI the end of this chapter, the student

should learn how to :
Instruct the patient In the correct

technique of obtaining a midstream
urine sample
demonstrate the use of a urinary diary
21 Incontine nce
Women 's health : a cora curriculum
• urine is sterile but often contaminated with The effect of incontinence oestrogen deficiency, emotional and psychiatric
Common clinical presentations vaginal flora - an infected ample should have on women symptoms.
A pregnant woman at 32 weeks' geslation a pure growth of a pathogen (> 105 colony
counts) and ~ 10 white blood celli per hW1
Surprisingly, many women regard incontinence as Examination and investigation
enquires how she may prevent urine and slool a normal burden to endure and treatment is not
loss problems after delivery.
Eight weeks after delivering her fourth baby a
woman enquires when she may expect to slop
-
power field.
Causes of urinary incontinence
sought. This may be because of a belief that incon-
tinence is incurable, because the needs of depen-
dants may be given a higher priority than per-
Perform an abdominal, vaginal and pelvic exami·
nation to assess oestrogenisation, perineal excori-
ation, prolapse, pelvic masses and strength of
wetling and soiling herself. Urinary incontinence may occur as a result of sonal health, or because of embarrassment. pelvic floor muscles. Ask the woman to cough and
injury to or dysfunction of the central or penph- Incontinence may affect the quality of life and self- record whether or not leakage was observed. A
A general health enquiry reveals that your urine sample should be tested to exclude infection.
eral nervouS system, striated muscles, conneCtlve esteem in many ways. Women may become social-
patient Is experiencing Incontinence episodes .
tissue and ligaments of the pelVIC floor, or the ly isolated due to the fear of embarrassing leakage Some expertS advise asking the woman to keep
A patient states that she is having trouble smooth muscle and mucosa of the bladder and in public, urgency and frequency that is difficult to a bladder diary, usually a record of times and vol-
making it to tl1e toilet when nature calls . urethra. Direct injury to these strUctures usually control, and the fear of a urine smell. Stress incon- umes voided, fluid intake and leakage episodes for
(I results from pregnancy and delivery. Pudendal tinence may affecr participation in SpOrt and exer- 2 consecutive days or longer. Excessive and
neuropathy may result from increased pressure cise. Leakage during intercourse may affect sexual reduced fluid intake can be assessed this way and
* Urinary incontine nce during pregnancy. Trauma, lschaerrua or malIg-

nancy may injure the spmal cord or central nerv-
ous system. Pelvic radiotherapy may damage blood
relationships. Significant leakage may also result in
frequent changes of clothes and bed linen, requir-
ing frequent laundering. Painful symptoms of cys-
excessive use of bladder stimulants and substances
with diuretic properties (mainly drinks containing
caffeine) can also be assessed. This type of record
Urinary incontinence is the . u:::!ntentional loss of supply to soft tissue and nerves. Many drugs .and titis and nocturia may affect sleep, leading to gives additional insight into the patient's bladder
urine. Urinary incontinence 15 reported m approx- medical conditions may affect unnary funcnon . chronic fatigue and depression. function and habits and the diary can be com-
imately 130/0 of women aged 18-23 years, mcreas- e.g. alpha blockers or anticholinergiC medlCanons, pared with a new record after treatment. The
ing to more than 35% in women over ~ . Sjogren's syndrome, diabetes , mellirus, multiple Can urinary incontinence bladder diary also gives an indication of the
Incontinence is a common reason for arumsslOn of sclerosis, myotomas or lvlarfan s syndrome. be prevented? woman's motivation.
elderly people to residential care facilines. Rates In
men are much lower. Urinary inconnnence IS often Types of urinary incontinence Elective caesarean section is probably nor effective Ma nagement
ass;.red Witb:~::~~rte:dSY::;rt~lms;f:
mC.2!llJD.'ll-ce, ut~ ______ ; - . p .
Urinary incontinence may be defined by subjective
in preventing further problems in parous women
who have abnormal bladder and bowel symptoms, An othenvise healthy woman with stress inconti-
symptoms or objective diagnoses. More than one nence, no previous treatment and no urinary
There are many mechamsms mvolved m conn- except where there is some anal sphincter disrup-
type of incontinence may be present. Some com-
nence and thus many rypes of mconnnence. tion. Antenatal and postnatal pelvic floor exer- infection should be instrUcted in pelvic floor exer-
mon types are as follows: cises have been shown to give short· term benefit cises. Pelvic floor exercises should be done regu-
Evidence supporting current invesnganon and
treatment modalities is often lacking. anagemenr Stress incontinence: a loss of urine associated but long-term data are lacking. larly: 10 separate, sustained contractions of the
generally requires a multidisciplinary approach. with activities that cause an increase in pressure levator ani group of muscles performed twice
within the abdominal cavity - coughing, History daily are sufficient. After 6 months, about 50% of
structure and function sneezing, lifting or exercise. . ' Key features in the history include the woman's women are happy with the results. Pelvic floor
of the lower urinary tract Urodynamic stresS incontlDence: streSs mconn- exercises will also assist women experiencing uri-
age, the nature of the problem, the effect that the
nence observed during a urodynanuc study m nary frequen'CY, urgency and faecal incontinence.
A derailed description of the embryology, structure problem is having on her life, the type and out-
the absence of a detrusor contracnon. . Exercising the levator ani group is not intuitive.
and function of the urinary tract can be found m • Urge incontinence: loss of urine associated With comes of treatments that have been tried (if any),
in addition to medical, drug, Sutgical and social Results may be better if an appropriately trained
many classic anatomy and physiology textS (Gray an uncontrollable desire to void . . It is usually
history. Look for contributing factors (chronic physiotherapist, continence nurse adviser or medi-
2000, Ganong 2003). associated with detrusor instablhry, I.e. an cal practitioner with a special interest gives the
For the normal adult female : observed detrusor contraction associated With cough, neurological dysfunction, obesity, reduced
mobility or pelvic floor injury associated with instruction. These professionals can provide edu-
• the bladder should comfortably retain 400-500 the desire to void in a person who IS trymg to cation, assess adequacy of technique and provide
pregnancy or previous surgery) and the patient-
mL of urine inhibit micturition. ..' additional motivation to the woman, and can offer
Overflow incontinence or obstructlve mCODU- specific risks of possible treatments. Note antibiot-
:~:~v~=:~=~;:::~d nence: loss of urine due to a reflex contraCOO n
of an overdistended detrusor. .
ic allergies, as urinary tract infection may require
treatment.
alternative methods such as the use of vaginal
cones, urethral plugs and biofeedback techniques
twice if over 60 is n~rmal • Vesicovaginal fistula : an abnormal conneCOo n You should establish what a woman means to wom en who are experiencing difficulry.
voidiIig IS usWilly a Quick "?~ efficient pws;ess by 'her problem', and specifically inquire about Although there is no data on the long-term out-
between the epithelium of the bladder and the
_ there should be no strauung, and the blad- other abnormal urinary or bowel symptoms, come of pelvic floor exercises, these exercises
vagina, which may result from trauma, malig-
der should be almost completely empno;d symptoms of prolapse, sexual d ysfunction, should probably be performed lifelong.
nancy, infection or radlOtherapy.
« 25 mL residual volume)
tt'
21 Incon tin ence
Oestrogen supplementation, often given intra- 600/0 of women report improvement in symptoms
vaginally, is used as an adjunctive therapy in with this type of approach. Operations devised for
Causes of faecal incontinence
operative treatment, are unfit for surgery d
postmenopausal women. To date no clinical stress incontinence or prolapse are inappropriate The causes of faecal incontinence are numerous not respond to surgery may, in conjunctiono
r
'rb
benefit for stress incontinence has been observed when detrusor instability is the cause of the but obstetric trauma is one of the most common pelVIC floor exercises, try dietary malU·pul WI
woman's incontinence. factors Identified. Here the causes appear to be h f .. anon
in randornised controlled trials comparing oestro- t e use 0 Constipating agents (loperamide'
gen with placebo. Obstructive incontinence means that the blad- pudendal nerve damage and/or direct trauma codeme phosphate) or biofeedback. Manage '
If surgery is being considered to treat stress der emptying is abnormal, typically slow and to the anal sphincter complex. Trauma to the IS usually multidisciplinary. ment
incontinence, urodynamic investigations are rec- incomplete. Symptoms may be the same as for sphincter complex is associated with forceps deliv-
ommended, because cure rates for genuine stress detrusor inStability, and recurrent bladder infec- ery,. high birth. weight, median epiSiotomies and
incontinence are reduced when detrusor instabil- tions may also occur with this condition. All oper- OCClPltO-pOSterIor fetal positions. Health maintenance
ity is also present. Detrusor instability is usually ations for stress incontinence cause a degree of Preconception counselling and ante-
diagnosed by cystometry and can also be observed obstruction to the outflow of urine. Outflow Investigation and management natal classes should Inform women
obstruction in women that is not the result of sur- about incontinence and encourage
fluoroscopically. External sphincter defeers may be obvious at deliv-
gety is mainly due to detrusor failure. The reason the practice of pe lvic floor exercises.
In the beSt hands, surgery will subjectively cure ery. Third and foUrth degree tears (involving the
genuine stress incontinence in over 90% of cases. for the detrusor failure is seldom identified. external anal. sphincter and anal mucosa respec- Pelvic floor exercises should be a reg-
Intermittent clean self-catheterisation is the first- ular port at a woman's life.
Hundreds of operations have been described. nvely) occur ill 0.5-1.0% of vaginal deliveries and
Complications include short-term or long-term uri- line treatment for these cases. are highly asSOCIated with midline episiotomies.
nary retention, urinary, wound and cheSt infections, Immobility can be an important contributor to . Sphincter trauma is more often occult and,
urge incontinence, simply as a result of the With anal endosonography, up to 35% of primi-
haemorrhage, bladder perforation, very occasion-
woman's inability to get to the toilet in time. parous women can be shown to have evidence of References
ally ureteric injury, de novo detrusor inStability,
Assistance may be required with household aids sphmcter complex disruption. The mainstay of Ganong WF 2003 Review of medical physiology 21st edn
deep venous thrombosis and, rarely, bowel perfor-
and appliances, in addition to other therapy. treatment IS pelv~c floor exercises. For obstetrical McGraw-Hill, ew York. , .
ation. Surgery is expensive, requiring 1-7 days in Often, a multidisciplinary approach is required
hospital and 2-12 weeks off normal activities, traumanc disrupnon of the sphincter complex, the
under these circumstances. treatment IS usually surgical, using an overlapping Gray 2000 Gray 's anatomy of the human body, 20th edn.
depending on the operation, the patient and the There are a wide variety of continence aids,
surgeon. The Burch colposuspension and the trans- external. sp~l?cter repair technique. Patients with Ba.rt!eby Com, New York.
including various pads, nappies and permanent lesser disability from incontinence who decline
vaginal tape (TVIJ procedures are the moSt com- catheters. Pads come in a variety of sizes, are
monly performed operations at the present time. expensive and may caus.e chafing and contribute to
Stress incontinence comprises 50% of cases of excoriation. Permanent catheters are the laSt resort
incontinence. In the others, urinary incontinence (due to discomfort and ever-present risk of infec-
is due primarily to detrusor instability. If there is tion) but will improve quality of life in women
an identified neurological cause, the diagnosis is with severe incontinence, when other therapies Questions
detrusor hyperreflexia. Spinal cord injuries, have failed or are unsuitable. 2. For a 50-year-Old Australian woman
stroke, diabetes and demyelinating disorders may complaining of urinary incontinence.
1. Which of the follOWing is the most
result in this diagnosis. Usually, there is no expla- whrch of the following Is true?
nation for the condition, and it is assumed that
there is a breakdown in the neurological pathways
* Faecal incontinence characteristiC of urinary stress
A ontinence?
~ OCcurs with a sudden increase in
a. She Is most likely to have a
vesicovaginal fistula .
that inhibit the detrusor muscle. This problem is Faecal incontinence can lead to social isolation rntra-abdominal pressure . b . She shOUld have an anterior repair
usually managed in a multidisciplinary way, with and reduced quality of life. Up to 7% of healthy as the first step of management.
pelvic floor exercises and bladder drill performed b . Considerable quantities of urine are
people over 65 years and up to a quarter of the lost.
under the supervision of a continence nurse ad- c. She is likely to have ureteric reflux.
women attending urogynaecological clinics report
viser or appropriately trained physiotherapist, faecal incontinence. c. Bed wetting OCcurs at night. 0 he should have urodynamic stUdies
with anticholinergic and antispasmodic medica- d. There is a deSire to empty the
Q~erformed .
tions and oestrogen replacement in appropriate Structure and function bladder again immediately after e. She is most likely to have had more
cases. In all cases, attention is paid to fluid intake mlctuntlon. than three children.
of the lower gastrOintestinal tract
and good bowel habit (especially avoiding consti- e. It is most commonly found in
pation). Bladder drill requires a conscious effort to A detailed description of the embryology, structUre teenagers.
delay voiding. Experts recommend that women and function of the lower gastrointestinal tract can
drink at least l.5 L daily and minimise the use of be found .in many classic anatomy and physiology
drinks containing caffeine and alcohol. About textS (Gray 2000, Ganong 2003) .
flk
*22
The menopause and beyond
Edited b y Martha Finn
The menopause Alastair Maclennan

Management of the menopause Alastair Maclennan
Postmenopausal bleeding Paul Duggan
Learning objectives
Knowledge counsel about evidence-based options

for management of the menopause
At the end of this chapter, the student explain to a woman the investigations a
will be able to: gynaecologist Is likely to undertake for
a woman who presents with
The menopause postmenopausal bleeding
discuss the influence of the menopause perform a cervical smear and bimanual
on women 's health pelvic examination .
identify menopausal symptoms
discuss the treatment options for Atti tudes
menopausal symptom s and their mixed
benefits and risks At th e end of' this chapter, the student
assess a woman's risk of developing should reflect upon :
osteoporosis
the many influences on a woman's
• discuss the strategies for prevention of health at the time of the climacteric
osteoporosis
the need to individualise treatment for
Postmenopausal bleedIng menopausal symptoms
discuss the clinical approach to • the impact of a diagnosis of
exclud ing a gynaecological g y naecological cancer on the woman
malignancy as a cause of
postmenopausal bleeding . • the value of long-term screening for
cervical cancer.
Skills

should learn how to :
• design a tailored plan for the

management of the menopause in an
individual woman
fIE
22 The menopause a nd b
eyand
* The menopause arotllld late perirnenopause and early posrrnenopause.

Severe sequelae of oestrogen deficiency, such as osteo-
porosis, more frequently occur in later life.
Vasomotor symptoms such as hot flushes night
sweots and palpitotlons ' Increasing oge -
Common clinical presentation Psychological symptoms such as anxiety Premature menopause
A 49-year-o ld married woman attends her Gp, Potential symptoms around depreSSion and unloved feelings ' • Family history of osteoporosis
complaining of severe hot Hushes, night sweats, the menopause Lo?omotor symptoms such as Joint Pa ins, muscle • Previous low trauma fracture
sleeplessness, tiredness, recent Irritability, loss of pains and backache • Low calcium Intake
libido, Joint pains and urinary frequency. Her Up to 80% of women around the menopause will
eventually experience some menopausal or oestro- • Urogenital symptoms such as dry vagina Low bOdy mass Index «20)
periods have become heavy and Irregular.
There is a fam ily history of cardiovascular gen-deficiency-related symptoms (Box 22.1). uncomforta ble intercourse ond urinary fr~qUency EatIng disorders aSSOCiated with decreased
weight
disease, bowel Cancer and osteoporosis. She Other putative menopausal symptoms are
smokes, drinks two glasses of alcohol per day muddled thinking and loss of memory. Loss of BOX 22.1 Oestrogen-deficiency symptoms • Immabllisation
and has no time to exercise because she Is libido is not closely associated with the menopause • Lifestyle factors InCluding smoking, alCohOlism
busy with her part-time job, husband, transition and is more associated with ageing, lack of exercise or excessive exercise '
Oestrogen_ Before 3 months 6 months
adolescent children and her elderly parents. general health and psychosocial issues. deficiency • Medical conditions that include prolonged
She asks for help, wants to 'go through therapy after
A menopausal symptom score (Table 22.1) is a symptoms after glucocorticoid therapy
menopause naturally' and is hesitant about starting starting
useful way of detecting the onset of the peri-
taking hormones. menopause, monitoring the severity of the symp- Hot flushes BOX 22.2 Clinical ri sk fac tors for osteo porosis
toms and the response to therapy. Women without Light-headed
menopausal symptoms or who are being ade- feelings
The menopause refers to the cessation of menstru-
ation due to the demise of ovarian function . The
average age of menopause is about 51 years with
the normal range berween 45 and 57. Due to rap-
quately treated usually score 10 or less, while
women with debilitating symptoms will generally
have scores varying from 20 to 50 in severity.
Headaches
Irritability *menopause
Management of the
DepreSSion
idly increasing longevity, most women will now Osteoporosis
live 30-40 years beyond the menopause. This has I Unloved feelings There ~e many nonho=onal influences On a
brought women a new way of life and a new way Loss of bone density occurs rapidly in the first few AnXiety woman s quallty- of-life around the age of
of death, with age-related diseases that were previ- years around menopause with about a 15% loss in menopause (Fig 22.2). Psychological, social and
the first 5 years. Bone loss continues at a slower Mood changes
0usly uncommon - such as osteoporosis, heart sexual ISSues need to be addressed. Lifestyle factors
disease, dementia and cancer. rate thereafter with the risk of an osteoporotic Sleeplessness are particularly impOrtant. Women should be
Premature menopause is usually defined as fracture graduclly increasing. By age 65 years, one UnUsual Hredness encouraged to maIntaIn their optimal weight
ocaming under the age of 40 years and is experi- in four women has experienced an osteoporotic through diet and exercise (30 minutes of weight-
Backache
enced by about 2q.-6 of women either naturally or fracture, by age 75 years one in three women has bearmg exercise each day), avoid excessive caf-
had such fracrure, and by 85 years one in two. Joint pains feme and alcohol (less than rwo standard drinks
o\ving to oophorectomy for conditions such as
endometriosis, pelvic inflammatory disease or Some women are at particular risk of developing Muscle pains per day) and stop smoking. Smoking has been
malignancy. Those women born \vith gonadal dys- osteoporosis (Box 22.2). associated With earlier menopause and more
New facial hair
genesis (e.g. Turner's syndrome) are particularly at Osteoporosis is best diagnosed by bone den- severe symptoms.
sitomerry at sites such as hip, spine and wrist (Fig Dry skin
risk of the long-te= consequences of oestrogen
deficiency. 22.1). The World Health Organization defines CraWling feelings Nonhormonal therapies
The climacteric consists of: osteoporosis as bone densities more than 2.5 under skin
standard deviation units below the young normal Vasomotor symptoms may reduce with venlafax-
• the perimenopause, which is a phase of menstrual Less sexual feelings me, gabapennn or c1onidine. Psychological symp-
mean (T score <2.5).
cycle irregularity and fluctuating menopausal Preventative measures should be considered in Dry vagina toms can be treated with antidepressants or
symptoms for up to 4 years before the last men- younger postmenopausal women with T scores Uncom fortable anxlOlytlcs and locomotor symptoms with anal-
srrual period and for 1 year after the final sponta- between 1.5 and 2.5. Treatment should be intercou rse gesICS or nonsteroidal anti-inflammatory agents
neous period recommended for all women who have a bone Lubncants may help a dry vagina and uncomfon~
Urinary frequency a bje mtercourse and antispasmodic agents may
• the posrmenopause, which includes all the symp- mineral density (BMD) below 2.5 standard
TOTAL SCORE h e p unnary urgency and frequency.
toms and sequelae of ovarian senescence and deviations and in women who have had an osteo-
which rnay be lifelong in some women. porotic fracrure. Seor lhJ:oesrrogens are present in foods such as soy
seve~ei~Pt"""" a s tallows Ni (0). MIld (I ). Moderate (2) and
an 0ha er vegetables. In large quantities, these foods
Menopausal symptoms can be exp~ rienced at any rnay ve a modest effect on the amelioration of
time during the climacteric but are more common TABLE 22.1 Menopause symptom score vasomotor symptoms but in randomised placebo
controUed rnals to date, commercially isolated
get.,
,Jet
Women's health : a c ore cunicvlum
22 Th e menopause and b
eVo nd
Reference: Total
BMD (glcm 2 ) YA T-Scole
husband's
1.24 2 'ondlOpause'
adolescent
1.12 children elderly
parents
1.00 o
0.88
0.76
~ ---------- -2 J
0.64
---------
--------- -J acceptance
of ageing ------I.~ MENOPAUSE .._______ deClining
~
0.52 ---4 libido
---------
I
O~ ~
~ ~
20 30 40 50 60 70 80 90 100
Age (years) changing
family role changing
BMD Young-Adult Age-Matched bOdy image
Region (g/cm 2) T-Scare Z-Score diffiCulty re-entering
workforce
Neck 0.893 -D,7 -D. 1
Words 0.729 -1.4 -1.3
Troch 0.592 -1.8 -1.3 FIGURE 22,2 PSYChologica l, social and sexual Influences around menopause
Shott 0.970
Total 0.826 -1.4 -1.8
(MacLennan et al 2001)_ Some studies also
suggest that psychological symptoms and joint mechanisms, including rhe inhibition of plaque for-
FIGURE 22.1 Bone density (D EXA) scan of the femu r of a 50-'/ear-old woman showing early osteo-
porosis. '(he shaded zone in th e graph represents the normal bone denSity range, which decreases paInS appearing around m enopause may manon m healthy arreries. However, secondary
from menopause, The white square re p resen ts this patient's bone density . (Courtesy Alastai r reduce with HT. cardioprevennon studies (i.e. in women wirh estab-
Maclennan/Department of Nuclear Medicine and Bone Densitometry, Royal Adelaide Hospital) 2. The prevention and treatment of osteoporosis. lished atherosclerosis or a past history of myo-
HT IS currently the only registered therapy for cardial infarction or Stroke) show no benefit in
the preventIOn of osteoporosis before the onset mmaang HT after these events and that HT rna be
oestrogens such as isoflavones have not been shown dose of oesrrogens used in HT is very much weaker of an osteoporotic fraCture . Irs advantages are detrnnental by destabilising the plaque ani in-
to have an effect greater than a placebo. in potency than the synthetic hormones used in low COSt, high therapy compliance added cr~asJng adverse cardiovascular Outcomes by about
The ~ffect of a placebo on hot flushes Over sev- oral contraception. Thus, perimenopausal HT symptom concrol, low numbers-ne~ded-to 1o, o~jJer year (WHI 2002).
eral months is usually around 50% and this should does not inhibit ovulation and is not contracep- treat to prevent one fracture and efficacy in an I he Women's Health Initiative (WHl) trial
be remembered when assessing the many commer- tive. In non-smokers, combined oral contracep- unscreened population. sought to determine whether HT had long-term
cial claims of unregistered over-the-counter prod- tives can be used in perimenopausal women for benefits or nsks for WOmen the majority of whom
The above are the two maio indications for were well past menopause and had no menopausal
ucts for the menopause. Currently there are no symptom control, menstrual control and comra-
the use of HT There is mixed evidence that HT symptoms or other indications for HT. The pri-
effective alternative (complementary) thetapies for ception. Later, when menopausal symptoms are
Improves some aspects of cognitive function (e g mary outcomes were cardiovascular disease and
the menopause and irs sequelae. Most have no experienced during the pill-free week, a HT regi-
verbal memory and menopausal depressio~): breast cancer. Women were enrolled between the
long-term safety data. men can be considered. In these circumstances,
reduces the nsk of dementia and improves the ages of 50 and 79 years. Many had established car-
after the age of 50 years pregnancy is rare. quahty of life III symptomatic women.
Hormonal therapies dIOvascular risk factors.
Indications for hormone therapy The combined HT arm (premarin and medroxy-
Postmenopausal hormone therapy (HT) differs Hormone therapy and progesterone acetate) of the WHI trial was
from the stronger synthetic oestrogens used in oral 1. Relief of menopausal symptoms. Systematic re- cardiovascular disease stopped <:fter 5 years, when it was deemed that a
contraception, in that HT usually contains the views of randomised controlled trials show that decrease III cardIOvascular evenrs was unlikely to
Animal studies, laboratory studies and epidemio-
human oestrogens, oestradiol or oestrone, or con- HT is much better than a placebo in reducing lOgIcal studies of women taking HT from around be seen and that an JOcrease in detected breast can-
jugated equine oestrogens which mostly vasomotor and urogenital symptoms (urinary cers had Just reached a predetermined conserva-
the age of menopause suggest that HT may playa
metabolise to oestradiol and oestrone. The average frequency, atrophic vaginitis and dyspareunia) nve and automaac stopping point for the trial. Its
pnmary cardioprotective role through several
global illdex, wbich combined seven beneficial
fft 2
Women's health : a core c urriculum
22 The men opa use and b
eyond
and adverse events, showed an increased adverse An absolute increased risk of 70,1% per year in
outcome for 1 per 100 patients on combined HT. Stroke and a similar reduction in hip and spine ~~~A l'alCI 0.17-0.86) compared to non-users
. I et 2002). However, as with cardiovascu- A full history is necessary including mem I d
The differences in the mixed outcomes are shown fractures was reported. Thus, the risk/benefit ratio menstrual
.
fill ca, rug,
' am y, sexua and psychosocial .
lar disease, combined hormone therapy does not
in Figure 22,3 . Thus, in this population, long-term is different for oestrogen-only therapy. It IS helpful to obtain the woman' . ISSues.
appear to be neuroprotective, when srarted in later
combined HT cannot be recommended as a
cardioprotective agent. Other risks and benefits of HT
age groups (65-79 years). Some women claim that
h
tde menopause and its possible therapies
a dress any myths or common misconce 'ti
anJ
s attlrud
to
to
. 11 .decrease symptoms of de pressIOn
oestrogens .
It can be debated whether this trial was a pri-
Short-term randomised trials show that the com- especla y If commenced around the peri: HT lS bemg considered, there is often a f~ar°thns. If
mary or secondary cardioprorection trial because may c .g h . at It
h ause weI . t gall. Placebo-controlled trialS
it is likely to have enrolled a population with mon early Start-up side effectS of oestrogen are ::ffeo;:pause: The mechanisms by which hormones
is
mixed risks for esrablished atherosclerosis. A trial breast tenderness and uterine bleeding. A small b bO~tlve funCtlon are not clear but appear s ow that weIght . gain common aroun d
to e 0 direct. and indirect through ossible menopause, especlally as exercise decreases and is
has yet to be conducted in women commencing number of women appear to be sensitive to the slffillar In both HT and placebo groups. Th; . d
unproved vascularIty to the brain and by aecreas-
long-term HT around the menopause ro test the progestogen content of HT and may complain effectS of combined HT should be put int ffiLxe
mg vasomotor symptoms, insomnia and tiredness
hypothesis that HT may have a primary cardio- about bloating and premenstrual-like symptoms.
protective role. Similarly, the hypothesis that early Changes in the HT regimen and in the route of ad- th~s fuProvmg overall wellbeing. Other neurolog~ speCtlve. Details of previous side effectS eO per-
Ie nCtlons reportedly affected by hormone enced while taking HT or ineffectiveness of?o%l~
and prolonged HT may give neuroprotection, i.e. ministration can often reduce these problems,
:erapy mclude Improved reaction times and pos- roures or regtmens are important to allow fu
may slow the decline in cognitive function and Quality-of-life benefits have been described in railormg of possible HT ture
fal sway compared to placebo therapy, This is
reduce dementia risk, has yet ro be tested in ran- symptomatic women on HT but not in asympto- re evant to the prevention of falls and may indi-
domised controlled trials. matic women, Other potential benefits are a
rectly contrIbute to reduced fracture rates on h _ Examination and routine investigations
The WHI trial has confirmed observational reduction in macular degeneration, dry eyes, mone therapy. or
data that HT is associated with a doubling of the tooth loss and skin -ageing effects. Other potential Physical examination should include breast and
risk of thromboembolism from the first year of risks are increased gallbladder disease and investi- Care of the individual pelVIC examination WIth a cervical Smear test wh
therapy. After 5 years of use of combined HT in gations for uterine bleeding, In summary, the COSt appropnate. en
the WHI trial, an increase of eight detected breast of HT and the mixed benefits and risks of long- Assessment and counselling Hormone tests are rarel)' helpful and d
jj , . fl 0 not
cancers for 10,000 women years was reponed, term HT do not warrant the liberal use of HT u~ua } .In uence management. Serum Ii ids
It ~s m:portant to allow more time for consulration
balanced by a decrease of eight bowel and unless there is a clear indication of a benefit for the w en Ifst assessing a woman entering menopause. tnglycende levels, thyroid function tests gl p ,
endometrial cancers per 10,000 women years and individual. d I· ,ucose
an a comp ete blood pictUre can be selected
a decrease of ten hip and spine fractures (despite Some randomised short-term placebo-con-
the WHI population being unselected for osteo- trolled trials in early menopause show that oestro-
15
porosis risk) (Fig 22.4). gen therapy improves verbal memory. In women 15
Breast Purmonarv
The oestrogen-only ann of WHI ceased in on long-term hormone therapy (> 10 years from cancers Stroke
embolism Stroke 12
2004, shOwing no increase in breast cancer or car- menopause) an observational study suggests an 8 8 8
diovascular disease in this population (Fig 22.5). associated reduction in the risk of dementia
a
g!. embolism
c 3
CD
E
o
;:
8o
o
8 7
Bowe/and Breast
CHD Hlp Total uterine cancers 10 cancers
concer cancer fractures deaths Fractures
~ 15 12
hip and spine
~ 15 Fractures
hip ond spine
• Combination hormone
replacement therapy o Placebo
FIGURE 22 4 S
CHD - Coronary heart diseose VTE - Venous thromboembolism risks a db' umrnary of the likely significant
I n eneflts after 5 yeo rs of combined HT FtGURE 22.5 Summo ry of main risks and
benefits Of oestrogen~only HT (CVD-
FIGURE 22.3 WHI d isease rates for women on combination hormone therapy or placebo (From ;o~~~man W~hout Cardiovascular ris, factors
nClng ormone therop y from early cord/ovasculor disease) (Based on WHI 2004)
Maclenna n 2003; reproduced with permission from Australian Prescriber)
menopouse (Based on WHI 2004)
4'"
'4'
Women's health : a core cu rriculum
22 Tho menopause and beYond
when indicated but are not merited routinely. Options tor the management
Mammography is recommended every 2 years or continuous Long-term goals tor
Perimen opou se
L -_ _----:-' oestrogen ot osteoporOSis
yearly when there is a strong farruly history. of healthy ageing
D~D~D~
cyc ~ cal
breast cancer. It need not be more frequent dunng progestogen In an older woman with cardiovascular risk fac-
Hr. A bone density scan (e.g. dual energy X-ray progestogen wlthdrowal bleeds Increasing longevity has brought with it an
tors and a recent low-trauma fracture but few
absorbtiometry - DEXA - of hip and spme) IS increased number of disability years. Disability
conffnuous menopausal symptoms, a bisphosphonate (alen-
appropriate when this influences management. A
Postmenopouse oestrogen years are defined as those when an individual is in
drcnate, risedronate or etidronate) may be an
thrombophilia screen may be considered where continuous the care of ochers for assistance with day-to-day
progestogen appropriate option. In a woman who has had an
there has been a history of thromboembolism. livmg. Women now have an average of 9 disabil-
contInuous osteoporotic fracture and has breast cancer con- ity years before death. The most common reasons
Affer hysterectomy L '_ _ __ _ _ ~ oestrogen
alone
cerns or fear of uterine bleeding, a selective for disability are cardiovascular disease, locomOtor
Pill, patches . paste , puff, oestrogen receptor modulator such as raloxifene
pessary or pellet? disorders such as arthritis and osteoporosis, incon-
should be considered. In younger women with tinence and dementia. The men opause and its sub-
Oral therapy is generally the firSt route of choice. FIGURE 22.6 Hormone t heropy reg imens symptoms and low bone densiry, HT could sequent management may influence all these.
However, poor absorption or excessive metabo- be considered. Parathyroid hormone and Stron- There isa needJor more research into improving
lism of oestrogen can occur ill the case of malab- prescribed where the progestogen is given contin- tium ranaleate may be other therapeutic options. the quality of bfe afrer menopause and reducing
sorption disorders, irritable bowel syndrome or Calcium, vitamin D, hip protectors and weight- the disability years.
uously, usually at half the dose of the pen-
the concurrent ingestion of H2 antagomsts for gas- bearing exercise are adj uncts to the above evi-
menopausal regimen. Ir is Important to counsel
* bPostm
tric refllLx. If oral oestrogen is ineffecnve, then It IS dence-based therapies.
that most women will have mmalmegular bleed-
reaso nable to try rransdermal routes. Some
women prefer oestrogen and progestogen patches, ing and then sporting over the first 3-9 months of Length of therapy enopa usal
but when there are skin allergies or the patches do a continuous progestogen and oestrogen regJrnen leed ing
not stick, an oestrogen gel may be preferred. An before endometrial proliferation ceases and a Women can be treated for as long as they perceive
intranasal oestrogen spray is another optIOn, giV- stable atrophic endometrium is established. There an improved qUality of life from the alleviation of
ing less risk of breast tenderness. Skin sprays are is usually no need to investigate dirmOlshing ltreg- menopausal symptoms. This time varies greatly Common clinical presentati on
currently under trial. Local vagJOal oestrogens can war bleeding in the first 12 months after the IillO- from woman to woman and can be from months to
A 54-yea r-old WOman presents With vaginal
be given as pessaries or creams for vagJOai symp- ation of combined continuous hormone therapy many years. It is reasonable for Women to have a bleed ing 3 years after her lost menstrual
toms with minimal systermc absorption or effect regimen. trial period off HT after 4 to 5 years of therapy. To period .
elsewhere. Implants are another way of debvermg A woman who has had a hysterectomy usually avoid rebound vasomotor symptoms, the dose can
hormones, but over time there is a risk of tachy- does not require progestogens and receives unop- be reduced over 1-2 months before cessation. Up CO
phylaxis. posed oestrogen therapy (Fig 22.6). approximately 40% of Women may experience a Postmenopausal bleeding is a symptom, not a diag-
return of debilitating symptoms, warranting the nosis. It refers to bleeding that occurs 12 months
Hormone therapy regimens Testosterone therapy option of a further course of therapy after or more after the last natural menstrual period.
counselling about the risks of longer-term therapy. The true incidence of postmenopausal bleeding is
Oestrogen therapy should be continuous, and There is insufficient data to clarify the optimal use Often a lower dose can be recommenced with unknown. There were over 46,000 hospital
doses can usualJy be given that ameliorate oestro- or long-term safety of testosterone. In some effect. admissions for diseases of the pelvic organs and
gen-deficiency symptoms without glvmg symp- women, it may help libido and anecdotally a fe~ genital tract in Australia in 2000-2001 in women
toms of oestrogen excess, such as breast tender- may expe rience improvement 10 energy an Tailoring therapy over 50 years of age. }dany of these admissions
ness. Progestogen therapy, in combmanon With the mood. Some may also expenence mcreased. fe~l would have been for evaluation of post-
continuous oestrogen regimen selected, needs to High continuance rates can be achieved with ade- menopausal bleeding. Figure 22.7 shows the age-
ings of aggression and in excess it can have vmlis-
be given cyclically around the perimenopause to fit quate initial counselJing, early follow-up and tailor- adjusted rate of cancers of the endometrium and
ing side effectS. There are currently no regIstered
in with the endogenous ovarian cycle and to aVOid ing of the regimen to minimise start-up side effectS cervix in Australian women. It can be deduced thar
breakthrough bleeding. The progestogen IS usuaJly preparations in Australia for women, although
and give effective relief of symptoms. After a satis- most instances of postmenopausal bleeding are
given for 10-14 days per month. A predictable low-dose injections and implants are often used,
factory regimen is established, yearly review is due to benign causes.
period or withdrawal bleed usually occurs afrer the especially in younger women who have had a pre-
appropriate. About 15% of women are sensitive to
cessation of progestogen therapy and often the mature menopause. A registered compound called
progestogens and may experience premenstrual Clinical evaluation
irregularity and heaviness of the penmenopausal tibolone can have a mild androgenic effect m post-
feelings. They may require lower progestogen
periods are improved. menopausal women and can be used as an 'all-m- An appropriate history, examination and investi-
. occupies
. and dosages or an intrauterine progestogen delivery sys-
After 4 years of cyclical progestogen therapy, or one' postmenopausal therapy, as It tem can be fitted that gives local endometrial gations are required. Proper steps must be taken to
if HT is commenced more than 1-2 years after stimulates the oestrogen, progestogen and testo- protection fo r 5 years without adverse systemic exclude gynaecological cancer, including referral
menopause, a postmenopausal regimen can be sterone receptors. effect. to a specialist gynaecologist. A careful explana-
tion, including the likelihood that cancer will
'IF
Women's health: a c ore curr iculum
22 The men opa use a nd b eYon d
Australian Cancer Statistics 1983-1999 resected. A common benign cause of postmeno-

30 pausal bleeding in older women is genital tract of endometrial thickness may Suggest the presence
0
0 atrophy, which results from oestrogen deficiency. of a malignancy but is not diagnostic. Many inves-
g 25 t- e- Ii Atrophic genital tract epithelium is pale, thin and tigators have reponed on this method of screening
0
(j) fragile and may bleed spontaneously, probably for endometrial malignancy in postmenopausal
Q 20 r- r- I I I
owing to chafing of opposing epithelium, or to women, using variable definitions of abnormal
<ll
"2 trauma (e.g. from a vaginal pessary, intercourse or thickness (berween 4 and 10 rrun). Recent repons
15 I c::- I
u o Uterus insertion of a vaginal drug applicator). Rarely, blood of endometrial cancer in women with sonograph_
U*
::J
a
<ll
10
5
• Cerlix
dyscrasias may be a cause of postmenopausal
bleeding. Vaginal infections hardly ever cause any
bleeding.
icaIly thin endometrium increase uncertainry as to
the place of this investigation.
Endometrial cancer spreads locally (lower
OJ
-0:
0 Ldl.J
,
20-24
J
30-34
1 1
40-44 50- 54 60-64 70-74 80-84
Non-gynaecological causes of
uterus, cervix and occasionally ovaries) and to the
pelvic lymph nodes. The preferred management is
postmenopausal bleeding tOtal abdominal hysterectomy, bilateral salpingo-
Age oophorectomy and pelvic node sampling.
It is very unusual for women to mistake rectal or Postoperative radiotherapy is offered to prevent
urethral bleeding for vaginal bleeding, but bleed- local vaginal cuff recurrence in appropriate cases.
~~~~~~e~2;~o~9:~~~~~~~~~~;~St~fo~~~~~r~f ~~~
endome trium and cervix in Australian women
Heolth website) ing from these sites should be considered and If the disease is too advanced for surgery or the
evaluated. Prolapse or eversion of distal urethral patient unfit for surgery, pelvic radiotherapy may
mucosa is common in elderly women and may be employed as primary management. Local
not be found, will greatly reduce the woman's endometrial biopsy and hysteroscopy could be present with bleeding. Carers of these women may recurrence may be managed SUrgically, with radio-
anxiery. I . I considered after this time. . initiate the presentation and may be confused therapy or chemotherapy. Ill! selected cases,
Identified risk factors for gynaeco oglca can- Speculum examination of the vagina and regarding the site of bleeding. gonadotrophin-releasing hormone (GnRH) ana-
cer may influence clinical declslOn making, cervix, a Papanicolau (Pap) smear, a bunanual logues or high-dose progestogen therapy may be
particularly when there is doubt regarding the examinati.on of the pelvic organs and an abdonunal En dometrial hyperplasia utilised. Overall, 20-year survival is estimated to
significance of the presentation (e.g. blee?mg examination must be performed. If hysterectomy be about 80% for Women diagnosed with
within 12 months of the 'last' penod). Tnese Simple hyperplasia is not a premalignant condi-
and/or oophorectomy have been performed, .the endometrial canc.er, but survival is poorer in older
risk factors include: tion. Atypical endometrial hyperplasia will pro-
histology and details of pOSSIble remammg ovarIan, postmenopausal women (Brenner 2002).
gress to adenocarcinoma in up to 40% of cases,
• past or current use of unopposed oestrogen uterine or cervical tissue must be estabhsh~d ..
may respond to progestogen therapy and is defin-
Blood loss is usually not heavy but. will influ-
itively managed by simple hysterectomy (Lethaby
CervIcal cancer
therapy d/ ' dr ence decisions regarding management, Includmg:
• polycystic ovarian syndrome an . or syn orne et aI 2003) . Cervical cancer appears to have a bi-modal age
X' (obesiry, hyperrenslOn, Insulin reSIstance), urgency of referral to a specialist for evaluation distribution (Fig 22.7). Women presenting in the
linked to endometrial cancer, pOSSibly as a prescription of continuous oral progestogens Endometrial cancer postmenopausal period with cervical cancer may
result of chronic unopposed oestrogen expo- to manage bleeding . never have had a Pap smear. Cervical cancer may
sure from ovarian and adipose sources Endometrial cancer (usually adenocarcinoma) is
• emergency transfer to hospItal for blood tranS- primarily a disease of older women (Fig 22.7). The be suspected from a Pap smear, but the diagnosis
• nullipariry. . fusion, vaginal packing or emergency radiologI- is histological, requiring a tissue biopsy for con-
arypical endometrial hyperplaSIa diagnosis is based on histology, with tissue obtained
cal or surgical intervention (all rarely reqUIred). by hysteroscopy and directed endometrial biopsy firmation. Most cervical cancer is of the squa-
• abnormal Papanicolaou (pap) smear
or by dilatation and curettage. mous cell rype, but adenocarcinoma is be-com-
previous gynaecological malIgnancy Benign causes of Dilatation and curettage, although a blind sur- ing increasingly impOrtant_ Unfortunately, a Pap
• family cancer history .
tamoxifen therapy for breast cancer or ItS pre- postmenopausal bleeding gical procedure, is probably as effective as hys- smear does not as readily detect adenocarcin-
oma of the cervix.
vention d b Hormone therapy (HTl is a very common cause o~ teroscopy and directed biopsy in diagnosing
• increased endometrial thickness measure y malignancy, but is more likely to miss benign Cervical cancer spreads locally (lower uterus,
bleeding in postmenopausal women. In. thorough!) cervix, vagina and adjacent Structures) and to the
ultrasound. evaluated younger postmenopausal women not tak- tumours. Outpatient endometrial sampling is a
cheaper alternative but is probably less diagnosti- pelvic lymph nodes. The preferred management
Recent cessation or current use of hormones ing HT, usually no cause is identified and It IS is an extended total abdominal hysterectomy
cally reliable than hysteroscopy or dilatation and
may be a simple explanation for the bleeding. assumed that the bleeding IS a result of narural and pelvic node sampling or pelvic radiotherapy,
. ally'. b ' endo- curettage. However, if outpatient sampling makes
Unscheduled bleeding in the fmt year of contInU- honnonal flucruation. OccasIOn emgn 6- depending on available expertise. Sometimes, the
a positive diagnosis of malignancy, it is not neces-
ous oestrogen and progestogen hormone replace- me trial polyps or subendometnallelOmyomata ~ sary to undertake hysteroscopy or dilatation and tumour is shruuk by radiotherapy before surgery.
ment therapy does not need invesnganon but broids) are identified and can be hysteroscopic Y In appropriate cases, postoperative radiotherapy is
curettage. Transvaginal ultrasound measurement
offered to prevent local recurrence. If the disease
'IF
22 rhe meno POuse and b
eyond
is too advanced for surgery or the patient unfit for The Cochrane Database of Systematic Reviews Questions
surgery, pelvic radiotherapy is offered. Local (The Cochrane Library), issue 2. O nline. Available, a . Evaluation is not required if h
recurrence may be managed surgically, with radio- htrp: IIWW'N.update-software.comlccchrane. hod a hysterectomy. s e has
1. Which Is the most appropriate
therapy or chemotherapy. Overall, 20-year sur- hormonal regimen for a 56-year-old b . This is likely to be endomet · I
MacLennan AH 2003 Horm one replacement therapy: postmenopausal woman with a uterus cancer. na
vival is estimated to be about 60% for women where to now? Australian Prescriber 26 :8-10.
who are diagnosed with cervical cancer, with who has many menopausal
symptoms? c. This is likely to be cervical cancer.
poorer survival in older postmenopausal women Maclennan AH, Lester S, Moore V 2001 Oral ocstrog"n
(Brenner 2002). a. Comb ined cyclical oestrogen and (3)The woman should be referred to
replacement therap y versus placebo for hot flushes. speclOllst for evaluation. a
In: The Cochrane Database of Systematic Reviews
cyclical progestogen
Other primary (The Cochrane Library), issue 1. Online. Available: b. Combined continuous oestrogen e. An ultrasound scan to measure
gynaecological malignancies htrp J /www.update-software.comlcochrane . and cyclical progestogen endometrial thickness is mandatory.
The rare primary uterine malignancies (leiomyosar- WHI 2002 (Writi ng Group for the Women's Health c. Combined cyclical oestrogen and 5. A 70-year-old woman with osteoporOSiS
continuous progestogen presents With light vaginal bleedln
coma and other sarcomas), ovarian granulosa cell Initiati ve Investigators) Risks and benefits of estrogen
tumours (which secrete oestrogen) or vaginal or plus progestin in healthy postmenopausal women. . Combined continuous oestrogen She has recently stopped using or~I'
Principal results from the Wom en's Health Initiative and continuous progestogen combined HT because of adverse
vulval cancers may present with postmenopausal
Randomised Conrrolled Trial. Journal of the Ame rican publiCity from the WHI study. Which of
bleeding. e . Cyclical or continuous oestrogen the fOllOWing Is correct?
M edical Association 288 ,321-333.
alone, depending on her wish for
Su mmary periods a. The bleeding is likely to be due to
WHI 2004 (Women's Health Initiative Sreering ,-() cervical cancer.
Most posrrnenopausal bleeding is unexplained or Committee) Effects of conjugated estroge n in
2. What Is the most common start-up side
posr.ffit:nopausa l women with hysterectomy. The \::I The bleeding is likely to be due to
due to hormone therapy, atrophic genital epithelium eH~ct of hormone therapy about vaginal atrophic changes.
or benign uterine tumours. Ho'.vever, a thorough Women's Health Initiati ve Randomized Controlled
which a postmenopausal woman
evaluation is required to exclude the uncommon but Trial. Journal of th e American Medical Association
should be warned , along with less c . The bleeding Is likely to be due to
291:1701-1712. common risks? endometrial cancer.
important malignant causes.
Zandi Pp, Carlson M C , Plassman BL et al 2002 (for the ~ lrregUlar bleeding d. The bleeding is likely to be due to a
Health maintenance Candida alblcans infection .
Cache C ou nty Memory Srudy Investigators) Hormone b . Breast tenderness
Lifestyle factors , psychological, social therapy and incidence of Alzheimer's disease in older e . The bl.eeding Is likely to be due to
and sexual issues, health education WOmen : the Cache County Study. Journal of the c. Breast cancer stoPPing HT.
and evidence-based management American M edical Associarion 288 :2123 . d. Weight gain
options all influence the quality of life 6. Which of the following is correct?
in the peri- and postmenopausal e. Bloating
a . Postmen opausal bleeding is
years.
expected In women Who are taking
Recommended reading and 3. Which one of the following therapies is warfarin .
useful websites not on eVidence-based therapy for the
References reduction of osteoporotic fractures? b. There Is never a role for oestrogen
The Australian Institute of Health and Welf.re website a. Raloxifene supplementation for women with
Brenner H 2002 Long-term survival rates of cancer patients postmenopausal bleeding.
achieved by the end of the 20th century: " pe ri od htrp:llwww.aihw.gov.aul
b. Bisphosphonates
analysis. Lancet 360 (9340) : 1131-1135 . c. A Pop smear is not necessary if a
The Australasian M enopause Society \\'cbsite, c. Vitamin D woman is over 65 years of age.
Lcthaby A, Farquhar C, Sarkis A et al 2003 Honnone
n.:placemenr therapy in posnnenopausaJ women:
htrp:llwww.me nopause. org.au. with links to tbe
Inte rnational M enopause Society, the North AmeriCln
Q Phytoestrogens . Hysteroscopy and endometrial
sampling are probably the best
endometrial hyperplasia and irregular bleeding. In: M enopause Society and the J ean Hailes Foundation. e. Hormone therapy
diagnostic tests for postmenopausal
bleeding.
4. A well 55-year-old woman Whose lost
menstrual period was 4 ye ars ago and e. There Is no chance of endometrial
who has never used HT presents with cancer If a woman presenting with
vaginal bleeding . Which of the postmenopausal bleeding has a
follOWing is correct? normal transvaginal ultrasound
scan.
'tf b
*23
Principles of operative
gynaecology
Phil Watters and Clement Chan
Learning objectives
Knowledge write postoperative orders for

intravenous fluids and analgesia
At the end of this chapter, the student assess a patient's postoperative
will be able to: recovery.
Preoperative
describe the physiological and Attitu des
psychological responses to surgery
describe common perlsurgical At the end of this chapter, the studen t
interventions , which minimise operative should reflect upon :
and postoperative risks to the patient
the balance between the benefits and
define 'material risks' and 'consent' risks of surgery
Postoperative the value of identifying Issues important
• describe postoperative care in the first to the patient
24 hours and following days the potential for litigation and how to
• discuss the factors that influence a minimise this risk .
patient 's recovery following surgery.
Skills

toke informed consent for various

gynaecological procedures
assess a patient's suitability for major
surgery
'Ii
23 PrinCiples 0 1 operalive g yna ec olo gy
women's health: a co re curriculum
* Gynaecological * Psychologica l re sponse

to surgery
Most of the conventional gynaecological opera-
tions can now be perfonned as MIS, but the longer
the operating time and the greater the amount of
potential for intraoperative complications such as
haemorrhage requiring blood transfusion, bowel
and urinary tract injuries, and pOstoperative com-
tissue dissection, the more likely the procedure will plications including sepsis, thromboembolism,
procedures be considered major. There are many advantages to severe adhesion formation and chronic pain. In
Gynaecological surgety involves organs of special
significance to body image and femlntnlty, and the MIS: overnight hospitalisation is usually not raday's litigious society and defensive medical
res onses to the need for surgery vary greatly required or is significantly reduced; magnification practice, more time than ever needs to be spent
d ili
A 45-year-<>ld woman presents with e using fibre optic insrruments enables significantly ensuring that the patient is aware of the potential
be;:'een individuals. PsycholOgical respons
menorrhagia that is poorly controlled by improved close-up views of the structures and tis- risk. In a recent judgment, it was stated that a
affected by the premorbid personality an e
medical therapy. nature of the surgery, whether It IS elecnve, emer- sues; convalescence is shorter; there are fewer material risk r.:~ anvrisk to which, once made
gency life-threatening or With a grave prognosIs (e.g. wound complications (e.g. pain or infection) with a aware of It t anent would attaCh suiliificance
b,
adv~ced cancer surgery). Anxiety~. depresslO faster return to nonnal activities. However, there is (United M edical Publications 2004). Deciding in
Gynaeco Ioglca. I procedures can be described in an er and occasionally frank hosnlity may . e a long learning curve to achieve the required each case what is or would be 'significant' to each
several ways: en~ountered. It is helpful for the surgeobn to 'den~ expertise and in some cases the effectiveness and
the complication rates do not match those of the
individual is a part of professional responsibility
and can be the most challenging aspect of the pre-
. aI vulval vaoinal cervical, uterine, those who may face psycholOgical pro lems m t e equivalent conventional procedures. There are also
1. Anatonuc - ''''' . f th postoperative period and to ensure the panent IS operative phase.
tubal or ovarian, or any combinauon 0 ese. increased cOSts owing to the use of disposable
mentally well-prepared for elecnve surgery. The sup-
2. Functional . hi '
• Removal of benign or malignant pat 0. og)'.
• ReconstrUction of anatomy or restoranon of se
function (e.g. correction of prolapse or un-
rt of family a social worker, bereavement coun-
pOllors and ' urn'es a psychiacrist may be valuable.
some
instruments. The time--<:ost-effectiveness balance
for each type of operation has to be evaluated and
will vary between different operatOrs.
* Pre-surgical interventions
*
Major operations involve removal of organs The use of pre-anaesthetic analgesia and sedation
nary incontinence surgery). if (e.g. the uterus, with or without fallopian tubes depends on the type and length of procedure.
• Interruption of fertility (e.g. tubal ster lsa- Minor procedure s and ovaries) and generally require extensive tissue Opioids such as morphine or pethidine, or seda-
tion) or menstruation (e.g. endometnal resec- dissection for both benign (e.g. severe endometri- tives such as benzodiazepines, are most often used
tion or ablation). h Minor procedures that are often performed alas out- osis with serious anatomical and tissue distOrtion) for major surgery, especially fo r radical surgery or
Su .cal - describing the route of approac . dau surgery with or Without loc anaes- and malignant pathology. Extensive reconstructive
panent or J , . _.1 al skin andlor protracted operating times.
3. (e.ivaginal, abdominal, endoscopic or a com- thesia, include surgery on the vwv surgery, such as in the treatment of prolapse or
bination of these approach es). the cervix by cold knife (scalpel), electrosurgery or urinary dysfunction, is also considered to be major
PrO~~Zlactic.nt~;: ! re fre~e~~~ recom-
mende f ryai' I nd for ro itita'nd
laser procedures. . al surgery. These operations can be performed extensive abdominal Sllcgcry with an increased
* Physiological response
Some minor procedures reqUire gener . or
regional anaesthesia. These include 'marsuplallsa-
tion' (forming a pouch of the cysrJabscess caVity
vaginally, abdominally or laparoscopicaUy (or with
a combined approach).
ri~ction. Anticoa~s are given rourine-
ly to those with nsk factors, mcluding pr.::!.2nged
operating; ti[lle, Rostoperative immobility and a
to surgery for drainage) of Bartholin'S cyst or abscess, and
d
.
dilatanon
en ometr!
of the cervix with curenage of the
· ·th
'al cavity (D&C), With or Wl out ys-
d"
teroscopy usually for lagnostlc purp
h
oses Utenne
.I
* Preoperative plann ing
and consent
previous history <iI thTomboembohsm.
Health maintenance
curenage' is also performed for incomp ete or
Preoperative preparation, in
missed miscarriage or therapeunc abornon. Preoperative preparation depends on the type of particular informed consent and
procedure being undertaken, the age of patients
*
assessment of a pati ent's surgical
and whether they have any preexisting medical risks , minim ises adverse outcomes.
Intermediate and major disorders. It includes consideration of choice ,!Jf
an~ appropriate mood tests (e.g. full
procedures
. . d rformed in hos-
These are more mvaSlve an are pe th . Most
blood count, urea and electrolytes, grouping and
cross-match of blood, as necessary) and inf~d
co~
* Postope rative ca re
pital under general or regional anaes eS' I
intermediate operations are performed as ay s~~d Implied consent is usually accepted when a
doctor examines a patient. For operative proce-
The first44 hours afrerJWt!CFY is the period~en
thJLQaticnt is most ..YUlnerable to complications.
gery but some intermediate and all major surgl . dures, however, formal written consent is For illICW)ediarl MIll- m2 jQ~ry, parenteral
ope;ations require hospitalisation. A laparoscop'c required. This includes informing the patient analgesia, intravenous fluids an monit!7I:'tn!(:Uf
on
or hysteroscopic procedure is the most comm ry about the nature of the operation, the anticipated temper'lifure, ~, blood pressure, r~iration
. .
minimally invaslve or nurum
. aI a
ccess surge
duration of surgery and convalescence, and the and UrInary output are reqUlred.In the 0 OWIng
(MIS) performed in this category. ---.....
'+, 7
Women's health : a core cu rri c ulum
days, attendants monitor the resumption of nor- concurrent medical disorders. Conditions where
V
mal bowel peristalsis after abdominal surgery,
return to normal diet and early ambulation.
the convalescent period is likely to be longer
include major surgery, laparotomy, reconsrructive Principles of oncology
Physiotherapy may be required to minimise the surgery for incontinence and surgery in the elderly,
risk of postoperative lung atelectasis. with or without medical disorders. Edited b V Martha Finn
* Recovery from surgery

Health m aintenance
Early postoperative mobilisation
reduces the risk of thromboembolism .
Screening for cancer of the cervix Jennifer Cook
Cervical carcinoma Jennifer Cook
The impact of hospitalisation depends upon the Screening for breast cancer Phillip Carson
patient's family situation, occupation and social Endometrial cancer Bruce Ward
support network. Physical recovery varies accord- Gestational trophoblastic disease Marc JNC Kelrse
ing to the type and length of procedure; whether Reference
Cancer of the ovary Marc JNC Keirse
abdominal or vaginal surgery was performed; if Unjted Medical Publications 2004 Risk Management. UMP,
the surgery was reconsrructive and if there were Sydney.
Learning objectives
Knowledge
Questions 2. Postoperative care for major list other causes of an abnormal
gynaecological operations includes At the end of this chapter, the student mammogram
1, Which of the following are mandatory which of the following? Will be able to:
before gynaecological surgery is • outline the management of a patient
performed? a. Observation of temperature, blood With a symptomatic or an asympto-
pressure , pulse , respiration, urinary Cer vical carclnoa;1O matic breast lump
~
naesthetlC assessment input and output chart In the briefly describe the normal histology
Immediate postoperative period describe the follow-up of an abnormal
urgical risk assessment and cytology of the cervix mammogram
. formed consent
b . Prescription of analgesia descrlb~ the national recommendations Endometrial c gaeer
c, Monitoring of bowel activity for cerVical screening and the national
. Group and cross~match of blood reporting system for cervical cytology indicate the prevalence of and list the
d. Early ambulation write a flow chart to summarise the risk factors for carcinoma of the
e, Prescription of prophylactic
antibiotics e, Abdominal wound care mana~ement of an abnormal smear endometrium
and hlstolo~ical diagnosis of cervical
O il of the above Intraeplthellal neoplasia (CIN) describe the postmenopausal changes
Inthe genital tract
summarise the pathophysiology of
metaplasia/oncogenesis with special out/ine the metabOlism of oestrogen and
regard to HPV (human papilloma virus) list sources of unopposed oestrogen
recogn.ise the public health implications describe endometrial hyperplasia and
of cerVical carcinoma and Its Its relationship to carcinoma of Ihe
prevention endometrium
outline the management principles for a list the causes of postmenopausal
patient With Invasive cancer of the bleeding (PMB)
cervIx
Screenin g far bregst cancer • describe the investigations for PMB
identify the risk factors for breast cancer • outline management principles for
cancer or.the endometrium
describe the anatomy of the breast and
the variation in breast architecture Ge..:!,atlonol trophoblastic disease
dunng the menstrual cycle and with
IncreaSing age • understand Plocentatio-;:)and the early
formation of the placenta
define the appropriate age group for
mammography Identify the chromosomal abnormalities
associated with hydatidiform mole
(Continued over)
'+1
Women's health : a c<ore cunir;UhJm
24 PrinCip les of OnCO logy
(Learning objecNves continued) Skills

Cells
~~
discuss the difference between hydatidiform At the end of this chapter, the student
mole, invasive mole and choriocarcinoma should learn how to :
perform a Papanicolaou (Pap) smear
~<!:>.c::::::!.:: ~ Superficial
describe the imaging techniques useful in <:::2~~
diagnosis and management of advise a woman about an abnormal !::>~ ~
trophoblastic disease smear and its management
~<QS~ (ffjjJP
~~CS
inform a woman about the implications of Intermediate
describe the role of HCG In the diagn?sis
and management of trophoblastic disease an abnormal mammogram and the
required follow-up
outline the principles of management of
8~0
~0 ffi0
trophoblastic disease. • outline a management plan for a woman
0
-0-ffi
with an enlarged ovary Porabasal
Cancer of the OvQlY • advise a woman about the in v~stigotions Cervical cytology
needed when ovarian cancer IS suspected
• Indicate the prevalence of cancer of the
ovary • counsel a woman about the type of 8888- Th e cytological fearures of squamous cells
removed from the surface of the normal cervix
• list the risk factors for development of
cancer of the ovary
surgery that is likely to be necessary when
cancer of the ovary IS diagnosed
antici ate what may be necessary in the care
G888GG[ 8 Basal reflecr the ltisrological appearance. Mature squa-
mous cells desquamated from the superficial layers
describe the age distributions of the of a t~rminallY ill patient with ovarian cancer FIGURE 24.1 Cell layers In the stratified squamous are relatively large with acidopltilic (Pink Staining)
various types of cancer of the ovary epithelium of the cervix and vagina (Based On cytoplasm. The nuclei are small and dense.
explain to a patient the meaning of
trophoblastic disease. Symonds & Symonds 2004. p 347, Fig 24.9) Cytological abnormalities that suggest CIN
relate the various types of ovarian cancer
include: Increased nuclear to cytoplasmjc ratio,
to the structures from which they originate
A ttitudes
Tall, columnar, mucus-secreting epithelial cells nLi"CIear hypercnromasla, nuclear leornor hism
line the endocervical canal and its glands. The junc- a;;a-val)'U1~ llHcl ear &ze (anisokaryoSIS .
provide a differential diagnosis for an At the end of this chapter, the stUdent ese
ovarian mass should reflect upon :
tion between the stratified squamous epithelium of changes re ect increased nuclear activity and
discuss the investigation of a woman with the impact of a diagnosis of cancer on a the ectocervix and me columnar epithelium of the poorer cell maturation and differentiation. The
an ovarian mass woman's body image and self-esteem . endocervLx is the transformation zone. Here, a pro- increasing number and severity of these cyto-
discuss the management principles of the sense of loss and grief associated With cess of squamous metaplasia occurs, where the logical abnormalities correlate with increasing
ovarian cancer surgery for gynaecological cancer. grades of CIN.
original columnar cells become obliterated by pro-
liferation of activated squamous reserve cells. This
immature metaplastic epithelium then becomes a
Papanicolaou smear
mature squamous epithelium. Ideally, the transfor- The Papanicolaou (Pap) S~r is a screening test
* Screening for cancer

of th e cervix
have seen a reduction in mortality from cervical
cancer of about 30%. Since the mtroclucnon of the
National Cervical Screening Program m the 1960s,
mation zone lies at the external .os. When it is lo- for precursors of cancer - cervical inrraepithelial
cated at some distance outside the external as, the neoplasia or CIN (50% sensitiyjty and 9 5% speo-
appearances are those of an ectropion. This is fisiJy). Published false-negative rates vary between
often seen during oral contraceptive use and preg- 5% and 10%, but false-negative rates of up to 50%
the incidence of and mortality from cervical can-
nancy. Conversely, during the postmenopausal have been reported in the literarure. They may
Common Clinical presentations cer in Australia have dramatically declmcd.
years, the transformation zone is often located result from either sampling errors or laboratory
A 30-year-old woman presenh; for a routine within the endocervical canal. As the rransforma- errors. Although these are ltigh false-negati ve
Histology of the normal cervix tion zone is constantly changing, it is the site rates, they must be seen in the Context of the rela-
Papanicolaou (Pop) smear.
The ectocervix and vagina are normally covered by where cervical intraepithelial neoplasia (CrN) is tively long premalignant period of cervical neopla-
A patient presents with the fol lowing Pop smear most likely to occur.
report: 'There are scattered groups of atyp ical
stratified glycogen-containing squamous eplthelt~ sia and the policy or taking smears at 2- or 3-year
(F 24 1) A prominent smgle-Iayered basal row intervals. A 3 ~earl~ screening program willEre-
squa mous cells with enlarged nuclei and
irregular nuclear margins. They show a. high ce;~ de~~rcates the epitheliwn from the undcr~mg Cervical intraepithelial neoplasia vent rna arc~o of cases of cervical c;U;cer.
stroma. The parabasal cells form the next !e~~
Cervical ;:aepithelial neoplasia fC~ i~: ~sro
nuclear:cyfoplasmic ratio consistent With a The alse-posIOve rate IS a out .
high-grade epithelial abnormality: With further maruration, the Intermediate .
show less basophilic cytoplasrrt and decreasm~
logical diCos!s ilgraded With pCsi sver- The false-negative rate of cervical cytology in
nuclear to cytoplasmic ratio. The clearer (more aa

ity as C 1, ' C 2 and CIN 3 - formerly the presence of clinically apparent invasive cervical
descnbed respectively as mild dysplasia, moderate cancers may be as high as 200/0, as invasive cancers
Cervical screening aims to prevent cervical cancer dophilic) cytoplasm contains abundant glycogen. dysplasia and severe dysplasia/carcinoma in siru. In may not shed abnormal epithelial cells.
by detection of precancerous leSions. Countries A slender layer of £lartened cells covers the sur~ce. Clli.l.(Fig 24.2), cellular rnaruration is presew d , The -dHW h,clIllt used to perform a smear
that have adopted a national screenmg program ormal squamous epithelium IS non-keranruse . but there are nuclear abnormalities present the includes a labelkd.sl..ide, Ayre's SJIT;rula, cyt~
ill and fixativ~ay (Fig 24.5). e speciilum is
Women's health : a cor e c urri c ulum
24 Princ iples of Oncol o gy
lubricated using a very small amount of aqueous

gel or luke-warm water. It is then gently. and
slowly inserted in the vagma until the cervIX 15
clearly visualised. Using the spatula, a cytolOgical
sample is taken from the ectocervIX and these cells
are smeared over the slide. The endocervlX IS then
sampled using the cytobrush and the cells are
transferred to the slide. The cells are fIXed on the
slide using the spray and allowed to arr dry.
Current Australian recommendations are that
all women who have ever had sexual mtercourse
should have a Pap smear every 2 years until the
age of 70 years. Screening should starr at 18 years
1. N egative smear
of age or within 2 years of frrst sexual mrercourse.
If a woman has had two normal Smear tests m the 2. Low-grade squamous intraepithelial lesion
(LSIL)
previous 5 years, she may cease screenmg at
3. High-grade squamous intraepithelial lesion
FIGURE 24.2 Histolog ical appearance of CIN 1. (HSIL)
The cellular abnormalities are confined to the
lower third of the epithe lium. (Photo courtesy 4. Inconclusive for high-grade squamous intra-
Eric Hu/Royal Darwin Hospital)
epithelial lesion
5. Unsatisfactory
A smear is reported as negative rather then nor-
ma!, as this is a screening rather than a diagnostic
test. A low-grade epitheliaJ abnormality (Fig 24.6)
is suggestive of histological changes of minor atyp-
FIGURE 24.5 Equipment used to perfo rm a ia, HPV infection or CIN 1. A high-grade epithelial
Pa panicolaou smear, ( Photo courtesy Peter abnormality (Fig 24.7) is suggestive of CIN 2, CIN
Farkas/Royal DarWin Hospital) 3 or invasive carcinoma. A smear that is reported as
FIGURE 24.4 Histological appearan ce of CIN 3,

There is lack of differentiation, With Ihe
FIGURE 24.3 Histological appearance of CIN 2, disordered cellu lar pattern Involving the full
Although there is some surface differentiation thickness of the epithelium , The basemen t
of cells, the deeper la ye rs show marked membrane is intact and there is no st romal FIGURE 24. 7 HSIL: squamous c ells with nuclear
FIG URE 24.6 LSIL: squamous cells with m ild
nuclear Irregula dty. (Photo courtesy EriC Invasion. ( Photo courtesy Eric Hu / Royal Darwin
nucle ar atypia and nuc lear enlargement. (Photo
~Igrgern{} n t~ high nucle ar to cyto plgsmrGiQtio,
c
Hu / Royal Darwin Hospital) Hospital) Irr"S!g! Ila 0 ' !cle ar 01 'Ulne and coa rse chromatin.
Courtesy of Eric Hu/Royal DarWin Hospita l)
(Photo courtes y Eric HU/Roya l Darwin HosPltaI)
Women's health : a co re c urriculu m
24 PrinCipl
as ot On Co log y
inconclusive for high-grade epithelial abnormality

shows some, if not all, cytological characteristics
of a high-grade epithelial abnormality. A smear may
* Cervical carcinoma
be unsatisfactoty if obscured by blood or exudate. Common clinical presentation
Management of the abnormal smear A 50-year-old woman presents with a 2-month
history of Postcolral bleeding . She has never
Ten per cent of smears will be reported as abnor- hod a smear test. On speculum examlnatlo
mal. Of these, 900/0 will be squamous abnormalities icant aceto-w .te areas.
friable sort moss is seen on the cervix, WhIC;' a
and less than 1 % will be endocervical (glandular) bleeds on contoct.
abnormalities. Women can generally be reassured, Adenocarcinoma-in-situ
as the vast majgrirY will not hays cancer. Adenocarcinoma-in-siru (ACIS) comprises 0.5-20/0
An JlPsatisfactory smear should be repeated of in siru carcinomas of the cervix. Most col po-
6-12 weeks later, Care should be taken to avoid Jervical ~ancer is the second most common cancer
scopists would agree that ACIS has no specific col-
tc:,sdng in the presence of blood or infection. P;;;y la nose m women after breast cancer
infection should be a ro nate! treated befOre poscopic fearures. pproxlmate y , new cases are lagnosed
Invasive adenocarcinoma may be diagnosed on worldWide each year and over 200 000
the basis of abnormal vasculature and irregular di h . ,women Clinical presentation
~e~ac year of cervical Cancer. Most of these
surface patterns. ACIS is associated with squamoYS are m developmg COUntnes with limited Patients with cervical cancer most common!
CIN in 500/0 of caw. ~~~ss to cerVICal cancer screening programs. present With abnormal vaginal b leeding. T!ii~
!Cal cancer IS now largely a preventable publ' IS-usually ostcon:aJ, but may aJso be irre I
,~~~~~~~~~~~~~~~~~~o r
Management of CIN IieatCh Issue. IC
or postmen0J'a sal bleeding. Patients '-;\:6
. dis"""
m resu t er51sts ew hould be referred
for co poscopic examination of her cervIX. All
women with smears of high-grade abnounaJUY
(li IS
excision of the transformati
e mos~op ar mo ity for the treat-
m ent of CIN. It is ceap, relatively sate, proVides a
Risk factors
more
di
c
~
L:
h aOYancL v-~ may ha ve a malodorous
: !e,m weIght loss or .obstructive urooatby.
~~e SClanc gerv e inv;';;:;nt
shoUld be promptly referre<Hor cOlposcopy. Recta bleedmg iO'cates spread to th - I'
speamen for analysis and can be performed under ~ e recta
My woman who presents wuh symptoms sus-
local anaesthesia. The arE. of SlISpecred eIN is
picious of cervical cancer (e.g. postcoital bleeding
removed to a depth of about 10 mm using a semj-
or purulent bloodstained discharge) or clinical • Human papilloma virus
arCUIai shaped diathermy wire. Complications
signs of cancer (e.g. contact bleeding or the
appearance of an exophytic, crumbly rumour or indude na~ge, 1% mcidence of cervical • Smoking - double risk
an irregular ulcer on the cervix) should immedi- stenosis an cervical inco m pe[egc;~. • Early age at coitarche (double risk It less th
ately be referred for colposcopy, irrespective of ~ernative methods include laser ablation, in 16 years) on
which an intense, highly focused beam of light can
cervical cytology.
be used to cut or bum the abnormal tissue, and
• ~~~~~~~dsexual partners (> 10 partners results In
Increased risk)
Colposcopic examination cryterapy, which destroys abnormal cervical tissue • Age 35-39 years and 60-64 yea rs
of the cervix by eezing it. Neither method, hOwevf'5 provides
tissue for pathological examination. iathermy, • A portner with cancer at the penis - relative risk 8
Colposcopy allows a visual examination of the cryosurgery and laser have comparable success rates • A portner whose previous partner(s) had
cervix to check for the presence of CIN. The col- of the cervix cancer
for treating CIN 1 (95 %) , and CIN 2 and
poscope is a magnifyin instrument with a ii't • Herpes vi rus may be a co-factor in HPY
3 185-90%).
attac e. e rans ormatIon zone must e VISU- transformation of cells
alised to establish the examination as satisfactory. A coviap,,!, is performed if there is~
After initial ins ec 'on f the cervix Lu ol's tion of invasion, if the le~~ is lar~e or t . • Multiparity - cervic al trauma, hormonal or
a concern regardins prese;; of a enocarcinoma- nutTitlonal Influences at pregnoncy
iodine IS a e . Both low- and . - a e eslOns
s ow eVldeD' of f cogen degletion. The ~ The cone-shaped section of the CgylX • Contraception - condoms, diaphragms
conta.!rung the abnormal cellS IS removed under and spe rmlcldes (antiViral) are protective Th
cervIX IS then painted wi d ilute acetIc aCiO. This oral contraceptive pill may Increase the risk e
is taken up by abnormal cells, w hiCh rum white. general anaesthetic usin a laser or seal el. FtGURE 24 S C · . owing to hormonal stimulation at viral DNA '
t • e rvlca l carcinoma : infiltra ting
Suchaceto-white lesions are associated with CIN C s associate with this procedure ~es s of atypical cells with squamous tronscrlptlon
because osmotic dehydration accenruates the high include infection, haemorrhage, cervical stenosis lrferlenHtiation. (Photo court esy Eric Hu/Roya l
Darw n os pita I)
comem of optically dense chromatin. The gr.591 and cervical incompetence. sox 24.1 Risk factors for cervicol cancer
'+1
Women's health: Cl cora curriculum
24 PrinCIPles 01 OnC Olo gy
On physical examination, there may be evi-

dence of supraclavicular and InguInal lym-
phadenopathy. Hepatic tenderness or enlarge-
ment may indicate metastatic disease. There may
• blood
• inrr;;peritoneal implantation.
Cervical cancer is a clinically staged diseas~ 0
Stage Extent of cancer
Concer-in-situ
* Screening for breast
cancer
(fable 24.1). An exarruriartOfi of die patient under I
be a tender pelvic mass in advanced disease. A Cancer connned to cervix
vaginal examination may reveal an ulcerated
cervix or a friable fungatmg mass that bleeds on
anaesthesia will enable the extent of disease to be
determined. A combined vaginal and .rectal exru:u-
nation is performeo. CYStoSCO will derernune
II Cancer has extended beyond the cervix
but not to the side wall
• • ..... - . .
A 48-year-<>ld mother at three teenagers Is
contact. There may be extension to the vagInal
fornices. A rectal examination may reveal spread
spread of . e er. A c est X-rex
lSI III Extension to side wall (no cancer-free
space on combined vaginal and rectal
worried about dying from breast cancer otter
consl ered a component of extended clmlCa discovering that her mother has just been
of disease to the rectovaginal septum and para- examination). Includes extension to
Staging. the lower third of the vagina and cases diagnosed with breast cancer at the age of 72.
of hydronephrosis or non-functioning
A 55-year-<>ld Australian woman of Chinese
Treatment kidney
heritage presents with a tender diffUse lump in
IV Spread beyond pelvis her lett breast. She has been on hormone
A therapy for 3 years.
Spread to adjacent organs (mucosa of
bladder or rectum)
8 Spread to distant organs
After skin cancer, breast cancer is the most com-
TABLE 24.1 FIGO (International Federation of
mon cancer affecting AuStralian women. One in
Gynaecalagy and Obstetf ics) staging of 11 women will develop breast cancer in their life-
carcinoma of the cervi x time with the peak incidence after the age of 50
years. Over 10,000 women develop breast cancer
thromboem b.Qljsm. Chronic complicatio ns of and 2500 die of the disease in Australia each year.
radiotherap y include ovarian comw-a mi sS, As in most of the Western world, the incidence of
breast cancer in Australia is steadily increasing,
~, chro nic diarrhoea rad ianon enteritis), although the death rate trend has been downwards
vaginal stenosis an p e VIC sarcoma. a io-
since 1993. Breast cancer is less common in devel-
therapy is associated with less than 1 %
oping countries, but the case mortality is higher.
mortality. Acute and subacute surgical comtjli-
These international and temp oral differences
ca1,nL in clude bleedin , infection, fistulae, appear to be related to changing patterns of fertil-
bla der atony, SOl el O'b'Struction and ity and lifeStyle.
thromboembolic events. Long-term complica-
rions Include a low incidence of chronic bladder Brea st stru c tu re, fun ction
External mac nodes ----11--1--1_ V dysfunction denervation). Surgery is associated and life c ycle
W It 1% morta ity.
The rudimentary breast develops under the influ-

Internal Iliac nodes PrognOSis ence of oestrogen at puberty. The primary func-
Five-year survival for patients wjtb stage mmA. tional structures are 15-20 heterogeneous lobes,
PorometrfaJ node
cancer of the cervix (late stromal invasion of the radially orientated around the nipple, with prepon-
cerv""iX/spread beyond the cervix but with no para- derance in the upper outer quadrant. Epithelial
~~~:k"o metrial involvement), if treated by radiotherapy or celJs that remain sensitive to oestrogen and proges-
surgery, is 8 5%. For stage lIB and eater the terone line these ducto-alveolar units. The rest of
results of sur e radica m the 'breast consists of supporting connective tissue,
\
Superficial femolel node
20 Yo to the tumour, blood and lymph vessels, and fat. These tissues are
dep~th of invasion and spread to lymph no es. based on the fascia overlying the pectoralis and
sertatus anterior muscles and wrapped in an enve-
lope of skin and subcutaneous fat. High oestrogen
levels, as experienced during pregnancy and the
FIGU RE 24.9 Th e ly mph otic drai n age o f the uterus . Limp h des
from th e cervix travel s t o the internal
There may a lso be spread to the luteal phase of each menstrual cycle, induce meta-
and e xternal iliac nodes and hence to t~e ~ara-(aB~S~cd ~n LI~w ellyn-JOnes 1999, P 335. Fig 44 . 15) bolic and structural changes in the epithelial and
sac ra l. ob turator and superficial femora no es ..
suppOrt tissues that lead to engorgement of the
breast. From the age of 40 years, there is a gradual
Women's health : 0 c or s curr ic u lum
24 Pr inCip les of oncology
involution of radiologically dense glandular tissue DCIS is incompletely understood, bur it is likely that Screening modalities
and replacement by radiolucent fat. Involution is most DCIS will in time progress to invasive cancer.
slowed by oestrogen replacement therapy. Mammography is the primary breast imaging
Risk factors modality In women over 35 years and is the only
Benign conditions modality that has been shown to decrease breast
Benign conditions of the breast follow an After gender and age, family history is the most cancer mOrtalIty in Whole-population screening
age-related pattern. They may give symptoms in important factor in predicting the risk of breast (FJg 24.11). Mammography becomes more sensi-
their own right but mainly provide a differen- cancer. However, less than 50/0 of breast cancers nve and specific in the postmenopausal age group.
rial diagnosis for cancer. Fibroadenomas are occur in women wj t6 a significant family history. Ultrasound IS a commonly used breast imaging
benign, firm, smooth round mobile neoplasms Women with a fi rst-degree relative diagnosed with modality that is particularly helpful in dense
that occur in the 20-35 -year age group . breast cancer before the age of 50, or cwo firSt- or younger breasts or in. funher characteriSing mam~
Fibroadenosis (fibrocystic disease) presents as a second-degree relatives on the same side of the mographic abnormalines (Fig 24.12). It can be
lumpy, sometimes tender area of breast tissue in family, have a moderately increased risk (1 in 8 to
older premenopausal women (35-50 years). 1 in 4 lifetime risk). High-risk women 1 in 4 to
Cyst formation, fibrosis, epitheliosis and adeno- in 2 lifetime risk) wi . able autosomal do '-
sis occur in various combinations. This condi- nan pattern 0 inherirance account fo r less tban
tion is so common that it is probably a variant .FIGURE 24.12 An ultrasound image of on
1%-;;f all breast cancers.
of normal ageing. The two conditions of Invasi ve cancer, which is seen as on Irregulor
'OIlier nsk factors for developing breast cancer mass (solid arrow) with posterior acoustic
fibroadenomas and fibroadenosis account for
the majoriry of symptomatic presentations in relate to the hormonal environment of the breast. Shadow ing (o pe n arrow) . (Photo courtesy
younger women. Mammary duct ectasia They include lo!:, 'j1a:i=ity, late first pregnancy, shon Peter Farkas/ Royal Darwin Hospital)
(periductal mastitis) may present as sponta- period of breaStfe~ding, earry menarche and~
neous nippl e discharge in 40-SS:year- menopause, exogenous oestrogen and possibly used as a screening tool in young or high-risk
old women. It tends to %j0di:C ~f.rc~ or o~d excess alcohol consumption. These women but has not been subject to rigorous pop-
brown dl~rarge fr0r m_tl P __ d_!:r. _he r have a minor influence on the individual nsk bur in ulaaon screerung trials. Magnetic resonance imag-
thanthe fdody disc arge from a sjni\le puct a population setting may account for most of the Ing . (MRI) IS a hIghly senSlUve modality, which
that can be IDdicative of an Intraduct papilloma international and historical variation in incidence. may have a place ill screening very high-risk
or ~arC1noma Women. Regular breast self examination and regu-
lar exarmnanon by a doctor have not influenced
Concepts of pathogenesis breast cancer mortality in population screening
of b reast cancer srudles. However, breast awareness and early
reporting of changes is likely to account for
The epithelium of the breast ductS may undergo
progressive change from hyperplasia, arypical unproved case monality between high- and low-
illcldence populations.
hyperplasia and carcinoma in-siru to invasive can-
cer capable of metastasising. The initiating stimuli Population-based breast cancer
and the sequential genetic changes accompanying
screening programs
these morphological changes are not fully cate-
gorised. The rate of growth varies, bur most inva- The ideal screening modality is sensitive, specific,
sive cancers are likely to have been present for cheap, harmless, acceptable and accessible to the
more than 3 years before they become palpable at target population. The OUtcome of the disease
1 cm in diameter. The ability to metastasise in- must be able to be influenced by early diagnosis.
creases with time and size of rumour but can occur FIGURE 24. 10 A magnified mammogrom of There IS no Ideal screeni ng rest for breast cancer
resected breast tissue that demonstrates the FIGURE 24. 11 A typical mammogrophlc
early. This imposes a limit on the benefit gained linear. bronching pattern of calcification by the above definition, but mammography is the
by early diagnosis of invasive cancer, which relies associoted with ductal carcinoma In·sltu appearance of a small invasive carcinomo best available Opnon. The best estimates suggest
on the detection of a solid mass. (DC IS). The calcification occurs within nec rotic presenting as a Splculoted. distorting moss ' that, if a woman undergoes 2-yearly, cwo-projec-
Ductal carcinoma in-siru (DCIS) tends to shed cells shed In the lumen of breast ducts. The leSIon (arrow). This c on cer also has some
central calcification. More subtle a symmetric non mammography from the age of 50 years, she
necrotic cells into the duct lumen, which can subse- staples seen centrally are used to orienta te WIll decrease. her nsk of dying from breast cancer
the spec imen . (P hoto co urtesy Peter densities or architectural dIsturbances may
quently calcify and display characteristic mammo- also be diagnostic of cancers. (Photo courtesy by 35%. This effect is diluted in a population-
graphic patterns (Fig 24.10). The natUral history of Farkas/Royal Dorwin Hospita l) Peter FarkOS/Royal Darwin Hospital ) based screerung program owing to incomplete
uptake, leading to decreased breast cancer specific
fIi
Women's health: a c a re c u rr iculum
24 Pri rl c ip les of On Cology
mortality in screened populations of around 20%. decrease in mortality in the decade before 2000. bi~strogen/progestogen hormone therapy
The maximum effect is seen in the S0-70-year age Endometrial cancer is the commonest gynaecolog- dence that screening procedures su ch
r~ or a sequennaI oeStrogen/progestogen reg-
group. Breast Screen Australia therefore targets iear iIiahgnang In Australia, With more than 1400 Imen, where the progestogen is given for more than sound or endometrial sampling are h~s ~ltr~
asymptomatic women SO-70 years old, with 2- neW'"Cases and more than 2S0 deaths occurring asymptomanc hlgh-nsk women e g b p m
10 days per cycle, confers a decrease in risk. survivors on tamoxifen. ' . . reast cancer
yearly biplanar mammography, but women aged each year. WI . family history of endometrial
40-49 years and over 70 years are also eligible to
Epidemiology and relationship bre~st or ovarian cancer are at mcrease ns ' Pathology
attend. Women in the moderately increased risk whde 60% of women aHected by the heredltar;
group are screened yearly, while those in the high- with oestrogen nonpolyposis colon cancer (HNPCC) syndrome Precursor lesions to endometrial cancer ar
est risk group are best screened by multiple modal- . d d e recog-
will deVelop the disease. WO£;len who have preyi- ruse an may represent a histoloo-ical
·th th di or
.
connnuum
ities outside of the national program. ousl deve.Io ast cancer have a _ 0 WI e sease. Endometrial hyperplasia may re-
w ee-fold mcrease in risk, wit a er doubling cede the development of endomerrial can P
cer, WI th
Opportunistic screening and a
of [lsk treated With adjuvant tamoxifen.
th lik lih d
e e 00 of progression related to the degr
evaluating symptomatic women of cellular atypia found within the hyperplasi~
Presentation Slffiple or CYStiC hyperplasia carnes a risk of malig-
Mammography can be normal in up to lS% of
breasts containing diagnosable cancer. In addition, The majority of diagnoses are made in response to nant development of less than 1%, while atypical
screening mammograms are interpreted in the abn~a! yaglD a ! bleeding - postmeno a al hyperplaSia carnes a nsk of concomitant cancer of
absence of a history and clinical findings, and there- ble~ heavy or abnormal menstruaT I(}ssY~r lS% With a 50% risk of subsequent development
fore cannot target symptomatic areas for special Interm~t:cJ.al..lt)ss. Soble Ovdlian ldIfiours may of carCinoma if untreated. Progestogen treatment
attention. It is therefore most important that women secrete oestrogen and predispose to endometrial has the capacity to reverse the morphological fea-
with clinically worrying breast symptoms or a pal- cancer. OccasIOnally, [he diagnosis is made by tures of endometnal hyperplasia, but not the
pable abnormality are not falsely reassured by a clear findmg endometrial cancer cells on a cervical malignant potential.
report from a screening mammogram. Evaluation of smear, these celis being exfoliated and discharged The most common malignancy of the endo-
a breast lump by the triple test is highly specific in or exogenous oestro en through the cervIX. The finding of normal metrIum . IS a carcinoma that reflects the
excluding malignancy and avoids open biopsy in the unopgQse y profestogens are lID~o rtant. endomettlal celis On ceryical smear is of no clini- endometnold lIneage, with or without associat-
majority of cases. The triple test combines the clini- DUrIng norma menstrua:! eyc es, oestrogen cal SlgrIiflcance in the premenopausal woman but ed squamous differentiation (Fig 24.13). Rarer
cal examination findings with appropriate imaging action is counterbalanced by progesterone pro- should prompt endometrial sampling in the ;ost- histologIcal types (generally representing a more
duced after each ovulation, and endometrial proli- n:enopausal woman because of the 10-15% asso- aggressive natural hiStory) include clear-cell
(marnmography or ultrasound) and percutaneous
biopsy (either fine-needle aspiration biopsy, FNAB, feration is thereby controlled. In anovulation or Ciation b~rwecn such findings and endomerrial hIgh-grade. squamous, mixed mesodermal 0;
or core biopsy). A more invasive biopsy is recom- oli o-ovulation, ro esterone release is r hyperpl~la and malignancy. serous paplilary carcinomas. Sero us papillary
mended if one or more of the components of the a sent or infre uent, an uncontrolled The diagnosis may be suggested by the finding
triple test arouse suspicion of malignancy. ri pro 1 eranon can occur. normally high of an abnormally thick endometrium seen on
levels of oestrogen can be seen in women with ultrasound examination for another gynaecologi-
* End ometri a l ca ncer

oestrogen-secreting turnours of the ovaries or in
obese women, where peripheral conversion of
androgen precursors to oestrogen occurs through
the S alpha reductase metabolic pathway.
cal mdicatIon. An endometrial thickness of more
than 4 mm m a postmenopausal woman is abnpr-
mil and endometrial sampling is regpj r, d.
EjdOmetrlil thiCkness measurement is of no clini-
Common clinical presentation Polycystic ovarian syndrome combines the factors ca use m the premenopausal woman because of
An obese 62-year-<lld woman presents with of obesity, insulin resistance and oligo-ovulation the Wide range of thicknesses seen throughOut the
postmenopausal bleeding. with consequent unopposed oestrogen. In women menstrual cycle.
receiving unopposed oestrogen as hormone
therapy, a practice common in the United Diagnosis
Adenocarcinoma of the endometrium is a disease States in the 1960s and 1970s, abnormally high
of affluence. There is a rwenty-fold difference in oestrogen levels were generated. In these situa-
incidence throughOut the world, with the highest tions, abnormal endometrial proliferation was
rates in the developed countries and lowest in the observed, with patterns of simple hyperplasia,
third world, even when controlled for life atypical hyperplasia and endometrial carcinoma.
expectancy by age standardisation. Si~ficant protection is afforded b~ use of FIGURE 2 4. 13 Endometrial Carcinoma:
In Australia, there has been a S% increase in the orat contraceptive pill dunng tlKW l:Qd.tlciY.e endometrl o ld carCinoma with Irregular
glandula r structures . (Phato Cou rtesy
the incidence of endometrial cancer and a 10% penoo; and by parter. POSCSSW'W' 1M I n;;;&!:{ll;
Enc Hu/Rayal Dorwin Hospltol)
II;
•
24 PrinciPles a t OnCology
carcinomas are particularly aggressive with poor needs to be made of myometrial in6.ltration by recorded in AUStralia over the last decade is most
prognosis seen even in well-staged, surgIcally tumour. This can be done with the naked eye or by likely due to a combination of earlier detection
confirmed, localIsed dIsease. EndometrIal stro- frozen section. The object of this assessment is to more effective treatment and lower treatment:
mal sarcomas are rare, often of low-grade malIg- categorise the risk of nodal metastases to triage those related mortality.
nancy, and have a propensity for local recur- cases needing node dissection. Pelvic and para-aomc
rence rather than metastatic spread. lymph glands drain the uterus and these need w be
Tumour grade (G1 - well di£ferentiat~d, G2 :- removed in cases where the risk of nodal disease
moderately differentiated, G3 - poorly dlfferenn-
ated or anaplastic) is a strong indicator of blOlogl-
cal aggressiveness and the probabIlity of meta-
stacie spread.
exceeds 5% (G1 and G2 cases with myometrial
invasion greater than 50%, all G3 cases, all clear-cell
or serous papillary cases). ..
* Gestationa l
trophoblastic disease
Racliotherapy is offered to women WIth disease
that has spread beyond the uterus. It has not been
Investigation, staging shown to reduce mortality but may allow better
and treatment disease control in the irradiated area. Women with
A primigravida presents at 12 weeks' gestation
clisseminated or recurrent disease should be man-
While the clinical staging of endometrial cancer is with minor vaginal bleeding and an enlarged
aged on an individual basis, with surgery, racliation, FIGURE 24.14 Complete mole : enlarged
surgical (Table 24.2), a preoperative chest X-ray IS uterus. Ultrasound reports the presence at an
chemotherapy and hormonal treatment all having a ovarian cyst. likely to be a luteal cyst. ond chorioniC villi with cystic swelling and
important to prevent unnecessary radical surgery role. High-dose proge.>l:ogen therapy will produce trop hoblast prOliferatio n . (Photo courtesy
multiple vesicular structures In the uterus.
in those with disseminated disease. a clinical response in about 30% of wome~ WIth Eric Hu/Roy al Darwin Hospital)
At surgery, peritoneal washings are taken as an few side effects. Responses are most likely ill the
initial step, followed by total hysterectomy and bilat- more highly clifferentiated tumours, which more in size from a few millimetres to more than 1 cm
eral salpingo-oophorectomy. While the tumour often express oestrogen and progesterone recep- and resemble a bunch of grapes. Microscopically,
grade may be known preoperatively from the tors. Chemotherapy may also be offered to women they resemble chorionic trophoblast, further char-
endometrial biopsy, an illrraOperatlve assessment with symptomatic clisseminated or recurrent diS- acterised by oedema in the stroma, loss of capil-
ease with reported response rates of up to 80% and laries and profound trophoblast proliferation at
50%, respectively. The most cffecnve agents are the surface (Fig 24.14).
Stage Extent of cancer There are two main forms: the classic complete
carboplatin, Taxol and Adriarnycin.
mole and the partial mole. The differences
Confined to the uterine body
Prognosis between the two are summarised in Table 24.3.
A no myometrial invasion In early pregnancy there are no distinguishing
B invasion of <50% myometrium Because more than 800/0 of women '.'.'i.th endomet- features between a molar and a normal pregnancy,
C Invasion of >50% myometrium
rial cancer present with localised disease, the ~ut except for a greater likelibood of hyperemesis
look is ge~erally favourable, with 5 -year SU[YIval and - more rarely - early development of pre-
Extending to cervix in women with accurately staged localised clisease o They occur in association with a pregnan1R" edampsia Or hyperthyroidism. Later, the uterus is
A no cervical stromal invasion in excess of 90%. Prognosis becomes poorer with ranging from early pregnancy loss up to a fU- unusually large for dates and feels very soft. Ultra-
B cervical stromol invasion the finding of metastatic nodal disease. Surglcal term normal pregnancy. sound provides a classical picture caused by
III Outside the uterus
removal of involved lymph glands results ill a sIg- o Their DNA alwar: cliffer from that of the the many vesicular structures present (Fig 24.15).
nificant improvement in survival . . patient's own UN_ Except with a partial mole, fetal Structures and
A extension through uterine serosa or Prognosis in poorly staged clisease drops off o Human chorionic gonadotrophin (~~ fetal heart action are absent. Ultrasound may also
positive peritoneal cytology
through the effect of unknown metastatic disease. produced b~ the trQphoblast is an e~ inclicate the presence of ovarian cysts (luteal cysts
involvement of adnexal structures
Adequate disease-staging also plays an tmportant tumour mar er, allowing reliable cliagnosis and resulting from the high HCG levels). Vaginal
C Involvement of pelvic or para-aortlc
role in preventing treatment-related SIde effects management. blood loss, sometimes containing a few of the
lymph glands
and complications, most of which relate to adJU- o They are ~ sensitive to chemotherapy as to characteristic vesicular Structures, may be the fjr~1:
IV At distant site vant radiation treatment. The use of intraoperanve permit a nearly 100% cure rate, often wu hout sign (it usually occurs later in pregnancy than the
assessment of risk and appropriate triage of loss of reproducnve fUncnon. __
A invasion of bladder or bowel mucosa blood loss associated with threatened miscarriage
women to radiation has substantially decreased the or ectopic pregnancy).
distant metastases or involvement of
numbers of women having radiation, with no loss Benign molar gestation With a partial mole, embryonic death usually
inguinal nodes
of efficacy of treatment. hydatidiform mole occurs first, followed later by miscarriage, ofren
TABLE 24.2 Staging of endometrial carc inoma
The 10% i'11provement in overall survival for In a molar pregnancy, the products of conception after the end of the first trimester (13-16 weeks),
women with endometrial cancer that has been consist largely of numerous clear vesicles that vary or a 'missed abortion'. It is often recognised only
by histological exam ination of evacuated products
"
24 PrinCiples 01
OnCOl o g y
Characteristics Complete mole Partial mole

• ultrasound examination of the liver
Frequency' 1 In 2000 pregnancies 1 in 1000 pregnancies CT scan of lung and liver
Usual origin • Paternal only • Maternal and paternal
• HCG determination in spinal fluid
• Fertilisation of an oocyte without genetic • Fertilisation of a normal egg cell by two mented with CT scan of the brain. ' comple-
material by one spermatozoon that spermatozoa (dispermy)
subsequently doubles Its chromosomes There are basically three forms of persistent
~ trophoblastic disease:
Karyotype Diploid - mostly 46XX Triploid - mostly 69XXY
Pathology • Hydropic oedema of all villi • Hydropic oedema 01 part of the villi
• Invasive mole - persistent trophoblast that
•
•
•
No embryonic structures
Substantial hyperplasia
No fetal erythrocytes
•
•
•
Embryonic structures present
Moderate hyperplasia
Fetal erythrocytes can be present
deeply Invades the myometrium afrer a mol
pregnancy. Sometimes there are metastases, us:
ally In the lungs and VagIna. Microscopically, it is
charactensed by.oedematous chorionic villi with
Clinically • Uterine size frequently lorge for dates • Uterine size usually normal or smaller trophoblast proliferaoon, as seen with a nonin-
than expected vasive mole.
• Usually presents as abnormal vaginal • Mostly presents as a 'missed abortion' • Choriocarcinoma - can occur after any form
bleeding In early pregnancy (otten with (embryonic death usually occurs before
passage of vesicular tissue), unless 10 weeks)
of pregnancy. Mictoscopy does not show chori-
diagnosed by ultrasound earlier OlliC villi, bur reveals large fields of invasive
• Otten recognised only on histological hyperplasnc and anaplastic trophoblastic tissue.
examination of evacuated products
MetastaSIs IS by the haematogenous route usu-
HCG levels • Frequently high originally • Frequently low originally ally to lungs, liver and brain. '
• Disappear on average 100 days otter • Disappear on average 60 days atter • Placental-site trophoblastic turnour - consists of
evacuation evacuation
placental-bed trophoblast invading the
Progression to 10-15% <3% myometnurn from the site of placental irnplanta-
perSistent non. Amenorrhoea or irregular bleeding some
trophoblastic
disease
tune afrer apregnancy may arouse suspicion, but
the diagnOSIS IS made only by its histology, which
• Reported Irequendes fange widely and ore 3--4 t1mes hiQher In Japan and A~jc than In Australia . Europe and the USA . FIGURE 24,15 Ultrasound image of differs from that of choriocarcinoma. The condi-
hydatidiform mole, showing veslcle.llke non IS rare, accounting for only O.l-D.I% of
echolucent areas, (Pho to courtesy Peter trophoblastic tumours.
TABLE 24,3 Distinguishing feature s b et we en the comple te and th e partial mole Farkas/Royol Da rW in H Osp llal)
Treatment of persistent trophoblastic disease is
been obtained, followed by monthly assays for by chemotherapy. For low-risk disease, single-drug
of conception, which partly accounts for the • HCG levels that do not drop consistently afrer
widely diHerent prevalence found in the literature. 6 months and I-monthly for another 6 months. pregnancy but plateau or increase regunens (methotrexate/folinic acid) are adequate,
but mulndrug regimens are recommended for
Pathological examination of the products of This requires secure conrraception for up to • After normalisation, HCG levels start to high-fisk disease (Box 24.2).
conception is mandatory to differentiate the clini- 12 months after the normalisation of HCG levels Increase again in the absence of a new preg-
to ensure that the follow-up is not jeopardised Surgery has only a limited place in the treat-
cal diagnosis from hydropic degeneration of the nancy. This occurs nearly always within one
by a new pregnancy. Combined oral contraception ment of trophoblastic disease. H ysterectomy may
placenta, which may occur after fetal death or in year of the end of a (mostly) molar pregnancy.
be a solunon for a woman with a molar preg-
anembryonic pregnancies, but which never leads is safe for that purpose.
Persistent trophoblastic disease is a potentially nancy and no further WIsh for reproduction. This
to persistent trophoblastic disease. lethal dISease that is easy to cure, provided it is will CUrtail the development of an in vasive mole
Treatment for a molar pregnancy consists of Persistent trophoblastic disease recogrused and treated in time. It requires careful but not necessarily metastases, and follow-up with
suction curertage, This is performed preferably Continuance of irregular vaginal bleeding after gynaecolOgIcal examination and thorough explo-
under ulrrasound surveillance, with oxytocic sup- evacuation of a mole or any pregnancy (ranging ran on of the many areas to which the rrophoblast
port and afret careful cervical dilatation to avoid from miscarriage to normal birth) may indicate may have spread. Spread of the disease is usually • Delay In treatment (>3-4 months)
perforation of an unusually soft uterus. Further persistent trophoblastic disease. Not infrequently, locally (In the pelvis) and haematogenous (most • Failure of previous chemotherapy
treatment is not necessary, except for careful fol- this is accompanied by the redevelopment of sub- notably affectIng the liver, lungs and brain).
Invesngattons should therefore include: • Metastases outside vagina and lungs
low-up with regular determinations of ~-HCG lev- jective symptoms of pregnancy. By far the highest
els to detect and treat progression to persistent risk is afrer molar pregnancy. • ChoriocarCinoma on histology
• a detailed gynaecological examination (includ-
rrophoblast disease. This involves weekly ~-HCG Persistent trophoblastic disease is diagnosed by Ing a search for vaginal metastases)
assays until two consecutive negative results have one of the following: • a chest X-ray BOX 24,2 Factors Indicating high -risk perSistent
trophoblastic d isease
tI.f
Women's health : a co re curric ulum
24 Pri nci ples ot onCOlogy
j3-HCG remains necessary. However, even initial degree relatives with ovarian cancer have almost a
treatment-resistant persistent trophoblast ill the 40% chance of developing the disease. There is endometrium, the lining of the cervix and the fal-
lopian tubes - originates from the coelomic epitheli- Haematogenous spread is rare and Usually occurs
uterus can usually be cured by·· multidrug also a relationship with the number of ovulations, only late m the process.
chemotherapy without losing subsequent repro- in that long periods of anovulation (for example, um of the miillerian duct. Through meraplasia, the
ductive function. Surgical excision of localised during pregnancy and oral contraception) offer serous Ovanan epithelium can evolve towards the Investigations
metastatic lesions that are relatively resistant to some protection. other epithelia from the miillerian duct, and this
chemotherapy (e.g. in the lung or an easily acces- determmes the histological characteristics of epithe- In young women, ovarian enlargement up to 6 cm
sible part of the brain) may be warranted to reduce Origin of ovarian cancers lial rumours (Box 24.3). Most frequently, they main- In diameter may be caused by simple cysts, which
rumour load. tam the serous ovarian characteristics. Next, in WIll resolve Spontaneously. Persistence or greater
The ovary contains surface epithelium, primordial decteasmg order of frequency, is change towards the enlargement should be thoroughly investigated, as
In the absence of metastases outside the pelvis,
follicles and ovarian stroma. It thus gives rise to endometnum (endometrioid tumours, which should should any ovanan enlargement in post-
99% of patients with persistent trophoblastic dis-
epithelial rumours, primordial cell (germ cell) not be confused with endometriosis) or towards menopausal women. Investigations include: a full
ease can be cured, with 95% maintaining repro-
rumours and stromal rumours (Box 24.3), all of endocervical epithelium (mucinous tumours). Clear- general examination; breast, pelvic and rectal
ductive function if they so desire. However, 5 -year
which can be benign, malignant or borderline (also cell tumours (related to endometrioid rumours) and examination; full blood COUnt; serum urea and
survival rates are markedly reduced when brain or
referred to as 'low malignant potential'). In addi- Brenner rumours (related to fallopian tissue) are less electrolytes; liver function tests; and tumour
liver metasrases are present and dismal when both
are present.
tion, the ovary may harbour malignancies that
arise elsewhere in the body (e.g. Krukenberg's
co rrun on . The histological type has some prognostic
Significance, as endometrioid tumours are more
markers, such as CA-125, HCG and alfa-fetopro-
teln (elevated with germ cell tumours). AbdOminal
rumour, originating from the gastrointestinal likely to be malignant than serous rumours and the
Recurrence tract). Overall, roughly 70% of ovarian rumours
or pelvic ultrasound will delineate the mass and
latter are more likely to be malignant than mucinous may show features suggestive of malignancy (Fig
Molar pregnancies carry a risk of recurrence in a are benign, 200/0 are malignant, and 10% are bor- tumours. However, all of these rumours can be 24.16). A chest X-ray is necessary to detect meras-
subsequent pregnancy from 1-1.5% after a single derline malignant. benign, malignant or of borderline malignancy (low tases. An intravenous pyelogram and barium
molar pregnancy to 20% after [WO or more molar malignant potential).
Epithelial cancers enema may be required if there are urinary or
pregnancies. Therefore, ultrasound (at 10-12
bowel symptoms. A CT scan of the pelvis will usu-
weeks) is recommended for early diagnosIs ill sub- Ninery per cent of ovarian cancers are epithe- Clinical presentation ally be necessary, but staging of the disease still
sequent pregnancies. lial rumours. The ovarian epithelium - like the In its early stages, ovarian cancer is asymptomatic depends :lil surgical exploration with histological
and IS discovered fortUitously during examinations examlllanon of suspect findings.
* Cancer of the ovary Epithelial tumours

Serous tumours
Mucinous tumours
performed for other reasons. Early symptoms are
orren vague and nonspecific: e.g. indigestion,
abdommal discomfort, loss of appetite, back pain
Treatment
Surgery is the cornerstone of management. It
Common clin ic al presentation Endometrloid tumours and weIght loss. Spread of the disease will eveutu- allows clinical staging (Table 24.4) and total or
Clear-cell tumours ally lead to symptoms that refer to the organs partial rumour removaL Except in the case of a
A 62-year-<)ld woman presents with slight Involved: colic, vomiting and constipation related
vaginal bleeding. Further history reveals loss at Brenner tumours young WOman who has disease limited to one
to bowel obstruction, loin pain and hydronephro-
appetite. constipation and a 'heavy' lower
abdomen for the last few weeks.
Germ celJ 1umours SIS due to ureter obstruction, abdominal distension
Dysgerminomo due to ascites and rumour mass, and general
Mollgnant teratomo weight loss. Most cancers are bilateral and [WO-
Choriocarcinoma (nan-gestotJonal) thirds are in an advanced stage when symptoms
Ovarian cancer accounts for only one-third of Endodermal sinus (yolk sac) tumour lead to their discovm.
gynaecological cancers, but its death rate ex~eeds
that of endometrial and cervical cancer combmed. Sex cord or stromal tumours Spread of ovarian cancer
It follows breast cancer, colorectal cancer and lung Granulosa cell tumours
cancer as a major cause of cancer mortaliry in The ovary lies relatively free in the peritoneal cav-
Theca cell tumours Iry. Malignant cells from its surface exfoliate into
women. Ovarian cancer is known as a 'silent Sertoli and Leydig cell tumours, androblastoma
ladykiller' because symptoms are usuall y nonspe- the peritoneal .fluid or gain attachment to nearby
Fibrosarcoma (extremely rare) structures, such as the uterus, fallopian tubes,
cific and late. In general, it is a disease of POSt-
menopausal women, with a peak frequency Metastasis from a primary tumour elsewhere broad ligaments and omentum. Malignant cells in
around 60 years of age and an incidence of 10--15 Primary: endometrium, colon, stomach or breast the pelVIC cavity may spread along the ascending
and descending colon and via the omenrum. FIGURE 24.16 Ultrasound Image of ovarian
per 100,000 women per year. . cancer, Showing a large cystic structure
The aetiology is unknown, but there IS a strong Lymphatic spread occurs to pelvic lymph nodes
BOX 24.3 His tolagicol types ot ovaria n cancer and along the ovarian vessels to lymph nodes containing irregular hyperechoeic 'solid' areas.
familial tendency. Women with [W O or more flrst- (Photo courtesy Peter Fo rkas/Royal Dorwin
high along the aorta and along the vena cava. Hospital)
fN
.1
Women's health: a core c urric ulu m
24 PrinCiples of oncology
Stage Extent rate is about 35% for all women and 600/0 for
those who showed complete remission. Because of potential to evolve into any of the cells that derive References
limited to the ovaries late recurrences, 5-year survival does not necessar- from that .mesenchyme: granulosa, theca, Leydig
and Senoli cells. These tumours occur at all ages Llewellyn Jones D 1999 Fundamentals f .
I-A One ovary
ily mean a definitive cure, and follow-up with
tumour markers (CA-125) is necessary to detect ili
d usually produce hormones: oestrogens from
e granulosa cell and theca cell types, and andro-
gynaecology, 7th edn . Mosb }" to nan.
dO obstetrICS and
1-8 Two ovaries recurrences, which generally respond well to fur- E.M., Symonds IM 2004 Es .]
Spread beyond the ovaries but contained ther treatment. gens from the Sertoli-Leydig cell types. Symptoms Symonds gynaecology, 'Ith cdn. Churchill~:~a obstetrics and
within the pelvic cavity Terminal care for women with ovarian cancer may reflect this hormone production. For exam- Edinburgh. ngstone,
can be a major challenge. While the disease is often ple,. granulosa cell tumours are a rare cause of pre-
III Spread outside the pelvic cavity but COCIOUS puberty, a cause of menstrual irregularity Further reading
within the abdominal cavity limited to the abdominal cavity, the patient may
become cachetic around a distended abdomen. and anovulauon dunng reproductive life and a Khoo S-H 2003 Clini",,] aspects of gestational cr .
IV Spread outside the abdominal cavity or cause of postmenopausal bleeding in older dISease; a revi ew based partly 0 25 ophob]asnc
Intestinal obstruction, with pain and vomiting, and
a statewide: registry. Australian a:d ;lee;r{;J:~nce of
with liver involvement
ascites, which require repeated paracentesis, are women. The tumours are usually of low-grade
TABLE 24.4 International classification of common. Adequate pain relief is crucial. malignancy and surgIcal removal is usually suffi- Journal of Obstecrics and Gynaecology 43;280-289.
ovarian cancer ~~tnt treatment, although metastases of granulosa
Germ cell tumours afr tumours, m parncular, may appear many years Natio nal Breast Cancer Cencre website.
er removal of the primary tumour. htTp;//www.oocc.org.• u. The Nati~na] Breast Cancer
ovary (stage lA) and wishes to preserve her fertil- Germ cell rumours are the second largest group of Cen~e 15 a Commonwealth-sponsored jnformation
ity, surgery is extensive, with total hysterectomy, ovarian neoplasms. They occur at younger ages d~ng house for breast cancer- Its numerous
bilateral salpingo-oophorectomy, appendicectomy Health maintenance eVIdence-based publications on all aspectS of breast
(averaging around 20 years of age), and the aim of Cancer can be accessed online.
and omentectomy. The omentum is often the treatment usually is to achieve a cure with conser- Regular cerVical screening reduces
source of further spread and debilitating ascites. vation of ovarian function and fertility. mortality from cervical cancer by
Depending on the clinical and histological staging 30%.
Dysgerminomas constirute 50% of germ cell
and the degree of tumour differentiation, addi- rumours. About 15% are bilateral and they are
tional combination chemotherapy is warranted_ sensitive to radiotherapy and specific chemothera-
Even advanced stages are primarily treated with peutic regimens. The latter off"r the advantage
surgery to alleviate symptoms and to reduce the that, after removal of the affected ovary, the
tumour mass (debulking), which is subsequently remaining ovary can maintain its reproductive
controlled by combination chemotherapy. function. The prognosis is relatively good and QUestions
c. The sampling technique Is
recurrences are extremely rare.
Borderline epith elial tumours Endodermal sinus (yolk sac) tumours are 1. Which of the following statements unsatisfactory.
Approximately 10--15% of epithelial tumours have aggressively growing tumours, which produce about cervical screen ing is correct? d. Sampling is confined to the
separate histological features and a less aggressive alfa-fetoprotein (a useful tumour marker) and a. It is more effective in detecting ectocervix.
behaviour that classify them as borderline tumours require surgical treatment, complemented with cancerous leSIons than in detecting
precancerous lesions . e. Condoms are the only form of
with 'low malignant potential'. Spread outside combination chemotherapy. They account for contraception used.
the ovaries occurs in approximately 350/0 of the approximately 20% of germ cell tumours. b . It Is effective In the early detection
serous and in about 10% of the mucinous types. Solid teratomas account for another 20% of of endometrial carcinoma . 3. Which statement about cervical
Treatment for borderline tumours is entirely surgi- germ cell tumours. Teratomas are the most com- cancer Is correct?
@ It needs to be repeated within 3 ..,.
cal, and it is unclear whether adjuvant chemother- mon ovarian rumours in young women. Most are
months If endocervical cells are not
apy contributes to a better prognosis. Fortunately, cystic (dermoid cyst) and less than 5% are solid. present. a. It does not OCcur In women who
about 70 0AJ of borderline tumours are detected in The latter are usually benign but can be highly are more than 10 years
stage I and only 10-15% in stage III or rv. malignant if they contain embryonic tissue. G).egUlor cervical screening reduces postmenopause.
Choriocarcinoma is the rarest of the germ cell mortality from cervical cancer by 30%.
b . It Is clearly associated with
Prognosis tumours. It can be a metastasis of gestational trO- e. All of the above .
nuiliparity.
phoblastic disease or can arise primarily from
The 5-year survival rate in stage I depends on the 2. I~ Which situation is a Pop smear more
germ cells. It contains trophoblast and secretes c. It can be excluded If a cervical
degree of differentiation of the tumour: 90-100% likely to result in on abnormal finding?
human chorionic gonadotrophin (HCG). smear report does not Show
with well differentiated and 60--80% with poorly abnormalities.
differentiated rumours. About 80% of the more @ A woman has hod three
advanced stage tumours respond to combination
Stromal tumours pregnanCies from three different
partners. It
d. does not Occur In women under
the age of 25 years .
chemotherapy, and about half of the women (40% The ovarian stromal cells are derived from the
overall) may go into remission. The 5-year survival embryonic sex cord mesenchyme and retain the b . The endacervlx is sampled befarJ
the ectocervix. V Q cancer.
It causes fewer deaths
/
than ovarian
tl;
women 's health : a core cu rri c ulum
2<1 Prlnclp l e~ o f On cology
4. Which of the following is reasonably 7. For which of the following women are
well established? investigations required to exclude
endometrial cancer as a cause of
e . conceived within 3 months atter a
prev ious pregnancy. @t Occurs predominantly during
reproduct ive life .
a. Cervicol cancer responds better to abnormal vaginal bleeding?
chemotherapy fhan to radiotherapy. 11 . Which Of the fOllowing is true of
a . Obese women choriocarCinoma? @ It frequently occurs in both
b. Cervical cancer generally has a ovaries.
better prognosis than endometrial b . Premenopausal women It is a disease that cannot be
cancer. present in a virgin . d. It spreads predominantly through
@ AII women over 40 years of age and
others selectively according to risk the ovarian veins .
c. Cervical cancer can usually be b. It Is always preceded by a molar
treated effectively by vagina l factors pregnancy. ...,. e . It usually produces steroid
hysterectomy. d. Women with diabetes mellitus hormones.
c . It is preferably treated by
I1rI Regular screening programs can @ AII of the above radiotherapy.
W' eradicate cervical cancer more
effectively than any other cancer of 8. How is endometrial cancer
~t can Occur atter normal childbirth . 14. Where does metastasis of ovarian
cancer most frequently OCcur?
the female reproductive tract. diagnosed? e. It could virtually be eliminated by
a . Brain
"'E>-Iequally
I of thevalid.
above statements are -l
r
a . Only by curettage and hysteroscopy
careful inspection of all products of
conception. b . Kidneys
{;;) Only by endometrial biopsy
~BY
5. Which statement is true of most women 12. In the second trimester of pregnancy, c. liver
any effective cytological or "-
a molar pregnancy can be excluded
living in Western countries who
develop breast cancer?
a. They have a first-degree relative
histological test
d. By ultrasound
with reasonable certainty in Which of
the following Circumstances?
d . Lungs
@ omentum
/
who had breast cancer before she e . By clinical examination a. i3-HCG levels are within the normal
was 50 years old . range . 15. Which of fhe following statements
9. Which of the following is correct for a about ovarian tumours is correct?
b. They are between 40 and 50 years woman with endometrial cancer? b. The uterine size is normal for the
old. ~ uration of pregnancy.
@ She must be treatedby a a . Most solid teratomas are malignant.
~They are nulliparous. gynaecological oncologist . p h e uterine size is smaller than /..
b. Granulosa cell tumours predominantly
expected.
d. They do not have recogn ised risk b . She must have lymph node produce progesterone.
factors . 4- dissections as part of her staging.-l, @)J bstetric ultraSOUnd shows a normal
~ They will have a premature death
owing to breast cancer.
Q related
She will have decreased disease-
morbidity by selective 0
fetus and placenta .
AII of the above.
c. Endometrio id tumours arise from
ovar ian endometriosis.

treatment based on individual
findings at staging . 13. Which statement is true of ovarian
(3 the
Few malignant tumours arise from
ovarian stro ma.
screening for breast cancer by Cancer?
d . Five-year survival with accurate ly
mammography? staged localised disease is very poor. a . It is the most common e . The ovarian surface epithel ium is
gynaecological cancer. inactive and unllk;Jy to undergo
@ It has been shown to reduce e . Tumour grade does not influence
mortality from breast cancer in metaplasia . ",/
probab ility of metastatic spread .
screened populations by around 0./.
20% . 10 . When is a molar pregnancy most like ly
@b. It is recommended at 2-yearly
intervals for women with moderately
to be present? In a woman who:
1d:\had a molar pregnancy previously
increased ris k.
v. reports a sudden cessation of /'
c. It is able to detect invasive breast pregnancy-assoc iated symptoms
cancer soon atter it develops .
c. conceived by intracytoplasmic
d . It saves most lives in the 40-50 age sperm injection (ICSI) and in vitro
group. fertilisation (IVF)
e. It reliably excludes cancer if the d. has a doubling of i3-HCG levels
mammogram is totally normal. every 3 days
'if
*25
Women and society
Teenage pregnancy Karen Harris

Violence against women and girls Dawn Miller, Angela Taft and Kelsey Hegarty
Loss and grief in women's lives Cello Devenish and Jeremy Tuohy
Learning objectives
Knowledge describe the possible presentations of

victimised women and girls in a wide
At the end of this chapter, the student range of medical settings
will be able to: • explain the doctor's role In the
assessment and management of
Teenage pregnancy violence against women and girls
indicate the prevalence of teenage Loss and grief In women's lives

pregnancy in Australia describe the different stages of the grief
process
discuss the interaction between
psychological, cultural and • discuss factors that impair the resolution
socioeconomic factors In determining of the grief process
the prevalence and outcome of • outline the role of the health
teenage pregnancies professional in a woman 's grief process,
discuss the medicolegal issues
associated with teenagers and health
care Skills
• discuss the importance of social
supports for pregnant teenagers and should learn how to:
the need for continuing education
discuss strategies for prevention of take a history from a pregnant teenager
teenage pregnancy including a detailed psychosocial
history
discuss the value of specific adolescent
counsel a teenager about contraception
reproductive health services
ask directly and appropriately about
VIolence agaInst remales violence In a supportive, non-
describe the epidemiology of common judgmental way
forms of violence against women and listen with sensitivity and empathy to a
girls grieving woman ,
(Continued over)
'If
WOmen's health: a c o re curriculum
25 Women an d SOCie ty
(Learning obiectives continued) the impact of unacknowledged violence

against women in society continuing relationship with the child. They are
more likely to come from low-income or disrupted Medical practitioners and other healthcare
Attitudes • the nature of the doctor-patient
relationship.
families and may be estranged from their parents workers need to be aWare of lOcal requirements for
should reflect upon: before or afrer the pregnancy is revealed. Good reportmg child abuse, including sexual abuse. In
parenting skills may be lacking, or there may not be New South Wales, it is mandatory under the
society's responsibility to break the vicious the necessary social supports to cope with the stress Children and Young Persons Protection Act 1998 to
cycle of teenage pregnancy of raising an infant. This social isolation leads to an report to the Department of Community Services
increased risk of child abuse and neglect: the (DOCS) any reasonable suspicion of abuse. The
daughters of adolescent mothers are more likely to obligation extends to the medical practitioner, but,
become teenage mothers themselves, and the sons lD general, It IS the role of the team social worker to
* Teenage pregna ncy establishment of regular ovulatory cycles. The po-

tential for conception in a sexually acove grrlls pre-
sent from the rime of menarche. Thus phYSical and
are at increased risk of criminal activity.
Options for antenatal care

notify about girls who become pregnant under the
legal age of consent. The department will then
assess whether any intervention is necessary that
may include involving the police.
Common clinical p resentations sexual maturations are almost lDvanabl y reached
A 15-year-old high-school student asks for confi- before full psychological and SOCial development. Continuing education
dential advice about termination of pregnancy. Pregnant teenagers frequently drop Out of school
Sexually transmitted diseases owing to financial pressures, the pressures of par-
A 16-year-old Intravenous drug user presents with
abdominal pain and is found to be 28 weeks In addition to routine serological screening for enthood and unwelcoming schools. With their edu-
pregnant. SYEYiliSI. hepatitis B and...£...and HIv, pregnant cation CUt shalt, they lack job skills and are more
ado escents sHould have a vag~ swab w - likely to live in poverty and depend on social secu-
formed at the 6;0£ aptenat al visit. teenagers ha~ e rity. This economic disadvantage can be sustained
a higb incidence (around 25%) of chlamydlal for years. Programs such as that at Plumpton High
Prevalence of teenage pregnancy infecuon wJllCTi may lead to neonatal m tectlon_ School in Sydney have been specifically devised to
In Australia, rates of teenage birth vary in different cer;rcal 'smear abnorma[mes are also common, keep pregnant pupils and new mothers in school
states. In New South Wales in i001 , there were making it essential to perform a smear on any (ABC 2003). Pupils are given suppOrt and encour-
3797 births to women under 20 years of age (19 of pregnant teenager who has not been screened agement from the school principal as well as a ded-
whom were under 15) (NSW Department of within the last 2 years, With appropnate colpo- icated social worker to help arrange transport,
Health 2002) . This represents 4.5 % of all births, scopic follow-up for suspected crN leSIOns. accommodation and childcare.
whereas in the Northern Territory the ~ate was
15.60/0 of all births (AIHW 2003) .. The lDcldence IS Smoking, alcohol and drug abuse Prevention o f teenage pregnancy
lower among mothers born rn non-Enghsh- The use of both leg<!.l. and JIIegal dru~ is common Parents can help to prevent teenage pr·egnancy by
speaking countries than among mothe~ born m in pregnant teenagers, with nearly h of the grrls providing guidance to their children about sexuality
English-speaking countries, and higher rn Abong- being smokers and 1.in 5 drinking alcohol to excess. and the risks and responsibilities of relationships and
. al and Torres Strait Islander mothers, of whom MariilJ3na is "sed by 2Q%, .and o.ne-third .of these pregnancy. School classes in family life and sexual
~~out 1 in 5 are teenagers. The fertiliry rate of girls also use other drugs, mcluding herom, LSD, education, as well as clinics providing reproductive
Australian teenagets peaked at 55.5 babies per amphetamines and solvents (Quinlivan 2002). The information and contraception to young people, can
1000 women in 1971, falling to 17.4 babies per use of illegal drugs is assoaated Wlth othernsk fac- Medicolegal issues also prevent pregnancy for some adolescents. At a
1000 women in 2000 (AIHW 2002). tors, including social isola non, psychiatric prob- broader policy level, prolonging education for girls
In 1999, more than half of all teenage preg- lems domestic violence and homelessness, making Adolescents, like all patients, have a right to pro- and improving social supports for families will
nancies in South Australia were ternunated (Chan it clifficult to study the effects of drug ~se alone on fessional confidentiality. The legaL:ge of consent reduce the number of teenagers with unintended
et al 1999). Based on these annual figures, about these pregnancies. Antenatal interventions need to for medical procedures is 18 years, althoUgh pregnancies.
1 in 25 teenagers will become pregnant at some be aimed at improYlDg these other factors, as well between the ages of 16 and 18 the patiem herself
stage between the ages of 15 and 19 years, and as reducing drug-taking behaviour. can ve COClSenr to contrace non r termination Fathers of teenage pregnancy
1 in 50 will give birth. of re a roval
Socioeconomic status a parents or guardian. Abortion laws vary In a survey of mothers aged between 15 and 19
years, less than half had used any form of contra-
Female sexual maturation and social support between states and counm es, but medicaHy per-
ception and few reported using condoms. The
formed termination of pregnancy is legally
N mal pubertal development begins between Pregnant teenagers are more likely to be single, fathers were aged 17 to 29 years and the majority
th~r;ges of 8 and 13 years and proceeds until the and the father of the child is less likely to have a
available in Australia if it is in the best interests
(including psychological) of the woman. were adults. On average, each father had know n
the mother of his child for more than 2 years but
fl·
Women's health: a CO IS cU i ii c ulum
25 Wom en and SOCiety
only one-third were resident fathers (i.e. living homicide was the most frequent principal cause of PsychOlogical Physical
with their infants) followmg the birth. In fact, con- incidental maternal deaths (6 out of 34) in 1994-96 arranged in consultation with a specialist family
tact with and suppOrt for their infant usually (AlHW 2001). Women who suffered domestic vio- Insomnia Obvious injuries, VIOlence suppOrt agency. and with access to coun-
decreased as time elapsed (McVeigh 2003). lence in pregnancy were shown tohave more fre- Depression espeCially to the head sellmg and legal adVice. Women rna d
and neck or multip le • C • d 'd d Y nee
quent hospital admissions, to utilise the soaal SuiCidal Ideation rnlormaOon an gul e referrals to take out ro-
services more often, to smoke more Clgarettes and areas teenon orders. p
Health maintenance Anxiety symptoms
take more prescription drugs, to have a high.er inci- Bruises In various stages It is inappropriate to offer a couple counselling
Information on reproductive h~allh Panic attacks of healing
dence of miscarriage, pregnancy terrrunatlon at the time of acute violence, but once an individ-
including sexuality, contraception and
STls should be provided In the and neonatal death than women who were not Somatitorm disorder Sexual assault ual has been identified as being at risk, she should
education system, the home and the abused during pregnancy (Webster et al 1996). Post-traumatic stress Sexually transmitted be made aware of the options available.
commun ity. Programs aimed at The violence encompasses many forms of coercive d isorder d iseases Documentation of the consultation, including full
reducing drug use, promoting . and intimidating behaviour by an intimate partner Eating disord ers Chronic pelvic or description of any injuries, is imPOrtant for ongo-
mothercraft skills and encouraging or family member, but most often includes phYSical abdominal pa in rng patient care and pOSSIble future litigation.
return to education should be Drug and alcohol
and/or sexual abuse and is frequently accomparued abuse Chronic headaches or Children are at rncreased nsk when there is vio-
incorporated into health services
provided to pregnant teenagers. by emotional abuse or harassment. Sexual assault is back pain lence in a family, and asking about the impact on
penegation of either vulva or anus by a pems or Lethargy them can be a catalYSt for women and men to
* Violence against
women and girls
another ~cr. Violence IS under-reported and
therefore cult to measure.
National population surveys in Australia
(Australian Bureau of Statistics 1996) and New
TABLE 25.1 Potentlol presenta ti ons a t women
experiencing partne r abuse or past his tor y of
child abuse
make beneficial changes.
In Australia, there is increasing awareness of
domestic and family violence, and screening pro-
grams have been established in many emergency
Zealand (Morris 1998) indicate that one lD four or departments and antenatal clinics. It is impOrtant
who are more at risk include those who are sep-
Common clinical presentations five adult women has ex erienced h Sl@ a to emphasise that the screening is voluntary and
arated or divorced, have a past history of child
ual use most a en om a rn e parmer) at some strictly confidential. The individual is interviewed
A young woman requests the emergency abuse, an overattentive accompanying partner,
time lD their lives, w'hile 2.6% of currently part- multiple presentations for minor issues or are on her own, in a non-threatening environment.
contraceptive pili. She has vague memories ot
the party the night betore. She awoke this
nered Australian women report violence in the non-compliant with treatment. Women may pres- Help may be offered in the form of relevant con-
morning in a triend's apportment with vaginal
previous 12 months. Women are particularly at ent with a range of psychological or physical tact telephone numbers (refuge shelters, coun-
pain and bleeding. She thinks she was raped . risk of Parmer abuse dunn~ preRey. Asurvey of symptoms, as outlined in Table 25.1. selling service, sexual assault referral centre, police
710 women randomly se ecte rom Australian Women may choose not to disclose violence domestic violence unit or legal aid), written infor-
A 7-year-<>ld girl presents w~h her mother. The girl federal electoral rolls reported a 200/0 prevalence for many reasons, including a feeling that they mation on domestic or family violence, referral ro
hos vulval pain and discharge. Her mother Is con- of childhood sexual abuse (CSA), the abuse involv- will not be believed or that doctors will not be a hospital or community-based domestic violence
cerned about increasing behavioural problems .
ing vaginal or anal interco~ in 10% of the vic- able to help, fear, isolation, emotional bonds ro service or to the police. Domestic violence orders
A woman presents to the emergency tims. The mean age at the fmt episode of CSA was parmer or family, hope for change and nor wish- (non-violence ordet, non-contact when drunk
department w~ a black eye and bruising to her 10 years, and only 109-b of such experiences were ing to upset or uproOt children. Having a back- order or fuJI non-contact order) may allow the
right forearm . She says she fell against a door. ever reported to the police, a doctor or a support ground of abuse may lead the women ro accept relationship to continue but with the security of
agency (Fleming 1997). While much sexual assa.nlt violence as normal. legal restraint. A typical screening tool is the ques-
The prevalence of violence is under-reported, up to 11.3% of Australian A physician's responsibility is to inquire in a tionnaire shown in Box 25.1. Such screening for
against women and girls women are estimated to have been Vl ctLInS ot rape non-judgmental way, to maintain confidentiality domestic violence in maternity settings is accept-
(Australian Bureau of Statisncs 1998). and to assist the victim to achieve safety. Doctors able to women, when it is conducted in a safe,
Violence against women and girls is worldwide. confidential and non -judgmental environment
require up-to-date knowledge of relevant special-
The mO$ com mop foWlS in mdusrnalised counrnes Identification and management (Bacchus et al 2002).
ist agencies and the law. Confidentiality is essential
are childhood sexual abuse, domesnc VIOlence, ~ Some physicians, in particular general practi-
u~and r~ Childhood sexuaJ abuse ranges Victims of violence may present days, months or unless there is severe or life-threatening abuse,
even years after the abuse. Even then, they may be when involvement of the police or another agency tioners, will also have the abusing male partner as
from inappropnate fondling to penetranon, most
reluctant to disclose it. It is important always to may be required ro ensure safety. When dealing a patient. If a Woman wishes to stay with her part-
often by a male family member. Domesnc VIOlence
consider the possibility of violence and be pre- with parmer abuse, ir is important ro assess a ner, men's behaviour change groups are widely
is the leading cause of injury among women .of
reproductive age and the single most common rng- pared to ask non-judgmentally about it. woman's risk (levels of fear, degree of violence available to assist a perpetrator who is ready to
and threat of weapons). If the violence is ongoing, take responsibility for change.
ger for female suicide (Stark et al1991). At the most
extreme end of tJie violence commuum, up to Domestic violence the woman may need a safety plan, with impor-
60% of woman who are murdered die as a result tant documents and money ready for a quick Rape and sexual abuse
The identification of domestic violence is a chal-
of a domestic dispute (cqs 1988). In Australia, escape to a refuge with friends or family, or ro
lenge to all doctors in clinical practice . Women
emergency accommodation. This should be Non-judgmental affirmation, privacy, confidential-
ity and suppOrt for a woman's decision about
25 Wo m en a nd so cie t y
Women's health: a core curri Cul um
experienced a particular loss. They need reas- Early phase Middle phase lIesolution
past history are particularly prone to chronic
1. Are you ever afraid of your partner or someone surance that nothing they did caused the event
pelvic pain, sexual problems and the psychological
in your family? to happen. Shack Anger Lessened pain
symproms listed in Table 25.1.
2 In the last year, has your partner or anyone in Disbelief Guilt Reflection
· your family hit, kicked, punched or hurt you? Management
Health maintenance Disorganised Despair Adaptation
3 In the lost year, has your partner or anyone In Acute grief is a time of heightened awareness. thinking
Obsession Assimilation
Health promotion at every level
· your family often put you down, made you feel Specifically, the woman will recall everything that
should inform men , women and Numbness
ashamed or tried to control what you do? was said, how and when it was said, and under Lack of
children that violence, particulcHly ,
Dissociation concenlration
<I In the last year, has your partner or anyone in? violence against women and girls, IS what circumstances. The aim of the healthcare
· your family threatened to hurt you In any way. a significant health I?sue and a professional is to minimise or prevent the pro- Sadness
5 In the last year, has your partner or anyone In , violation of human rights. longed effectS of grief. This can be achieved by
· your family made you have sex when you dldn t good communication and sUppOrt, but also by TABLE 25 .2 Phases of grief
want to? resolving uncertainty. In the case of infertility,
Continue to question 6 only It domestic/family
violence has been identifIed In any of the
above .
* women's
Loss and grief in
lives
assessment and the efficient provision of effective
therapies in a predictable time frame can reduce
grief. Allowing the woman time to grieve in a
sadness and guilt. During this middle phase,
there may be withdrawal, avoidance of people
6. Would you like help with any 01 this now? supportive environment, in a manner appropriate or proneness to accidents, accompanied by
Common clinical presentahons to her beliefs and culture, can prevent long-term somatic symptoms such as nausea, chest pain,
BOX 25.1 Screening tor domestic/family
violence (Adapted from Women's Health adverse consequences. Communicating clearly weakness, sleep disturbance and dreaming about
Strategy Unit 2003)
A couple in their 30s have Just experienced a
and honestly will make information easier to the loss.
third consecutive miscarriage,
assimilate. Sharing the sadness reduces an indi- Resolution allows a return to normal activities,
A new mother grieves over the loss of her full-
renewed social relationships and realistic memo-
' g are also necessary . after a.
disclosure of vidual's sense of isolation: some women may
rep oron ' ries of the loss. Grief is painful and the pain is less-
sexual assault. A comprehensive history,. examma- term stillborn baby boy. interpret crying and appropriate touching as
ened and resolved by allowing all aspectS of the
tion and, if possible, forensic tesnng, With careful A <lO-vear<>ld woman has been trying to evidence tbat a health professional cares. A sup-
loss to be reflected upon, thus facilitating adapta-
documentation, are reqUlred. This may be used as conceive for 3 years, with several unsuccessful portive silence and attentive listening to the in- tion and assimilation of the new situation. Factors
evidence if a formal complaint is lodged With the attempts at in vitro fertilisation . dividual's story can facilitate grief. Ensuring that may complicate grief include perceived stig-
police. Most population centres have doctors spe- suppOrt networks exist and function will carry the mata such as HIY, infertility, suicide and impo-
cially trained in sexual abuse care. Invesnganon ongoing care into the community. Helping to tence. These circumstances may inhibit the appro-
and possible treatment for sexually trarlSmltted Sooner or later everyone experiences a significant assemble memories (e.g. photos and footprints of priate sharing of grief with others, and hidden
infections and prescription of emergency contra- loss in his or her life. Chro.nie illness can allow a dead baby, a favourite toy) may help make th.e
loss real (Kohner 2001). Rituals such as funerals,
grief may have serious long-term outcomes. Prior
ception should be considered. Follow-up care and more time to prepare for this and antlClpatory depressive tendencies and dependent attachments,
counselling referral should also be arranged, along grief can be beneficial to a family urut. Sudden memorial services and memorial books can assist whereby an individual defines herself by a panner
with follow-up pregnancy and testing for sexually unexpected loss leaves no time for preparauon. the grieving process. or offspring, may complicate the resolu tion
transmitted infections if required. During their lifespan, women expenence mare process. General health may suffer from depres-
biological changes than men. In the past, loss of The grieving process sion, impaired immunity and post-traumatic stress
Childhood sexual abuse children was a common event. Both stillbirths and The normal grieving process is influenced by disorder.
infant mortality were cornman. In many develop- culture, religious beliefs and personality, as well
If an underage girl presents with unexplained vag- ing partS of the world, this is still the case. Modem Counselling and support
inal discharge, or mood or behaVloural disorders, as by past experiences of loss, which mayor may
expectations of a perfect, healthy mfant, con-
child sexual abuse may be the cause. not have been resolved. The typical early reac- Allowing adequate time for listening, explaining
ceived and born without difficulty, do not always
Identification, affirmation and support of an tion (Table 25.2) to loss is the shock of disbelief, events and absorbing information will help the
match reality. . 1
abused child is particularly important, as ~hildren Relationship breakdown is readdy acknow - slowed and disorganised thinking, numbness , grieving process. Counselling should always be
are dependants and are usually unable to Identify edged in modern culture, but there IS httle mfor- and a feeling of unreality, associated with weep- considered and offered. Good information and
or seek out assistance for their own health needs. mation available for the general pubhc about ing. There may be hyperactivity and lack of suppOrt groups exist, such as the Stillbirth and
Girls may be subject to threats and mtlmldatlon or grief. Grief can be experienced not only after awareness of surroundings. This initial phase Neonatal Death Society (Si\NDS 1991), miscar-
self-blame, so careful, non-judgmental attitudes the loss of loved ones, but also as a consequenci may be followed by protest, despair and preoc- riage associations, infertility support groups and
and questioning is required. Doctors are expected of surgery, infertility and miscarriage. A sense ~ cupation with the loss. Impaired memory, lack cancer support groups. Different groups have dif-
ro report child abuse to child protection services. guilt often accompames gnef: women m y of concentration and worry may all be experi- ferent cultural and religious ways of acknowledg-
Adult survivors of childhood sexual abuse are blame themselves or look for reasons why they enced. There will also be feelings of anger, fear, ing and supporting afflicted women. Respect
common in clinical practice. Women With such a
fj:F
\

25 Wo men and sociei '.'
for these differences is essential, and tactful ques- CCJS 1998 Homicide in Canade 1987: a statistical
tioning will determine the best option for individ- perspective. Deparrment of Supply and Services,
Canadian Centte for Justice Statistics, Ottawa.
ual women. Assistance with funerals and cremato- QUestions
rium arrangements is always appreciated, and 2. Which of the follOWing statements
Chan A., Scott J, Ngu yen A et aI 1999. Pregnancy Outcomes 1. Which of the following is true of about pregnant teenagers are correct?
interpreters should be available for minority in South Australia 1999. Pregnancy Outcome Unit,
groups who have language difficulties. Epidemiology Branch, Department of Human Services,
teenage pregnancy? a. They have a higher inCidence of
Addaide. a. Fertility is reduced under the age of Candida infection than olde
Q
Women. r
20 years. .
Health maintenance Fleming JM 1997 Prevalence of childhood sexual abuse in a b They are more likely to be smoke
community sample of Australian women. Medical b. Abortion without a parent's consent than older women, rs
It is important to have Information
Journal of Australia 166 :65-68. IS Illegal In a girl under 18 years of
available about groups that facilitate age.
grief, such as miscarriage, cancer f;;)hey are more likely to come from
and stillbirth support groups. Kohner N 2001 When a baby dies. Routledge, New York. ~bortion without a parent's consent \....) Isrupted family. a
V I s Illegal In a girl under 16 years of d. They all need to be reviewed b
McVeigh C 2003 Focus on fathering. In: Sullivan R (ed) age. PsYchiatrist. y a
Who ate the fathers? ACER, Melbourne. d. One in ten girls will become
References e. They should be taken out of school.
pregnant between 15 and 19 years
ABC 2003 Teenage pregnancy at Plump ton High School Morris A 1998 Victims of crime: the women's safety survey. of age.
(fV documentary). Australian Broadcasting New Zealand Law Journal (February):46-48.
e. Teenage birth represents
Corporation Television Archive, Ultimo, Sydney.
NSW Department of Health 2002 New South Wales approximately 20% of all births In
Australia.
AlHW 2001 Report on maternal deaths in Australia mothers and babies 2001. NSW Department of Health,
1994-96. (NHMRC cat. no. 0145246, AIHW cat. no. Public Health Division, Sydney.
PER 13). Australian Institute of Health and Welfare,
National Perinatal Statistics Unit, Canberra. Quinlivan JA., Evans SF 2002 The impact of continuing
illegal drug use on teenage pregnane)" outcomes: a
AlHW 2002 Australia's health. Australian [nstitute of prospective cohort stUdy. SJOG: an International
Health and Welfare, Canberra, p 170. Journal of Obstetrics and Gynaecology
109:1148-1153.
AlHW 2003 Australia's mothers and babies 2000. Permatal
Statistics Series no. 12 (AlHW cat. no. PER 21). SANDS 1991 Guidelines for professionals on miscarriage,
Ausrralian Institute of Health and Welfare, National sril!birth and neonatal death. Stillbirth and Neonatal
Perinatat Statistics Unit, Canberra. Death Societ)" London.
Australian Bureau of Statistics 1996 Women's safety Stark E, Flitcraft A 1991 Spouse abuse. In: Rosenberg M,
AuStralia 1996. Australian Bureau of Statistics and Finley A (eds) Violence m America: a public health
Office for the Status of Women, Canbara. approach. Univergiry Press, ew Yotk.
Australian Bureau of Statistics 1998 Crime and justice Webster J, Chandler J, Battistutta D 1996 Pregnancy
special article: violence against women. In: Australian outcomes and health care use: effects of abuse.
Bureau of Statistics Year Book, Canberra (ABS cat. no. Ameticm Journal oi Obstetrics and Gynecology
1301.0) . 174:760-767.
Bacchus L, Mezey G, Bewley S 2002 Women's Women's Health Strategy Unit 2003 Identifying and
perceptions and experiences of routine enquiry for responding to domestic and family violence: a resource
domestic violence in a maternity service. BJOG: an kit for health professionals. Department of H ealth and
International Journal of Obstetrics and Gynaecology Community Services, Northern Territory Gov(!rnment,
109:9-16. Darwin.
fl:P
*
Index
abnormal glucose tolerance 113-16 anaemia in pregnancy 109-11

diagnosis 115 iron-deficiency anaemia 64, 110
epidemiology 113-14 physiology 109
fetal monitoring 115 screening for 11 0-11
management 115 sickle cell syndrome 111
pathophysiology 114 thalassaemia 69, 110-11
prognosis 115 anatomical gynaecological procedures 250
screening 114 aneuploidy, and fetal growth restriction 95
abnormal labour see labour anogenital warts 41-2
abnormal vaginal bleeding 12-18 antenatal care 67
anatomy and pathophysiology 13-15 first trimester 77-9
epidemiology 12-13 models 78
fibroids 17-18 pregnant teenagers 279
impact/outcomes 18 second trimester 84-6
investigations 15-16 third trimester 86-8
management 16-17 antenatal education programs 70, 78, 86, 152
antepartum haemorrhage 164-6
symptoms and signs 15
causes 164-6
abortion 218-22
definition 164
access 220
anti-D immunoglobulin 11.3
ethics of 220
anxiety disorders, in pregnancy 204, 206
first-trimester 220-1
Apgar scores 181
medical 221
atrophic vaginitis 36
second-trimester 221 Australian Standard Vaccination Schedule 183
septic 220
statistics 219 bacterial vaginosis, in pregnancy 46
termination law 218-20 barrier methods 58
abruption placentae see placental abruption benign molar gestation 267-8
acute pelvic pain 50 beta-thalassaemia 69, 110-11
adenocarcinoma-in-siru (ACIS) 258 bipolar mood disorder, in pregnancy 206-7
adenocarcinoma of the endometrium 264-7 birth
adenomyosis 9 mechanism of 150
AIDS see HIV/AIDS models of care 151
ageing, long-term health goals 243 operative vaginal delivery 154-6
alcohol positions for delivery 150
and pregnancy 65, 76 six steps of 150
in teenage pregnancy 278 birth education 70
alpha-thalassaemia 110 birth plan 87-8
amniocentesis 67, 68, 78, 85 Bishop score 158
amniotic fluid volume 100 blood composition, during pregnancy 141-2
amphetamines, and pregnancy 76 borderline epithelial rumours 272
'1;'
m
Index
normal histology 254--5 cytomegalovirus, in pregnancy 95, 129-30 endometrium, physiological changes in menstrual
bowel function, postpartUm 189 cycle 13-14
screening 254--8
breast adenocarcinoma-in-situ 258 deep vein thrombosis (DVT) 119, 120 epidural analgesia, in labour 150
benign conditions 262 management of abnormal smear 258 dehydroepiandrosterone (DHEA) 21 episiotomy 198-9
structure, functi on and life cycle 261-2 delayed miscarriage 83 indications 199
Papanicolaou (Pap) smear 255-8
breast cancer 261 trauma 199 delayed puberty median 199
concepts of pathogenesis 262 chickenpox 65, 128 causes 21-2 mediolateral 199
risk factors 262 child health communiry nurse 184, 191 treatment 22 role in obstetrics 199
breast cancer screening 261-4 childhood sexual abuse 280, 282 Depo-Provera 57 epithelial rumours 270-1
modalities 263 childhood vaginitis 36 depression borderline 272
opportunistic screening 264 Chlamydia trachomatis 44--5, 52, 134 during pregnancy 204, 206 erythema infectiosum 129
population-based screening programs 263-4 and pregnancy 47 Escherichia coli 127, 131
see also postpartUm depression
breast development stages 20 chorioamnionitis in pregnancy 130-1 diaphragms 58 essential hypertension 119
breast engorgement 190 causative organisms 13 0-1 dilatation and curetrage 221 eugonadism 22
breast milk, transmission of drugs in 194--5 diagnosis and management 131 extremely low birth-weight infants 178
dilatation and evacuation 221
breasrfeeding 178,189-91 choriocarcinoma 267, 269, 272 disability years 243
cornmon problems 190-1 chorionic villus sampling 67, 68, 78 face presentation 172
domestic violence 280-1
ejection (let-down reflex) 190 chronic hypertension in pregnancy 116, 118 faecal incontinence 232-3
Down syndrome 67-8, 181
milk formation 190 chronic pelvic pain 9-10, 50 causes 234
ductal carcinoma in-situ (DCIS) 262
breech presentation 171 climacteric 236 investigation and management 233
dysfunctional uterine bleeding (DUB) 12, 15, 17, 18
brow presentation 172 clomiphene citrate 24, 214 family, development of 204--5
dysgerminomas 272
bulbocavernosus muscles 197 coagulopathy 15 family pedigree 69-70
dysmenorrhoea 8-12
cocaine, and pregnancy 76 feeding, newborn infant 178
caesarean section colposcopic examination of cervix 258, 260 fetal anaemia see isoimmunisation
common complications 192 combined oral contraceptive pill (COCP) 56-7 early congenital syphilis 43 fetal blood sampling 100
management of furure pregnancies after 193 administration 57 eclampsia 118 fetal circularion, changes at birth 180
prophylactic interventions to reduce side effects!risks 56-7 ectOpic pregnancy 79-82 fetal growth 77, 94--9
complications 192-3 types of preparations 56 diagnosis 79 assessment by serial SFH measurement 94
cancer see oncology complete androgen insensitivity syndrome 22 effect on future fertility 81-2 establishment of gesrational age 94
candidial vaginitis 35 complete miscarriage 83 emergency treatment 79-80 fetal wellbeing 99-103
cardiac failure in isoirrununisation 112 complete mole 267, 268 epidemiology 79 and cerebral palsy 102-3
cardioresp iratOry system changes in newborn 178, condoms 58 management 80-1 clinical assessment 100-2
180 condvlomata acuminata 41-2 pathophysiology of tubal damage 79 threats to 99-100
cardiotOcography 100-2, 157 cong~nital hypothyroidism 181 sites 79 fetomaternal haemorrhage see isoimmunisation
cardiovascular disease, and hormone therapies for contraception 55-61 Edinburgh Postnatal Depression Scale 208 fetus
menopause 239-40 efficacy 56 effacement 147 effect of medications on 207
cardiovascular system emergency 60 embryonic development 77 growth-restricted 95-8, 99
during pregnancy 141-2 irreversib Ie 60-1 endodermal sinus (yolk sac) tumours 272 large-for-dates 98
postparrum 189 reversible methods 56-60 endometrial ablation 17 malpresentations 170-2
cerebral palsy 102-3 cord prolapse 169-70 endometrial biopsy 16 physiological changes during labour 149
cervical carcinoma 245-6, 259-6 1 cordocentesis 100 endometrial cancer 264--7 small-for-dates 94--5, 98
clinical presentation 259-60 counselling diagnosis 265 fibroadenomas 262
management/prognosis 260-1 before pregnancy 64--7 epidemiology and relationship with oeStrogen fibroadcnosis 262
following loss and grief 283-4 264--5
risk factOrs 259 fibroids 17-18
spread 260 for HIV/AlDS 46 investigation, staging and treatment 266 fifth disease 129
staging 260, 261 for menopause 241
pathology 265-6 first stage of labour 147
cervical intraepithelial ne oplasia (GIN) 255, 256, genetic 69
presentation 265 first trimester 77-9
cystic fibrosis (CF)
258 prognosis 266-7 clinical and laboratory diagnosis 77
family pedigree 69-70
cervical mucus method 60 endometrial hyperplasia 245 diagnostic tests 78
neonatal screening 181, 182
cervix
prenatal diagnosis 69 endometriosis 9, 51-2 embryonic, fetal and placental growtb 77
colposcopic examination 258, 260
rr
Women's health : a core c urric u lu m
Index
flrst trimester - continued management 95- 7 hyperemesis gravidarum - continued

minor symptoms/complications 77 gynaecological procedures 250 ischiocavernosus muscles 197
diagnosis and investigations 108 isoirnmunisation 111-13
routine blood and other investigations 77-8 intermediate and major procedures 250--1 management 108-9
minor procedures 250 common antigens 111
screening 68 physiology 107
investigations 112
ultrasound 78 physiological response to surgery 250 hypertension
pathophysio logy 111-12
first-trimester termination see abortion postoperative care 251-2 chronic 116, 119
prevention 113
folic acid supplements 64 preoperative planning and consent 251 gestational 116, 118
follicle-stimulating hormone (FSH) 21 pre-surgical interventions 251 hypertension in pregnancy 11 6-1 9 jaundice 183
forceps delivery 154--5, 156 psychological response to surgery 250 classification 116
formula milk 178 recovery from surgery 252 eclampsia 118
KielJand forceps 154, 155
functional gynaecological procedures 250 posrpartum management 118-19
haemolytic disease of the newborn (HDN) 111, 112 preeclampsia 116, 117-18 labour
Gardnerella vaginitis 35 hearing tests, newborn 183 hypothyroidism, congenital 181 abnormal 153
genetic counselling 67-70 heparin 121 hypovolaemia 169
active management 152-3
genital herpes 40-1 hepatitis B hysterectomy 11, 17 definition 146
laboratory cliagnosis 41 impact/outcomes 127 hysterosalpingography 213 dysfunctional 151-2
management plan 41 in pregnancy 46, 126-7 hysteroscopy 16
fetal physiological changes 149
signs and symptoms 40-1 management 127
induction of 158
genital tract vaccine, newborn infants 183 immunisation, newborn infants 183
herpes simplex maternal physiological changes 149
anatomy 197 imperforate hymen 22 no rmal 146-51
infection and puerperal sepsis 194 and pregnancy 46 implantable progestogens 58 birth steps 150
prolapse 223-7 type 2 virus 40 in vitro fertilisation (NF) 214 duration 147-9
trauma 198-200, 298 herpes zoster 128 incompl.ete miscarriage 82-3 mechanisms 146
geni tal warts 41-2 high-risk pregnancies 65-6 incontinence 229-33
and pregnancy 46-7 hirsutism 25, 26 pain management options 149-50
faecal 232-3
process 147
management 42 HIV/AIDS 45-6 urinary 230-2 timing 146
prevention 42 and pregnancy 47,65 inevitable miscarriage 82 onset of 152
signs and symptoms 42 counselling and testing 46 infertility 211- 15
operative vaginal delivery 154--6
germ cell tumours 272 in'.wtigations 45 epidemiology 212
prolonged 151-2
German measles 65 pathophysiology 45 female 213 , 214
aetiology 151
gestational age, establishment 94 treatment 45-6 history and examination 212 definition 151
gestational cliabetes mellitus (GDM) 113-16 hormone-releasing IUDs 58 investigations 212-13 diagnosis 151
screening 114 hormone therapies for menopause 238 male 212-14
management 152
gestational hypertension see hypertension in preg- and carcliovascular disease 239-40 medicolegal and ethical issues 214--15 Outcomes 151
nancy indications for 238-9 pathophysiology 212 prolonged pregnancy 156-9
gestational trophoblastic disease 267-70 other risks 240-1 treatment 213-14
three stages of 147
hydaticliform mole 267-8 human immunodeficiency virus (HI\') see informed consent 251 lactogenesis 190
persistent trophoblastic clisease 268-70 Hrv/AIDS infundibulopelvic ligament 224 laparascopic salpingectomy 80
gonadotrophin releasing hormone (GnRH) 214 human papillomavirus (HPV) 41, 259 inj ectable progestogens 57-8 laparoscopic ovarian drilling 24
agonists 7 hydatidiform mole 267-8 intermenstrual bleeding 12-13, 15 laparoscopy 11, 213
Gonococcus, in puerperal sepsis 194 hydronephrosis 225 International Cerebral Palsy Task Force guidelines large-for-dates fetus 98
gonorrhoea 44 17-hydroxyprogesterone 27 103
and pregnancy 47 hyperandrogenism 25-7 large-loop excision of the transformation zone
intracytoplasmic sperm injection (ICSI) 214 (LLETZ) 258
grief see loss and grief assessment and investigation 26-7 intrauterine devices (IUDs) 58, 60 laser ablation 258
Gro up B Streptococcus (GBS) long-term consequences 27 intrauterine growth restriction 96-8 late congenital syphilis 43
in pregnancy 130, 131, 134, 136 signs and symptoms 26 implications 97 latent syphilis 43
in puerperal sepsis 194 treatment 27 importance of prenatal education 98 leukorrhoea 34
growth-restricted fetus hyperemesis gravidarum 107-9 intraventricular haemorrhage (fVH) 183, 184 levator ani muscles 197, 224
and subsequent prenatal education 98 aetiology 107 invasive mole 257, 269
life table analysis 56
implications 97 clinical picture 107-8 involution, process of 188-9
lifestyle issues in pregnancy 74--6
..
Women's health: a core curricu lu m
Index
loss and grief in women's lives 282-4 mifepristone (RU486) 60,221 obstetric emergencies 163-74 pain management options during labour 149-50
counselling and support 283-4 milk formation 190 antepartum haemorrhage 164---6 painful nipples 190
grieving process 283 minimal access surgery (MIS) 250-1 malpresentations 170-2 Papanicolaou (pap) smear 255-8
management 283 minipill57 primary postpartum haemorrhage 167-9 management of abnormal smear 258
low-birth-weight infants 178 miscarriage 82-3 shoulder dystocia 172-3 parenting education 70, 86
low cavity delivery 155 causes 82 umbilical cord prolapse 169-70 partial mole 267, 268
lower abdominal pain 49-53 definition 82 17~-oestradiol 21 partograms 147, 148, 151, 152
endometriosis 51-2 diagnosis 82-3 oestrogen abnormality, and endometrial cancer parvovirus B19 , in pregnancy 129
pelvic pain 50-1 epidemiology 82 264--5 patient consent 251
lower gastrointestinal tract, structure and function management 83 oestrogen therapy 242 PearJ index 56
232-3 missed 83 oestrogen-deficiency symptoms 23 6, 237 pelvic congestion 9
lower genital tract, bleeding from 166 molar pregnancy 267-8 oncology 253-73 pelvic floor 197
lower urinary tract, structure and function 230 recurrence 270 breast cancer screening 261-4 exercises 225, 231
luteinising honnone-releasing hormone (LHRH) 21 cervical carcinoma 245-6, 259-61 pelvic inflammatory disease 44
morning sickness 107
screening 254--8 and chronic pelvic pain 9-10
mother-baby-father relationship 204--5
macrocytic anaemia 110 impacrloutcomes 53
mother-infant suckling 178 endometrial cancer 264--7
male infertility see infertility pathophysiology 52
multiparous women, abnormal labour 153 gestational trophoblastic disease 267-70
malpresentations, fetal 170-2 signs and symptoms 52-3
ovarian cancer 270-3
mammary duct ectasia 262 pelvic pain 50-1
natural family planning 58-60 operative gynaecology 250-2 pelvic ultrasound 27
mammography 263, 264
marijuana, and pregnancy 76, 278 Neisseria gonorrhoeae 44, 52, 134 operative vaginal ddivery 154--6 perimenopause 236
mastitis 190 neonatal resuscitation 179-81, 182 co mparison of forceps and vento use 156 perin:ltal mortality 99, 142-4
material risk 251 neural tube defectS 64--5 complications 156 definitions 142-3
maternal mortality 140-2 Neville-Barnes forceps 154, 155 contraindications 155-6 rates and prevalence in Australia 143-4
definition 140 newborn infants 177-84 delivery 154 perineal trauma 189
in Austral ia 140-1 Apgar scores 181 incidence 154 episiotomy 198-9
influence of physiological changes of pregnancy changes in cardiorespiratory system 178, 180 indications and prerequisites 155 lacerations 198
141-2 definition and problems 178 instrument design 154--5 persistent trophoblastic disease 268-70
rares 140 Down syndrome 181 rypes of delivery 155 diagnosis 269
maternity leave 74--5 examination 181 opiates, and pregnancy 76 forms of 269
menopause 235-43 feeding 178 osteoporosis 236 management 269-70
examination and investigations 241-2 health checks 184 management 243 pets, and pregnancy 76, 130
hormone therapy (HT) regimens 238-41 immunisation 183 prevention and treatment 239 phen ylketonuria (PKU) 181
individual care 241-2 normal, characteristics 179 outlet delivery 155 phytoestrogens 237
assessment and counselling 241 posmatal care 179, 188-91 ovarian cancer 270-3 placenta praevia 164--5
tailoring therapy 243 premature 183-4 borderline epithelial rumours 272 management 165
management 237-43 preparation for home 184, 191 clinical presentation 271 presentation and diagnosis 165
non-honnonal therapies 237-8 resuscitation 179-81,182 epithelial rumours 270-1 placental abruption 165-6
osteoporosis 236, 239, 243 germ cell rumours 272 management 166
screening 181-3
symptoms 236-7 investigations 271 presentation and diagnosis 165-6
six-week postpartum visit 191
symptom score 236, 237 placental growth and development 77
temperature control 178 management 271-2
testosterone therapy 242 placental-site trophoblastic tumour 269
weight 178 origin 270
menorrhagia 12 polycystic ovary syndrome 23-5, 264
nitrous oxide 149 prognosis 272
causes 14 clinical manifestations 23-4
investigations 15-16 normal labour see labour spread 271 long-term consequences 25
management principles 16-18 normal puerperium see puerperium stromal tumours 272-3 management 24
menstruation 19 nuchal translucency scan 68 ovarian function, postpartum 189 postcoital bleeding 13
microcytic anaemia 11 0 nulliparous WOmen ovulation 213 post-dates pregnancy 156
microwave endometrial ablation (MEA) 17 abnormal labour 153 induction agents 214 posr-maturit: 156-7
mid cavity delivery 155 onset of labour 152 oxytocin 153, 158, 190 postmenopause 236
't-'
• Women's health : a c o re c urriculum Index
postmenopausal prolonged 156-9 preterm prelabour ruprure of membranes (PPROM) pulmonary embolism 119, 120
bleeding 243-6 clinical assessment at 40 weeks 157 136-8
hormone therapy 238--43 diagnosis 157 aetiology 13 6 rape 281-2
posmatal depressi on see posrpartUm depression induction of labour 158 diagnosis 13 7 recreational drugs
labour and delivery 158 management 13 7 and pregnancy 65, 76
posmatal care, newborn infant 179, 188-91
management options at 4 1 weeks 157-8 prognosis 137-8 in teenage pregnancy 278
postoperative care 251-2 respiratOry distress syndrome 183
pathophysiology 157 sequelae 136-7
postpartUm blues 142, 207 primary dysmenorrhoea 8 resuscitation, neonatal 179-81, 182
postpartUm depression 142, 207-9 see also preg- subsequent prenatal education 158
psychological experience 142, 203-9 management plan 10-12 Rhesus isoimmunisation 111, 112
nancy symptoms 10 prevention 113
postpartUm haemorrhage 167-9 depression and anxiety 204
development of the family 204--5 primary postpartUm haemorrhage 167-9 rhythm/calendar method 58-60
epidemiology 167 progestogen-only emergency contraception 60 rotational delivery 155
emotional changes 204
evidence 168 progestogen-only pill (POP)/minipill 57 rubella 65, 126
management 205-6
management 168-9 side effects/risks 57 impact/outcomes 126
postnatal metal health 207-9
pathophysiology 167-8 progestogen therapy 242 in pregnancy 126
psychiatric disorders 206-7
secondary 195-7 social, emotional and culrural issues 204 progestogens (contraception)
signs and symptoms 168 implantable 58 salpingectomy, laparascopic 80
renal system 142
postparrum psychosis 142,208 injectable 57-8 salpingostomy 80
sexual activity 75
post-term pregnancy 156 sexually transmitted infections 46-7, 278 prolonged labour see labour schizophrenia, in pregnancy 206
preeclampsia 96,117-18 prostaglandin Ez 158 screening
smoking in 65, 76, 278
clinical assessment 117-18 prostaglandin FZo; 8~9, 169 abnormal glucose tOlerance 114
social support 66, 70, 184, 204, 278-9
HELLP syndrome 118 psychoactive medications, effect on the ferus 207 anaemia in pregnancy 110-11
teenage 278-80
pathophysiology 117 puberry 18-19 breast cancer 261--4
termination 218-22
prevention and treatment 118 delayed 21-2 cervical cancer 254-8
weight gain secondary sexual characteristics 19-21 cystic fibrosis 181, 182
pregnancy see also ferus, postpartum depression
air travel 75 pubococcygeus 197 first trimester 68
premature infants 183--4 puborectalis 197 gestational diabetes mel!i rus 114
alcohol and drug effects 65, 76, 278 premarure ovarian failure
antenatal care 67, 77-8, 77-9, 84--8 puerperal psychosis 142, 208 maternal serum screening (MSS) for Down
causes 28-9 puaperal sepsis 193-5 syndrome 68, 84
counselling before 64--7 investigations 29 and transmission of drugs in breast milk 194-5 newborn infants 181-3
culrural issues 204 long-term consequences 29 genital tract infection 194 prenatal 67 , 68, 69, 84-5
dental care 76 premenstrual syndrome (PMS) 7-8 risk factors 194 second trimester 84--6
diabetes 65-6, 113-16 management plan 7-8 thromboembolism 194 thalassaemia 69, 110
diet 64, 75 symptoms 7 urinary tract infection 194 viral, pre-pregnancy 65-6
ectopic 79-82 prenatal diagnostic testS/screening 67, 68, 69, 78, wound infection 194 seatbelts, and pregnancy 75
emotional changes 204 84--5 puerperium second stage of labour 147-9
epilepsy and 66 prenatal education 98, 158 care after caesarean delivery 192-3 second trimester 84-6
exercise 75 preoperative planning 251 genital tract trauma 197-200 education 86
folic acid and prevention of neural rube defects pre-pregnancy investigations 64, 65 normal 188-91 follow-up antenatal care 84
64--5 pre-surgical interventions 251 bowel function 189 maternal serum screening (MSS) for Down
genetic counseling 67-70 preterm binh 13 3-8 breastfeeding 189-91 syndrome 68, 84
health education for 63-70, 74 consequences of 134 cardiovascular system 189 screening tests 84-6
high-risk 65-6 definition 134 ovarian functi on 189 second-trimester termination see abortion
infections 125-31 prophylaxis 135-6 perineal trauma 189 secondary dysmenorrhoea 8
iron-deficiency anaemia 64, 110 preterm labour preparation for home 191 causes 9-1 0
lifestyle issues 65, 74--6 diagnosis 134--5 process of involution 188-9 secondary postpartum haemorrhage 195-7
maternity leave 70-1 incidence 13 4 six-week postpartUm visit 191 clinical signs and symptoms 195, 196
medical disorders 105-21 management 135 urinary system 189 management 196
pre-pregnancy investigations 64, 65 prognosis 136 routine management 187-200 preventative strategies 197
physiological changes during 141-2 risk factors 134 secondary postpartUm haemorrhage 195-7 surgical approach 196
fi P
I. Women's health: a core curriculum
Index
secondary sexual characteristics 19-21 secondary 43 Turner's syndrome 21 uterus, anatomy 197, 224
selective serotonin reuptake inhibitors (SSRls) 7 tertiary 43 type 1 (insulin-dependent) diabetes, and pregnancy
semen analysis 212, 213 teenage pregnancy 278-80 65-6 vaccination, newborn infants 183
septic miscarriage 83 and sexually transmitted diseases 278 vagina, anatomy 224
sexual abuse 280, 281-2 and smoking, alcohol and drug abuse 278 ultrasound vaginal agenesis 22
sexual assault 280 antenatal care options 279 first trimester 78 vaginal discharge 33-6
sexual education 279 fathers of 279-80 second trimester 85 normal 34
sexually transmitted infections 39--47 importance of continuing education 279 umbilical arterial resistance 100, 101
pathological discharges 34--6 46
and pregnancy 46-7 medicolegal issues 279 umbilical cord prolapse 169-70
vaginal lacerations 199 '
in pregnant adolescents 278 prevalence 278 diagnosis 169-70
vaginal packing 225-6
shingles 128 prevention 279 management 170
vaginal pessaries 226
shoulder dystocia 172-3 socioeconomic starus and social support 278-9 urinary incontinence 230-2
vaginitis
diagnosis 172 temperature control, newborn infants 178 causes 230
atrophic 36
management 173 termination law 218 effect on women 231
candidial 35
risk factors 172-3 Australia 219-20 examination and investigation 231
history 231 childhood 36
sickle cell sy ndIome 111 New Zealand 220
management 231-2 Gardnere lla 35
slapped cheek syndrome 129 termination of pregnancy see abortion
prevention 231 trichomonal 36
small-far-dates fetus 94--5, 98 testosterone therapy, for menopause 242
types of 230 varicella zoster virus 65
impact of growth restriction 97 thalassaemia 69, 110-11
urinary system, postpartum 189 in pregnancy 128-9
importance of subsequent prenaral education 98 carrier screening and prenatal diagnosis 69, 110
urinary tract infection (UTI) vasa praevia 166
management 95-7 third stage of labour 147, 149
and puerperal sepsis 194 vasectomy 60
normal growth 95 management issues 168
third trimester 86-8 in pregnancy 127-8 venrouse cups 155, 156
smoking
and preterm birth 134 minor complications 87 diagnosis 128 very low birth-weight infants 178
in pregnancy 65, 76 physiology 87 management 128 vesicovaginal fistula 23 0
in teenage pregnancy 278 preparation for birth 87-8 pathophysiology 127 violence against women and girls
social support threatened miscarriage 82 uterine atony, causes 167 identification and management 280-2
after taking the baby home 184 thromboembolic disease in pregnancy 119-21, 194 uterine fibroids 17-18 prevalence 280
for pregnant teenagers 278-9 deep vein thrombosis 119, 120 uterine ir,'olution 188-9 viral screening, pre-pregnancy 65
in pregnancy 66, 70 heparin use 121 uterine prolapse 223-7 vulval haematomas 199
solid teratomas 272 planning for next pregnancy 120-1 uterine ruprure 199 vulval trauma 199
spermicides 58 thromboprophylaxis 121 uterogenital prolapse 223-7
spironolactone 24, 27 pulmonary embolism 120 applied anatomy and physiology 224--5 Women's Health Initiative trial 239 240
Staphylococcus, in puerperal sepsis 194 thrush 35 clinical evaluation 225 Wrigley forceps 154, 155 '
Staphylococcus aureus, in mastitis 190 Toxoplasma gondii 130 management 225-7 written consent 251
Streptococcus (Group B), in pregnancy 130, 131, toxoplasmosis, in pregnancy 76, 13 a prevalence and incidence 224
134, 136 transcervical resection of the endometrium (TCRE) risk factors 225 Yupze method 60
stromal tumours 272-3 17
suckling 190 trans cervical sterilisation 63
suction curettage 221 transcu taneous electrical nerve stimulation (TENS)
sudden infant death syndrome (SIDS) 65 149
superficial transverse perineal muscles 197 transvaginal pelvic ultrasound scan 15
surgical gynaecological procedures 250 transvaginal sonohysterogram 15
recovery from 252 transverse lie presentation 171
symphysis-fundal height (SFH) 94 lIeponema pallidum 43
symprothermal method 60 trichomonal vaginitis 36
syphilis 42-3 trisomy 21, 67-8
and pregnancy 47 trophoblast tumours 267-8
diagnosis and managernent 43 rubal ligation (TL) 60
primary 43 rubal patency 213
'tl

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WO EN'S HEALTH

Foreword v 4 Lower abdominal pain 49

Reversible contraceptive methods 56

Beverley Vollenhoven MBBS (Hons), PhD,

HSV herpes simplex virus

Knowledge recall the physiological changes in the

(leaming objectives continued)

However this approach remains conrroversial,

simple opiates and can be used in combination

combines the speedier recovery from vaginal sur- Ovulation

progestogens, such as me d roxypro gesterone .d I Irregular DUB

Tre atm ent Fibro id s

- "'-'tS~", V'V'o7 ll'r

does not support the surgical removal of fibroids Impact / outcomes

All the physical changes of pubeny occur as a

absent sense of smell are key findings. Anatomical

Symptom Frequency (range)

L) lOllktl - I " l . . "'~~ 4 .x:~.{\" -\ l~

Farquhar C, Anoll B, Ekeroma A et al 2001

Rymer ], Fish ANj, Chapman M 1997 Gynaecology, 2nd

Farquhar CM, Lee 0, Toomath R et al 2003 Spironolactone

Speroff L, Glass RH, Kase NG, Seifer DB (eds) 2001

A 16-year-old girl comes to see you

8. A 3D-year-old woman presents with a

Trichomonal vaginitis Childhood vaginitis

Atrophic vag initis References

Genital herpes, female genital warts (condylomata acuminata) Mark Erion

Knowledge • list the treatment options for removal of

• discuss the educational initiatives to outline a management plan for the

summarise the public health impli - Gonorrhoea

Chlamydia trachomatis is an obligate intracellular Treatment

* delivery and low-birth-welght mfa~ts amo ng of Medicine 337:507-515.

c . It may be caused by a Chlamydia

* Pel vic pain

ness~ tenderness in the adnexa and on moving the Further reading

Reversible contraception explain to a woman the efficacy,

o There may be a slightly increased risk of breast

Kno wle dge Sk ills

Counselling before pregnancy: general outline to a woman the requirements of

Women with genetic concerns • explain to a woman the principles of

Women's heallh : a c ore curriculum

Counselli ng thalassaemia minor generally have clinically

research. Table 6.4 summarises corrunon pedigree Health maintenance

FIGURE 6. 5 Pe d igree o f a p a tient with cystic

Lifestyle issues in pregnancy Penelope Black and William AW Walters

Knowledge • discuss the effect of ectopic pregnancy

• discuss lifestyle Issues in pregnancy define miscarriage and the types of

risk of complications, including gestational dia-

is taken and physical examination performed. The

Suspected ectopiC pregnancy

Patient haemodynamically unstable

Deteriorating clinical Signs/unstable -

shorter hospital stay, lower analgesic requirements

Women's heolth: a c ore curriculum

* Anten atal care -

• Nausea and vomiting (usually resolving by early In

4, Which is the most like ly diagnosis in a

b . It occurs aHer fetal viability, I. e . Wh ich of the following is an essential

d , It is most commonly due to sporadic a , Dipstick testing of urine

7, Which of the following statements d . Che ck ing the amount of oedema in

Management varies depending on the maternal pathoPhYSiOIY._t~;~r\! 00110 c&lVbt causes